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DEPOSITED IN
Boston Medical Library,
' BY THE
'UBLIC LTijRARYOF THE
City c
■^CN.
THE FRANCIS A. COUNTWAY LIBRARY OF MEDICINk
HARVARD MEDICAL LIBRARY-BOSTON MEDICAL LIBRARY
MEDICAL RECORD
A Weekly yournal of Medicine and Surgery
EDITED BY
GEORGE F. SHRADY, A.M., M.D.
SURGEON TO ST. FRANCIS HOSPITAL, NEW* YORK ,* CONSULTING SURGEON TO THE NEW YORK CANCER HOSPITAL, AND CONSULTING
PHYSICIAN-IN-CHIBF TO THE HOSPITALS OP THE HEALTH DEPARTMENT OF THE CITY OF NEW YORK
THE FRANCIS A. C0UN7WAY
LIBRARY 0. •• ' HiCliC
BGB'iua MA
OCT z -i 2003
JULY 7, 1894 — DECEMBER 29, 1894
NEW YORK
WILLIAM WOOD & COMPANY
1894
\
n
^
Vft-JU \V>
• •• •
•♦• : ..i
• • '
Trow Directory,
Printing and Bookbinding Company,
201-213 East \ith Street ',
New York.
LIST OF CONTRIBUTORS TO VOL. XLVI.
Abbott, Dr. George E., New York.
Abrahams, Dr. R., New York.
Abrams, Dr. Albert, San Francisco,
Cal.
Adams, Dr. Robert S., New York.
Aiken, Dr. Hugh K., Laurens, S. C.
Aiken, Dr. Wm. F., Savannah, Ga.
Alger, Dr. Ellice M., New York.
Ambrose, Dr. Daniel R., New
York.
Ashmead, Dr. Albert S., New York.
Aulde, Dr. John, Philadelphia, Pa.
Baginsky, Dr. Rudolf, Berlin, Ger.
Bannan, Dr. Theresa, Syracuse,
N. Y.
Barry, Dr. John H., Long Island
City, N. Y.
Baruch, Dr. Simon, New York.
Bashore, Dr. Harvey, West Fair-
view, Pa.
Beck, Dr. Carl, New York.
Beebe, Dr. Alfred L., New York.
Bellamy, Dr. Russell, New York.
Benedict, Dr. A. L., Buffalo, N. Y.
Biggs, Dr. Hermann L., New York.
Blair, Dr. Louis E., Albany, N. Y.
Bleyer, Dr. J. Mount, New York.
Blumenthal, Dr. Oliver A., Syra-
cuse, N. Y.
Bogle, Dr. J. C, Danville, Ky.
Bosworth, Dr. F. H., New York.
Bottoms, Dr. Frank A., New York.
Brandenburg, Dr. F. D., Cleve-
land, Ohio.
Brewster, Dr. J. D., Windsor, Vt.
Briggs, Dr. M. D., Champlain, N. Y.
Brown, Dr. Sanger, Chicago, I1L
Bull, Dr. William T., New York.
Bullitt, Dr. James B., Globe, A. T.
Cadwallader, Dr. Rawlins, Fall
River Mills, Cal.
Callender, Dr. C. H., New Boston,
Mass.
Carleton, Dr. Th. B., Sabathu, In-
dia.
Carroll, Dr. C. H., Pavaris, Fla.
Cartwright, Dr. Silas S., Roxbury,
N. Y.
Caverly, Dr. Q S., Rutland, Vt.
Chapin, Dr. H. D wight, New York.
Chapman, Dr. W. L., Lynn, Mass.
Clark, Dr. L. Pierce, Middletown,
Conn.
Cleaves, Dr. Margaret A, New
York.
Coleman, Dr. Warren, New York.
Collins, Dr. Joseph, New York.
Collyer, Dr. H. L., New York.
Comegys, Dr. C. G., Cincinnati, O.
Conklin, Dr. W. J., Dayton, Ohio.
Conn, Dr. H. W., Middletown, Conn.
Cordier, Dr. A. H., Kansas City,
Mo.
Craig, Dr. Thomas C, U. S. Navy.
Crary, Dr. George W., New York.
Crosse, Dr. W. A., Jenkinton, Pa.
Crossfiild, Dr. Fred. S., Hartford,
Conn.
Cushing, Dr. Clinton, San Fran-
cisco, Cal.
Dalrymple, Dr. F. W., New Rochelle,
N. Y.
Daly, Dr. W. H , Pittsburg, Pa.
Dana, Dr. Charles L., New York.
Dawbarn, Dr. R. H. M., New York.
Dickinson, Dr. George S., Erie, Pa.
Dickinson, Dr. R. L., Brooklyn,
N. Y.
Dixon- Jones, Dr. Mary A., Brook-
lyn, N. Y.
D'Oench, Dr. F. E., New York.
Dowd, Dr. Charles N., New York.
D wight, Dr. Thos., Nahant, Mass.
Eastman, Dr. Jos., Indianapolis, Ind.
Edes, Dr. Robert T., Boston, Mass.
Ely, Dr. John Slade, New York.
Embden, Dr. Oscar, Brooklyn, N. Y.
Engman, Dr. Martin F., New York.
Estes, Dr. W. L., South Bethlehem,
Pa.
Ewing, Dr. A. C, Salt Lake City,
Utah.
Fischer, Dr. Louis, New York.
Flagg, Dr. R. N., Yonkers, N. Y.
Foster, Dr. Burnside.
Francis, Dr. Richard P., Mont-
clair, N. J.
Frank, Dr. J., Chicago, 111.
Freeman, Dr. Leonard, Cincinnati,
Ohio.
Freeman, Dr. Rowland Godfrey,
New York.
Friedenwald, Dr. Julius, Balti-
more, Md.
Gage, Dr. W. V., McCook, Neb.
Gardner, Dr. H. D., Scran ton, Pa.
Garrigues, Dr. Henry J., New
York.
Getz, Dr. Charles, Baltimore, Md.
Gibson, Dr. C. L., New York.
Gifford, Dr. H., Omaha, Neb.
Gleason, Dr. W. S., Newburg, N. Y.
Godfrey, Dr. Guy C. M., U S.A.
Goffe, Dr. J. Riddle, New York.
Goldstein, Dr. Samuel, New York.
Gorton, Dr. Eliot, Morris Plains,
N.J.
Gowers, Dr. W. R„ London, Eng-
land.
Grandin, Dr. Egbert H., New
York.
Grissim, Dr. J. D., Paterson, N. J.
Groom, Dr. W. S., Britt, la.
Gross, Dr. M., New York.
Guthrie, Dr. W. E., Bloomington,
111.
Hance, Dr. Irwin C, Saranac
Lake, N. Y.
Hartley, Dr. Frank, New York.
Hartwig, Dr. Marcell, Buffalo, N.
Y.
Hawkes, Dr. J. Marshall, New
York.
Healey, Dr. Joseph S., New York.
Heffron, Dr. J. L., Syracuse, N. Y.
Herrick, Dr. H. J., Cleveland, O.
Herrick, Dr. J. F., Ottumwa, la.
Higgins, Dr. F. W., Syracuse, N. Y.
Hill, Dr. J. Sutcliffe, Bellows
Falls, Vt.
Hill, Dr. W. J., Statesville, N. C.
Hinde, Dr. Alfred, Chicago, 111.
HOCHLERNER, Dr. R.
Hoelscher, Dr. J. H., Chicago, 111.
Hopkins, Dr. George G., Brooklyn,
N. Y.
Horton, Dr. D. B., Batavia, N. Y.
Horton, Mr. Thomas, Monlclair,
N.J.
Howell, Dr. J. Morton, Washington
Court-House, O.
Hupp, Dr. J. C, Wheeling, W. Va.
Hutton, Dr. T. J., Shenandoah, Pa.
Ill, Dr. Edward, Newark, N. J.
Jacobi, Dr. A., New York.
Jacobson, Dr. Nathan, Syracuse,
N. Y.
Jaisohn, Dr. Philip, Washington,
D. C.
Jeffery, Dr. Aaron, Radford, Va.
Jennings, Dr. Charles G. R., El-
mira, N. Y.
Johnson, Dr. W. B., Patersm, N. J.
Jones, Dr. Isaac J., Austin, Tex.
Kammerer, Dr. Fred., New York.
Keen, Dr. W. W„ Philadelphia, Pa.
King, Dr. Herbert M., Grand
Rapids, Mich.
Klebs, Dr. Edwin, Strassburg, Ger-
many.
Knowles, Dr. Francis E., South
Orange, N. J.
Krieger, Dr. G. E., Chicago, 111.
Kunz, Dr. S., Chicago, 111.
Lamkin, Dr. J. S., Yonkers, N. Y.
Lanphear, Dr. Annette E., New
York.
Landes, Dr. Leonard, New York.
Lanphear, Dr. Emory, St. Louis,
Mo.
Leszynsky, Dr. Wm. M., New York.
Leyien, Dr. Henry, New York.
Leviseur, Dr. Fred. J., New York.
Lewis, Dr. J. C, Panama, N. Y.
Liell, Dr. E. N., New York.
Loyeland, Dr. Bradford C, Clif-
ton Springs, N. Y.
McBrayer, Dr. L. B., Asheville,
N. C.
McCartie, Dr. D. B., Newark,
N.J.
McChesney, Dr. Willard, Janes-
ville, Wis.
McCourt, Dr. P. J., New York.
McCullough, Dr. John W. S., Al-
liston, Ont.
McGee, Dr. W. C, Little Sandusky,
O.
McGuire, Dr. C Monroe, Walsen-
burgh, Col.
Macalester, Dr. R. K., New York.
MacArtney, Dr. W. N., Fort Cov-
ington, N. Y.
MacFarlane, Dr. Andrew, Albany,
N. Y.
IV
CONTRIBUTORS TO VOL. XLVI.
MacPhatter, Dr. Neil, Denver,
Col.
Magill, Dr. Wm. S., Chicago, 111.
Maine, Dr. F. E., Auburn, N. Y.
Maisch, Dr. Charles O., New York.
Maloney, Dr. F. W., Rochester,
N. Y.
Maloney, Dr. J. A., Washington,
D. C
Mann, Dr. Edward C, New York.
Marcy, Dr. Wm. A., Buffalo, N. Y.
Ma*sh, Dr. James P., Troy, N. Y.
Martin, Dr. Robert W., Philadel-
phia, Pa.
Martin, Dr. William A., San Fran-
cisco, CaL
May, Dr. Charles H., New York.
Mayo, Dr. W. J., Rochester, Minn.
Mettler, Dr. L. Harrison, Chicago,
111.
Meyer, Dr. Willy, New York.
Michels, Dr. John, New York.
Miles, Dr. Geo. W., Oneida, N. Y.
Milliken, Dr. Sam'l E.f New York.
Moffat, Dr. Henry, Yonkers, N. Y.
Montgomery, Dr. Charles J., Au
gusta, Ga.
Moor, Dr. William, New York.
Moore, Dr. H. B., Colorado Springs,
Col.
Morton, Dr. William J., New York.
Moser, Dr. William, Brooklyn,
N. Y.
Mullen, Dr. J. J , Pittsburg, Pa.
MundI:, Dr. Paul F., New York.
Mynter, Dr. Herman, Buffalo, N. Y.
Nammack, Dr. Chas. E., New York.
Newton, Dr. Richard C, Mont-
clair, N. J.
Norbury, Dr. Frank P., Jackson-
ville, 111.
Noyes, Dr. William, B., New York.
Oppenheimer, Dr. L. S., Bartow,
Fla.
Otis, Dr. W. K , New York.
Outerbridge, Dr. Paul, New York.
Overholser, Dr. W. P., Harrison-
ville, Mo.
Page, Dr. Charles E., Boston, Mass.
Park, Dr. W. Hallock, New York.
Pendleton, Dr. Edward, Owens-
boro', Ky.
Phelps, Dr. A. M., New York.
Phelps, Dr. W. C, Buffalo, N. Y.
Phillimore, Dr. R. H., Cookshire,
Canada.
Phillips, Dr. Geo. A., Ellsworth, Me.
Pilcher, Dr. James E., U. S. Army.
Plummer, Dr. Frederick H., Plymp-
ton, Mass.
Post, Dr. Sarah E., New York.
Preston, Dr. G. J.f Baltimore, Md.
Pryor, Dr. John H., Buffalo, N. Y.
Putnam, Dr. W. E., Whiting, Ind.
Rankin, Dr. D. N., Allegheny, Pa.
Richardson. Dr. Maurice H., Bos-
ton, Mass.
Richmond, Dr. Nelson, Fredonia,
N. Y.
Robinson, Dr. Beverley, New York.
Robinson, Dr. Byron, Chicago, 111.
Rockwell, Dr. A. D., New York.
Rose, Dr. A., New York.
Rosenberry, Dr. H. L., Menominee,
Mich.
Roy, Dr. P. S., Washington, D. C.
Runge, Dr. E. C, St. Louis, Mo.
Rupp, Dr. Adolph, New York.
Satterleb, Dr. Richard H., Buffa-
lo, N. Y.
Schirman, Dr. A., New York.
Schumpert, Dr. T. E., Shreveport,La.
Seitz, Dr. Albert, McMinnville,
Tenn.
Sherman, Dr. W. H., Yonkers, N. Y.
Shrady, Dr. George F., New York.
Siegfried, Dr. C. A., U. S. Navy.
Smith, Dr. C. B., Binghamton, N. Y.
Smith, Dr. E. A., Santa Clara, Cal.
Smith, Dr. J. Gardner, New York.
Smith, Dr. Stephen, New York.
Smith, Dr. W. Harvey, Winnipeg,
Manitoba.
Smith, Dr. Wm. G., Sturgis, S. D.
Snow, Dr. Sargent F., Syracuse, N.
Y.
Souchon, Dr. Edmond, New Or-
leans, La.
Southworth, Dr. Thomas S., New
York.
Spence, Dr. Arnot, New York.
Spratling, Dr. William Philip,
New York.
Starke, Dr. G., New York.
Starr, Dr. M. Allen, New York.
Stebbins, Dr. Roswell O., New
York.
Stedman, Dr. Thos. L., New York.
Steele, Dr. Thomas B.. Cambridge,
Md.
Stephenson, Dr. F. B., U. S. Navy.
Stewart, Dr. Thomas M., Cincin-
nati, Ohio.
Stewart, Dr. William W., Colum-
bus, Ga.
Storrs, Dr. Frances S., Topeka,
Kan.
Stowell, Dr. Wm. L., New York.
Straight, Dr. Howard S., Cleve-
land, Ohio.
Study, Dr. Joseph N., Cambridge
City, Ind.
Summers, Dr. J. Will, Hammond,
111.
Swasey, Dr. Edward, Worcester,
Mass.
Sweeney, Dr. M. J., Kane, Pa.
Thompson, Dr. J. H., Kansas City,
Mo.
Thornton, Dr. James B., Boston,
Mass.
Tingley, Dr. Hilbert B., Rockaway
Beach, N. Y.
Trent, Dr. J. H., Brooklyn, N. Y.
Tyrrell, Dr. R. Shaw, Toronto,
Canada.
Valentine, Dr. Ferd. C, New York.
Valk, Dr. Francis, New York.
Van Dyke, Dr. F. W., Grant's Pass,
Ore.
Vineberg, Dr. Hiram N., New York.
Wagner, Mr. Charles W„ Bing-
hamton, N. Y.
Ward, Dr. J. M., Cornelia, Mo.
Warfield, Dr. Clarence, Galveston,
Tex.
Washburn, Dr. W., New York.
Wasse, Dr. G. M., Baldwinsville,
N. Y.
Watkins, Dr. Robert L., New York.
Weber, Dr. Leonard, New York.
Webster, Dr. David, New York.
Weir, Dr. James, Jr., Owensboro,
Ky.
Weir, Dr. Robert F., New York.
Wells, Dr. Brooks H., New York.
Wendt, Dr. Edmund C, New York.
Werder, Dr. X. O., Pittsburg, Pa.
White, Dr. A. Campbell, New York.
Wiener, Dr. Alexander C, Chi-
cago, 111.
Wiggin, Dr. Frederick Holme,
New York.
Wirt, Dr. Wm. E., Cleveland, O.
Wylie, Dr. W. Gill, New York.
Zangger, Dr. Theodore, Zurich,
Switzerland.
Zenner, Dr. Philip, Cincinnati, O.
Zwisohn, Dr. L. W., New York.
Societies from which Reports have
been received.
American Association of Genito-
urinary Surgeons.
American Association of Obstet-
ricians and Gynecologists.
American Climatological Asso-
ciation.
American Dermatological Asso-
ciation.
American Electro - therapeutic
Association.
American Gynecological Society.
American Laryngological Asso-
ciation.
American Medical Association.
American Neurological Associa-
tion.
American Orthopedic Association.
American Pediatric Society.
American Physiological Society.
American Public Health Asso-
ciation.
American Surgical Association.
Association of American Physi-
cians.
British Medical Association.
Canadian Medical* Association.
Congress of American Physicians
and Surgeons.
Medical Society of New Jersey.
Medical Society of the County
of New York.
Medical Society of the State of-
Pennsylvania.'
Mississippi Valley Medical Asso
ciation.
New York Academy of Medicine.
New York County M bdical Asso-
ciation.
New York Pathological Society.
Practitioners' Society of New
York.
Southern Surgical and Gyne-
cological Association.
Medical Record
A Weekly Journal of Medicine and Surgery
Vol. 46, No. 1.
Whole No. 1235.
New York, July 7, 1894
$5.00 Per Annum.
Single Copies, xoc.
©rigitmt Articles.
ENTERIC FEVER IN INFANCY.
By WILLIAM B. NOYES, M.D.,
NEW YORK.
The recent epidemic of typhoid fever in Montclair,
N. J., arising from a polluted milk supply, developed an
unusually large proportion of cases in young children.
We are so apt to consider typhoid a disease of older
children and adults, that cases occurring in earlier in-
fancy have a fair chance of not being diagnosed unless
occurring in connection with other cases. Northrop, in
his long experience in the Foundling Asylum, among ten
thousand cases has never had a case of typhoid, and he has
never seen a case under two years in his entire experience.
Huber has seen but three or four cases, Holt has seen no
cases under sixteen months, Prudden has seen nothing of
it in a pathological way, and others of large experience
hive seen little of typhoid during the first two years.
The first case I wish to report is one which I followed
very closely during its entire course, and can vouch for its
absolute accuracy.
Case I. — A. G. N , eleven months of age, a
healthy male child of somewhat nervous temperament, of
healthy parents, with no tendency to tuberculosis or any
other disease. Had suffered from scarcely any of the or-
dinary diseases of childhood. He was taken to Montclair
for a visit of ten days soon after weaning, and was fed on
milk diluted with barley-water, not boiled or sterilized.
He rapidly improved in health during these days. Soon
after his return to the city he became fretful, restless, and
had a slight fever attributed to his " cutting teeth. ' ' When
I saw him first, except for a slight angina and a temper-
ature of 1020 F. in the evening, there was nothing char-
acteristic or positive in his condition except the proba-
bility that he was developing something. For two days
he improved, though still with a moderate temperature.
On the next day he had a roseola, which disappeared in a
few hours.
March 27th. — His temperature was 102. 6° a.m. ; 103. 8°
F., p.m. ; and for the first time he appeared very sick.
Moderate diarrhoea with collicky pains, straining at stool.
Tongue coated. Vomiting occasionally.
Diagnosis, gastro-enteritis. Treatment, a mixture of
hydrochloric acid, pepsin, and bismuth.
March 28th.— Temperature, 102. 6° to 1040 F. Mod-
erate diairhoea with colic.
March 29th. — Temperature, 102. 6° to 103.40 F. Di-
arrhoea with frequent stools of a very foul odor. Tongue
coated white; tip and sides red. Lungs gave phys-
ical signs of bronchitis. No angina. Slight dulness
under the left scapular. Breathing rather high-pitched
and rapid. Very fretful. Hands brought frequently to
the head as if suffering pain. Pupils equal. No other
definite symptoms.
March 30th. — Temperature, 101.80 a.m. to 102. 8° F.
p.m. Condition somewhat better. Lung symptoms less
marked.
April 1st. — Temperature, 102. 20 a.m., 1030 F. p.m.
Patient being in better condition, it was decided to move
him back to the country for a change of air, and to es-
cape suspected plumbing. No bad results from the trip.
Dr. H. B. Whitehorn, of Verona, N. J., after this time
associated with me in the case. During the two weeks
which had elapsed since he had left Montclair, about fifty
cases of typhoid fever had developed, and about this time
it was publicly recognized that the origin of every one of
these cases was due to one cause alone, the polluted milk
served to the families of all the cases by one dairyman,
G , who had two cases of typhoid in his family one
month before, and had infected his well, and used the
well-water to wash the cans and bottles. The baby had
fed for ten days on this milk. The combination, there-
fore, which now appeared before us, of a high continued
temperature during the past week, the coated tongue, with
clean margin, some tympanites, all this pointed directly
to a diagnosis of typhoid. The stools, which, on a nap-
kin, appeared similar to an ordinary stool in diarrhoea
trouble, examined in a vessel were not unlike the typical
pea soup discharges.
April 2d. — Temperature, 1040 F. ; pulse, 160 ; respi-
ration, 25 ; stools, 4. Rose spots first seen on abdomen
and chest, very marked, disappearing on pressure ; very
distinct when bathed. Patient coughed occasionally and
vomited once or twice. Another case of typhoid in the
family, the nurse of the baby, who had used the same in-
fected milk, diagnosed at this time.
April 3d. — Temperature lower, 1030 F. ; pulse, 160;
respiration, 25. Tlie diet, which had consisted of steril-
ized milk and barley-water, was not agreeing well, vomit-
ing and diarrhoea being troublesome. Changed to a
combination of Pasteurized milk, lime-water, and cream,
which was afterward well borne.
April 4th.— Temperature, 101.50 to 102. 50 F. ; pulse,
150; respiration, 35. Occasional coughing; baby very
restless, giving signs of pains in the head.
April 5th to 7th. — Patient doing well, restless at times.
Temperature reached ioo° to 10 1° F.
April 8th. — Baby still fretful and cried occasionally
with a sharp shrill cry. Some undigested milk in the
defecation.
April 9th. — Baby slept fairly well, nervous when awake,
same shrill cry as before. Temperature arose from 1 00. 2 °
to 1 040 F. Pulse, 150; respiration, 27. It was no-
ticed that he held his head drawn back and made con-
tinual motion with his hand as if to grasp some object.
Pulse feeble, extremities cold and somewhat cyanotic.
Under vigorous stimulation the condition passed away.
April 1 oth.— Temperature, 102. 6° to 1030 F. Pulse
over 160. Patient somewhat better, treated for tendency
to convulsions by sedatives, and systematic heart stimula-
tion by means of champagne and minute doses of heart
tonics.
April nth.— Temperature, 1010 to 1040 F. Pulse,
160 to 180; respiration, 30. A condition of irregular
pulse and cyanosis was noticed which reacted to heart
stimulation. Condition of rigidity of the neck, opis-
thotonos, general hyperesthesia, inco ordination of eye-
balk, peculiar cry, with occasional convulsive movements
of the hands, became now very marked. Dr. Huber, of
New York, called in consultation.
April 1 2th. — Condition of patient very poor. Tem-
perature, 102. 40 to 104.80 F. An irregular feeble pulse
and great restlessness calling for careful heart stimula-
tion. Urine carefully examined, no trace of albumin
found. A third case of typhoid fever in the family de-
veloped at this time.
April 13th.— Temperature, 102. 20 to 103. 40 F. Res-
piration, 30 to 40 Rapid and shallow. Pulse 152,
slightly irregular. One very bad spell in the afternoon,
MEDICAL RECORD.
[July 7, 1894
the most serious attack of collapse thus far, with cyanosis
and faint pulse, checked by vigorous stimulation and
high hot enema.
April 14th — Temperature, 101.5° to Io2.8° F. ; pulse,
152 to no; respiration, 55 to 53; difficulty in getting
him to swallow anything except champagne, which he
took readily. At times the convulsive movements and
symptoms of heart failure.
April 15th. — Statu quo. Temperature, ioi° to 103° F.
April 1 6th. — Quiet day until a severe collapse in the
afternoon, which was nearly fatal. All forms of stimula-
tion were used from 2 to 6 p.m., including artificial res-
piration, oxygen, electricity, and other agents, without
response. Vomiting of a greenish-brown fluid. A com
bination of tincture of musk, aromatic spirits of am-
monia, spirits of camphor, and a one per cent, solution
of nitroglycerine, one minim of each every five minutes
in the mouth by a medicine dropper, was followed by
improvement and restoration to a fairly good condition.
April 17th. — Temperature, 104° F. ; pulse, 152. Con-
vulsions and collapse at 5 a.m ; died from heart failure
and respiratory paralysis, 10 a.m.
Of 1 15 cases of typhoid and similar cases occurring in
Montclair and vicinity, where the infected milk was sold,
7 were reported of three years of age or younger, all hav-
ing been fed on this milk.
Case II. — Reported by Dr. Smith. Girl, aged three,
previously healthy, had subsisted entirely on the milk
from the G dairy. When first seen, March 1 2th, had
diarrhoea, tympanites, eruption, and all the symptoms of
typhoid. The case ran an uneventful course and termi-
nated after two weeks.
Case III. — Reported by Dr. Brown. B. B , aged
eighteen months. Female, one of three children, aged
one and a half, three, and five years, respectively, who
were all attacked with typhoid ; sick about twenty-eight
days, with bronchial catarrh, high temperature, very fret
ful, constipated ; no rash, mouth, or nerrous symptoms ;
diagnosis, typhoid, on account of the epidemic.
Case IV. — Reported by Dr. Newton. H. B , aged
eleven months. Male. Treated from April 1st to April
1 ith ; entire illness, sixteen days. Eruption present, eight
to ten petechiae noted. Temperature about 1020 F. Some
tympanites. Moderate diarrhoea. Yielded readily to a
diet of boiled milk and pepsin. Dr. Newton was first
called in to see the patient on account of sore mouth, and
found an aphthous condition of the mouth, gums sore and
bleeding. Tongue had a heavy brownish-white coat.
Breath offensive. Colicky pains until relieved by calomel.
Patient had an uneventful run of fever and short con-
valescence; never vomited, and never refused his bot-
tle.
Case V. — Reported by Dr. Wilson, of Bloomfield.
Infant, aged thirty months. First seen about April 25th.
Sick two weeks. Eruption present. A mild case.
Case VI. — A boy, under three years, reported by Dr.
Shelton, of Montclair, suffered from typhoid at the same
time that a brother, aged five years, and a sister, aged six
years, all having been fed on the infected milk. Fever
lasted four weeks, varying from 100.50 F. a.m., to 1030 to
1040 F. p.m. Temperature curve fairly typical. Erup-
tion present Extreme restlessness and tendency to
scream out suddenly noted. The pulse generally 128, at
times intermittent. Distended abdomen, considerable
flatulence at times. Frequent offensive stools, somewhat
formed, with greenish particles. Urine negative. Occa
sional coughing. Otherwise uneventful course and re-
covery. The case of the girl, aged six years, was ex-
ceedingly severe, with obstinate constipation for many
days, great prostration, emaciation, and bed-sores.
Temperature reaching 104.50 F. the second week.
Great restlessness, coughing, delirium, abdominal pain,
and offensive breath.
Case VII. — Communicated by Dr. Brown, of Mont-
clair. Child, aged three years, very sick for twenty-
eight days. Sister of Case III. Temperature running
from 1030 to 1050 F. for some time. Marked nervous
symptoms for several days. Great restlessness, tossirg
its head from side to side. Rigidity of muscles of the
neck. Opisthotonos. Almost complete blindness for
five days, strabismus at times, hydrocephalic cry. Tym-
panitic abdomen, no eruption, no urinary symptoms,
tongue coated and moist. Picked at its nose until the
nose became raw. Case recovered under treatment of
bromides and phosphoric acid. Constipation was
marked. Dr. Brown has seen six cases of clear typhoid,
under five years, in this epidemic, three under three
years of age. He recalls in previous years a number of
cases with a high fever running for several weeks, with
constipation more frequently than diarrhoea, no noticea-
ble rash, which he now considers, in the light of his ex-
perience gathered in Montclair in the recent epidemic,
to have been undoubtedly enteric fever.
Case VIII.— Reported by Dr. Newton. E. B ,
girl, aged two and a half years. Sister to Case IV.
Actively sick about one week, with temperature reaching
1030 F., lowest 980 F. Eruption; no diarrhoea.
Treated from April 6th to May 5th. An exceedingly
mild and uneventful case. An older sister of this case,
aged seven years, also sick with typhoid fever, with a
maximum temperature of 1040 F. Excessive eruption
for two weeks. At one time one hundred and fifty
petechial spots on body and limbs.
We have given our own case in detail, not because it
is the youngest case on record, for it is not, but the
cases on record usually quoted are too abbreviated to be
entirely trustworthy. There are cases quoted by various
authors occurring soon after birth and during the first
year. Pregnant mothers contract typhoid, and give
birth to infants who develop symptoms of typhoid a few
days later. Eichhorst mentions the following examples
in early infancy : 1. Found twice by Charceley in the
new-born. 2. Hastelius : In a foetus taken dead in the
eighth month from its mother, who had died from
typhoid, there was found splenic tumor and marked in-
filtration of intestinal follicles and mesenteric glands. 3.
Neuhaus has found typhoid bacilli in the organs of a
foetus. 4. Chantemesse and Vidal found it in the
blood of the placenta, and proved that the typhoid ba-
cilli could be transferred to the foetus by experiment.
5. Eberth in the heart and in the foetal membranes and
placenta, expelled, in the third week of an attack of ty-
phoid. 6. Hildebrand demonstrated them in the
spleen, liver, mesentery glands, and nervous system. 7.
Reher made successful cultures from the fluids in the liver
of a foetus.
The youngest case recorded contracting the disease it-
self is at the age of four and a half months. Reported
by Ogle in The Lancet, 1892. After a week of fretful-
ness, fever, and indefinite gastro intestinal symptoms, the
case yielded, on autopsy, swollen and reticulated Peyer's
patches with ragged ulcers, partly ulcerated solitary fol-
licles, enlarged mesenteric glands, and enlarged and soft-
ened spleen.
Earl, of Chicago, reported a case, five months four days,
with fever, diarrhoea running a mild course like an inno-
cent gastro-enteritis. Finally, after suddenly developing
symptoms of collapse and symptoms strongly resembling
peritonitis, the infant died, and was found to have swol-
len solitary follicles, partly ulcerated Peyer's patches, and
enlarged mesenteric glands. Peritoneum normal.
Murchison showed intestines of an infant of six months
to the London Pathological Society, which had been
attacked with typhoid at the same time as liis mother,
and had the typical lesions of typhoid in a marked degree.
Henoch reports two cases, at six and seven months,
with diarrhoea, splenic tumor, bronchial catarrh, otitis,
somnolence, characteristic fever curve. Autopsy showed
very slight changes, slight swelling of single mesenteric
glands, one Peyer's patch swollen. He pronounced the
cases as undoubtedly typhoid.
Abercrombie described a case in an infant of six
months and one at seven months, with autopsy yielding
typhoid lesions. Shadier narrates a case of a seven
July 7, 1894]
MEDICAL RECORD.
months1 infant whose mother died about the same time
from typhoid.
England1 quotes in detail a case at eight months, with
vomiting, diarrhoea, tympanites, enlargement of liver and
spleen, rose spots, and fever for three weeks.
Fuller, The Lancet, 1892, a case at nine months char-
acterized by diarrhoea, headache, continuous fever, not
over 1020 F. for ten days, tympanites, pain on deep press-
ure. Autopsy showed the typical lesions of typhoid.
Long * reports in detail a case, of one year, with typical
typhoid symptoms.
Dr. Huber saw two cases some years ago ; one, an in-
fant of eighteen months, the other, two years and six
months, both occurring at the same time with other cases
in the same family. Indefinite symptoms, but diagnosis
clear from the presence of other cases.
Northrup had a case of a child two years of age, in the
Presbyterian Hospital, who caught typhoid from its
mother who was sick at the same time. The eruption
and ordinary symptoms of typhoid were present. The
patient made a prompt recovery.
Jacobi has seen many cases of typhoid in infancy.
If these cases are authentic, and there is little doubt
that they are, we cannot help thinking that we have be-
fore us a disease, rare not because it does not occur, but
rare because it is not recognized when it does occur.
Henoch states his firm belief that the greater part of cases
formerly called gastric fever (febris gastrica remittens) are
really typhoid. The "febriculae" so frequently men-
tioned in text-books, and vague intestinal disorders so
often seen in clinics, with little systematic study of their
temperature, are very often probably abortive typhoid
fever in their natures, terminating between the tenth and
twentieth day with absorption of inflammatory products
and no ulceration.
Vogel reports, out of 1,017 cases, 7 under one year;
Montmellen, out of 295 cases, 1 5 under two years ; Henoch,
out of 280 cases, 8 under two years ; Earl, out of about
40 cases, 7 under five years. The undeveloped condition
of the glandular structure of the intestines, as urged by
some writers, might vary the pathological changes and
symptoms, but cannot render infants of any age proof
against infection, if they drink any infected water or in-
fected milk, or use infected bottles, or are in close con-
tact with typhoid patients.
In the prodromal period symptoms are not pronounced.
The onset will, in most cases, be so insidious that it must
be a number of days before a correct diagnosis can be
made with any degree of certainty. If there is diarrhoea,
a gastro-enteritis or entero colitis will explain all the
symptoms that have yet appeared. If there be actual con-
stipation, or merely occasional movements consisting of
somewhat altered or putrid stools, a diagnosis of pto-
maine poisoning from some undigested fermenting sub-
stance in the intestine will explain all the symptoms.
This is not really a false diagnosis, it merely does not
state what is the bacterial agent that causes the ptomaine
poisoning.
Donkin states that 24 out of 62 of his cases in children
showed a more definite onset of the disease than in adult
life. Headache, shivering, vomiting, pain in the belly,
back, or legs. Henoch says that it is rare to begin with
a chill. Brown, of Montclair, has noted in several cases
a rather abrupt commencement.
The fever in the cases occurring in infancy is apt not to
present a typical curve at first, for there are so many causes
that influence the temperature of a child that would not
affect an adult. The fever may be moderate throughout,
or it may reach a high point early, and the original diag-
nosis be changed solely because the temperature is too high
and too continuous to be caused by a simple enteritis.
Two distinct periods that may be found in the tempera-
ture of an ordinary typhoid in an adult: (1) disturb-
ance due to the typhoid bacilli, causing a sub- continuous
fever ; (2) disturbance due to the formation and separa-
1 Canada Medical Record, vol. xx., p. 95.
* Archives of Pediatrics, 1893, p. 53.
tion of intestinal sloughs, causing a remittent fever, are
apt in early childhood to be varied because the second
element is imperfect, short, or often entirely absent, due
to the fact that the intestinal lesions frequently undergo
resolution without any ulcerations (Keating).
Gariock 1 states that the process in Peyer's patches is
generally limited to the lymphoid cells and is superfi-
cial. The proliferated cells undergo fatty degeneration
and are absorbed without formation of ulcers. A fever
after fourteen days is due to absorption through open ul-
cers. And few children with such ulcers can escape a
secondary fever.
The milder degree of intestinal lesions, and especially
the absence of ulcers, would make us expect that we should
find less abdominal tenderness, less pain, less diarrhoea,
and less tympanites than in the adult, which all recorded
cases show to be undoubtedly true. Gerhart states that
the swelling of Peyer's patches shows itself earlier than in
adults, and is seen with greatest frequency near the ileo-
cecal valve, often reaching • higher. This swelling is
sufficient to cause the patches to protrude out beyond the
mucous membrane in projections that are frequently the
seat of excoriations and little ulcers. These may later de-
velop deep ulcers and sloughs, as occurred in twenty-
nine out of his forty- four examinations. On the other
hand, this frequently clears up without ulceration.
Henoch holds that the ulcers are comparatively rare and
of small size. He found them in 13 out of 23 autopsies
of his 239 cases in children. He says that when they
occur they are generally small, shallow, and instead of
occupying the whole of a Peyer's patch occupy merely a
part. The Peyer's patches may form what he calls
"plaques molles," a condition of fatty degeneration of
the new-formed cells resulting finally in resolution, or they
may form hard plaques, indicating an infiltration of the
entire gland tissue and tissues beneath, which will ulti-
mately result in the foimation of ulcers.
Granted that typhoid fever is commoner than we have
realized, what symptoms will enable us to recognize one
of these cases or make an early diagnosis ?
t. Any long- continued fever that will not yield to ap-
propriate doses of quinine is suspicious, especially when
higher in the evening, and when no existing conditions
of the throat and lungs or bowels suggest an explanation.
A temperature remaining continuously high, and yielding,
if systematically taken, a fairly typical typhoid fever cone
after a few days. Jacobi lays stress on the probability of
typhoid with a continuous high fever, which is well borne
by the infant.
2. Gastro-intestinal disorder, especially when a decided
tendency to constipation is present ; putrid stools of an
especially offensive character and odor when there is any
diarrhoea. If these are only seen on the diaper they will
not look very different from the green spinach stools that
occur in other diarrhoeas, because the fluid is soaked up on
the napkin. If seen in a vessel, the thin, semifluid char-
acter, greenish particles, and all the characteristics of a
typical " pea- soup M stool are present. If there is trouble
with insufficient digestion of food, the lumps of undigested
casein will somewhat change the appearance. The lack
of acute symptoms of an intestinal nature is more char-
acteristic than violent symptoms. Vomiting may or may
not be present.
3. The first absolutely sure symptom is the appearance
of rose spots, which may come early or late, or in two or
three crops, and are said by some writers to occur quite
as regularly as the rash in scarlet fever. Brown, of Mont-
clair, among his six cases has seen several with slight rash
or no rash at all. Earl found them in all his cases but
three.
Roseola, or sudamina, or other indefinite rashes, may
be present at any stage, and possibly confuse diagnosis.
4. Symptoms of headache, which a baby will indicate
by rubbing or picking at its head, nose, or ears, or bur-
rowing its head back in the pillows, but not by active
head symptoms which would characterize meningitis. As
1 Transactions of the New York Medical Association, 1891.
MEDICAL RECORD.
[July 7/1894
the disease goes on these head symptoms will frequently
increase.
5. A tongue coated with yellowish or brownish- white
far, generally red at the tip or sides. It may be so heavily
coated and the entire mouth so affected that a condition
resembling aphthous stomatitis may be present. In the
case reported by Dr. Newton this was the symptom that
first caused the physician to be called in ; but the con-
dition of sordes is not as frequent in infants as in adults.
6 Enlarged spleen is very important when found, but
not always to be accurately demonstrated in a young child,
especially if tympanites is present.
7. Tympanites, sometimes excessive, but in most re-
corded cases very moderate.
8. Bronchitis seems to be almost as regular a symptom
as in measles, agreeing with the pathological changes de-
monstrated by Uffelman of swelling and redness of bron
chial tubes, but the breathing is, later, too superficial to
make rales.
9. There may be angina* I have seen it twice, once
in the present case, and once in an older typhoid patient.
Henoch says that it is not uncommon. When found it
is apt to confuse rather than help the diagnosis.
10. The stools, when carefully examined very early in
the disease, may contain typhoid bacilli, but this has very
rarely been detected in most of the recorded cases. If it
could be, it would b* of very great importance as an ab-
solute means of diagnosis, but after the second week it is
very rare to be able to find them.
When the diagnosis is made from the spots, spleen,
tongue, and temperature, as the cases in children ad-
vance, several variations in typical symptoms of adults
are to be expected. Ileo csecal tenderness or gurgling
is hard to satisfactorily determine, and when present is
worthless because it can be found in various other diar-
rhoea! diseases in children. The hard, dry tongue, the
swollen tongue, or excessive sordes, are rarer in children.
Hemorrhage or perforation is very rare. As a whole,
the severer symptoms common to adults frequently fail.
The nervous symptoms are interesting and will often
confuse the diagnosis from the beginning, suggesting
acute, subacute, or tubercular meningitis, according to
their severity, especially if the previous history of the
child and family is suspicious. The regular occurrence
of headache, even in the youngest, has been noted ; and
though more difficult to detect in the very young infants,
will, in most cases, be suggested by the actions of the
child.
Intestinal cases present quite a variety of reflexes in the
head ; for instance, a constant picking of the nose, which
was noticed from the beginning to the end in my own
and in other cases, instead of being a local irritation is a
reflex, which Louis Starr, called a regular symptom of gas-
tric and intestinal irritation. It occurs also in tubercu-
lar meningitis. Henoch says it is an early typhoid symp-
tom, but may last throughout. Picking at ear may ac-
company otitis.
As stated by Keating, in infants and young children
nocturnal delirium, which an adult would present in early
weeks of typhoid, is accompanied, or more often replaced,
by sudden sharp and prolonged outcries, with great rest
lessness or excitement not easy to pacify. This will re-
semble a hydrocephalic cry, and is again a very startling
symptom. Extreme restlessness is almost sure to occur.
Earl also calls attention to continued crying at night,
stiffness of the neck, jerking of the muscles. There may
be apathy or a condition of coma, when the muscles
become lax and the movements of the eyes are no
longer co ordinated. Blindness may occur as in Case
VII.
In spite of all these symptoms real meningitis, as a com-
plication, though it can occur, is exceedingly rare. He-
noch has never seen a case. But the symptoms I am
about to relate are very much like the symptoms of men-
ingitis.
In my case, about the end of the second week, following
a little trouble in digestion, vomiting occurred and general
irritability increased. Temperature rose four degrees, and
there developed a stiffness of the neck and back, which
became after a time a condition of opisthotonos. There
was inco-ordination of eyeballs and a peculiar movement
of both eyes upward and to the side, great hypersensitive-
ness to sound, light, and touch, especially touching the
head. Irregular and at times convulsive movements, es-
pecially marked in the left arm and leg, and continued
twitching of the fingers. The baby cried out frequently
in a new and strange way, and the pulse became very
rapid, 160 to 180, irregular and occasionally intermittent.
Respiration rapid, irregular, and sometimes sighing. All
this pointed in my mind almost certainly to an acute
meningitis. Dr. Huber, who saw the case at this time,
while agreeing absolutely with the original diangosis or
typhoid fever, held that the presence of an active menin-
gitis might be ruled out for the following reasons : 1. The
fontanelle was depressed, not elevated. 2. The child
was bright enough to notice things. 3. No tache cere-
bral. 4. No boat- shaped abdomen. <. The vomiting
had not been expulsive. 6. The photophobia and hyper-
sensitiveness to light and sound were less than one would
expect in an acute meningitis. The entire condition,
acute as it seemed, he held to be a passive congestion in
the vessels of the brain caused by the weak heart, and
held that heart stimulation already begun would remove
these symptoms, which actually took place within a few
hours.
I have mentioned this in detail because it shows how
far an extreme case of the ordinary nervous symptoms of
typhoid can simulate meningitis. Henoch reports a case
of tremor and stiffness of the extremities, constant jerk-
ing of the same, which showed on autopsy no brain
lesion. Also one where there was contracture of both
legs and right arm, continued grinding of the teeth,
yielding at autopsy only slight changes. Also another
case of a girl, four years of age, who showed distinct stiff-
ness of the neck, later actual opisthotonos, and marked con-
tracture of the neck, with grinding of the teeth. Autopsy
showed no brain lesion. Foster reports a case of trismus
and opisthotonos which lived. Brown's case (quoted as
Case VII.) had opisthotonos, blindness for several days,
and numerous other severe brain symptoms, and recov-
ered. Among other nervous symptoms exaggeration of
the knee-jerk has been noted.
Marked and persistent tremor sometimes occurs, and
is said by Donkin to point to a deep ulceration, a point
much emphasized in typhoid of adults by W. G. Thomp-
son. No lesions of meningitis were found in these cases,
and cases resembling meningitis, which occur occasion-
ally in hospitals and die, on autopsy, instead of the
lesions of meningitis, frequently fail to show any change
in the brain or membranes. The cases of acute maniacal
delirium with high fever and rapidly fatal termination
which at times occur, have no change in the tissues out-
side of the blood-vessels. That there has been some
cause and some lesion is certain, but no exudation of
serum, fibrin, or pulse, or even marked congestion, is to
be found. There is left the probability either of tempo
rary changes in the blood-vessels and circulation which
have left no traces, or more probably, some very subtle
delicate change that our usual methods of preparing
brain specimens do not detect. As strychnine affects
the cord centres, so, I believe, the ptomaine of typhoid
fever may affect the brain centres.
It maybe asked, in view of these extensive nervous symp-
toms, how one can be certain that his case is not one of epi-
demic cerebral spinal meningitis, which may begin like
typhoid, run many .weeks with a rather similar course,
with vomiting, hydrocephalic cry, rigidity of the neck,
and opisthotonos, and all those meningeal symptoms
mentioned, an indefinite eruption, and similar eye symp-
toms, strabismus, photophobia, inequality of pupils, and
even blindness. The resemblance is certainly great, but
the temperature curve is not characteristic, generally not
over 1020 F. , and there is no regular evening rise. Pain in
the back, limbs, calves, and thighs are more marked in the
July 7, 1894]
MEDICAL RECORD.
epidemic meningitis. The eruption, if present, is more
apt to be like herpes than a rose spot, as in typhoid.
The pulse is almost invariably slow instead of rapid, and
does not follow the variations of the temperature as in
typhoid. There is apt to be a nasal catarrh, this being
the method of entrance of the bacterial agent in the epi-
demic form, probably. Joint complications are also apt
to occur.1 The progress is constantly toward the fatal
outcome, with paralysis, either hemi- or mono- or para-
plegia, while in typhoid recovery is to be looked for in
a fair proportion of cases.
Tubercular meningitis, like the epidemic form, re-
sembles typhoid, but almost always has an antecedent
tubercular trouble in some other organ, and a more
gradual onset. The temperature is seldom high, aver-
aging 1010, and reaching 102. 50 only near the end.
The vomiting is violent, frequent, and propulsive, and
occurs without reference to food taken. Pulse slow
and irregular. Respiration sighing, abdomen markedly
boat-shaped, and the skin may develop an erythema. At
first there are marked and severe brain symptoms without
special " typhoid symptoms. " Later a " typhoid state "
is sometimes developed with a rapid pulse and diarrhoea
that might be confusing if compared without knowledge
of previous history. As a rule, the symptoms will be
first those of a general meningeal irritation, then local-
ized brain and meningeal irritation, and finally symptoms
of absolute paralysis of different brain areas, becoming
more and more complete until the vital centres are in-
volved and death ensues.
We have laid stress on the low pulse in these two
forms of meningitis. In typhoid the pulse should vary
from 90 to 120, according to the height of the temper-
ature. It has been observed from 152 to 180 and irreg-
ular, in cases that afterward recovered.
The heart is commonly affected more or less in typhoid
in infants, and Donkin states that a modification of the
first sound is generally found in most cases in the second
week, and that observation of the radial pulse alone is not
enough to show how the heart is working. In my case
two very alarming spells of heart failure and collapse fol-
lowed two very careful attempts to make an examination
of the back of the chest. I cannot too much lay stress on
the necessity of keeping the little patient continuously on
the back, giving him the benefit of the doubt and avoid-
ing any risk from extensive physical examinations, how-
ever careful, extensive bathing, or any unnecessary
changing of the position. Let objective symptoms give
information of any new condition developing in the
lungs, always remembering that both lobar pneumonia
and broncho-pneumonia are rare complications. Hypo-
static pneumonia or oedema of the lungs must be looked
out for and avoided by the treatment if possible. Ne-
phritis or other urinary symptoms are rare.
The duration of the disease is variable. In 190 cases
of Henoch, 1 1 terminated between the seventh and ninth
day ; 36 cases between the tenth and twelfth, inclusive ;
45 between thirteenth and fifteenth ; 40 between sixteenth
and eighteenth ; 25 between eighteenth and nineteenth
day ; 39 between twentieth and twenty- third day ; 14
between twenty fourth and thirtieth ; 6 between the thirty-
fifth and forty- fifth day.
Collapse and sudden death are rare except in the graver
cases, and owing to the less extensive lesion in the intes-
tines many children do well.
In treatment a conservative course will commend itself.
Tub-baths will not be well borne in most cases, though
sponging rather than antipyretics will best bring down
the temperature. The task of choosing a food that will be
digested and leave no undigested masses in the stools, is
very difficult, but must be very carefully studied and
watched, or there will be trouble. Brown suggests con-
stant under-feeding, or a starvation treatment. A mineral
acid and a little bismuth may be all the drugs needed in
favorable cases, in others bromides or other mild sedatives
for the nervous symptoms, and drugs by rectum rather
1 Berg : Archives of Pediatrics.
than by the mouth if there is constipation, will be valua-
ble. For the heart symptoms, frequently repeated doses
of champagne were found exceedingly valuable, and were
well taken by the patient. Diffusible stimulants, like
ammonia and camphor, were quite as effective as the more
powerful ones, digitalis, strychnine, or sparteine, though
all were tried in appropriate doses at certain times. Heat
over abdomen, and high hot enemas, were always prompt
and efficient means of counteracting collapse until the last.
In a very severe collapse with cyanosis, fluttering feeble
pulse, and failing respiration, when all other heart stimu-
lants, including oxygen and electricity, had failed, at the
suggestion of Dr. Whitehorne a combination of spirits of
camphor, aromatic spirits of ammonia, tincture of musk,
and the normal liquid of nitro-glycerine, of each one
minim, dropped on the tongue with a medicine dropper,
was followed by a change from what had been almost a
moribund condition to restoration of life, fair pulse, and
a favorable condition for half a day. The preparation was
absorbed from the mouth and acted quite as promptly as
a hypodermic and with far less shock and irritation to
the infant. In an experience with cases of collapse and
shock by no means small, the writer has never seen such
a prompt reaction from so desperate a condition.
Two other suggestions will be made as a result of the
study of these cases : 1. Sterilize or Pasteurize all milk
used for young children, and boil all water during the
early years. 2. In all cases of a diarrhoea! nature in chil-
dren, disinfect the stools — a measure indicated if it is only
a simple summer diarrhoea, since the more recent studies
in its bacterial origin and doubly indicated from the pos-
sibility always present that these cases may be irregular
or hidden typhoid fever.
VARIX OF THE RIGHT AURICLE ENDING
IN RUPTURE.
By WM. G. SMITH, M.D.,
STURGIS, SOUTH DAKOTA.
Considering the rarity of the above-named affection
and the interesting features of its development, I will de-
tail the progress of the disease as it developed in a pa-
tient under my care.
Louis L , of French Canadian parentage, born at
Quebec, aged fifty-six, and by occupation a teamster, a
married man although not living with his wife for several
years prior to his last sickness.
Mr. L gives a history of having the diseases of
childhood with no ill effects following the same. He was
an excessive tobacco user and an excessively hard drinker
in former years. He denies any venereal trouble and no
history of any hereditary disease in ancestors can be
elicited.
The above disease commenced on June 12, 1889,
while Mr. L was making a trip from Sturgis to Dead-
wood, S. D., on a rainy day when the roads were very
muddy. His wagon broke down, which compelled him
to do some very heavy lifting. After one strenuous ef-
fort he was suddenly taken with acute pain and oppres-
sion in the mid-sternal region. He continued his trip to
Deadwood and sought advice, as the pain was very severe
and as he was at the same time suffering from the effects
of a cold. Treatment consisted of cough mixtures, ano-
dynes, and counter-irritations.
On the following i6ih of June he wrote me to send
him some medicine for pain in the chest and a cold. I
prescribed an expectorant mixture containing an ano-
dyne, and advised his return to Sturgis if he did not
soon get relief, so I could make an examination.
Some three days later he reported at my office, still
suffering from the acute pain in the chest. I made a
careful examination and found the acute pain located
over the region of the right auricle but somewhat diffused
in area. I could find no increased dulness on percus-
sion. The heart beating was rapid and tumultuous, the
pulse at the wrist was compressible, and the artery gave
MEDICAL RECORD.
[July 7, 1894
somewhat of a cord-like feel, and the sensation of high
tension or blood pressure.
The urine was normal in every respect. There was
some oppression in the chest and slight dyspnoea, which
I took to be of nervous origin due to tumultuous heart
action. I was unable to be positive in my diagnosis,
and treated on the symptomatic plan. Gave a hydra-
gogue cathartic with the effect of lowering blood-pressure
and unloading the bowels. Gave fluid ex Tact of digitalis
to quiet tumultuous heart beating, and an anodyne, as the
pain showed great obstinacy while upon the above treat-
ment.
I was not satisfied, and upon further examination and
meditation I came to the conclusion that the exertion
had produced a strain on the aorta ; and fearing aneurism,
I put my patient on iodide of potash and Squibb' s fluid
extract of ergot, informing him that he would likely be
sick some time, and instructed him to drink as little of
liquids as possible, not to overload the stomach, desiring
in this way to keep the blood-pressure as low as possible.
Also advised him to avoid mental excitement and physi-
cal exertion.
I was favored in a few days by the pain's decreasing,
the faintness and dyspnoea disappearing, and in four
weeks' time my patient felt in his usual good health and
resumed his ordinary occupation. The result caused me
the more to doubt my fear of aneurism and left the real
nature of the disease in obscurity, for previous to this
sickness my patient had always been very robust and
possessed an iron constitution, so to speak.
A year later, in June, 1890, Mr. L , for the first
time since his previous treatment, returned to my office
complaining of the same old pain and oppression in the
chest, which he said had been troubling him for the last
three or four days. The pain was so severe that I gave
him an opiate, and instructed him to return for an exam-
ination as soon as he was easier and able to lie quietly.
He did so, and upon this examination I found cardiac
dulness slightly increased tranversely to the right. Heart
action was slower, numbering fifty-six pulsations to the
minute, and temperature was normal. There was, how-
ever, an increased shock to the impulse beat.
Remembering my former inclination to believe in an-
eurism I carefully examined, but could get no bruit. I
could get no distinct dulness separate and distinct from
that of the heart. I could detect what I took to be a
tendency to atheroma and I proceeded to my diagnosis
by the exclusion method ; but was unable to entirely ex-
clude aneurism, and still I was unable to make a positive
diagnosis of it, but inclined to that disease, and again
commenced my former treatment of iodide of potash and
Squibb' s ergot, instructing my patient to avoid all alco-
holic beverages, to refrain as much as possible from the
use of tobacco, to limit his use of liquids, to avoid over-
loading his stomach and to avoid mental excitement and
physical exertion.
I gave cascira sagrada for the bowels, which were con-
stipated, a condition which I must say was very rare, for
the regularity of the bowels was very marked even when
opiates had to be administered.
Daring the later part of July, 1890, I thought I de-
tected slight evidence of bulging of the thorax in the
raid-sternum region. The apex beat at this time was one
inch to the right of left nipple and three-fourths of an
inch below a line passing through both nipples.
Auscultation gave negative results, as nothing abnormal
could be detected except the increased cardiac force.
There was no jugular pulsation, as frequently occurs in
tricuspid regurgitation or dilated right ventricle, no buzz-
ing in the ears, no vertigo, but a slight tendency to syn-
cope and a slow pulse, ranging as a rule from fifty-six to
sixty to the minute.
This time the pain, weakness, syncope, and oppression
did not respond so quickly to treatment, and an occas-
ional opiate had to be administered.
About this time a travelling doctor from Omaha was
making monthly visits to the Black Hills and took in
Sturgk The unrest that is so liable to overtake a sick
person troubled my patient, and he began to want to
know how long it would take him to get well. I told
him that in my opinion he would not be able to resume
work during the summer. This made Mr. L all the
more want to try Dr. P , who was advertising quick
cures, no cure no pay. Finally Mr. L went to see
the doctor, who, the patient said, would agree to cure
him for $10 in advance. Mr. L offered to put
in the bank the $10 subject to the doctor's order in
case of cure, but this proposition was not accepted.
My patient did not improve as fast as he thought he
ought to under my treatment, and later put himself under
the care of Edward J. Sexton, a regular practising physician
of ability. In talking the case over later with Dr. Sexton
he kindly informed me that his first diagnosis was dilata-
tion of the left ventricle, and he treated him for such ; but
upon a re-examination he changed his diagnosis to aortic
aneurism, and treated him accordingly. The doctor in-
formed me that the pain was so severe and rebellious
that he had tried all the anodynes, and the only relief,
which was partial, was from morphia.
The disease gradually progressed, the patient being
able to walk about, until October, 1891, when he was
stricken down with hemiplegia of the left side, lying for
several days very near death's door, while stopping with
friends in the country.
In January, 1892, Mr. L was removed to Sturgis,
and as his means of support had been exhausted he be-
came a county charge, and again came under my care, I
being the county physician. At this time he was still
suffering from hemiplegia, although somewhat improved
and able to be up. I put him on tonics containing phos-
phorus and strychnia, and also made tri weekly applica-
tions of faradism, which improved the muscular action.
An examination at this time showed more marked
bulging in the right auricular region, and increased dul-
ness, which extended farther to the right. The apex
beat was marked and increased in force. There was
dyspnoea and a dry senseless hacking cough present. The
second heart-sound seemed slightly accentuated ; a faint-
like feeling was complained of, and the pain, which was
described as piercing, tearing, burning, aching, and wear-
ing in character always at the seat of the bulging, passing
posteriorly to the upper interscapular region, most
marked at the left of the spine, was the most severe
symptom, although remitting at intervals, and then re-
turning with increased vigor.
I could detect no murmurs, no jugular pulsation, no
bruit, no irregularity in heart's rhythm, no intermittency in
heart's beating, no dulness separate and distinct from
that of the heart, and no inequality in radial pulses.
There was, however, an increased cord-like feeling in
radial arteries, and the anterior convex portion of the
bulging in the chest was softening, and a pulsating beat
was plainly felt on palpation, which gave the impression
of transmitted shock and some interference, with vesic-
ular murmurs at apices of both lungs.
Although still uncertain I felt quite positive the disease
was aneurism of the aorta, and at that portion beyond
the point of the origin of the left subclavian artery, for
the reason that there was no inequality in radial pulse.
I again resorted to drachm doses of Squibb' s fluid extract
of ergot with scruple doses of iodide of potash three
times a day.
My patient being indisposed sufficiently to keep him
in bed, I could see a slight diminishing in the size of the
bulging, which I took to be the result of medication ; but
in a few weeks he regained his appetite and strength
enough to be up, and no amount of argument or per-
suasion would make him keep quiet, and as soon as he
began to walk about the bulging began again to in-
crease.
As before stated the severe pain was the most trouble-
some symptom I had to deal with, and I found that any
drug that lowered the arterial tension gave temporary re-
lief. On one occasion my patient came into my office
July 7, 1 894]
MEDICAL RECORD.
nearly wild with pain. I had him lie down on the lounge
and gave him one minim of nitrite of amyl, and was sur-
prised at the instant relief of the pain. Seeing the quick
results, I prescribed a mixture of nitrite of amyl and fluid
extract of prun. virg., and for some time it acted admira-
bly ; later 1 also tried glonoin, but it did not act as well
as the nitrite of amyl. At a glance one will readily see
that the nitrite of amyl antagonized the effect of the ergot
S3 far as it affected the arterial tension, and recognizing
this fact my first dose was an experimental one.
In treating the pain I resorted to various anodynes
and somniferous drugs, frequently without avail, and had
occasionally to return to morphia either by mouth or
hypodermically.
I always advised the taking of small amounts of liquids,
the avoidance of stimulants, restricted diet so as not to
overload the stomach, and thereby mechanically increase
the pressure, avoidance of mental excitement and physi-
cal exertion.
The bulging gradually increased until no trace of rib
or cartilage could be detected by palpation at the seat
of bulging, and the wall i of the sac became adherent with
the anterior chest-walls so intimately that, in making the
dissection after death, there appeared no division between
the auricular sac and the chest-wall, and the pulsation of
the local bulging could b; easily seen several feet dis-
tant.
Palpation gave the impression of transmitted shock.
As the disease advanced the dyspnoea became more
marked, due, in my opinion, to the pressure causing im-
perfect pulmonary circulation and deficient aeration of
blood.
There was, at times, slight inequality of the pupils,
never well marked. Patient suffered also from an occa-
sional headache. The cardiac dulness gradually in-
creased to the right and the respiration became more
laborious as the pressure increased.
There was at no time any dropsy, no inequality of ra-
dial pulse, and the cyanosis was slight.
Photograph, Figure 1, was taken early in July,
Fig.
1892. In the condition here represented the patient
would occasionally have two or three days at a time com-
paratively free from pain, and then again it would come
on in the severest manner, extending to the left shoulder
and down the left arm to the finger tips, similar in char-
acter to the subjective symptoms in disease of the cardiac
valves.
During the last week in July I was called away for a
few days, and I had Dr. Ira 1,. Sanderson, of Sturgis, a
physician and surgeon of long experience, formerly of
the United States army, attend my patient, as frequently
hypodermic injection of morphia had to be administered
to allay the pain. After my return Dr. Sanderson in-
formed me that he considered the case as one of aneu-
rism of the aorta.
I continued iodide of potash and ergot for the reason
that I thought I hid an aneurism to jdeal with and knew
of no better medication. About this time difficulty in
swallowing food developed, and the above symptoms
continued, gradually increasing in severity.
Fig. a.— Organ laid Open.
In this you can readily see the disease has made
greater strides. During the last two months superficial ul-
ceration has already commenced in that portion nearest
the right nipple, and its development progressed rapidly
considering that only ten days had elapsed since the ul-
ceration commenced.
During this process of ulceration the patient had no
rest night or day, morphia having no effect in ordinary
doses, and the hypodermic injections were increased up
to two grains per dose, and repeated every hour for three
doses the day before he died, as iupture seemed pos-
sible at any minute and humanity demanded some relief,
but sleep was not produced. At my last visit, the day
before his death, October 7, 1892, Theodore Haas, a
druggist, accompanied me, it being near midnight. I had
previously covered up the ulcerated portion of the bulg-
ing with a piece of lint smeared over with carbolized vas-
eline and gave instructions that it should not be removed,
but my patient's curiosity became uncontrollable, and
while my back was turned he removed the lint, and
suggested more vaseline. While applying more vaseline
to the lint I heard him cry out, " I am bleeding to death."
Mr. Haas had just previously noticed him remove a
black object, which was a clot of blood, which acted as
a plug in one of the ulcerated holes, and when removed
allowed the blood to flow out freely, which it did, spurt-
ing probably some two feet for a moment and then grad-
ually lessening its expulsive force.
The blood was venous in character and more regular
8
MEDICAL RECORD,
[July 7, 1894
in flow than it would have been had the blood been arte-
rial. In half a minute or less another clot filled the
opening.
My visits were very frequent during the last few days
of his life, and I was at his bedside a few moments be-
fore his death, which occurred at noon on October 8,
and it was with great difficulty that he swallowed even
liquids for the last few days of his life. Death really re-
sulted from inanition, as his inability to eat food had
caused marked debility and excessive anaemia.
Thus ends the case of our supposed aneurism of the aorta,
and a hasty review of the subjective and objective symp-
toms, which have been misleading, in which the underlying
etiological factors produce appearances not especially
peculiar to ir, but common to a frequent and well known
affection of the blood-vessels, we can usually see wherein
our error lay, before we detail the results of the post-
mortem examination perhaps would not be amiss.
As in aneurism (intrathoracic) we had pain in chest,
even extending to shoulder and down left arm to fingers,
and here I would quote from Dr. Walshe, who says,
" The absence of symptoms and signs indicative of ordi-
nary affections of the heart and lungs in an individual
suffering from persistent anomalous disturbance within
the chest, even although he does not exhibit any failure
of general health, affords strong motive for suspecting an-
eurism/1
We have in our case the disturbance in the chest
spoken of, we have failure of general health, we have
dyspnoea, we have some inequality in the pupil, not
marked ; we have laborious respiration with disturbance
in vesicular murmur, we have difficulty in swallowing,
we have the hacking senseless cough, although no paral-
ysis of either pharyngeal nerve ; we have evidence of
atheroma, as shown by hemiplegia; we have a pulsating
or heaving expansile tumor, although not distinct from
that of the heart ; while, on the other hand, we cannot de-
tect any systolic bruit, which is often absent in aneurism.
We cannot detect separate and distinct dulness from
that of the heart, we cannot detect any inequality in
radial pulse.
My mistake in diagnosis was due to a lack of proper
consideration being given to the heaving expansile im-
pulse of the pulsating tumor, which was not distinct from
that of the heart, and in my case misled me by giving
the impression, by palpation, of transmitted impulse,
which condition was caused by the expansile impulse be-
ing interfered with by the interstitial inflammation, which
caused an adhesion of the sacculated portion of the heart
to the internal anterior wall of the chest, thereby causing
a lessened elasticity, lessening the expansile thrust and
producing with the impulse of the tumor a tendency to
shock.
I am aware that diagnosis of sacculated ruptures of the
heart's cavities, or as some prefer to call them " heart
aneurisms'1 or "heart varices," are frequently not made
until the patient reaches the post- mortem table ; but
nevertheless I now consider this expansile impulse, with
a seeming tendency to transmitted shock, very diagnostic
of a sacculated rupture of one of the heart's cavities,
when its dulness is not distinct and separate from that
of the heart's dulness.
One other conclusion I shall draw, and that is in refer-
ence to the pain. In aneurism the pain is more fre-
quently first complained of in the shoulder or passing
down the arm to the hand, while in sacculated heart cavi-
ties, as in valvular disease of the heart, the pain is more
frequently first complained of in the cardiac region and
then radiates to the shoulder and then down the arm.
We will now look at the heart as it appeared on being
removed from the body as shown by photo marked Fig-
ure 3. Letter a represents aorta ; b, left innominate ar-
tery ; c, the sacculated portion of the right auricle as rep-
resented in Figure 2, by the bulging in the chest ; z/, the
right auricle ; and e, the heart's apex.
Viewing the heart as it is laid open, as represented by
photo marked Figure 2, a represents aorta laid open ; </,
the left auricle ; ard r, the posterior wall of the right auri-
cle ; and the letter b intended to represent the anterior wall
of the right auricle, and the rupture or hole in the same.
Letters e and/ represent the ventricles ; and ^ the apex
of the heart.
We find the aorta dilated, so also the auricles ; but
more marked in the right There is dilatation of supe-
rior vena cava, but not excessive.
Upon examination of the sacculated right auricle from
a pathological point of view, I am of the opinion that the
disease originated in a local circumscribed fibroid condi-
tion of the inner surface of the anterior wall of the auricu-
lar chamber, which resulted in new cellular growth, there-
by producing interstitial pressure on the muf cular fibres
causing or resulting in fatty degeneration. There is no
doubt but that the whole thickness of the anterior wall of
the right auricle at the seat of the disease was affected
and the muscular fibres degenerated.
The localized sacculated portion of the auricle, the seat
of the fibrosis, presented a glistening fibrous appearance,
of a dirty white or nearly grayish color. I believe the
fatty degeneration exceeded the development of fibrous
Fig. 3.— Appearance on Removal.
tissue, and as a result the affected circumscribed, area
softened and thinned at the same time and in this man-
ner the bulging took place.
The fatty degeneration could easily be detected by
pal pa* ion and inspection, for it presented a greasy feeling
even after the specimen had been in alcohol several
weeks, as well as a greasy aspect. The fat had in-
creased considerably, but more markedly so in the inner
layer of the sac, as manifested by the increased number of
oil cells, as shown by examination with the microscope,
and every condition present suggested that the limited
area of the sac, as represented by the letter b, was in-
tensely and uniformly affected, though sharply defined or
limited. This limited circumscribed spot was circular,
but presents a more elliptical form in photo, caused by
the position in which it was held while being photo-
graphed.
As a usual rule the ventrie'es are more often affected
than the auricles ; indeed some authors doubt that the
auricles are ever affected. They are certainly occasionally
the seat of fibroid degeneration and their walls may be
affected in a limited area, which is sharply defined, and
through the entire thickness of the walls, as illustrated in
the case before us.
In primary rupture of the heart the immediate cause of
-the tear is probably an unnatural, excessively energetic
contraction of the heart, producing a greater strain upon
the fibres than their degenerated condition can resist.
This condition of energetic contraction can be brought
July 7, 1894]
MEDICAL RECORD.
about by excessive lifting, straining, or perhaps a violent
coughing.
This condition, as can readily be seen, would most
often affect the ventricles, as the greater blood tension
would there exist during such efforts ; but I take it that
in a localized, sharply denned, circumscribed fibroid
condition, succeeded by fatty degeneration in the auricle
in our case, the force being less than in the ventricle,
there would be less liability to rupture, or a complete
tear through the wall ; but the weakened part would
partially give way, and in time, considerably longer than
in case of the ventricle, a sacculated condition would form,
gradually distending, and through pressure on adjacent
organs the various symptoms, as in the case before us,
would be produced.
As Jenner pointed out, congestion of the walls of the
heart is a cause of fatty degeneration of the muscular
fibres ; but this degeneration is rarely simple — more or
less fibroid growth is usually conjoined. In the present
case the cause of the fatty degeneration is probably alco-
holism, the same being the cause of the atheromatous
condition, and I take it as the probable cause of the fi-
brosis, augmented, perhaps, by the tobacco habit
In fatty degeneration we expect to find diminished
force of impulse and a weak apex beat, together with en-
feebled heart action ; but in the present case we find the
very opposite condition, and I account for this by the
fact that our limited area of degenerated muscular fibres
was in the auricle, and even in forcible heart action
the tension was not sufficient to complete rupture, and
not sufficient even to prevent regular ventricular con-
tractions, which have more to do with impulse and apex-
beat, when the muscular fibres of the ventricles are not
degenerated, than do the auricles.
The energetic effort at lifting, at the first appearance
of pain, was probably the immediate cause of affecting
the diseased auricle, and no doubt resulted in an injury
to the diseased area, thus producing inflammation and
local congestion and allowing every excessive increase
in blood pressure to add to the mischief already existing,
which gradually progressed until the results as portrayed
by the photographs finally developed.
CRIMINAL ABORTION.
Its Evils and Its Sad Consequences.
By MARY A. DIXON- JONES, M.D.,
In law the term abortion is applied to the expulsion of
the foetus at any period of pregnancy before the term
of gestation is completed.
Abortion, induced at any time, or for any purpose ex-
cept for the mother's welfare, or for the preservation of
the life of the foetus, is a crime and a murder. This foul
taking off has been the cause of the destruction of an
uncounted number of children ; and has, in unnumbered
instances, resulted in the death or ill health of the
mother.
Under these two heads I will briefly discuss a few
phases of the subject : First, the danger to the mother ;
second, loss of infant life ; and third, as further develop-
ing the thought, will give instances of women who have
sought to have abortion produced ; and finally, will re-
fer to the medico legal aspects of the subject.
As soon as conception takes place the vital forces are
summoned to new energies and new activities, dormant
powers are aroused, and wonderful processes commence.
The uterus and whole organism begin preparing for the
great work, the growth and development of a human
being, to be perfected in the short space of nine months.
To interrupt these processes is a shock — a shock to the
whole being, the nutritive, nervous, and mental systems ; it
does violence to the procreative organs, and renders them
incapable of ever as efficiently performing their special
functions. Subinvolution cannot take place as in the
normal termination of pregnancy. This gives rise to
multiplied evils, the full significance of which are, as yet,
not fully understood. The uterus and its adnexae, espe-
cially, suffer in many respects, swelling from the increase
of living matter ; then follow enlargement, hyperplasia,
various misplacements, inflammations, and fibrous degen-
erations ; in some cases, cancer or malignant growth is
the natural outcome ; in all, there will result some trouble
that, for years, may give distress, suffering, and last-
ing weakness. Women may not at first show the full
sad effects, may even, after repeated abortions, appar-
ently do well ; but, though not recognized, grave con-
sequences always follow, resulting ofttimes in disease that
may become more and more complicated, more and more
dangerous, many times terminating fatally ; and always,
to some extent, shortening life. Many strong, healthy
women have, by it, been made invalids for life, and to
it many date the commencement of their sufferings and
their continued ill health. Thomas says : * " That this
criminal practice constitutes a prolific source of uterine
disease, no one engaged in gynecology can for a moment
doubt." Even the sepsis that is apt to follow may cause
rapidly fatal peritonitis, or may induce an incurable dis-
ease of the uterine appendages, which is not only a cause
of much suffering and ill health, but ofttimes eventuates in
subsequent and absolute sterility. Septic inflammation
most frequently destroys all functional capability of these
organs ; and in connection with this I dare assert, and
believe the fact can be fully substantiated, infinitely
more women have been made sterile by sepsis introduced
at abortion, or even ordinary labor, than results from all
the cases of removal of the uterine appendages ; and this
disproportion is vastly increased by noting the fact that in
most of the cases where the diseased uterine appendages
have been removed, the individuals had previously been
rendered sterile by the disease of the named organs. I
have known repeated instances where young married
women, even in their first confinement, have by some
sepsis been forever deprived of the privilege of subse-
quent maternity, have by this sepsis been made perma-
nently sterile. I have known such repeated and sad in-
stances of this, and so impressed have I been with the
fact that I said in an article in the New York Medical
Journal? that " an obstetrician should be an antiseptic
surgeon.'' As illustration and proof of this we have
only to refer to the brilliant obstetric work of many of
our great antiseptic surgeons. James Murphy, in his
late address before the Section of Obstetrics, at the An-
nual Meeting of the British Medical Association,1 said:
" Puerperal septicaemia is the most fatal disease that
childbearing women are exposed to, and though its fre-
quency has been discussed of late, its fatality has, I fear;
been but a little, if at all, reduced."
But immediately fatal results ofttimes eventuate from
the attempt to produce criminal abortion ; the shock,
unexpected injury, uncontrollable hemorrhage — all make
a sad record in this horrible work. The coarse brutality
that will allow one to engage in it, is necessarily accom-
panied by more or less unskilfulness, that shows in every
detail a lack of scientific refinement and natural delicacy.
In the American Journal of Obstetrics 4 Dr. Hektoen,
of Chicago, reports a case of an abortion, produced by a
" Dr. S.," at the fourth month of pregnancy; "the in-
sertion of a rubber catheter, its disappearance, rupture of
the uterus, eventeration of the large intestines, and im-
mediate death." It also states that the operator, "Dr.
S.," had even pulled on thesupposed placental cord, and
that the patient herself had taken hold and pulled with
all her power, "in order to expedite matters !" Two
lives were thus sacrificed.
Dr. Hektoen, in the same article, gives another in-
stance of an abortion at the fourth month, also resulting
in rupture of the uterus and death. In the Pittsburgh
1 Diseases of Woman, p. 50. 1880.
9 Another Hitherto Undescribed Disease of the Ovaries, May 10
and 17, 1890.
» British Medical Journal, August 26, 1893, p. 453.
« July, 189a, p. 69.
IO
MEDICAL RECORD.
[July 7, 1894
Medical Review 1 there is reported a smiiar case of rupt-
ure of the uterus from an attempted abortion, followed
by immediate death. The Cincinnati Lancet and Clinic *
reports a case of rupture of uterus and death. The Journal
<T Accouchement* reports the case of "a woman, six weeks
pregnant ; death followed almost immediately from the
attempt to introduce an instrument into the generative
organs. ' ' Oskar Sattler reports tetanus as following a sim-
ilar attempt. Stephen Crowe, of Baltimore,4 reports the
case of " a woman three months advanced in pregnancy.
A tent was introduced; in the attempt to remove it
it was broken, and three quarters remained in the uterus.
The patient was removed to the Maryland General Hos-
pital; temperature, 1030 F.; pulse, 140; abdomen enor-
mously swollen."
Dr. £. J. Ill * says : "A knitting-needle was in one in-
stance forced through Douglas's cul de sac and the mesen-
tery into the liver, to the depth of an inch,jwhich was
found after her death.1' He also tells the case of a
" crochet needle, which passed through the fundus into
the peritoneal cavity." The Australian Medical Jour-
nal* states that "within a week four women, in the
prime of life, met death by the forcible introduction of
an instrument into and through the walls of the gravid
uterus." Eight lives were sacrificed. J. Phillips ' reports
"a patient dying from injection of nitrate of mercury
into the vagina to procure abortion." In the Albany
Medical Annals 8 there is reported "an attempt to blow
air into a uterus three months pregnant, the woman fell
over unconscious, and expired a half- hour later."
The Boston Medical and Surgical Journal* reports the
case of instant death from " an attempt at criminal abor-
tion on a strong, healthy woman, in the seventh month
of pregnancy, air being forcibly injected into the uterus,
causing instantaneous death." The inter- uterine douche
may have detached a portion of the placenta, so that the
air entered the circulation through the opened uterine
sinuses, forming an air embolism. The entrance of air
into the blood-vessels has frequently in these attempts
caused instant death.
In many ways the effort to produce abortion may
be immediately fatal. The newspapers of every city
teem with reports of such ghastly deaths. Many may
be unknown and unrecorded, but women hasten on.
Many of them are like the daughter of the pious old sex-
ton, of New York ; healthy, young, and full of life, she
entered the operator's office ; he promised immediate re-
lief, she never came out alive. The double crime was
perpetrated. Uncounted millions of unborn infants have
thus perished. There is no darker page in history. The
extent and fearfulness of this work is not known or rec-
ognized, and cannot be measured. Those who engage
in the traffic certainly do not comprehend its full import,
or understand the deep, dark iniquity of their deeds. No
words can depict its horrors or its terrible risks. It al-
ways destroys the life of one human being, and possibly
a second ; or, at least, may make a wreck of the poor
misguided woman.
Statistics state that in New York City there are annu-
ally twelve or thirteen hundred of still-births. Prob-
ably half of the still-births are from induced abortion.
In fifty years this would amount to over thirty thou-
sand ; and counting other cities of the Union, there
would be hundreds of thousands more. But even these
numbers are as nothing compared to the millions of " si-
lent ' ' births that are constantly being produced in the ear-
lier months of pregnancy. As a mother said a few days
ago, " I have missed twice, but I am going to bring my
courses on." Thousands of thoughtless women are do- -
1 1867, p. 22.
» 1879, p. 361, W. J. Chenoworth, Decatur, 111.
» Liege, 1888, vol ix., p. 265.
• Maryland Medical Journal, Baltimore, 1892, vol. xxvii., p. 1013.
6 New York Journal of Gynecology and Obstetrics, p. 893, 1892.
•Australian Medical Gazette, Sydney, vol. v., p. 39, 1885-86.
7 Transactions of the Obstetrical Society, London, voL xxxii. , p.
308, 1890
• S. B. Ward : p. 1, 1889.
• Pp. 185-192, 1879.
ing the same thing ; and there are unnumbered " profes-
sionals" at hand to help. The British Medical Jour-
nal1 gives the name of an old man, " Hippolyte Terle,
who confessed to having practised it for years," and
this man acknowledged that he "could not tell the
number of times he had committed the murder,"
probably almost countless. The same journal 2 gives the
name of another prisoner for the same crime, one " Eliz-
abeth Topham ; " nor could she tell the number of times
she had produced illegal abortion. Well did Professor
T. G. Thomas, in his excellent work, say : s " Statistics
showing the frequency of criminal abortion never have
been, and never will be, written." There are thousands
engaged in the work, reaping their rich harvests ; and,
at the same time, making a harvest of deaths. But the
most deplorable fact is, that there are a multitude of
mothers willing to assist, or, doing it continually.
Who can tell the number of infant deaths ? A holocaust
— a great army of little children are destroyed. The
loss of infant life is amazing.
But, if possible, there is yet a greater evil. The wom-
an who entertains such thoughts, who has such inten-
tions, the mother who thus seeks the destruction of her
own child, thereby perjures and blackens her own soul,
and demoralizes her whole moral being. It is a prostitu-
tion of all her higher nature. To think of a mother
contemplating the murder of her own child ! studying to
destroy the being that rests nearest to her own life, and
bound to her by every tie of kindred, love, and interest.
What a soul- staining ! Could anything be more debas-
ing and blunting of all the finer feelings and affections?
She who in secret broods over such thoughts, who has
such intentions, is making of that child and of her chil-
dren murderers. The child must take on the then con-
dition of the parents, moral and physical. It is as much
a part and parcel of the parent as is the lower order of
animals, where procreation is by subdivision. I could
imagine that he who is guilty of signal crimes and mur-
derous intents is born of such a woman — a woman who
for days was trying to compass his murder, and was seek-
ing opportunities to do it secretly and successfully.
What reason do women give for so doing ? Some say,
" It is inconvenient to have a child ! " It should be their
greatest happiness. Others say, " They have too much
to do, too many claims upon them, the demands of soci-
ety, fashion/ etc. But this is their first duty, and should
be nearest and dearest to them. Others say, " A child
is too much trouble." Ah ! an infinite source of delight
should the care of her little one be to any true mother.
Others again declare " they have not the means to sup-
port it," or that " they want, for a while longer, to take
their pleasure," "at some more convenient season,"
say they. A burglar who takes a man's life wants the
money, because work is inconvenient, he has so many de-
mands upon him, and this may relieve him from care
and trouble, and enable him, a while longer, to take his
pleasure.
There is more similarity between the two than we dare
trace out. Women are not taught to understand these
things, they are not sufficiently instructed as to the won-
ders of their own being, or even of the simplest laws of
life and health. They do not sufficiently know the
great mysteries and beauties of life, that from the mo-
ment of conception a child begins to live, that as soon
as there is a combination of the two elements, it is
a human being. If not then, will anyone say when
life begins, at what time the soul meets the body ? I
maintain that the destruction of this new being, even
in the earlier periods of existence, is as much murder as
it would be in the latter months of pregnancy, or in the
earlier periods of infancy. I hold that it is as much
murder to destroy a child that will be born next May as
one that was born last May. Some have asserted there
is no life till it moves, or what is understood as the
" period of quickening." At the first moment there is
1 October 17, 1891. * March, 1893, p. 612.
8 Diseases of Women, p. 50, 1880.
July 7, 1894]
MEDICAL RECORD.
11
motion, and there is motion every moment of its exist-
ence. The new being unceasingly moves, and the
powers, processes, and changes, even at this early period,
are marvellous. It is then a human being. To destroy
it is worse than vandalism. To attack it thus, in the
dark borders of its existence, in the vestibule of its
being, when it is so helpless and defenceless, is a most
cruel warfare, a most unfair battle, more cowardly than
the midnight assassin, or he who puts the dagger in the
heart of the unsuspecting. But it is not the " dark bor-
ders of existence.'1 It is holy ground. Eternal Wisdom
is there at work. " He formed us in the depths." " Our
substance was not hid from Him." '.' He breathed into
us the breath of life.'1 From the first it is a living soul,
endowed with vast capabilities and possibilities. It has
work in life to do, and an eternal destiny. Have we a
right to deprive it of its future possibilities, and oppor-
tunities of fulfilling its high mission ? Shall their unborn
spirits go to Him, and say they were not allowed' to ac-
complish their allotted work? What if the mother of
Washington, of Shakespeare, of Lincoln, or of Milton
had so acted ? In eternal light there will be just as sad
reckoning, in every case. A sin so terrible brings its
full and increasing evil, with arithmetical progression.
The responsibility is not all in the simple act, it carries
a weight beyond. Are those who help women to do
this deed any less to blame? Is not their work the
blackness of darkness, by whomsoever performed ?
In 1879 Mrs- G ,l the mother of children and the
wife of a prosperous business man, called at my office.
She was then twenty-eight years old ; married six years,
had three children, and one miscarriage. She stated
that she had found herself again pregnant, and wanted
" to get clear of it 3 " also said that her miscarriage was
brought on by her physician replacing the womb, add-
ing : " My doctor knows that I am now pregnant, but he
does not think I can carry it, and that it would be just
as well to bring it away now. He has been trying, and
gave me aloes, told me half a teaspoonful was the dose,
but if I would take three it would make it all the surer/1
Here a woman of some wealth, position, and a church
member, deliberately comes and asks me to help her to
destroy her unborn child, saying, '* She is not going to
have it, because she has too much to do." Murder was
in her heart. While I had the most intense disgust and
indignation, I quietly told the poor woman she ought to be
thankful and feel honored that another member was to
be added to her household, that nothing was more
lovely or interesting than a large family of children.
She coldly and cruelly replied : "I am not going to
have this child, and my family physician has been giving
me pills to enable me to get clear of it." She gave me
his name, I warned her of the danger, urged her to de-
sist, and asked her if she had any more right to destroy
that child than any other member of her household.
The woman went home ; I feared my word would not
sufficiently impress her, so the next day I wrote her, em-
phasizing the same thoughts. The child was allowed to
live. He is now a big boy, attending school. I have
seen him many a time, but how near he came to destruc-
tion ! and probably he will never be as finely consti-
tuted as if his mother had not brooded over and contem-
plated so heartlessly her own boy.'s murder. When will
mothers look into these things and understand.
In 1866 a mother called to see me, wanting then to
get rid of her unborn babe, saying that " she had three
children, and her husband was not able to support any
more." I inquired if she was not willing to share her
little with this one also. I presented many considera-
tions. She heeded nothing, but, with cold selfishness,
seemed determined on her child's murder. I gave her
more serious words of warning. She went I knew not
whither. This woman was more cruel than the Hindoo
mother who throws her child into the Ganges.
1 AU the circumstances here narrated are facts. Names will not be
mentioned, whether the parties live in Maine or Mexico. The facts
belong to me, and are accurately stated.
One day, more than twenty years ago, I was called to
see a sick patient. It was a home of comfort and plenty.
The young woman, scarce eighteen years old, lay in her
bed ; she was a delicate, feeble girl. By her bedside
stood the mother, a refined, elegant woman. The
mother simply called my attention to her sick daughter,
that ^she was not regular, and that she wanted "her
courses brought on." My duty was to find the cause of
this retention. Examination showed that the patient
was two months pregnant, and my first inquiry was how
long she had been married. This revealed all. The
mother, in her deep grief, told the tale of sorrow, of the
daughter's engagement, and the man had gone !
This read a whole lecture as to a mother's duties and her
watchful care, and how she should instruct her daughters
in all that is right, and show them the beautiful side of
life. The mother exclaimed : " This must be got away."
" But," said I, " the daughter must now do what is right.
She cannot destroy the being to whom she has given
life." " Ah," said the mother, "death before dishonor ;
my daughter is not going to be disgraced all her days,
and the man go scot-free." I reminded the mother
again that it was a living child, and that to destroy it
would be murder ; and besides, would imperil her own
daughter's life.
I left them in their grief. The next day the father
saw me, said " he knew of my removing successfully a
tumor from the womb of a lady who was a friend of his
wife, and that I could do this just as safely." " That,"
said I," was done to save life ; you ask me to destroy life,
possibly two lives." He offered a price ! "No," said
I, " not for this city full of gold, nor for ten million
cities besides, would I take the guilt of murder on my
soul." Notwithstanding all my warnings they found
someone to do the dark deed. It was done in some way
or somehow. Years after I met this young woman. She
was an invalid. She married, but no babe ever came to
bless that wedlock. She had to think of the pearl, the
priceless jewel, that she had thrown from her, and that
she had destroyed her own child ! If young girls were
instructed, if they understood, they would be far from
such work.
In 18 — a young lady called at my office. She was the
only daughter of a prosperous merchant, for whose
household I had been the family physician for more than
a dozen years. I listened to her sad story — engaged to
be married— one false step ! I advised her if she loved
the man to marry him, but to go first to her mother for
counsel and instruction. She did both, the child was
saved, and the daughter's life was spared.
In 1878 a young girl of education and intelligence
called. She was pregnant and her affianced gone ! When
will girls learn to do right, and when will their mothers
instruct them in all things. The principles of moral
rectitude, planted deep, would deter from such con-
duct. If conscience or delicacy does not restrain, they
might remind themselves of the startling tragedy of the
king's daughter: "The hatred wherewith Amnon, the
betrayer, hated her was greater than the love wherewith
he had loved her." I advised this young girl, she trusted
me, the child lived, and she thus saved her own health
and strength, and had not the sin of murder on her soul.
She must think of the rest.
A few years after, a grief-stricken one called on me as
a physician to tell her tale of woe. I was more than
grieved that she and others so little understood me as
to imagine that I could or would help in such nefarious
work. I attempted to give her light and advice. Two
days after, the marriage rites were solemnized.
Another in like circumstances. I gave her the same
counsel and advice, both child and mother were saved ;
but what a history of remorse and self-condemnation.
For the young unmarried girls there might possibly be
some forbearance, some sympathy for them, in their des-
peration and misery. They are led on, deceived by false
promises ; they trust, and are left in desolation and bewil-
derment ; they fly anywhere, anywhither for help or refuge ;
IS
MEDICAL RECORD.
[July 7, 1894
but married women, what excuse have they? For them
there is the most utter condemnation and execration.
In 1885, during the month of December, a married
woman, Mrs. C , called at my office, elegantly and
expensively dressed. She informed me that she was then
in the third or fourth month of pregnancy, and expressed
her determination to get clear of the child, saying that
she had suffered so much, had been sick since her last
confinement, nine years previously, at which time she
was ill in bed many weeks with high fever; on the
eleventh day was not able to turn her head, and since
that time the distress in her pelvis had continued, espe-
cially on the left side. She said further, " I do not want
this child, it is an unwelcome visitor, and I will get clear
of it. I have taken ergot by the quart, and have pills
from the physician ; he says he can help me, but as I
have to go in the cars it might endanger my life." I
explained to this woman the danger of such attempts,
that it was almost sure destruction to her own health,
that nothing was more disastrous than expelling prema-
turely the foetus, that the uterus was not then physiolog-
ically prepared for the work, and that the injuries result-
ing therefrom might prove fatal ; and besides, her already
deeply lacerated cervix would be an added element of
danger. I also reminded her that the child was a living
being, even showed her a papier mach^ preparation re-
presenting the fourth month ; that at that time the foetus
was a perfectly formed child. She looked at it, tears
came into her eyes ; she said, " Is it so formed ? " But she
soon controlled her feelings, adding, " I do not believe
God has anything to do with it, I shall get clear of it."
Can anyone realize the stony hardness of her heart ? I
reminded her that this child might one day be a blessing
to her, probably was given to comfort her in some trying
period of life. Again I asked her, " What right had
she to interfere with its existence.11 Then I told her
plainly and positively that I would not, for all she had,
and twice the mines of Golconda, help in so foul a deed.
I heard nothing more from this woman until the fifth of
the next May, when I was called to attend to her con-
finement. After the confinement she was able to be up
in nine days. A month after I repaired successfully the
old laceration of the cervix.
I hold that a woman who can understanding^ con-
template such work is in no way to be trusted. This
patient left without paying me for the examination, or
the two hours' talk by which the child's life was saved,
and probably her own ; nor has she since paid for my at-
tending her in confinement, or for the surgical operation
or the subsequent medical attention. Also the two phy-
sicians who assisted me in the operation have received no
financial pay for their work ; we have only the conscious-
ness of right doing.
The child was a little girl, and many times have I seen
this little fairy playing in the street ; but will anyone tell
me that her young soul was not tarnished by such desires
on the part of the mother.
Many beautiful little children are now walking the
streets that I have saved — have prevented their mothers
from destroying them. These mothers came to me with
the unholy purpose and most wicked request. To all
alike I have endeavored to show them their error and
point them to the right course.
A good woman, the mother of many children, a lady
of considerable wealth, and who for years had been a
patient of mine, and consequently would have been sup-
posed to have known better ; yet this woman joined with
her daughter-in-law to destroy the latter' s unborn child.
She coldly informed me that she was going to have it
done! I expressed my condemnation in the most un-
measured terms, telling her that it was not only a mon-
strous crime, but would be a great wrong to the daughter.
I said much, and presented many considerations, but
strange, this mother was firm and decided ; said her son
had enough children, and that he had to get along in life.
The parties went to a neighboring city to have the crime
committed, by whom I do not know. I knew that the
time was fixed. I made one more effort and wrote the fol-
lowing letter to the mother : " May 26, 1880. I cannot
let this day pass without giving you another warning. I
have reminded your daughter of the great danger, that if
there is one death in a hundred she may be that one. I
have urged her to desist, now I appeal to you. A child
that is three months old has as much right to live as one
who is nine months old."
This letter was carried by my faithful coachman, and
delivered in person. The operator who was engaged to
do the atrocious work, I suppose, dared not proceed ; at
least the child was saved, and possibly, thereby, the
woman's life also. -
In 1882 I was sent for to see a Mrs. M . She was
the mother of a large family of children, and was then in
the fourth month of her ninth pregnancy. The uterus
was in extreme retroversion, there was a deep transverse
laceration of the cervix, and the perineum gone. I re-
stored the uterus to position, and put in place a Thomas
Cutter's pessary, which made traction from without and
held the organ securely. The patient showed very much
improved conditions, was comfortable, and in every re-
spect progressing well, when her sister, who prays and
talks in meeting, called to see her, and insisted that the
child be got rid of, that the patient should not be allowed
to suffer, saying that her sister had already more children
than she could take care of. Thus this sanctified woman
wanted to destroy the four months' old child, and was
urging me, the physician in attendance, to do the deed.
I reminded her that the patient was doing well, that she
would suffer vastly more if such procedures were adopted,
that in themselves they were full of peril. Yet this emi-
nently pious lady still insisted. It was now my turn to
give "a Bible Reading." I only reminded her of the
sixth commandment, and then left, with the authoritative
command that the patient should in no way be disturbed.
Four and a half months after, I attended the woman in
confinement. She was delivered of a fine, healthy boy,
without any unpleasant symptoms. A few months later,
I repaired for this woman the lacerated cervix and peri-
neum. She did well in every respect.
Mrs. B . The patient was a happy wife and mother.
I had attended her in several confinements ; her luxurious
table was surrounded by many "olive vines." She re-
moved to a neighboring town ; she sent for me. I found
the patient very much emaciated, and the abdomen enor-
mously enlarged. After a most careful examination I
pronounced her in the fifth month of pregnancy, with
probable dropsy of the amniotic coat. She was grieved
to hear of the pregnancy, and said : "I must get clear of
this ; I must." I showed her a more excellent way. She
heeded my counsel, and, four months after, I attended her
in confinement. Amid the multiplicity of water there
was the little, silken-haired baby. Subsequently this
woman was again pregnant, and this time was threatened
with a miscarriage ; she sent for me ; I took measures to
prevent it. She said : " Let it pass, let it pass, I have
too many children." The child was saved. He is now
the pride of the family.
Many a woman who asks that abortion may be pro-
duced would be very far from it if they understood what
it signified, or had an idea of the enormity of the crime.
A kindly hearted woman came to see me one day, she was
in distress, she had been unfortunate. " The time," said
I, " for you to have thought of these things was before the
first wrong step, the only way now for you is the path of
rectitude. ' ' I asked her if she would deliberately destroy
a human being. "Why," said she, "it is not a living
being until it moves. " "It moves a long time before you
perceive the motion, and it is a living being from the first. ' '
She seemed almost frightened at the contemplated act,
and left saying on no account would she allow anyone
to commit the deed.
In 1888 or 1889 a patient came to consult me for con-
tinued ill health that had existed since early menstrual
life. She had been married a number of years and had
no children. I found the cervix anteflexed, uterus re-
July 7, 1894]
MEDICAL RECORD.
13
troverted, and the ovaries enlarged, prolapsed, and con-
gested. After some weeks' treatment her improvement
in all these respects was marked. The pain in the pelvis
very much diminished, the ovaries were reduced in size,
and were less sensitive and sore. A few days before she was
to return to her home in another city, to make drainage
more complete for the uterus and the adnexae, I again
dilated the cervix, remarking to the patient that "there
might possibly be a chance of 'her becoming pregnant."
At the expiration of some months the patient returned
for further treatment. I found she was pregnant, I in-
formed her of the same, supposing it would be a cause of
great joy and congratulation. On the contrary, she was
grieved and depressed ; and, to use her language, asked
if "she could not be relieved. n Even her husband
called and ventured to introduce the subject. I told him
of the perils of such procedures, that I considered his wife
extremely and unexpectedly fortunate, and believed it was
her last chance ; that certainly she ought to consider it
her's and her husband's greatest happiness.
The wife continued to take sad views of the situation,
and after their return home she wrote: "Oh, my dear
doctor, if it only had not happened. I cannot be com-
forted with your idea that it is a blessing. Will you please
tell me of something that will take away this sickness of
the stomach, for I feel that I would rather die than live
like this.9'
Again she wrote : " When I came home the first time
I had not felt so well and happy in all the years of my
married life. Everyone remarked how well I looked — but
oh, this trouble — oh, dear doctor, please help me out of
it — I cannot have it so, and if you will not I will do
something. I cannot let it go on. I was so nervous at
night that I felt I could kill myself. Please give me
something or do something, for it nearly makes me wild.
I want to be free, that I may get well and take my com-
fort/' Poor misguided woman 1
I wrote the husband at length, repeating what I had
said in a previous conversation. A later letter from the
wife says : " I have given up all hope of this passing
away, for it must be three months. Oh dear ! I have so
longed for it, I know that I shall never live through it,
and sometimes when I think of it, I feel like killing my-
self— am no more reconciled. I was in hopes to write you
I was all right once more, but no such pleasure is mine.
Good- by, good by, with love and thanks for making me
as strong and well as I am, even if you did get me in
more trouble than I was before.1'
I warned the woman again and again, yet she found
someone, in her far-off home, who would undertake it.
"September 30, 1890. My dear Doctor: I have been
very sick. I was taken unwell, and it terminated in a
hemorrhage. The physician used cotton, sponges, etc.
If I attempt to walk across the room, the pains come.
What I so longed for and prayed for has happened, and
now I do regret it, for it was a little boy, and I suffered as
much as if I had gone through it all, and nothing to show
for it. It is five weeks, to a day, since I was taken sick,
and here I am, not out of my room, and have my nurse
with me yet, and am now beginning to think I shall al-
ways have to keep her. I am again flowing, and the last
two days it has been very bad. The doctor left me some
medicine. I am so discouraged that I cry most of the
time. I am so sore that I can hardly move, and have
such a heavy feeling. Write me as soon as you can spare
a few minutes, and tell me how I can get well, instead of
being so sick and miserable.'1
This poor young woman never will be as well as she
otherwise would have been. If she had let the pregnancy
continue, she would have had a normal parturition, and
been better physically and mentally than she had been in
years ; and I believe her hysterical nervousness, from the
congestion of the ovaries, would have gradually disap-
peared. She is now a sick woman, and it will no doubt
take a long time to repair the injury she has done her-
self; and how can she ever rest under the thought of
having destroyed her own child, probably the last that
will ever come and ask for her loving embrace. This
poor woman could not comprehend die enormity and
danger of her work.
Some know well all they do, the full significance of
their crime, and their doubly stained souls are filled with
deception. April 20, 1890, a woman called to see me,
with a man whom she said was her husband, requesting
to consult me in my private office. She gave her name,
and said, " she had been married twelve years, had one
child ten years old, and was now two months pregnant,
and wanted to be relieved." I examined her case, I told
her she was not pregnant, and did not believe she could
have a child in her present condition. She repeatedly
said, " Pass the sound, pass the sound." Under her sup-
posed condition this seemed so brutal I thought that a
woman who could so speak was " fit for treason, strata-
gems and crimes," and conspiracies / I dismissed her
from the office, and in a few minutes went into the parlor
to speak to the "supposed husband. " Both had disap-
peared ! I sent a letter to the fictitious name, and to the
probably fictitious address, emphasizing all I had said, and
adding that the apparently innocent expression, " Pass
the sound," might be fraught with tremendous evil ; and,
to my mind, in her si pposed condition, was cruel acd
wicked.
One Saturday morning, in September, 1890, my door-
bell rang ; I was called to the office ; there stood a young
married woman. She related her clumsy story. Without
ceremony I should have dismissed her, but wanted to
give her a word of warning, and show her the exceeding
sinfulness of her proposed course. I called a friend from
the parlor, a lady of rare intelligence, who kindly added
to and emphasized all that I had said. This young, ig-
norant, coarse woman, recovering herself, said, " It is a
commercial transaction, you give me the medicine, I
give you the money." She imagined it a fine argument.
There she stood with her paltry dollar, her husband prob-
ably making $7 or $9 per week. Ten million times the
wealth of Europe and Asia would have been a trifle far
too small. Turning again to the woman I said, " Abso-
lutely, if a grain of medicine would enable you to carry
out your vile purpose, I would not, for unnumbered mill-
ions, give it to you."
One Sabbath day, in September, a girl, some twenty
years of age or over, called to see me. A few touches
painted the tragic story. She said she wanted her courses
brought on. "Do you know what that means?" said
I. " It is one way of destroying your child, now two
months old. You are sorry for what you have done, and
want to hide it ; you cannot The only right way is to
have the child, whether you marry the man or not."
She left, promising that she would go to no one for the
wicked purpose.
A school-girl came in the summer of 1887. She was
pregnant, and in distress. She said that she was able to
pay for it, and would go where she could have it done.
I said, "To you it will be especially dangerous, you have
been diseased since early menstrual life." She said,
"There were doctors that would do it for money."
" Don't let anyone do it. Your only right way is to go
through with it. You do not know what may be the
consequences of another course." I wrote the same and
more in a letter to her mother,~requesting the daughter
to deliver it. I knew nothing more.
One day a beautiful young girl, aged sixteen, reared in
the lap of luxury and wealth, came in a coupe" with her
affianced and false lover. She had in her hands a large
roll of bills, which she held prodigally and wanted to
give lavishly. I felt her very presence was contamina-
tion. Said I, " You are an only daughter, your mother
knows nothing of this, your father does not know where
you are." They had given her every luxury, but had
not given her the most valuable of all — parental control,
instruction, and discipline.
I hold that children should be educated in the right
way and taught to do right. If they have coarse natures
which pi event them from going in the right path, they
14
MEDICAL RECORD.
[July 7, 1894
should be made to do right. Eli's only sin was that he
did not make his sons do right. In unmistakable terms
I gave the girl words of warning. Her beautiful face
listened kindly to all I said. She went I know not
whither.
How many are taken from the home of innocence and
purity, scarce conscious of what they are doing ; they do
not realize the heinousness and great wickedness of this
one false easy step. After ! Oh, heavens ! The pall of
darkness comes upon them, they go deeper and deeper.
One young man sent the following letter to Dr. Charles
N D. Jones, when he was House Surgeon in the Brook-
lyn City Hospital :
" I am in a little trouble, and I want you to help me
out, if you can. A young lady friend of mine I am afraid
is in the family way. Now, I will not keep it from you,
I think I am to blame. It has only been a week, so you
can fix her easily, I think. I wrote her to come to you,
but if she does not, will you please call and see her? She
lives (he here gives the number and street). You send
the bill to me, and I will fix it. She has not had her
usual monthly sickness, and I am frightened. As soon
as you get this, please call and see her. Her name is
(he here gives the name in full). Now, please try and
get me out of this trouble, and I will be everlastingly in-
debted to you. It is not convenient for me to come up
to the city, else I would go up and bring her to you.
Hoping that you will be able to fix her all right, and
trusting that you will, of course, keep quiet. Get me
out of this trouble. I remain, etc."
The reply :
"Cut Hospital, Brooklyn, July 31, 1884,
" Mr. : Yours of the 29th received. Your friend
was here to see me the day before I received your letter.
I must answer you as I did her. I would not think of
doing the least thing to bring on her courses, and no
man in his right mind would presume to ask me to do
such a thing. I most positively decline to aid in any
such work. Yours, etc.,
"C. N. D. Jones/ '
This trusting young girl was sent to the office of a
young doctor in a public institution, saying : " Send me
the bill, and I will fix it" But how will he, the lover,
ever fm it with the young girl. That girl's mother
trusted him !
The way back condition, as I have before intimated,
is that m 3 thers should instruct their daughters, teach
them first parental obedience, and then all that relates
to their high moral duties and obligations, unfold to
them the great principles of life, of their physical being,
their organization, and then tell and explain to them the
beautiful laws of health. This is necessary for every day
welfare. Why should not young ladies study these sub-
jects as well as rocks and stones, stars and flowers?
Does she hesitate to examine a flower, acknowledge it a
thing of beauty and joy forever? Just as pure is it to
examine this greatest of nature's work. Girls are igno-
rant and uneducated, and thousands are led into evil and
everyday violations of the most ordinary laws of health
as well as of morality, for want of knowledge, or because
they have not been properly trained and instructed.
In 1887, a young girl, scarce eighteen years of age,
called to see me ; she wanted to know if she was preg-
nant. I found her in the second month. She told me
the sad story, and said with burning tears, " It must be
taken away. ' ' I could not say to her, " Marry the man ! ' '
The one who had so treated this young girl had sacred
and legal obligations to another. I could only say to
this child, "Go and tell your mother, she is your best
friend ; but destroy the child, you must not." If one for
his wife's honor may shoot down the betrayer, how in-
finitely much more does he deserve such a fate, who leads
astray and blasts irretrievably the young girl.
A sad, broken-hearted woman, lifting her beautiful face
to heaven, vowed that she would destroy the wretch, the
author of her misery, nor would she nourish or give life
to the product of his being. He made her promises of
marriage, but left her overwhelmed with anguish. Why
will women trust and sacrifice so much ?
Another young woman, of more than ordinary intelli-
gence, was in despair and broken hearted. Her child
was born in a public institution. As the mother looked
upon it as from him who had blighted her hopes, she
vowed that she would destroy it. It was necessary to
watch her night and day; for, continually and constantly
she threatened the child's destruction.
One, in her shame and desperation, drowned her own
little helpless one. Ever she saw the little outstretched
hands of her own babe pleading for help. The picture
never could be effaced. She became wild, her reason
dethroned, but where was her betrayer? She was
wrecked, but no one suspected him of wrong doing.
" One more unfortunate." The young and beautiful
daughter of a goodly man trusted a young student He
went to honor and emolument, she to insanity and death.
Thousands perish thus in misery and desolation.
Women are always the greatest sufferers. Nathaniel
Hawthorne relates a touching story of human frailty.
The young and beautiful Hester Prynne stood on the pil-
lory of public shame ; a select number of wise and virtu-
ous persons, all with grim rigidity and cold severity, were
on a high platform, to deal with this poor girl, touching
the vileness and blackness of her sin. There she stood,
under the weight of a thousand unrelenting eyes on this,
to her, a scaffold of execution. One of the said righte-
ous judges to condemn the young woman, was the father
of her child !
A similar touching incident is related in an ancient
volume ; and, probably, from it, Hawthorne gets the gem
thought of his classical story. Judah, a great man, high
in office and high position, heard that his daughter-in-
law had played the harlot. His righteous soul was filled
with holy horror. "Bring her forth, and let her be
burned." The young woman stood before the assembled
multitude. " Discern, I pray thee, whose are these, the
signet, and bracelets, and staff." Judah acknowledged
they were his. Months before he had met this young
woman behind the rocks, and this pledge he had given
to her S
A story is told of another judge. Again, a lonely and
desolate woman stands before an incensed multitude.
" Master," said they, "she was taken in the very act."
The judge, with words of infinite wisdom, said unto
them, " He that is without sin among you, let him first
cast a stone at her." " And they that heard it went out
one by one, and the judge was left alone, and the woman
standing in the midst." Not one of all that vast multi-
tude could cast a stone !
There is another chapter of this medico-moral legal
subject that cannot be omitted. Very lately a gentle-
man, of high respectability and intelligence, called, in-
forming me that his wife was pregnant ; but that neither
he nor she thought it right to have this child, adding,
" that any doctor who wanted a good practice should
take care of his families ; that this was the physician's
duty, and it was done by the best." I replied, "It
can be the duty of no one ; and no promise of practice
would be of the least consideration." The gentleman
unwittingly mentioned the name of the physician whom
his wife was then consulting, and stated that this phy-
sician "had already put something in the womb that
had made her flow," at the same time assuring him, her
husband, that "ail would be right" This gentleman
also remarked that " he had sent this physician fifty such
cases," then quoted the words of a medical man who had
said : " Abortion was not legal, but it was right"
A few months after, it happened that I again saw this
young man, and remarked to him, " So your wife lost
her child. Do you know how the doctor did it ? " Be-
fore thinking, he quickly replied, " Ye?, I do, I know ex-
actly how he did it." Alas, alas ! it was done, and by a
physician, and he a member of a County Medical So-
ciety !
An article, in the New York Gynecological Journal
July 7, 1894]
MEDICAL RECORD.
15
says : l " The specialist in abortion exists. He is no
ideal, but an actuality, a real living man, as a professor,
ably rilling a chair in college, he is perhaps well known.
As a specialist in abortion, he is recognized only by a
favored few."
An editorial, in the same number of the journal quoted
above, says: "Practices, not infrequently carried out
nefariously, by reputable physicians. Some hypocriti-
cally practise it in secret, while repudiating it in public.'1
This editorial further makes the startling announcement :
' ' It can be no secret to those of us who have been even a few
years in active practice, that foeticide, in the early months
of gestation, is constantly performed with the flimsiest
excuses, by prominent reputable men and women too, in
every community," adding: "This has long been a
plague spot in the profession.11
-# I cannot agree with the words of the editor, or of his
correspondent. I absolutely deny the assertions, though,
four times lately, I have heard physicians say, " All do
it; " and a member, at the annual meeting of the Ten-
nessee State Medical Society, asserted,1 " I fear that the
profession frequently takes a hand in the nefarious busi-
ness." This also is untrue. It is not the profession.
It is a few unworthy ones in it. In no profession are
there men of more exalted morality, nobler aims, and
purer integrity than in the medical profession. They do
what is right. With large-hearted benevolence, they aim
at doing the best for all.
In 1883, 1 stood in the parlor of a prominent member of
the County Medical Society above referred to; the mem-
ber pointed from his window diagonally opposite to the
residence of another prominent member of the same so-
ciety and said, " That man will do it any time for $50."
I did not believe it then, nor do I now. (But how these
brethren love !) It is sadder to know that one member
of this same County Medical Society, and one who held a
position in the Health Department, was sentenced for
this offence ; and, as I am informed, others in the same
society have been under suspicion.
The writer of the article in the New York Gyneco-
logical Journal \ further says : " We opine that the world
would be better if abortion were done oftener."
What doctrine is this to teach in a medical journal !
Certainly, the profession does not stand by such teach-
ing. Good men, everywhere, raise their voice against
the evil.1 As far back as 1857, at the annual meeting of
the American Medical Association, a committee4 was ap-
pointed to investigate the subject, with a view, if possi-
ble, to the suppression of the growing evil ; which com-
mittee, at the annual meeting, 185 9/ made a report, say-
ing : " As a profession, we are unanimous in our con-
demnation of the crime ; and, as a committee, would ad-
vise this body, representing, as it does, the physicians of
the land, publicly to express its abhorrence of the unnat-
ural and now rapidly increasing crime of abortion — the
wanton and murderous destruction of the child." The
Association then unanimously passed the following reso-
lution : Resolved, " In view of the prevalence and in-
creasing frequency of the crime, publicly to enter an
earnest and solemn protest against such unwarrantable
destruction of life. ' '
But farther back than this, Hippocrates, the father of
medicine, in the Hippocratic oath, pledged each of his
pupils — and to which every physician must swear — never
to be guilty of unnecessarily inducing miscarriage.
1 Special Operation for Abortion, C. H. Harris, Ga., p. 84a, Sep-
tember, 1892.
■ Transactions, fifty-fourth annual meeting, State of Tennessee Med-
ical Society, p. 176.
f8* I am glad to record also that this young and vigorous journal con-
demns it ; it says r " We heartily reprobate the article by Dr. Harris,
not merely because we are opposed on principle to the practice
which he advocates, but equally because his' advocacy of them is il-
logical, and founded upon arguments of expediency which appeal to
self-interest of the lower and more dangerous kind " (p. 846).
* This committee consisted of Dr. H. K. Storer, of Massachusetts ;
L W. Blatchfbrd, of New York ; H. I. Hodge, of Pennsylvania : Bar-
ton, of South Carolina ; G. A. Pope, of Missouri ; A. Lopez, of Ala-
bama ; W. A. Brisbane, of Wisconsin ; A. J. Semraes, of District of
Columbia.
* Transactions American Medical Association, vol. xii. ,'1859, p. 75.
In May, 1871, soon after the startling disclosures in
connection with the professional abortionists, Wolff and
Lookup, the New York Academy of Medicine passed a
resolution in reference to the "wide-spread crime."
Again, September 21st of the same year, the Academy
adopted a set of resolutions, pledging, "All its influ-
ence, its efforts in support of any legislative or other
measures, which our law officers may propose, as offer-
ing a reasonable provision of mitigating, if not removing,
the perpetration of criminal abortion, which is upon our
country/1 The Medical Society of Berks County, Pa.,
passed similar resolutions. The New York Medico-
Legal Society appointed a committee 1 whose report was
made and unanimously adopted, at the Society meet-
ing held on December 14, 1871, at the College of Phy-
sicians and Surgeons, of which the following is an ex-
tract : "As the proper name for the intentional destruc-
tion of the foetus is murder, it is hoped that the time
will arrive for its punishment as such."
At the meeting of the Crawford Medical Society,1 on
July 5th, the following resolution was passed : " Whereas,
the practice of criminal abortion is steadily increasing,
and in numerous cases which prove fatal — be it re-
solved that we petition the Legislature of this State, at the
coming session, to enact a law by which the dying dec-
larations of a person, who may die from the effects of a
criminal abortion, shall be received as evidence in trial
of anyone indicted for such offence." Copies were sent
to various medical societies for consideration.
The Journal of the American Medical Association,
Chicago,1 calls it the highest crime — from some stand-
points, at least — of which humanity is capable, and whose
prevalence exceeds the highest estimates." He says, in
another number : 4 " The obligation rests upon the
medical profession to propose a method for checking the
fearful progress of this evil."
The Boston Medical and Surgical Journal : 6 "A crime
in itself one of the foulest, and against which, in times
past, the severest penalties have been attached, and which
three hundred years ago subjected those convicted of its
committal to all the penalties inflicted on murderers."
It adds : " With regard to the proposed remedies for this
evil, we confess we have little confidence in mere legis-
lative enactments. It is rather to the medical profession,
and those more immediately connected with the morals
of the community, that we are chiefly to look for the
true remedy. The physician may do much by warning
his patients against the dangers and guilt of this awful
crime, involving, as it does, the guilt of murder and a
cold indifference to the most sacred privileges with which
woman is endowed."
An editorial in the Medical News * says : " The News
has contended that it is the duty of medical men to in-
struct the lay world, through the lay journal, concerning
hygiene and medical truth."
The report of the committee of the American Medical
Association * further said : " If to want of knowledge, on
a medical point, the slaughter of countless children, now
steadily perpetrated in our midst, is to be attributed, it
is our duty, as physicians and as good and true men,
both publicly and privately, and by every means in our
power, to enlighten this ignorance."
The Australian Medical Journal said : " We need a
medical bill for the colony. Within a week four women
in the prime of life have been sacrificed."
The late Professor Hodge, of Philadelphia, in his in-
troductory lecture, quotes the ruling of Judge King, of
Philadelphia : " Every act of procuring abortion is mur-
der, whether the person perpetrating such act intended
to kill the woman or merely feloniously to destroy the
1 This committee consisted of James J. O'Dea, M.D., Elbridge T.
Gerry, M.D., George F. Shrady. M.D., William Shrady, M.D.,
Stephen Rogers, M.D. , and Gunning S. Bedford.
8 British Medical Journal, September 24, 1892, p. 675.
» 1885. p. 42
« Foeticide and its Prevention, H. C. Markham, xi., p. 805, 1888.
• February 16, i860, p 65.
• September 2, 1893, p 271
• Transactions of the American Medical Association.
i6
MEDICAL RECORD.
[July 7, 1894
fruit of the womb." Dr. Hoag^ays: "All believe
the practice to be sinful as well as criminal." H. R.
Storer says, in his essay : " The offence is one of the
deepest guilt, a crime second to none." J. B. W. New-
lin" says: "To correct the evil, recommends that the
profession should teach the public the facts of embryol-
ogy, in so far as they relate to the enormity of this
crime; that they should thoroughly instruct our law-
makers, so that laws may be formulated which will let
no guilty one escape."
The writer in the New York Gynecological Journal
above quoted, further remarks : " Poor women are to
suffer and to sacrifice everything at the shrine of mater-
nity, as if it were for this alone they were made." I re-
ply, maternity is woman's highest mission, and should
be her greatest pride. While a woman may possibly ac-
complish, in other directions, all that is high, noble, and
good, yet everything should bow to maternity. This is
the shrine to which she brings her noblest offerings. Is
she educated, has she physical health, and physical per-
fection ? Are her mind, heart, and soul cultured and
highly endowed ? It is that she may give birth to more
perfect and more beautiful children. This is the end,
and should be her highest aim. This also should be the
object of a mother's earliest solicitude and training for
her daughter. To the shrine of maternity all should be
dedicated. As I said in an article : a " She is a mag-
nificent woman who can give birth to a large family of
children and still retain her health."
The writer in the New York Gynecological Journal 'con-
tinues : " What sense is there in allowing a woman with
diabetes, albuminuria, and the grave forms of disease, to
run the gauntlet of pregnancy and labor ? At once empty
the uterus." This, when life is endangered, may be ju-
dicious; but, in general, if one's individual judgment
may decide whether it is best for a child in utero to
live, may not the same individual judgment decide
whether it is expedient for a boy or girl of five or ten
years of age to live. If, in one's judgment, a human be-
ing in utero may be destroyed, with equal right may we
not destroy a human being at any age of existence?
May we not, at any time, decide whether anyone's life is
useful or to the advantage of him or herself and to the
community? Is not this a most dangerous doctrine?
Could a more cruel despotism exist ? A physician has
no more right to destroy a human foetus, because he im-
agines it, in future years, may be sickly, than he has a
right to destroy the delicate baby, because it possibly
may have before it years of invalidism.
The writer of the same article next gives explicit di-
rections as to how abortion shall be produced. He
says : " . . . ," etc. He continues : " Snare N9. 1
is passed into the uterus ; sweep the staff around the
globe of the ovum. Pull gently with forceps, until the
mass is either extracted entire or cut in twain. In the
latter event, repeat the procedure until it " (the baby !)
" is chopped into fragments of easy extraction ! " Hail
horrors ! lay on, Macduff. One almost shivers in reading
these descriptions, and for this horrible work the writer
holds out the inducement of " handsome returns and fat
fees for special services."
I maintain that all this work is murderous, unprofes-
sional, and degrading to the high office of a physician.
A physician stands as a preserver of life, and should be
the embodiment of honor and high morality.
November, 1893.
The Consumption of Absinthe. — According to some
statistics recently issued by the French Government, the
consumption of absinthe in France has risen from 57,000
hectolitres (1,254,570 gallons) in 1885, to 126,000 hecto-
litres (2,773,260 gallons) in 1892. The increase in the
consumption of other alcoholic beverages during this
period has been nearly in the same proportion.
1 Medico-Legal Journal, New York, 1800-1891, viii., p. 118.
1 Fifty-fourth annual meeting of the Tennessee State Medical So-
ciety.
1 Mbdical Record, September 9, 1892, Sterility in Woman.
gr00t*8a of piedical Jfcfcetice.
Acute Vertebral Osteomyelitis. — Dr. Morian relates
two cases of this rare disease. An important complies
tion consists in the spread of the inflammation and suppura-
tion into the spinal canal. From the front the pus could not
so easily penetrate into the canal owing to the ligament,
but behind there is a space between the dura and the
arches filled with a loose and vascular tissue to which the
suppuration has ready access. The membranes and the
cord itself may also become involved. In one case pus
escaped from the situation named above when the spinous
process and arch were removed, and in the second case
die abscess extended from the third cervical to the twelfth
dorsal, and from here again down to the third lumbar
vertebra. The pleura or peritoneum may also become
involved. The suppuration is more likely to remain lo-
calized behind the peritoneum than behind the pleura.
Osteomyelitis of the spongy bones is likely, according to
the author's experience, to run a more unfavorable course
than when the long bones are affected. As to the symp-
toms, the onset was rapid, with fever and pain in the
part of the vertebral column involved. The column was
held rigid. At first the second case resembled epidemic
cerebro spinal meningitis ; the head was drawn back, the
neck and back muscles rigid, and the pupils unequal.
Later, however, the pain became more localized, and a
swelling appeared. In the acutest cases death may occur
before the site of the disease can be localized. Preverte-
bral suppuration may cause diagnostic difficulties. Acute
rheumatism very rarely affects the vertebral column, and
then other of its manifestations are present. Acute pneu-
monia or lumbago might be confounded with it. The
prognosis depends on the severity of the toxic symptoms.
It is more serious if die dorsal vertebrae are involved, ow-
ing to danger of spread to the pleura. The abscess should
be opened as soon as possible, and the focus of disease, if
it can be got at, scraped away, or better still, as in the
case of the arches, removed. The first case occurred in
a boy, aged ten. He had pain in the loins, headache,
and fever. He kept his back rigid. Some ten days or
so later a swelling was found along each side of the lum-
bar spinous processes. This was incised, and the spinous
process of the fourth lumbar vertebra and apart of the
arch on either side were removed, pus escaping from out-
side the dura. A swelling over the foot had also to be
incised, and subsequently another one over the humerus.
The boy eventually made a good recovery. In the sec-
ond case of a lad, aged seventeen, a swelling appeared in
the region of the eleventh and twelfth vertebras about
seventeen days after the onset. This was incised, and
the vertebra found bare. There was some improvement,
but the pleurae became involved, and the patient died.
The body of the vertebra showed foci of pus. A com-
munication was traced between the pleural cavities and
the disease. The outer surface of the dura was altered.
Small abscesses, were present in the kidneys. *The staphy-
lococcus was cultivated from each case. — The British
Medical Journal,
Four Children at one Birth, two boys and two girls,
all healthy and well developed, is the record of a proud
and happy mother in Tennessee.
Mrs. Kadumbini Ganguli was the first native female
graduate of the Calcutta University. She passed the
L M. S. examination of the Calcutta Medical College
with credit seven years ago, and last year became a licen-
tiate in Medicine and Surgery in England.
Konnandy Cattle. — The American Veterinary Review
recommends the introduction of Normandy cattle (Coten-
tine the breed is called in Europe) to take the place of
the Jerseys which are so prone to tuberculosis. The edi-
tor says that in addition to the fact that the breed is
claimed to be the finest milking race in the world, it is
free from pleuro- pneumonia and tuberculosis.
July 7, 1894]
MEDICAL RECORD.
17
Medical Record:
A Weekly Journal of Medicine and Surgery.
GEORGE F. SHRADY, A.M., M.D., Editor.
Publishers
WM. WOOD & CO., 43, 45, & 47 East Tenth Street
New York, July 7, 1894.
CAUSES OF DISEASES PECULIAR TO WOMEN.
The causes of diseases peculiar to the female sex are
surprisingly few in number and limited in character. Ig-
norance and neglect seem to be the most powerful fac-
tors in the production of such disorders. A paper in the
International Medical Magazine, August, 1893, by Dr.
Charles P. Noble, states that these causes are about five
in round numbers. The first in importance is imperfect
development of the sexual organs. Gonorrhoea comes
next. The third is septic inflammation following child-
birth. The fourth is lacerations due to childbirth.
And the fifth may be said to be mechanical and chemi-
cal, viz., constipation, erroneous habits of living, and er-
rors in dress.
Imperfect development of the sexual organs as a cause
of disease in women is often overlooked. As a rule,
when the development of the sexual organs is interfered
with, the development of the whole body is also arrested.
Almost without exception, such women belong to the
class of neurotics. They are especially liable to neuroses,
especially chorea, headache, and neuralgia. Puberty is
often delayed, and menstruation is always painful. The
pain belongs to the type of the so-called ovarian dysmen*
orrhoea : it begins a day or several days, perhaps a week,
before the menstrual flow, and is especially felt in the
ovarian region. Uterine dysmenorrhea, due to lack of
development in the uterus (especially of the cervix), is
frequently present. The pain is paroxysmal, and less
marked when the flow has become fully established. Too
much school work and too frequent examinations impair
the tone of the nervous system, stimulate emotion, inter-
fere with digestion and sleep. Anaemia and depraved
nutrition follow, and these in turn aggravate the neurotic
state. When such girls arrive at puberty there is not
enough vital force left over for the proper development
of the sexual organs. The most remarkable cases of this
arrest of development are to be found among the very
poor, among girls who have not been forced at school,
and who in some instances have never been to school at
all. The cause of arrest of sexual development among
them is hard work undertaken too early and steadily, as
in mills and factories. Absence of fresh air, outdoor ex-
ercise, and this excess of work, do for the very poor just
what lack of fresh air, outdoor exercise, and too much
study and excitement, do for the rich. Menstruation
among these girls is tardily established, never perfectly
performed, and may cease or become irregular between
the twentieth and thirtieth year. One common cause
of this arrest of development in the female sexual
organs the author has overlooked, and that is infectious
disease during childhood. Scarlet fever, measles, mumps,
diphtheria, etc., set up inflammatory processes here that
result often in permanent damage to the tissues. There is
not only arrest of development in these organs, but there
is also destruction of their substance proper, due to the
various poisons of infectious disease. Neurotic girls need
lighter tasks and more fresh air and sunshine than their
stronger sisters, more rest, and more sleep. Any func-
tional disease should be attended to at once and cured.
This will help store up vital force for the exigencies of
puberty. When menstruation fails to appear at the ac-
customed time, special care is necessary, the case being
watched carefully till menstruation is fully established.
Such a plan as this must of necessity diminish dysmen-
orrhea and sterility, and laceration of the cervix and the
perineum, and also decrease the cases of chronic ovaritis
and ovarian cystomata.
Gonorrhoea, one of the most prolific sources of dis-
ease in women, is to-day very generally recognized,
though a knowledge of its full significance is of recent
date. Noeggerath, in 1873, published his paper on " La-
tent Gonorrhoea in Women,' ' and called attention to its
serious ravages. His views met with fierce opposition at
the time, but their truth has been established by the work
of modern abdominal surgeons. It is now well known
that gonorrhoea is one of the chief causes of uterine,
tubal, ovarian, and peritoneal inflammation. The exact
percentage is not yet determined. Cities containing
great numbers of the poor and the vicious, and of the
rich and immoral, give a higher percentage than rural
communities having a more decent population.
Septic vaginitis, endometritis, and metritis, are
well- known forms of puerperal inflammation. They fre-
quently persist and require treatment after the puerperal
period. Aside from the more rapidly fatal cases, the
most serious result of infection during labor is the spread
of the septic inflammation to the uterine appendages, giv-
ing rise to salpingitis, ovaritis, and peritonitis. Some-
times there is perfect recovery. More often the result is
chronic inflammation, with formation of adhesions to the
neighboring structures, or the collection of fluid, serum,
blood, or pus, in the tubes or in the ovaries. How far
this is due to puerperal septic inflammation, and how far
to latent gonorrhoea, is a mooted point. A much less
frequent result of puerperal infection is acute inflamma-
tion or abscess of the broad ligaments. Phlebitis and its
associated condition, phlegmasia alba dolens, are other
abnornal manifestations due to puerperal septic infection.
Gonorrhoea and puerperal sepsis together cause fully
ninety five per cent, of all cases of tubo ovarian inflam-
mation.
Lacerations due to childbirth are also followed by con-
ditions disastrous to health. Those of the pelvic floor
are even more important than lacerations of the . cervix
uteri, since cystocele, rectocele, and prolapsus uteri are
directly due to them. Constipation is a bad habit com-
mon to women, and one that predisposes to the develop-
ment of hemorrhoids, and to uterine and ovarian conges-
tion, to retroversion of the uterus and prolapse of the
ovaries. The full rectum can displace the cervix forward,
i8
MEDICAL RECORD.
[July 7, 1894
and the straining at stool, especially if the bladder be full,
can topple the uterus over backward. Relaxation and loss
ot tone of the pelvic tissues due to congestion, also pre-
dispose to retroversion of the uterus and to prolapse of
the ovaries. Constipation aggravates the symptoms of
every pelvic disease, partly by pelvic congestion and partly
by general deterioration of health, due to fecal absorption
and contamination of the blood, and by loss of appetite
and disordered digestion. Indolence, luxury, or the
' strained and monotonous life of the poor, induce pelvic
disease. Tight corsets, tight bands about the waist,
heavy clothes, heavy skirts, tend to displace the abdom-
inal viscera downward. As rational dress is perfectly
possible at present, without sacrifice of taste or beauty,
these evils are no longer necessities.
The remedy for diseases peculiar to women, since they
are so largely preventable, is to be found in applied knowl-
edge. Growing girls, especially about the time of
puberty, require care that will secure for them a normal
development of the sexual organs. Gonorrhoea should
be more vigorously treated than it is, the patient kept
under observation until ail abnormal discharges are ar-
rested, and proper instruction given concerning absti-
nence in the matter of sexual intercourse. Laceration of
the cervix and perineum are to be repaired early. Every
effort should be made to prevent the spread of infec-
tious disease. The evil effects of constipation, improper
dress, and erroneous habits of living, require constant and
careful explanation. This is pre eminently the duty of
the family physician, who is brought in contact with ab-
normal conditions in women before they come under the
specialist's direct and exclusive observation.
Dr. Belkowski agrees with the other observers that bile
is frequently present in the chyme. He finds that beet's
bile is particularly injurious to digestion, much more so
than that of carnivorous animals.
He finds further that the secretion of the Brlinnerian
glands does not have any digestive power when the acidity
of the medium is over one per cent, and that the part which
it plays in gastric digestion is practically of no impor-
tance. The pyloric secretion has an almost equally
slight value. Finally he finds that neither of these secre-
tions has any part in neutralising the bile, and that
gastric digestion can and does go on very well despite
the presence of bile. Hence a " little bile on the stom-
ach ' ' is more or less normal and does no harm.
The duodenal glands in man are few and probably
rudimentary organs, though well developed in the sheep.
Even the pyloric end of the stomach may come to be re-
garded as only vestigial — like the appendix.
THE PART OF THE BILE AND THE BRUN--
NERIAN GLANDS IN DIGESTION.
A view which many persons take of their indigestion is
that they have " bile on their stomachs ; " and they cor-
roborate this by speaking of the bitter taste in the mouth
and of various other evidences of a so called " bilious-
ness.M Now physiologists have generally been disin-
clined to believe that bile often gets in the stomach, since
it is poured out into the intestine some distance below
the pylorus and since peristalsis always occurs normally
in a direction away from the stomach.
Professor Herzen, however, in his observations on a
man with a gastric fistula, asserts that bile is a very con-
stant ingredient of the gastric juice or, rather, of the
chyme (La digestion stomachale, p. 78). In 107 out of
142 tests, bile was found in greater or less quantities.
This view is supported by the experiments of M. Ch.
Contejean, who in a large number of tests upon himself
— a healthy man — found bile in the chyme. It is known
that bile in any amount, however, retards and may even
stop altogether gastric digestion. It is stated that from
30 to 50 drops will stop digestive processes in 3 c.c. of
gastric juice. The theory has been put forth by Schiploff
that one function of the glands of Brlinner is to antago-
nize this dyspeptic action of the bile.
Dr. J. Belkowski, in the Revue Mi die ale de la Suisse
Romande, has made an elaborate series of experiments in
order to determine just what function the bile does play
in gastric digestion and what the glands of Briinner have
to do in the same process.
THE REFORMATORY INVESTIGATION.
It is gratifying to observe that the State Reformatory at
Elmira is at last being subjected to a really judicial in-
vestigation. The verdict rendered against this most
famous of penal institutions a few months ago, after an al-
leged investigation prompted by a vicious newspaper at-
tack, was a surprise and shock to every one familiar with
the methods of the institution and its marvellous results
in the reformation of youthful delinquents. The present
investigation is apparently being conducted in a way to
get at the actual facts. Thus far the results are reassur-
ing to those who have looked to Elmira as the most suc-
cessful reformatory in the world, and to the movement
inaugurated in this country by Superintendent Brockway
as the one reasonable method of turning back the tide of
criminality that is rising so rapidly in most civilized
countries.
No brief account could possibly give a comprehensive
idea of the work done at Elmira. It is a school whose
pupils are criminals from the lowest walks of life, illiter-
ate, vicious, seemingly irreclaimable, and whose graduates
are men changed in their entire mental and moral atti-
tude— educated, developed, regenerated . The matriculant
is a criminal at war with society ; the graduate a skilled
tradesman ready to go out and earn an honest living in
the world. Of the several thousands treated at Elmira,
more than eighty per cent, have gone out thus regener-
ated, and are now living useful lives. This work has
made Mr. Brockway famous the world over. The United
States Bureau of Education in a recent report says of him
that he is "justly recognized in Europe, as well as in
America [note the sequence] as the most successful in the
actual reformation of the criminal.,, For the direct
practical elevation of the ethical level of our race, Mr.
Brockway has perhaps done as much as any other single
individual in the world.
But it chances that one part of the admirable system by
which Mr. Brockway has achieved such marvellous results
includes the application of corporal punishment to wilful
misdemeanants, as a last resort. There was never any-
thing secret about this. Such punishment was always
administered by the Superintendent in person, after nu-
merous charges had been preferred and proven, and after
the misdemeanant had been repeatedly warned and ad-
July 7# 1894]
MEDICAL RECORD.
19
monished by the Superintendent. A record of the en-
tire case was always kept in the books of the institution,
including not only the fact of punishment, but the exact
number of blows administered. The published annual
reports of the institution described this portion of the re-
formative treatment, and it was perfectly understood and
generally approved by all persons familiar with the work
of the Reformatory. But about a year ago a sensational
newspaper in New York made the startling discovery of
the existence of this method of treatment, and assailed
the institution, with the ultimate result of bringing on
the investigation already referred to, of which the present
investigation is the sequel.
At the beginning of the present investigation the " ter-
rible weapon " with which the spankings were adminis-
tered was produced. It proved to be a strap twenty- two
inches long, three inches wide, and three-sixteenths of an
inch thick, weighing, handle included, sixteen ounces —
an instrument, one would suppose, admirably adapted to
produce a corrective tingling of the cuticle, but utterly
incapable of producing the lasting injuries that were al-
leged to have resulted from its application. These in-
juries, damaged spines, impaired vision, and what not
are rapidly disappearing when subjected to critical exam-
ination in the concrete by expert physicians called by
the investigating commission, or by the medical member
of the commission, Dr. Austin Flint. It is being shown
that the inmates who furnished the adverse testimony be-
fore are largely malingerers and incorrigibles. One of
them is on record in the book of the Reformatory as hav-
ing committed about five hundred misdemeanors and
breaches of discipline, from attempted murder down, dur-
ing the two years of his stay in the institution. The
marvellously exact and explicit records of the institution —
in themselves testimony to the great executive ability of
Mr. Brockway — when consulted in full and not merely
in garbled extracts, have gone a long way toward clearing
up the charges made against the Reformatory management.
Admissions made by witnesses called for the prosecution
have also strengthened the case of the defence. Already
the hope is justified that the researches of the investigat-
ing commission will lead to a report fully restoring the
Reformatory to its place in the public confidence.
PATENT MEDICINES AND THE TEXAS DOC-
TORS.
There are troublous times in Texas again ; but the clouds
are clearing, and the Lone Star is beginning to filter its
pellucid beams anew over a distempered world. It all
began from a combination unfortunately made between
the Austin Statesman and the State Medical Society.
The Statesman (who does not seem to have quite grown
up) published the remarkable assertion that at a meeting
of the Society one of the doctors spoke anent patent
medicines as follows :
" No doctor who has any consideration for his calling
will prescribe a patent medicine compound for a patient.
If he is a doctor at all he will write a prescription con-
taining the same ingredients. By this means the drug-
gist is enabled to make his percentage on the prescrip-
tion and the doctor gets a rebate. Now, if the doctor
prescribes a patent medicine, the druggist only gets a
small margin of profit, and the doctor gets nothing at
all. So, in consideration of this fact, if for no other, a
doctor should never prescribe a patent medicine. "
Naturally such an avowal as this led to strong denun-
ciations by the editor, of the medical men of Texas and
everywhere else, with incidental criticisms of druggists
and their business ways. Slander loves a shining mark ;
but when it strikes the Texas doctors, the mark not only
shines, but corruscates, with a blinding brilliancy that
wilts, dries up, and utterly defibrinates the slander. The
doctors of Austin got together and passed some resolu-
tions, which we publish in full :
" Whereas, There recently appeared in the local edito-
rial or reportorial columns of the Statesman an article
headed, ' The Reason Why Doctors Object to Patent
Medicines, as Explained by One of Them,' in which
article it is asserted that the writer had heard a delegate
on the floor of the recent Medical Convention in this
city state in substance, ' That, by writing a prescription
for the same ingredients of which a patent medicine is
composed, the druggist makes a larger profit and gives
the doctor a rebate ; ' and, further, that he, the said wri-
ter, in a conversation with an Austin druggist, was in-
formed by said druggist that ' it is a common practice
for doctors to prescribe a small quantity of a patent
medicine and have it put up as a prescription, the drug-
gist charging a much larger price for this part of the bot-
tle thus dispensed than the whole bottle would be sold
for ; and by that means he made a larger profit, and gave
the doctor a rebate.' Or, in other words, that this
druggist stated, in effect, that doctors and druggists are
in collusion to rob their patrons.
"Resolved, That the statement that a delegate on the
floor of the recent Medical Convention in this city, at
any time during its sessions, made any such statement,
is false and libellous upon the medical profession ; that
members of the Austin profession, who were present and
heard all the discussion on the subject of patent medi-
cines, assert positively that no such statement was made
by any member or delegate at any time, and that no
language was used that could, by any honest interpreta-
tion, be so construed.
"Resolved, That the statement, by whomsoever made,
that any reputable physician in this city is, or has been
guilty of any such collusion as is in said article attributed
to them, is false and libellous ; and we assert that no
reputable physician asks, expects, or would receive from
his druggist any rebate or percentage on his prescriptions.
" Resolved, That the entire article is a misrepresenta-
tion of facts, and an unmerited insult to the entire medi-
cal fraternity of this city and State.
"J. W. McLaughlin, M.D., President Texas State
Medical Association ; T. J. Bennett, M.D., President
Austin District Medical Society; Q. C. Smith, M.D. ;
S. E. Hudson, M.D., President Travis County Medical
Society; R. M. Swearingen, M.D. ; F. E. Daniel,
M.D., Editor Texas Medical Journal ; A. N. Denton,
M.D. ; E. V. Hamilton, M.D. ; T. J. Tyner, M.D."
This resolution not only sets the Texas doctors all
right, but lays down the rules of a correct and advanced
ethics as regards doctors, druggists, patent medicines, and
rebates. The Statesman has been shown to be an erring
mortal and no better than a Populist ; the profession of
Texas has been vindicated, and the cause of morals
advanced. After a stir in Texas the air is always clearer.
20
MEDICAL RECORD
[July 7, 1894
UDexas of tfoe WSLwk.
The Number of Medical Students at the Paris Faculty
of Medicine has been steadily increasing until, from 384
new matriculates in 1885-86, the number has reached
719 in 1893-94. Despite this the size of the teaching
corps is not increased, and the students do not have suffi
dent personal instruction from the faculty. Unless
something is done, Paris will soon fall still further behind
as a great teaching centre.
Prunus Virginiana as a Heart Tonic.— There is yet
another drug which I venture to think may be unknown
to some of you. That is the prunus virginiana or Ameri-
can wild cherry. My attention was first called to it some
years back by an article in one of the journals by Dr.
Clifford Allbutt I can reiterate all that he says in
praise of the drug. It relieves the flagging and distended
ventricle of the chronic bronchitic, it stimulates the flap-
ping chambers of the anaemic, and it increases the mus-
cular tone in subjects recovering from fever and other
exhausting diseases. It is also givea with great advan-
tage in the irritable "convulsive" heart of the over-
worked man of feeble physique. It is especially useful in
dilatation of the right heart, whether as a result of
chronic bronchitis or of mitral stenosis. I use it more in
private than in hospital practice ; and perhaps no drug
has brought me so much credit. — Dr. Seymour Taylor,
in The Clinical Journal,
Discovery of the Bacillus of Acute Rheumatism.— A
number of the clinical features of acute articular rheuma-
tism have suggested to the minds of many the probability
that it belongs to the ever-growing class of infectious
diseases. Its acute onset and febrile and self-limited
course, its complications, and the frequent involvement
of the joints as a complication of many infectious dis-
eases, are regarded as supporting this theory. The care-
ful investigation of a typical case of the disease by Sahli
(Deutsches Archiv /. klin, Med., 1893, P- 451)* has
added the evidence of the bacteria themselves. Endo-
carditis, pericarditis, and pleurisy were associated with
the joint lesions. There was no suppuration. Bacterio-
logical examination disclosed the presence in all the
lesions of a micrococcus, identical morphologically and
culturally with the staphylococcus citreus, but of very
low virulence when inoculated into animals as compared
with it. As there was no ground to suppose a mixed
infection in this case, Sahli regards this germ as its ex-
citing cause. He is in doubt whether the germ discov-
ered is a distinct species, or whether it is merely a staphy-
lococcus citreus of degenerate virulence. He is inclined
to the latter view because of the frequent association of
rheumatism and endocarditis, whose intimate relation-
ship to the pyogenic cocci has been repeatedly shown.
A note appended to the report of this case states that in
several other cases more recently examined, similar cocci
of low virulence have been found.
In connection with this account, which is abstracted by
Dr. Ely in the American Journal of t lie Medical Sciences,
we may call attention to the statement of Dr. Edward
Grim of Putney (Lancet, May 6th), that he finds the
blood in acute rheumatism "charged with bacteria in
the form of minute cocci," which are easily stained by
a warm solution of methylene blue. We fear that Dr.
Griln is troubled with muscae volitantes. Dr. Lucatello,
of Genoa, has shown at the Italian Medical Congress of
1892, cultures of a micro organism which he obtained
from cases of acute rheumatism. The microbe was small,
round, and neither pyogenic nor saprogenic. Altogether,
the evidence is as yet insufficient to place acute rheuma-
tism among microbic diseases.
Another Plea for a National Bureau of Health.— The
Maryland Medical Journal says, editorially : " Once
more it seems necessary to arouse the profession to the
importance of using every effort for the passage of a bill
in Congress to form a National Bureau of Health. It is
only by united effort and by constant appeal to our rep-
resentatives in Congress that the end will be attained.
Not only medical journals, but the lay press of all parties
have made a strong fight for the establishment of this bu-
reau ; and in our commerce with other countries which
protect themselves by sending us their sick and diseased,
it is no more than right that we should defend this fair
country against disease and pestilence from without. In
addition there are filth diseases, like typhoid fever, which
spread and do incalculable harm and which, without re-
spect to state and municipal boundaries, spread from com-
munity to community, and it is for the better protection
against disease both from within and from without that a
bureau of health is needed. The general work of such a
bureau is shown in the proposed bill, which has already
been printed.1 '
The Idaho State Medical Society will hold its second
annual meeting at Boise, on Monday, Tuesday, and
Wednesday, September 10, n, and 12, 1894. The offi-
cers of the Society are : Dr. W. W. Watkins, of Moscow,
President ; Dr. C. L. Sweet, of Boise, Secretary.
Dr. Juan J. Ulloa, of San Josl, who was the official
delegate of the Republic of Costa Rica to the Pan-
American Medical Congress in Washington, has been
appointed Secretary of the Interior and of Public Im-
provements by the President of Costa Rica. Dr. Ulloa
is a graduate of the Medical Department of the Univer-
sity of New York, and after serving on the house-staff of
St. Vincent's Hospital, practised for a time in this city.
The Plague in Hong Kong is still on the increase ac-
cording to advices brought by the steamer Peru. Dur-
ing the week ending June 14th over seven hundred per-
sons died of the pest. Five British soldiers are among
the victims. The native inhabitants are fleeing from the
city, and it is feared will spread the disease through the
surrounding districts.
Dr. E. C. Seguin, of this city, has been elected a cor-
responding member of the Academie de Meclecine of
Paris.
Dr. Ezra M. Hunt died on Sunday last in Metuchen,
N. J., aged sixty four. He was a graduate of Princeton
College in the class of '49, and obtained his medical de-
gree from the College of Physicians and Surgeons in this
city in 1852. He was surgeon to one of the New Jersey
regiments during the war, and had previously lectured for
a number of years in the Vermont Medical College. Dr.
Hunt was very prominent in health matters in New Jer-
sey, and had been secretary of the State Board of Health
from the time of its organization in 1878.
July 7, 1894]
MEDICAL RECORD.
21
Jtactetg Reports,
and jftrogeotts.
75b>rf Triennial Meeting, held at Washington, D. C,
May 29, 30, 31, and June 1, 1894.
(Continued (com Vol. 45, page 799.)
AMERICAN LARYNGOLOGICAL ASSOCIATION.
Sixteenth Annual Meeting, held in Washington, D. C,
May jo, 31 y and June I, 1894.
First Day, Wednesday, May 30TH.
President's Address. — Dr. D. Bryson Delay an, of New
York, said that the object of his address was to review
the history of the Association, study the means by which it
had attained success, estimate its present, and finally in-
vestigate the methods by which its mission of usefulness
for the future might be most surely and successfully ac-
complished.
The history of the Association was intimately related
to that of laryngology, for Manuel Garcia was still living
and one of its Honorary Fellows. It was a pity that
Horace Green, who had been the actual leader of the
world in the study of diseases of the throat, should not
have lived to see the Association established. The lar-
yngoscope was said to have been introduced into this
country in i860. By 1878 its use was being taught in
twenty different institutions, and the specialty at first op-
posed by the general profession had gained a respectable
position. The American Laryngological Association was
formed in 1878. The motives which actuated its foun-
ders were eminently philanthropic and ambitious. The
society has been completely successful. Its meetings had
been held regularly, they had been well attended and the
scientific work done had been of a high order, and the
discussions have been remarkably valuable. Its fifteen
volumes of transactions were a great credit to it. They
contained over three hundred and thirty papers. Mean-
while ten years elapsed before the example of the Associa-
tion was followed. In 1888 the British Laryngological
Association was formed by Sir Morell Mackenzie, and
later associations have been started in France, Belgium,
Italy, and Holland. Local laryngological and rhinolog-
ical associations have greatly increased in numbers of
late years. The first of these was the New York Lar-
yngological Society, founded by Dr. Clinton Wagner in
r873, and since merged into the very successful Laryngo-
logical Section of the Academy of Medicine. Successful
local societies exist also in London, Berlin, and other
centres. The latest ones have been established in Phila-
delphia, and Buda Pesth. Wherever such societies and
associations have been established, their influence has
been elevating and inspiring, as shown in the improved
quality and amount of the scientific work done and in the
general tendency toward higher planes of professional
education and culture. It is satisfactory that this move-
ment should have been started, and at so great a distance
• in advance, in this country. The knowledge of this, how-
ever, should only serve as a spur to greater exertion on
our part.
The American Laryngological Association has always
held a leading place in the general and journalistic liter-
ature of the specialty, the Archives of Laryngology having
been one of the first special journals ever published. The
influence of the Association upon its members has been
stimulating and salutary and has resulted in great good
to many. The great function of the society in the past
has been that of a teacher. Herein lies its greatest hope
of usefulness for the future. It is a teacher of teachers,
and as such should not confine itself to laryngology alone,
but should pay some attention to the study of pedagogy,
as it relates to this department. This has always been
carefully considered by our Association as it relates to
undergraduate instruction. Of late a great advance has
been made in medical instruction in the establishment of
graduate schools. This movement, together with the
great increase in the literature of the subject, has given to
laryngology a startling popularity! and the multiplication
of the number of practitioners who assume to treat dis-
eases of the throat has been very great and has called
loudly for increased and improved facilities for instruc-
tion. This want has been met by the graduate school,
which, first started in New York, has become a recognized
factor in education all over the country. The greatly di-
versified nature of graduate students as to age, general
and special education, makes the problem of their suitable
instruction a difficult one. The theory of graduate in-
struction in this country is a triumphant success. How,
then, can we best attain the practical ends demanded by
it? The answer to this was first given by Dr. Elsberg,
the Association's first president, who was the first and
best to enter this field.
The most important factors in the improvement of
graduate instruction are : 1. A higher and more general
education on the part of the student 2. A modification
of the best undergraduate methods to suit the needs of
the older men. 3. More careful selection of instructors.
The future of the Association is bright and promising. It
has attained success in the past only by the exercise of
much labor and careful attention to its best interests.
It would be unwise to lower its standards in any way.
The dangers which threaten any such institution are —
lack of interest on the part of its older members ; the
multiplication of other societies ; and worst of all, the in-
troduction of politics and the desire of self-aggrandize-
ment. We cannot believe that such dangers can threaten
us so long as we live up to the principles upon which the
society was founded.
A great .change has taken place in late years in the
matter of special work, and larger numbers of men are
engaged in it than ever before. If, in this vast extension
of knowledge, our standards are to be lowered, and work
not of the worthiest accepted at equal value with the
best, the results will be disastrous to the advance of true
science. Such a calamity we are unable to foresee.
Outside competition will only stimulate to higher attain-
ment and higher skill, while from the vast body of new
aspirants must arise men who will penetrate still more
deeply into the hidden recesses of nature. With the
progress of science in our department the American Lar-
yngological Association is intimately associated and
largely responsible. It is to be hoped that it will respond
to the demands made upon it.
Nasal Polypus ; Its Association with Ethmoiditis and
Its Treatment by Resection of the Middle Turbinated
Body.— A paper with this .title was read by Dr. W. E.
Casselberry, of Chicago. An analysis of forty cases
confirms the view that nasal polypus is but a symptom or
concomitant of other nasal maladies, the most frequent
being various forms of ethmoiditis. Two previous papers
by the author are reviewed, in the first of which he ad-
vised a vigorous surgical treatment having for its object
first access to and then eradication of the actual seat of
attachment, most frequently in the immediate vicinity of
the hiatus semilunaris. For eradication of the attach-
ments, upward beneath the middle turbinated body, he
has recently substituted for the cautery point, before rec-
ommended, a small sharp curette with which the borders
of the hiatus and the bulla ethmoidals are well scraped.
In a supplementary paper in 189 1, he advised, as part
of the radical treatment, the removal of the antero infe-
rior part of the middle turbinated bone, in order to give
freer access to the actual points of development.
Additional experience with this operation has but con-
firmed its utility and demonstrated its harmlessness. The
middle turbinated body, a process of the ethmoid bone,
is rarely itself in a healthful condition in these cases, a
phase of the subject which is amplified in the present pa-
per. Furthermore, it appears from the cases reported as
typifying the various forms of associated ethmoid disease,
22
MEDICAL RECORD.
[July 7, 1894
that polypus is commonly one of the earliest prominent
manifestations of ethmoiditis, and resection of the mid-
dle turbinated bone, in addition to its efficacy for the
polyps themselves, is regarded as a prophylactic measure
against the development of the more serious suppurative
type of ethmoiditis and infection~of the maxillary, fron-
tal, and sphenoidal sinuses, by facilitating drainage from
the ethmoid cell?.
A clinical classification of the various conditions which
are found associated with and underlying the formation
of nasal polypus is deduced from the analysis of forty
cases, and a case typifying the characteristics of each
group is detailed.
Type I. — Nasal Polypus with Hypertrophic Rhinitis. —
This is characterized by simple enlargement of the inferior
and middle turbinated bodies and without evidence of
ethmoiditis other than the suggestiveness of the polyps.
Drainage is defective, and the accumulation of muco-
purulent secretion in the middle meatus seems to encour-
age polyp growth. Recovery without recurrence follows
removal of the polyps and reduction of the hypertrophied
turbinated bodies by the cautery. Only six of the series
of forty cases were of this type.
Type IF. — Nasal Polypus with Simple Myxomatous
Ethmoiditis. — This is characterized by great enlargement
of the middle turbinated bodies, which have a glistening
aspect and a pultaceous touch indicative of oedematous or
myxomatous degeneration ; pressure in the ethmoid re-
gion, productive at times of infra orbital swelling and
broadening of the base of the nose.
After resection of a considerable part of the middle
turbinated bone the muco periosteum of the parts of the
ethmoid bone thus exposed — the borders of the hiatus,
bulla ethmoidalis, etc. — is found in a state of myxomatous
degeneration and covered by polypoid excrescences, the
same extending upward into the ethmoid cells*
Fourteen of the series of forty cases were of this nat-
ure, and five of them were subjected to the operation of
resection of the middle turbinated bone?.
Type III. — Nasal Polypus with Vaso-Afotor Ethmoi-
ditis.— This is regarded as a variation of Type II., and
presents the same evidences of myxomatous degeneration
of the muco-periosteum of the ethmoid region. In addi-
tion, asthma was a universal symptom, which, to some
extent, influenced the grouping together of these particu-
lar cases, under the conviction that asthma of this variety
is caused by a similar vasomotor tumefaction of the bron-
chioles.
The group comprised nine cases, and four of them suf-
fered from hay fever, which further indicated the posses-
sion of a fundamental neurotic habit. They were all
affected by supersensitiveness to the extent that various
irritants, such as dust, coal smoke, fog, aroma from
horses, etc., would suffice at any season to excite a form
of nasal tumefaction suggestive of yaso dilatation, and in
most cases the ethmoid region seemed especially sensi-
tive.
Type IV. — Nasal Polypus with Suppurative Ethmoidi-
tis.— This is characterized by a purulent discharge from
the ethmoid- cells, co-existing frequently with empyema of
the maxillary, frontal, and sphenoid sinuses. It is regarded
as a sequel to Type II. or Type III., suppuration occur-
ring only after myxomatous tissue has accumulated suffi-
ciently to obliterate the natural drainage channels, which
view is substantiated by a case in which suppuration of
the frontal sinus occurred in conjunction with oblitera-
tion of its outlet. This group comprises six cases, of
which five were subjected to resection of the middle tur-
binated bone on one or both sides, in addition to other
measures.
Type V. — Nasal Polypus with Necrosing Ethmoiditis.
— Dr. Woakes' contention that nasal polypus indicated a
chronic inflammation of the ethmoid is in large meas-
ure substantiated ; but that necrosis or even caries of bone
is a " usual " accompaniment is not confirmed, so that it
would seem wise to limit the term "necrosing ethmoi-
ditis " to the class of cases in which necrosis or, at least,
caries, actually exists. Only five cases were accompa-
nied by unmistakable necrosis of bone.
Concerning the technique of resection of the middle
turbinated bone, the author has devised curved serrated
scissors with 'which to cut the bone for a variable dis-
tance backward, when the operation, if not complete,
can be finished by the snare or sharp forceps. The re-
section need not be completed at one sitting, but is more
often accomplished fragment by fragment, the latter
method alone succeeding when the middle turbinated
body is greatly enlarged and closely impacted within its
space.
Conversely if the middle turbinated body be of normal
contour and present no impediment to drainage, to the
transmission of light or instruments, there will then be no
occasion to interfere with it.
This paper was discussed by Drs. W. H. Daly, of Pittf-
burg; F. H. Bosworth, of New York; J. H. Bryan, of
Washington ; J. N. Mackenzie, of Baltimore ; F. W*
Hinkel, of Buffalo ; W. Peyer Porcher, of Charleston ;
J. C. Mulhall, of St. Louis ; Jonathan Wright, of Brook-
lyn, and C. C. Rice, of New York. These gentlemen all
agreed on the main features of their remarks. Over-
zealous surgery in the nose should be avoided. One case
of severe hemorrhage has resulted. In one instance, im-
mediately after removal of the turbinated, severe parietal
pain was felt in the head. The patient became demented
and died of cerebral abscesses. The heart could not be
examined at the autopsy and it is possible that the brain
lesions in this case came from a cardiac embolus, though
the patient had always been in the best of health previ-
ously. Acute cases of ethmoidal trouble will often sub-
side under local antiphlogistic measures ; but in the chronic
cases it is useless to expect a cure without radical opera-
tive procedure.
Papillary Hypertrophy of the Vasal Mucous Mem-
brane.— Dr. Jonathan Wright, of Brooklyn, N. Y.,
presented a paper entitled " Papillary Hypertrophy of the
Nasal Mucous Membrane Compared with a True Papil-
loma.'1 The writer stated that there was much confusion
in the literature of rhinology, from the loose use of the
term papilloma as applied to intranasal excrescences.
Hopmann has described a pathological formation, which
the Germans speak of as papilloma, but it is not true pap-
illoma at all. Such growths in the nose are rare.
Dr. Wright exhibited drawings illustrating the differ-
ence between the two conditions named in the title of
his paper. The nasal growth was removed from the mid-
dle of the inferior turbinated bone and the true papilloma
from the uvula. The latter consisted of a thick stem
with irregular sprouts, — some simply conical, springing
directly from the central stem, but the larger number
again divided into stems and sprouts, the whole looking
like a budding tuberous vegetable. A drawing of the
nasal growth showed a symmetrically rounded mass,
divided by cross lines into more or less regular portions
resembling the "mulberry" hypertrophy, so frequently
seen on the posterior ends of the inferior turbinated
bones. The mass was sessile, but movable, and removed
by a cold snare. Although the operation was prolonged
over nearly an hour, severe hemorrhage resulted three
hours later. As contrasted with the true papilloma, al-'
most any fold of the nasal specimen communicated with
the central mass, without any appearance of a " budding "
process. The line of surface epithelium was not espe-
cially thickened or irregular. The papilloma was without
glands, had only small capillaries, and a slight branching
framework of connective tissue. The latter was covered
everywhere by a large number of regularly situated layers
of flat, epithelial cells. The papillary hypertrophy con-
sisted of all the constituent parts of the mucous mem-
brane of the inferior turbinated body. The dilatation of
the venous sinuses was especially marked. Glands were
present, but scanty. The fibro-connective tissue was
greatly increased. This, at the periphery, was divided
into regular processes covered by epithelium, and sepa-
rated from each other by depressions giving a nodular
July 7, 1894]
MEDICAL RECORD.
23
surface. These growths are papillary hypertrophies of
the erectile bodies of the inferior turbinated bones.
These enlargements result from a continuous and exag-
garated contraction and dilatation of the sinuses in a
stroma deprived by chronic inflammation of much of its
elastic and muscular structure.
Metallic Electrodes in Nasal Disease. — Dr. C. C.
Rice, of New York, next read a paper entitled " The
Use of Metallic Electrodes in Nasal and Post-Nasal Dis-
ease," His plan of treatment is to make the positive
electrode of the circuit of some such substance as copper.
When the current passes, the metal is dissolved, and a
new metallic salt, the oxychioride of copper, is formed
and earned through the tissues by kataphoresis. Allu-
sion was made to the experiments of Gautier, Morton,
Cleaves, and others along this line* There was no proof
that the action of the salt was germicidal. It was claimed
that the new salt was actually carried into the tissues,
that it was in this way more efficient than a solution of
the substance applied to the surface, and that the patho-
logical foci, being beneath the surface, were thus more
effectually reached. Part of the advantage was undoubt-
edly derived from the current itself and from its own
electrolytic action upon the tissues. He had found the
treatment especially satisfactory in various forms of nasal
disease where, succeeding the removal of all offending
material, there was a continuous hypersecretion. En-
larged turbinates could be punctured with a copper nee-
dle, the negative electrode being a flat sponge on the
nape of the neck. Succeeding the current was a tempo-
rary coryza, which usually disappeared in twenty-four
hours. He had found the copper needle preferable to
the cautery in epistaxis from eroded spots on the nasal
septum. Out of twenty cases of these various ailments
he had cured six, and benefited fully three quarters of
the remainder. Paper discussed by Drs. Wright, A. W.
de Roaldes, of New Orleans, J. O. Roe, of Rochester,
Daly and Casselberry. All these gentlemen were unan-
imous in doubting the accuracy of the various mille-
amp£re metres which are necessarily used in the foregoing
electrical procedure, and doubt was also expressed as to
the distinct effect of the metallic salts as apart from the
general stimulating one of the current itself.
ASSOCIATION OF AMERICAN PHYSICIANS.
Ninth Annual Meeting, held in Washington, D. C, May
29*30,31, and June 1, 1894.
Second Day, Wednesday, May 30TH.
Modification, Temporary and Permanent, of the Phy-
siological Characters of Bacteria in Mixed Cultures.
— Dr. Theobald Smith, of Washington, D. C, read
a paper with this title. The variability of species of
bacteria is a most important subject. The changes in
virility by passing through animals, and by heat or chemi-
cal agents, are well known. The objects of these studies
are to determine the modification of bacteria when grown
in mixed cultures. In 1890 the accidental association of
proteus vulgaris with a pathogenic bacillus (B. cholera
suis) in an agar culture produced, within a few months,
a very marked reduction of the pathogenic powers of the
latter. Repeated trials with mixed cultures confirmed
this observation. A return of the original virulence of
the pathogenic species was noted after it had been culti-
vated by itself; but this return was preceded by a pro-
longed period of attenuation, lasting in one instance
about nine months.
These results suggest the possible modification of patho-
genic and aprophytic species in the soil by similar agen-
cies. They also throw some light on the extent of the
mutually destructive action of different species accident-
ally vegetating together. Dr. Smith detailed at length
his experiments. He grew the bacilli of hog cholera
alone, and mixed with the proteus vulgaris. He also
maintained a pure culture of the proteus. The result
upon the proteus of growing in conjunction with the hog-
cholera bacillus, was the evolution of a variety resembling
the proteus mirabilis and proteus Zenkeri of Hauser.
Dr. Sternberg, of Washington, said that a few years
ago every bacillus that differed a little in its action was
considered a different species. Now we know that many
are varieties of each bacillus. Whether the variations go
so far as to produce species which will not revert, we do
not know. He said that he had been much misled by
this during his studies in Cuba.
Dr. William H. West, of Baltimore, said that the
tendency now was to identify species of bacilli by mor-
phological rather than by physiological characteristics.
He said that the hog-cholera bacillus in 'the laboratories
of Germany was probably a different species from that
which had been under observation in Baltimore. He
considered Dr. Smith's contribution valuable.
Dr. Smith closed the .discussion.
The Effect of Various Metals on the Growth of
Pathogenic Bacteria.— Dr. Meade Bolton, of Balti-
more, said that some metals seem to have no influence
upon the growth of the bacteria, while others have a more
or less marked inhibitory action, as shown by a broader
or narrower clear zone around the pieces of metal on
plates otherwise crowded with colonies of bacteria. Just
outside the clear zone, whether this is broad or narrow,
there is, in nearly every case, a zone of intensified growth
where the colonies are thicker than on other parts of the
plate.
In the few tests as yet made for this purpose, there was
entire absence of living bacteria in the clear zones. In-
oculations from the clear zones remained sterile.
In some cases there are three zones around the metals,
viz. : A clear zone immediately surrounding the metal ;
a zone of intensified growth, arid a second narrower zone
where growth was inhibited. It has been possible to de-
tect in the medium, by chemical reagents, the presence
of traces of those metals that exert inhibitory power.
The solution of the metals in the nutrient medium takes
place independently of the growth of bacteria, as it is
possible to detect the presence of the metals in sterile
media in which they have been placed, after they have
lain for a few days, at any rate. A discoloration of the
medium surrounding the metal, often makes a special test
unnecessary.
Some metals have a much more powerful inhibitory
action than others, as is shown by the broader clear zone.
There is also some difference in the different bacteria
with one and the same metal.
Some of the metals that have been tested were abso-
lutely pure; others were commercial metals, marked
chemically pure, and a few were either impure or alloys.
Silver has a marked action. Hence silver wire sutures
are less apt to give stitch abscesses than sutures of other
material.
Votes on the Observation of Malarial Organisms, in
Connection with Enteric Fever. — Dr. W. Gilman
Thompson, of New York, called attention to the possi-
bility of a double infection with malarial and typhoid
germs. A typical case of typhoid fever lasting fifty- five
days, with eruption, tympanites, and hemorrhage from the
intestine, complicated by chills and hyperpyrexia, during
the third week, with appearance of malarial organisms.
Two other typical cases of enteric fever, with the obser-
vation of malarial organisms, which appeared in connec-
tion with chills during convalescence. Rarity of the
mixed infection in the vicinity of New York, which is
common in the South.
Dr. Osler, of Baltimore, said that chills in typhoid
were common apart from malaria. He exhibited a chart
of the only case of this mixed infection that had been
seen at the Johns Hopkins Hospital. He related a case
of mixed infection of pneumonia and pneumia.
Dr. F. P. Kinnicutt, of New York, related a case which
was mistaken for typhoid, but which was proved to be
malarial.
Dr. G. L. Peabody said that chills in typhoid were
sometimes pyaemic, and these were of more importance.
24
MEDICAL RECORD.
[July 7, 1894
He believed that the frequency of " typhomalaria " was
exaggerated by many.
Dr. E. G. Janeway, of New York, said that he had
often seen chilis in typhoid due to the administration of
antipyretics.
Dr. Sternberg, of Washington, said that the so-called
"typhomalaria" was not such as was shown by the
author, but cases which, being mistaken for malaria,
afterward turned out to be typhoid. The physician, to
save his reputation, added his final diagnosis to his pro-
visional diagnosis.
Dr. J. C. Wilson, of Philadelphia, said that the name
"typhomalaria" was unfortunate, in that it interfered
with prophylaxis in typhoid cases.
Dr. J. H. Musser, of Philadelphia, reported a case of
mixed infection of scarlatina, measles, and intermittent
fever.
Dr. H M. Lyman, of Chicago, and Dr. W. T. Coun-
cilman, of Boston, reported cases bearing on the subject.
Dr. F. C. Shattuck, of Boston, said that chills in
typhoid might be due to phlebitis of inaccessible veins.
Dr. J. C. Reeves, of Chattanooga, believed in a fever
intermediate between typhoid and malaria.
Dr. George Dock, of Ann Arbor, had made autopsies
on many cases of typhomalarial fever, and had found
typhoid lesions.
Dr. Thompson closed the discussion by emphasizing
the importance of examining the blood of fever patients
for malarial organisms.
Experiments in Artificial Melanosis. — Dr. George
Dock, of Ann Arbor, Mich , read a paper with this title.
Investigations in cases of malarial fever with great pig-
mentation, show some departures from the changes that
have been described as the result of injecting finely pow-
dered substances (cinnabar) into the circulation. The
object of the present series of experiments was to control
the older observations, and to observe especially the
behavior of the various kinds of leucocytes, as known by
modern methods, to the foreign bodies. The animals
used are dogs and rabbits ; the substance injected, lamp-
black suspended in normal salt solution. At this time
the experiments are not finished, but have gone far
enough to say that the changes found are not identical
with those in malaria. The greatest difference is the
slight participation of the macrophages in the experi-
mental cases, as compared with malaria. The other ob-
servations as to the localization of the pigment were con-
firmed.
Some of the Chemical and Bacteriological Charac-
teristics of Milk.— Dr. Thomas M. Rotch, of Boston,
dwelt upon the importance of reaction in milk, in infant
feeding. By feeding cows on sugar-beets in addition to
other food, the milk was rendered alkaline. Alkaline
milk is more like human milk than that usually obtained.
Cows milked under antiseptic precautions gave the fol-
lowing results : First half of milking showed bacilli.
Milk drawn with a sterile cannula was practically sterile.
Hence the conclusion is drawn that the bacilli came
from the tract between the udder and the end of the
teet. In this way sterile milk is obtainable.
Dr. F. Forchheimer, of Cincinnati, O., Said that the
extreme importance of the subject merited further investi-
gation.
Dr. T. Smith, of Washington, agreed with the author.
Dr. Rotch closed the discussion.
MEDICAL SOCIETY OF THE STATE OF PENN-
SYLVANIA.
Forty-fourth Annual Session, held in Philadelphia, May
IS, 16, and 17, 7894.
First Day, Tuesday, May 15TH.
The Society was called to order by the president, Dr. H.
G. McCormick, of Williamsport, Pa. After an opening
prayer by Rev. A. B. Philputt, an address of welcome was
given by Hon. Edwin S. Stuart, Mayor of Philadelphia.
He recalled the fact that the first hospital for the treatment
of the sick was inaugurated in Pennsylvania on the appli-
cation of Benjamin Franklin, and was erected in Phila-
delphia, and from that time until now it has been doing
excellent work. The first medical school and the first
school of anatomy were also located in Philadelphia.
Some time ago the city contained many colleges which
were a disgrace to it, but those have now been wiped out,
The address of the Mayor was followed by one of
welcome by Dr. E. E. Montgomery, of Philadelphia,
chairman of the Committee of Arrangements.
Reports were made by the secretary, Dr. William B.
Atkinson, and the Treasurer, Dr. G. B Dunmire. Dr.
Atkinson said there were now fifty county medical soci-
eties in good standing, and that the State Society had
at present two thousand five hundred members. The
treasurer reported a total of $4,122.24 received for 1894.
and expenses amounting to $2,423.45.
Dr George M. Gould then presented a resolution
calling upon the Legislature of Pennsylvania to adopt the
law for the prevention of blindness in infants, recom-
mended by the Committee of the Section on Ophthal-
mology of the American Medical Association adopted by
the Legislature of the State.
Address in Surgery. — Dr. G. D. Nutt said success in
many operations is often modified by the time when and
place where such operations have to be performed. A
great responsibility rests upon the family physician in
many of those diseases of a purely surgical nature or
tending that way. He is usually the first to see these
cases ; and unless an early surgical consultation is called,
the time may pass when an operation can be safely
performed. Many fallacies are taught in our text-books
that have been proven false by modern surgery, which
the general profession are slowly but surely accepting.
Modification of PirogofTs Amputation. — Dr. F. Le
Moyne read a paper with this title, advocating the pres-
ervation of the malleoli and the excavation of the retained
section of the calcis at a point to correspond with each
malleolus, with the object of gaining about three- fourths of
an inch in the ultimate length of the limb, and procuring
more accurate and permanent coaptation.
Psoriasis. — Dr. George V. Shoemaker showed cases
illustrative of the etiology of psoriasis. Two of the cases
were frankly rheumatic, two probably of arthritic ten-
dency, and the fifth was the subject of chronic gastro enter-
itis. Dr. Shoemaker explained that psoriasis is often excited
by the presence of rheumatism or gout, while in other cases
it depends upon chronic disturbance of the digestive or-
gans, disease of the liver, disorders of the blood, and mal-
adies of the nervous system. He also explained that the
appearance of the papules, patches, and scales, is charac-
teristic and typical, whatsoever the cause. The facts re-
lating to its etiology are most significant guides to treat-
ment. In each case we must endeavor to ascertain the
origin. Though the lesions present exactly the same ap
pearance, the therapy must obviously differ in accordance
with the etiology, and routine treatment of psoriasis is an
impossibility. The defects of digestion and nutrition
must be corrected; constitutional and approximately
specific remedies must be administered, or the state of the
nervous system must be improved. The habits of the diet
must be regulated or changed. The Doctor asserted that
ingestion of thyroid glands is a mode of therapy service-
able in certain cases. The grand principle of treatment
is to determine the origin of each case. Acting upon
this belief the Doctor lays comparatively little stress upon
topical treatment. Dr. Shoemaker said that increasing
experience convinced him that accuracy in tracing the
genesis of the'disease pointed to an internal therapy, upon
which could be placed the reliance of the profession more
firmly than upon local measures.
Organic Stricture of the Urethra. — Dr. Orville Hor-
witz, in a paper with this title, called attention to the fact
that dilatation should be employed in all cases of recent
strictures which are dilatable, occurring in any portion of
the urethra, and which are not either resilient, irritable,
July 7, 1894]
MEDICAL RECORD.
25
or nodular. This treatment is by far the safest in persons
suffering from disease of the heart or kidneys, or diabetics
who are broken down in health, who are suffering from
debility, or who are advanced in years.
Continuous dilatation was recommended as an adjunct
to other more radical means of treatment. It should be
employed in tight strictures of the membranous portion
of the urethra, complicated with retention of urine, and
in those cases where the stricture is of small calibre, when
located in the fixed portion of the canal ; the patient is
thus enabled to pass water with sufficient ease to allow
him to be prepared for ladical operation.
Modified rapid dilatation was advised for the treatment
of filiform strictures, situated in the neighborhood of the
bulbous and membranous portions of the canal, which
are neither irritable, nodular, nor resilient, and which
cannot be treated by gradual dilatation.
Internal urethrotomy should be limited to well-organ-
ized strictures, situated within from three and a half to
four inches from the meatus.
Strictures at the meatus, or in the neighborhood of
the fossa naviculars, should be divided on the floor of the
urethra, especially if they give rise to reflex symptoms.
Dilating internal urethrotomy should be limited to
strictures that are well organized and of long standing,
within from three and a half to four inches from the
meatus, which are nodular or resilient.
This operation should not be performed on those who
suffer from impotence, neurasthenia, nocturnal emissions,
or sexual hypochondriasis.
In these cases ordinary internal urethrotomy, by the
Gross instrument, is advised. Combined internal and ex-
ternal urethrotomy is commended in nodular strictures
of the penile portion of the urethra, and in strictures of
the bulbous portion of the canal. External and internal
urethrotomy, with or without a guide, is advised under
the usual conditions.
Electrolysis was not recommended.
Cramming in Medical Schools. — Dr. Oscar H. Allis,
surgeon to the Presbyterian Hospital, stated that the
lengthening of the term of study of medical schools had
increased the number of professors, many of whom were
not authors, and this made note taking indispensable.
That as there was no time for the student to do this, it
made it imperative that he place himself under a quiz
master throughout his entire course. That between lect-
ures, laboratory work, hard work, demonstrations, clin-
ics, and quizzing, he must put in between sixty and
seventy hours a week. The average class room work in
schools, colleges, and seminaries, he said, was three hours
a day for five days. The speaker complained that men
in medical schools were compelled to take a three or four
years' course, spend hard-earned or borrowed money for
lectures and maintenance, and be " plucked " at the last
moment. Every man in the seminary or school who is
diligent and moral gets his degree. Ten per cent, of
the medical students fail. If a rigid entrance examina-
tion were instituted, many of those who fail would be
arrested at the outset.
It was urged that some return should be made to those
who fail ; that if medical schools were compelled by law
to return the fees for instruction, the number of gradu-
ates would not be diminished, but the ten per cent, who
now fail would stand on a different footing. Such a
course would compel medical schools to compare their
requirements, their methods, and courses of study, with
other institutions of learning. In literary institutions
class-room work counts more than final examinations.
In medical schools the professor knows little of the stu-
dent, classroom work has little influence, and the final
examination decides the fate of the applicants. Dr. Allis
declared that good, faithful men are thus often sacrificed.
Second Day, Wednesday, May i6th.
Election of Officers. — The session was called to order by
the president, and the report of the Committee on Nom-
inations was announced as follows : President, John B.
Roberts, of Philadelphia ; First Vice-President, Dr. S.
C. Stewart, of Clearfield County; Second Vice President,
Dr. J. A. Lippincott, Allegheny County ; Third Vice-
President, Dr. J. H. Wilson, Beaver County; Fourth
Vice-President, Dr. R. Armstrong, of Clinton County;
Secretary, Dr. William B. Atkinson, of Philadelphia;
Assistant Secretary, Dr. H. G. Chritzman, of Franklin
County; Treasurer, Dr. G. B. Dun mire, Philadelphia
County ; Delegates to New York State Medical Society,
Dr. I. W. Groff, Montgomery County ; New Jersey So-
ciety, Dr. C. A. Rahter, Dauphin County; Maryland
Society, Drs. A. C. Wentz, of York, and P. R. Kcons, of
Cumberland County.
Address in Medicine. — Dr. W. S. Foster, of Pitts-
burg, read the annual address in medicine. He said that
recent advances in medical practice have been the crys-
tallization of therapeutic measures by slow processes as
compared with the picturesque leaps and bounds that
have characterized surgical practice, and that tuberculin
and cerebrin have been equally fatuous attempts at rapid
advance ; the first, a legitimate and therapeutic attempt,
the last, a palpably fraudulent scheme. The recurring
popularity of calomel and other mercurial compounds and
renewed use of digitalis in the continued forms was com-
mented upon. Pure oxygen was recommended as wor-
thy of trial in pneumonia where the respiratory area is
greatly encroached upon. The routine use of antipyret-
ics was condemned as irrational. In the use of anaes-
thetics, Syme's principles were mentioned as bein£ again
recognized as the correct ones for the guidance of the
physician. Ether was declared equally as dangerous as
chloroform, while its after-effects upon the emunctory
organs, it was asserted, make it an agent to be used with
the greatest caution.
Christian Science in its Eolation to the Medical Pro-
fession.— Dr. Hildegabde H. Longsdorf, of Carlisle,
read a paper with this title. The subject, he said, was
more important than it might at first sight appear, even
contemptible, yet from the proneness of the uninformed
to exaggerate and mystify disease all remedial agen-
cies carry with them an overpowering influence, and to
the younger practitioner especially are baffling and vexa-
tious. Christian science wss probably the most preten-
tious and certainly the most successful of the outgrowths
of our modern high- pressure civilization, which, not con-
tent with its acknowledged empire over material nature,
must enter the realm of psychological phenomena and call
upon a too credulous public to believe what it cannot ex-
plain and revere what it cannot comprehend. There
have been many such mock systems in former years.
Christian science, however, goes a step beyond any of its
forerunners, is one shade finer and more plausible in its
theory, and more conspicuously successful than any simi-
lar intellectual epidemic the world has ever witnessed.
These fatuous misbeliefs are the intellectual scandal of
the age, and it becomes a puzzling question how to re-
gard those who honestly believe in them, and what
should be the attitude of the physician toward those who
aspire to the office of healer.
If it were not for the fact that the doctrine is rapidly
spreading, gaining friends and influence among the most
intelligent classes, the subject might well be dismissed
with a smile as one more of the numerous phases in
which the ever- restless mind has manifested itself. But
it has a vast and increasing power, and not only among
the uneducated. It has its representative literary jour-
nals, and an array of special agents or missionaries, a
respectable showing of institutions or metaphysical col-
leges, and a vast number of private establishments for the
cure of every disease under the sun.
The question arises, how are we to regard it and how
we are to be armed against its inroads ? It would be out
of place to argue against mental cures, and it would be
idle to deny the power of mind over the body, but the
fact remains that the process cannot be rationally ex-
plained so that the subjects of it can clearly understand it.
26
MEDICAL RECORD.
[July 7, 1894
Consequently, in endeavoring to maintain our profes-
sional self respect we are in danger of becoming illiberal,
narrow minded, and dogmatic. The importance of some
definite restraining force for these abuses can scarcely be
overestimated, and if public opinion and the advanced
philosophical science of our era have been powerless to
effect this, it would seem to come into the province of
legislative enactment.
Should the Journal of the American Medical Associa-
tion be Used to Promote Quackery ?— Dr. S. S. Cohen
read a paper with this title, which was an arraignment of
the trustees of the Journal of the American Medical As-
solution for persisting in publishing advertisements of
secret nostrums, contrary to the unanimous resolution of
the association in 1892.
After D:. Cohen's remarks a series of resolutions for-
wirded to the State Medical Society by the Philadelphia
County Medical Society, urging that action be taken to
have such unethical advertisements excluded from the
fournil of the American Medical Association were dis-
cussed. These resolutions have all been printed in vari-
ous journals to which they were sent at the time of their
original adoption by the Philadelphia County Medical
Society.
Dr. Thomas then offered a resolution, which was
adopted, that the resolutions of the Philadelphia County
Medical Society on this subject be sent to each trustee
of the Journal and that the delegates of the Society be in-
structed to present them at the meeting of the American
Medical Association in San Francisco next month, and
that the trustees be informed that it is the sense of this
Society that they would prefer to have the publication of
the Journal discontinued if the money received for such
improper advertisements is requisite for its continu-
ance.
A resolution was adopted also to the effect that if the
funds of the association will not permit the Journal to
be published without a violation of the code of ethics,
the trustees cease it publication.
Croup and Diphtheria.— Dr. B. H. Detwiler, of
Williamsport, spoke of the pathology and treatment of
membranous croup and dwelt largely on the importance
of an early diagnosis of it from the croup of diphtheria.
Dr. Detwiler asserted that diphtheritic croup has a mor-
tality of sixty to eighty per cent, and that the phlogistic
treatment which he advised had absolutely no mortality
record. He dwelt upon the duality of the two diseases,
making the anatomical construction of the ciliated epi-
thelium tissues of the vocal dorus and the squamous epi-
thelium of the pharynx and fauces and their inflamma-
tory products the diagnostic signs of duality. His plan
of treatment is to produce free depletion by leeches after
cyanosis begins, with revulsion by cantharidal blisters and
calomel in quarter-grain doses every half hour till the
spinach stools are voided.
The Operative Treatment of Muscular Asthenopia
(Heterophoria). — Dr. Charles Hermon Thomas read a
paper with this title. A number of illustrative cases were
reported which showed the extremely varied character of
the symptoms and the favorable results of operation.
The subjective symptoms of asthenopia show almost no
distinct characteristics pointing to their origin, whether
refractive or muscular ; the same headaches and the same
sense of eye strain are complained of under both condi-
tions. Graduated tenotomy (partial) is practicable and
efficient because of the elasticity of the margins of the
tendons. Muscular asthenopia may present symptoms of
all grades of importance, from the slightest to the most
serious. As in refractive, so in muscular asthenopia the
gravity of the symptoms bears no constant relation to the
amount of the physical defect or muscular error. As
much — and very much the same kind of — relief is to be
expected from the correction of muscular anomalies as
from the correction of errors of refraction and accom-
modation, as might be expected from the similarity in
the symptoms. The muscular condition in every case
should, as a matter of routine, be as carefully investigated
as are the media, eye ground, the refraction, and the am-
plitude of accommodation.
An Epileptic Colony. — A resolution was offered and
ad?pted that it is the sense of the Medical Society of the
State of Pennsylvania that an epileptic colony should be
established for the benefit of those epileptics whom the
commonwealth is obliged to support, and for others sup-
ported by their friends. Copies of this resolution to be
sent to the governor, speaker of the House, and presi-
dent of the Senate, and to the president of the State
Board of Charities.
Dr. H. G. McCormick, president of the State Board
of Examiners representing the Medical Society of the
State of Pennsylvania, announced that the first examina-
tion under the new law for license to practise in Penn-
sylvania would be held on June nth, in Philadelphia
and Pittsburg respectively, the same questions being
given to all applicants at both cities.
A resolution was adopted urging Congress not to dimin-
ish the usual appropriation for the support of the Library
of the Surgeon General's Office at Washington.
Address on Mental Diseases.— Dr. T. M. T. Mc-
Kennan, of Pittsburg, read the Annual Address on Men-
tal Diseases. A statement was made of the progressive
advancement in hospitals for the insane, and especially
in the education and training of nurses. The toxic ori-
gin of many of the insanities was dwelt upon and espe-
cial attention called to auto intoxication as a factor in
the etiology of insanity. The influence of gynecological
operations and pelvic diseases in women in causing in-
sanity were touched upon. The relation of syphilis to
general paralysis of the insane was dwelt upon, and the
great probability, amounting to almost positive proof, of
the syphilitic origin of general paralysis. Trianol and
duboisine were spoken of as two new hypnotic agents of
value, and electricity as a valuable therapeutic agent.
Studies in Obstetrics and Gynecology. — Dr. Anna
M. Fullerton in this paper presented her views as to
the most frequent causes of pelvic disease, and the re-
sultant decrease in the child-bearing capacity of civilized
women. The opinions advanced were founded upon the
observations made by her during eight years of service
as physician in charge of the Woman's Hospital of
Philadelphia. The teaching that the majority of pelvic
diseases are of microbic origin was upheld ; and the vul-
nerability of the woman of the day to such diseases was
shown to be the result of general debility of all the tis-
sues in consequence of the physical and mental strain
induced by the habits and requirements of modern life.
The remedy for this evil was felt by the writer to lie
in a clearer understanding of the laws of reproduction as
affected by the changed conditions of civilization ; and
especially in the higher education of women, in order to
give them a proper appreciation of physiological and
educational laws, and thus better fit them to act as guard-
ians over the pre natal as well as the post natal influences
affecting the well-being of the child.
Whooping-Cough. — Dr. W. C. Hollopeter spoke of
the need of a specific for this specific disease, for as such
he regards it. He said that by most authorities this dis-
ease was regarded as the most fatal of all the diseases of
children under one year of age. This fatality is not
limited to the first year of life, but continues to mani-
fest itself long after this period in broken health of all
kinds referable to the respiratory, intestinal, as well as
the various glandular organs. The speaker placed con-
siderable value on the peculiar puffiness of the mucous
membrane of the eyes and the swollen or (Edematous
condition of the whole of the face, almost dusky ; this
condition may exist for days before the catarrhal symp-
toms have extended throughout the respiratory mucous
membrane. The cough at this stage may not be at all
suggestive — it may be, in fact, purely bronchial. This
symptom of fulness about the eyes, which is quite as con-
stant in measles as in pertussis, and with measles it is close-
ly associated and must be differentiated. As measles are
diagnosed by the appearance of the eruption first on the
July 7, 1894]
MEDICAL RECORD.
27
hard palate, so, he contended, whooping-cough may be
diagnosed in its earliest stage by the characteristic swol
len condition of the eyes and face. He insisted upon
this factor as of the greatest importance, as its recogni-
tion will enable the physician to institute specific" treat-
ment early, when the disease is yet local and may be
brought more speedily under control. The drugs he has
found most efficient in the catarrhal stage have been
hydrogen peroxide in sterilizing the naso-pharynx, and
assafcetida occasionally used for the paroxysms. Bella-
donna also is to a high degree beneficial in young chil-
dren, and should be placed first. This he pushes until
toxic effects are secured, when less suggestive characteris-
tics of the cough are observed.
Amputation near the Ankle. — Dr. G. G. Davis, of
Philadelphia, showed four cases of amputation in the
neighborhood of the ankle as] a protest against abandon-
ing these operations in favor of amputation below the
knee. The first case was a Chopart amputation of thir-
teen years ; never any trouble wearing a shoe made by a
common shoemaker. The second was a Chopart with
apparatus, showing no deformity, and walking well with
scarcely a perceptible limp. The third was a Pirogoff
with apparatus, walking well. The fourth was a double
amputation in a man weighing two hundred and twenty
pounds. One leg was removed below the knee — seat of
election — and the other a Pirogoff. The patient stated
that the Pirogoff was much the more satisfactory.
It was held that in none of these cases would their
condition have been improved by an amputation high up
on the leg.
Third Day, Thursday, May 17TH.
Address on Hygiene.— Dr. J. H. Wilson, of Beaver,
read the Annual Address on Hygiene. He spoke of the
reduction in the amount of sickness, and attributed it to
the increased number and improved efficiency of the
boards of health. In speaking of the practice of free
school supplies prevalent throughout the State, Dr. Wil-
son said : There is not a pretence to give the scholars
the same books and pencils as the day before, and from
the habit of children chewing lead-pencil*, diphtheria
and other diseases may be transmitted. There should be
some method of disinfecting the books. It would be
much better for the child to be supplied by the parent
than to take the risk under the present method. Some
school boards need to be taught that foul air is heavier
than pure air and cannot be gotten rid of by ventilators
at the top of a room. Dr. Wilson went on to speak of
the physician's duty in instructing those of the masses
who come under his care in the simple laws of hygiene,
such as removing all the day clothing when retiring for
the night, and washing the entire body every day.
Electricity, he said, is becoming recognized as a sci-
entific agent. It has been experimented with in puri-
fying atmospheric dust and in disinfecting sewage. In
speaking of tuberculosis, Dr. Wilson said : The annual
mortality by this disease in this country is 165,600, or
an average of 450 a day. Dr. Fletcher's labors in this
city have attracted much attention. He has proven that
certain residences in this city, in the Fifth Ward, are in-
fected by this disease. In the discussions which followed,
Dr. William P. Munn, of Denver, said : We have in
Denver a house to-house inspection, conducted by a
trained sanitary inspector. The inspection consists not
only of the house and its immediate surroundings, as the
pavements and the alleys and sewers, but also the habits
of its inmates. The results of these inspections are classi-
fied and indexed in a manner similar to cards used in
libraries. Anyone contemplating buying a house can
go to the Health Board and have this information spread
out before him, and see the condition of the house.
Many people are in this way saved by the records of the
Health Department from buying infected houses. " And,
in many instances, negligent landlords, knowing that
their properties will not be rented while they are down
in the health records as bad, have them put in a health-
ful condition. "
Prophylaxis in the Treatment of Tuberculosis. — Dr.
Lawrence F. Flick, of Philadelphia, in his paper with this
title, asserted that a most valuable lesson taught by the
organic theory of tuberculosis is prophylaxis in the treat-
ment of the disease. Tuberculosis is strictly a parasitic
disease. In nature's effort to get rid of the parasite, re-
infection is liable to take place.
Were it not for reinfection, all cases of tuberculosis
would get well. The disease is really a series of invasions
of the organism producing it.
The prevention of auto-inoculation gives the key to the
treatment of this disease. In so far as this can be ac-
complished, treatment is successful, and no farther.
Auto-inoculation can be controlled in two ways : by
building up the system of the patient so as to enable it to
resist new deposits, and by preventing the readmission of
the organisms into the system.
Strychnine in Pulmonary Consumption. — Dr. Thomas
J. Mays, of Philadelphia, in his paper with this title, claims
that, next to rest and food, strychnine in large doses is
the most important agent in the treatment of pulmonary
consumption. Begin with -fa of a grain, and gradually
increase to ^V, -jV, or J of a grain, or even give it in
larger doses, four times a day. According to the author
it does not produce albuminuria or diabetes, as is gen-
erally supposed. It alleviates the loss of appetite, the
vomiting, the constipation, the nervousness, and sleep-
lessness, the pain in the chest, the cough and expectora-
tion, the dyspnoea, the weakness of the heart, and acts as
a blooi-builder in an eminent degree. Its usefulness
rests on its influence over the nervous system, and is an-
other link, the speaker said, in the chain of evidence,
which shows that, in the great majority of cases, pulmo-
nary consumption is the direct result of primary disease of
the pulmonary nerve-supply.
Tubercular Meningitis. — Dr. Daniel Longaker, ot
Philadelphia, in a short paper emphasized the frequency
of tuberculosis of the mediastinal glands ; the occasional
dissemination of acute tuberculosis from such foci, some-
times general, but usually more limited — in the case in
question, to the cerebral meninges and the spleen. It
may be latent, but frequently causes long-continued
cough, and such cough, if associated with even slight im-
pairment of the general health, should be looked on with
suspicion. In adults the general health may be perfect.
It must be regarded as a menace to the life of the indi-
vidual, although under favorable conditions it produces
no harm in the majority of cases. A mass of authiakosis
in the cheesy gland, near the bacilli, seemed to prove in-
halation as the origin of the disease.
Colorado Climate for Consumptives. — Dr. Wm. P.
Munn, of Colorado, said that tuberculosis of the lungs is
curable. He spoke of climatic environment as the great-
est factor in the battle of the human organism against
micro organism. He said that the climatic advantages of
Colorado are: 1. Its low absolute and relative humidity.
2. Rarity of atmosphere dependent upon altitude. 3.
Sunshine. 4. Cool and equable temperature.
The great majority of cases of consumption if sent to
Colorado, will recover, if only sent early. Hemorrhagic
types of the disease are especially benefited. Residence
in Colorado should be permanent, if possible, but in no
case less than five years.
Early recognition of pulmonary consumption is essen-
tial to its successful climatic treatment. The healthy
children of tubercular parents now coming to adult life
in Colorado are a strong argument against the heredity
of consumption. Favorable climatic environment pro-
tects them from the direct contagion of their parents due
to residence in the same home.
A Bureau of Public Health. — A resolution was offered
and adopted that the society expresses its approval of the
establishment of a bureau of public health, and its opin-
ion that the welfare of our country would be greatly ben-
efited thereby, and requests that the representatives of
28
MEDICAL RECORD.
[July 7, 1894
our State aid the passage of the bill in Congress by their
earnest efforts. A copy of the resolution was ordered to
be sent to each Senator and member of the House of
Representatives at Washington.
Address on Ophthalmology. — Dr. George £. de
Schweinitz, of Philadelphia, divided the art of restoring
health to disordered eyes into optical, surgical, and medi-
cal therapeutics. After a brief review of the most im-
portant advances in the first two departments of this di-
vision, he addressed the Society on the medicinal and
non-surgical ocular therapeutics. He reviewed subcon-
junctival injections of corrosive sublimate, commending
them in selected cases, and described his experimental
work and that of Dr. Chasseaud in connection with intra-
ocular injections of antiseptic substances, concluding that
this form of medication, although presenting attractive
features, had not yet reached a safe status in ophthalmic
practice.
Abuses of mercury in the treatment of diseases of the
eye were referred to, and, in the management of optic
nerve atrophy, suspension, injections after the manner of
Brown S^quard, and the effects of various drugs, particu-
larly antipyrin, strychnia, and nitroglycerine were de-
scribed.
The relation of electricity to diseases of the eye re-
ceived attention, especially the method of treating optic
nerve atrophy by means of voltaic alternatives, and the
use of the continuous current in the management of vit-
reous disease and chronic irido-choroiditis.
The medicinal treatment of the congested choroid
coats, as the result of eye strain, was insisted upon as an
essential aid in the management of asthenopia. Follow-
ing this, modern investigations in regard to the untoward
effects of cocaine were discussed, the new mydriatic, sco-
polamine, was compared with atropine, and the address
closed with a reference to the proper method of procur-
ing conjunctival antisepsis, as nearly as this is possible,
and the danger of powerful germicides in relation to the
cornea.
Dr. de Schweinitz closed with a strong appeal to each
physician to use his personal influence to assist in secur-
ing legislative regulations for the prevention of blindness
from ophthalmus neonatorum.
Treatment of the Corneal Ulcer by General Practi-
tioner.— Dr. S. Lewis Ziegler asserted that corneal ulcer
is not necessarily dangerous, but may seriously impair vis-
ion, especially when central. Lachrymo-nasal lesions
are the immediate cause, gastrointestinal disorders from
errors in diet are the remote cause ; constitutional dys-
crasiae may have some influence as a predisposing cause.
If septic materials are present in the ocular cul de sac, a
break in the corneal epithelium will court infection and
subsequent ulceration.
To summarize : Simple corneal ulcer is a purely local
inflammatory process, arising chiefly from infection by
septic secretions, and originating in lachrymo nasal le-
sions.
The treatment required is: 1. Apply a mild antisep-
tic, soothing lotion to the eye, a mydriatic if needed,
and hot applications when indicated. 2. Treat the nose
locally with compound tincture of benzoin and the use of
a cleansing spray. 3. Regulate the diet, give salt-water
baths, and improve the hygiene generally.
Uterine Fibroids. — Dr. Charles P. Nobre, in a paper
with this title, referred to the teaching concerning fi-
broids current ten years ago, viz. : 1 . That the disease is
a benign one, tending to a spontaneous cure at the men-
opause. 2. That it never causes death. 3. That hyster-
ectomy is the most dangerous operation in surgery, hav-
ing a mortality of forty per cent. He pointed out that
ten years' study of the disease has demonstrated : 1. That
it is a serious disease, almost invariably producing marked
invalidism, and not infrequently causing death by hem
orrhage, by undergoing malignant, cystic, or necrotic
changes, by paving the way for intercurrent diseases, by
proving an obstruction to labor, and by piessure upon
the urinary organs and other abdominal viscera. 2.
That the menopause is delayed from five to ten years. 3.
That spontaneous cure not infrequently does not follow
the menopause, and that many fibroids grow more rapidly
after than before that period. 4. That hysterectomy,
except in complicated cases, has been a comparatively
safe operation. He quoted the recent experience of
Kelly, Baer, Polk, and himself in hysterectomy — includ-
ing all classes of cases as they come, one hundred and
sixty-eight cases, nine deaths, or a mortality of five and
three-tenths per cent
The deaths were in the broken-down complicated cases.
The failure of ergot and electricity and the comparative
failure of oophorectomy to cure was referred to. The
principle of early operation, now accepted for ovarian
tumors, was urged in the treatment of fibroid, so that the
mortality can be still further reduced.
A Cause of Failure in the Surgical Treatment of In-
ternal Strabismus. — Dr. Thomas F. Hansell, in his
paper with this title, said that Donders' theory of the
causation of internal squint in hypermetropia is incom-
plete, in that he taught that the excessive action of the
accommodation in overcoming hypermetropia induced
corresponding excessive convergence only; whereas its in-
fluence is not thus limited to the interni, but extends to all
the muscles under the control of the third nerve. Dr.
Hansell believes that the simple, pure, internal strabis-
mus of hypermetropia, as described by Donders, cannot
exist, but must always be complicated by an upward
strabismus, for the following reason : The stimulus of the
overacting ciliary muscle is communicated not only to
the nucleus of the internus, but to that of the superior
rectus, of the inferior rectus, of the inferior oblique, and
of the pupil.
The nucleus of the levator palpebral is probably also
involved ; but since the function of this muscle is to
elevate the lid, and not to rotate the cornea, its action is
not relative to the subject of this paper. Hence their
combined action is :
1. Contraction of the pupil.
2. Esotropia, because the external rectus, the antago-
nist of the internal, receives no motor impulse.
3. Hypertropia, because the two elevators of the cor-
nea, the superior rectus, and the inferior oblique, over-
come by their contraction the single depressor, the
inferior rectus, which is the only one of the depressors
belonging to the third nerve group, the superior oblique
having an independent nerve supply.
Therefore,
1. The squinting eye is invariably rotated inward and
upward.
2. In alternating squint, fixation is transferred from
one eye to the other at the patient's will, and the non-
fixing eye immediately turns inward and upward. Fixa-
tion with R. means left hyperesotropia. Fixation with
L. means right hyperesotropia.
3. In constant squint, fixation is always made with the
same eye ; hence there is no transference of either esotro-
pia, or hypertropia, and the eye not used in fixation is
rotated inward and upward.
4. In concomitant squint, binocular vision is established
by correction of the refraction and tenotomy of both
internal muscles.
5. In constant squint, in addition, vertical equilibrium
must be restored by tenotomy of the superior rectus of
the squinting and possibly of the inferior rectus of the
fixing eye.
The President-elect, John B. Roberts, of Philadelphia,
was introduced by Dr. McCormick. He took the chair,
and announced the appointments for the annual addresses
of next year as follows : Address on Medicine, Dr. I. C.
Gable, of York County ; Address on Obstetrics, Dr. W.
B. Ulrich, of Delaware County; Address on Surgery,
Dr. C. L. Stevens, of Bradford County ; Address on Hy-
giene, Dr. Hildegarde H. Longsdorf, of Cumberland
County; Address on Mental Diseases, Dr. F. X. Der-
cum, of Philadelphia County ; Address on Otology, Dr.
L. H. Taylor, of Luzerne County.
July 7, 1894]
MEDICAL RECORD
29
A QUESTION OF FACT AND ACCURACY IN
STATISTICS.
Dr. Spence takes Issue with Dr. Beck.
To tub Editor op the Medical Record.
Sir : My letter in your issue of June 2d, which seems to
hare aroused Dr. Carl Beck to an unusual degree, as evi
denced by his reply in your issue of June 16th, was not
intended as a discussion of the doctor's paper on pyo-
thorax. It was written simply to correct the false con-
clusion which he drew from my article in The St. Louis
Clinique.
I am sorry, after aiming to make my remarks very
easy of comprehension, he should, besides misinterpret-
ing so many of its statements, consider the letter as an
attack upon himself. These are hardly of sufficient con-
sequence that I should take up your space to convince
Dr. Beck of his errors ; but I must, in justice to those
concerned, reiterate those statements of mine which the
doctor has directly contradicted.
I was present at the meeting of the County Medical
Society the evening Dr. Beck read his paper, and I state
again, " the general opinion was, that free incision with
good drainage was all that was necessary in the majority
of cases." Dr. Beck evidently forgot that four men dis-
cussed his paper, and only one (one of the surgeons he
mentioned) was mildly in favor of resection. It seems to
me, therefore, the general opinion was as I have stated.
Dr. Beck refers to a patient on whom he says he " un-
happily had the bad fortune to be compelled to perform
resection " after Dr. Ripley had made an incision. It
will be my good fortune, while assuring him of my sym-
pathy, to give the doctor here the true history of that
case. I am surprised to find that it differs so materially
from the one published by Dr. Beck, for this appears to
be Case IX. of his paper.
The child, a girl of six years of age at the time of the
operation, not ten as published, was taken sick in March,
1893, *** pfcim> pneumonia. Dr. Ripley, in private
practice, saw the child in consultation with the family
physician, and diagnosed an empyema.
On April 4, 1893, Dr. Ripley made a free incision into
the chest, and after liberating a large quantity of pus, in-
troduced a good sized drainage tube, dressed the wound,
and gave the necessary instructions. He only saw the
child once more, and that was four days after the opera
tion. On April 14th, ten days after the incision, the
family for some reason became displeased with their
family physician and dismissed him. That of course
ended Dr. Ripley's observation of the case. Another
physician was now called, who on the advice of another
consultant, sent the child to St. Luke's Hospital, under
the supposition that the other pleural cavity also con-
tained pus. This proved to be incorrect, for so the St.
Luke's people decided after a careful examination includ-
ing the insertion of an exploring needle. They found no
pus in the chest into which they introduced the needle.
Therefore, as the child was never in St. Francis Hospital
or in any other except St. Luke's, contrary to Dr.
Beck's report she was not " aspirated for empyema in a
hospital of this city."
The last attending physician was recalled after the
child had been sent home from St. Luke's Hospital, and
by means of a chain saw he exsected a small piece of rib,
and introduced a drainage-tube of very small calibre.
This exsection was done about three weeks after the in-
cision, and some time later a piece of this small tube
broke off into the chest. It is ridiculous to say, as Dr.
Beck does in his history of this case, this tube, " after it
had courageously resisted the permanent rush of the re-
tained pu?, at last resigned and broke beneath the safety-
pin," when you reflect that this pus cavity had been
opened twice and was constantly draining during the
previous three weeks.
Now on May 15, 1893, less than six weeks after Dr.
Ripley's incision, instead of six months as he reports in
his pathetic history, Dr. Beck exsected a piece of rib
three eighths of an inch long. The parents showed me
these curios, the piece of bone last exsected and the sev-
eral drain- tubes, which they keep for safety in a little
plush lined jewelry box.
Dr. Beck's report of this case now reads as follows :
" Four weeks later recovery was perfect, after the poor
child had been aspirated, incised, and resected, first with
saw and then with shears." This reads well, but what
are the facts ?
The mother tells me the child was confined to bed
during May, June, July, August, and into September,
the next four months after Dr. Beck's operation, and the
wound was not healed until Christmas, 1893. Thus, in-
stead of recovery being perfect in four weeks, as Dr.
Beck has the presumption to tell us, the child was four
full months in bed, and recovery was not complete till
seven months after Dr. Beck's resection.
These facts need no comments; but they show how
valueless this case is as to the relative merits of incision
and resection. It was a resection, following an exsec-
tion.
I have gone rather minutely into this history, in the
hope that Dr. Beck will copy it into his casebook, so
that he may have it at hand, should information be again
requested of him. I really trust he has been more ac-
curate in the histories he has published of the other
cases.
Dr. Beck says in his letter, " The value of the fourteen
histories which were appended to my reasons why resec-
tion is the better treatment, consists in their unusual and
interesting additional circumstances." It must be ad-
mitted they are both unusual and interesting, especially
Case IX. It is very unusual, even after, according to Dr.
Beck, the irrational operation simple incision, to have
fistula? remain as long as in the case twenty -six years ol
age, mentioned in his paper, and in Cases III., V., and VI.
Certainly Cases V. and VI. cannot be cited as very en-
couraging examples of the " only rational method ot
treating empyema." Surely the doctor does not give to
resection the credit for the recovery of Cases XII. and
XIII. ; for he says he did not operate on them at all, the
first case having expectorated the pus, and in the other it
was absorbed.
Statistics, in order to be valuable, should be as to their
material facts, correct.
Arnot Spbnce, M.D.
70 West Seventy-west Street, June 89, 1894.
A LARGE DOSE OF CYANIDE OF POTAS-
SIUM.
To the Editor or tub Medical Record.
Sir : In the issue of the Medical Record for June 9,
1894, I notice a criticism upon my report of a case in
which a large dose of cyanide of potassium was swallowed
without a fatal result.
I have just written to my patient of two years ago and
enclose his answer. Since it is so naive and corresponds
closely enough to his first statement to me, with which
I took care not to acquaint him, I hope you will print it
entire, simply suppressing the signature.
In my opinion this letter of my patient is characterized
by about as much " precision and exactness of detail "
as we are liable to get in suicidal attempts.
If my critic has any cases in which large amounts of
cyanide were weighed and recorded before being taken,
I hope he will publish them. As a rule, however, this
means of satisfying our laudable scientific curiosity is not
taken by the suicide.
On the part of the doctor in this case, there has been
no " guessing " at all, as I have simply reported the
statements of the patient.
I am very sorry that my critic is dissatisfied with the
definiteness of my report, but I have simply furnished
3°
MEDICAL RECORD.
[July 7, 1894
what I had to give, hoping that it might be of value to
someone of my fellow-laborers.
Yours respectfully,
F. W. Higgins, M.D.
" Syracuse, N. Ym June 13, 1894.
"Dr. Higgins —
Dear Sir: Yours of June 11 at hand and in reply
I went to a drug store and could not find just such a
shaped piece of cyanide potassine as I took, but had to
break it off of a large chunk, and it was rough and
ragged and weighed nine grains. Now I think the piece
I took was heavier, as it was about the same size but was
a solid piece and perfectly smooth on all sides. I do
not think it was possible for any of it to have remained
in the glass, as it was a hard chunk, and I swallowed it
immediately after drawing about one ounce of whiskey
on it. Now, if you will draw up such papers as you want
and send same to me I will go before notary public and
swear to and save them. The date was October 7, 1892.
Hoping the above will be satisfactory, I remain yours,
and ready to do you a favor."
MUST THE PARSON PAY?
To ■
Editok or tub Medical Rxcokd.
Sir : Periodically the question of " Must the Parson
Pay?'1 is resurrected, and at this particular period it is
viable again. This afternoon I have read an article from
a Durham, N. C, doctor, and an answer from "A
Minister,1' both of which are clear of the true inward-
ness of the question. Both speak of the amount of
money received by each, respectively and relatively, and
upon that base their respective sides of the argument.
This is not the question at all. And there is one which,
while very much lower than the highest, will appeal to
the reason of even the Durham M.D. Indeed, he chal-
lenges the argument when he says that, when he had de-
termined that those well-fed and well paid North Caro-
lina preachers were no longer " objects of charity,1' and
consequently not entitled to the doctor's largess, with
a magnificent burst of generosity he increased his sub-
scription to the minister's salary " from $39 to $50 per
year." He " had been a member of the church for
years," and, of course, was under obligation, according
to his own showing, to pay for what he got in preaching.
How well does he do it. Fifty dollars per year. Fifty-
two Sundays in each of those years — two sermons each
Sunday and one Wednesday evening at prayer-meeting,
give an aggregate of one hundred and fifty- six hours of
his preacher's time devoted to the doctor's welfare every
year, for which the doctor pays the munificent sum of
thirty cents (in round numbers) for each hour's work.
If the doctor hasn't a wife, he ought to have, so to the
two the price is reduced to a little over fifteen cents for
each ; and when he says he has practised medicine at
Durham for twenty years, it is at least presumable that
the doctor has averaged during that time three children
to hear each sermon. So that three cents is the figure
at which his spiritual medicine comes to him per hour per
head. And this takes no thought of the many kindly
offices done by the good pastor to the parishioners with
never a thought of compensation. Now, it seems perti-
nent to ask the doctor if, when he sends in the parson's
bill, he will in the spirit of " the one for the other,"
which he so insists upon, fairly estimate his prescriptions
at the same royal fees which he pays the parson. To a
man up a very dwarfish tree, it looks, if he look with
good eyes and fairly, that the parson is the one who
" wears the yoke," and not the doctor, and if the par-
son should " rebel," preaching would come quite a good
deal higher to the most of us than it does at present.
" Objects of charity," indeed! If there is a man on
earth who earns every dollar of his salary, it is the
preacher of the gospel. True, the doctor earns his —
true, the doctor does a great deal of his work for people
who cannot pay ; but it is also true that many members
of the Durham church can't pay anything for their
preaching, and others won't, so that this is only as broad
as it is long. The doctor has appealed to the quid pro quo
argument, and should be held to it. The fee for office
prescriptions in smaller towns is usually $1. If the Dur-
ham doctors will, in local society assembled, proceed an
other step in their reformation, and at next report be
able to show that they each have raised their church sub-
scription to $156 per year for each member of each fam-
ily, then they will have earned the right to vaporize
upon this question some more, and the preachers will
make no objection to paying their medical bills like
other folks.
For shame, my brethren ! Blush to remember that
you ever thought to say such things before, and don't
ever do so again. I intimated that there was a higher
and better reason than I have indicated for holding up
the hands of these men, but I am no preacher, and the
Medical Record is no publisher of sermons. I am a
practitioner of medicine, however, and I don't belittle
my profession when I claim that we could do less well
without the offices of the faithful, conscientious pastor
than he without us. My pastor — God bless him —
ministers faithfully to my living and has lovingly and
tenderly buried my dead, and when opportunity offers I
shall serve him, glad to be able to in some measure show
my love and gratitude. Charity, indeed ; God save the
mark! J. C. Bogle, M.D.
Danvillt, Kv., June 11, 1894.
Utoedicat Stems.
Contagious Diseases — Weekly Statement— Report of
cases and deaths from contagious diseases reported to the
Sanitary Bureau, Health Department, for the week end-
ing June 30, 1894.
Tuberculosis
Typhoid fever
Scarlet fever
Cerebro-spinal meningitis
Measles
Diphtheria
Small-pox
Cholera
Varicella
Pertussis
Erysipelas
Leprosy .................
Cases.
Deaths.
99
48
7
6
63
10
4
4
86
10
23a
6t
9
4
0
0
0
0
0
0
0
O
0
0
New Laws of Interest to the Medical Profession. —
The last Legislature was no exception to the average run
of legislatures as to attempts made to break down the
safeguards of the medical profession. One bill cut the
fee for admission to the regents' examination from $25
down to $5 ; another made the State pay the fee instead
of the student ; and a third, in the interest of the Faith
Curists, provided that any person may freely contract for
the services of whomsoever he considers competent to
alleviate suffering, or prevent or heal disease, and it shall
be lawful for persons so employed to attend, treat, nurse,
and endeavor to heal the employing patient and receive
compensation therefor, subject to the medical laws of the
State relative to improper practice. None of these bills
were passed.
A law was passed providing that any person holding a
diploma of date prior to January 1, 1880, conferring the
degree of bachelor or doctor of medicine from a reputable
incorporated American medical school or college, and
who has been a resident and citizen of this State continu-
ously since June 1, 1880, and who omitted or neglected
to register with a county clerk as prescribed by law, shall,
upon production of his or her diploma and satisfactory
proof of such facts, as provided in section two hereof, be
entitled, upon payment of a fee of $25, to receive from a
State board of medical examiners recommendations upon
July 7, 1894]
MEDICAL RECORD.
3i
which the regents shall issue, under seal, a certificate of
the facts that he or she may register in the clerk's cffice
of the county where he or she may reside, which shall,
after such registration, be a sufficient license to practise
medicine in the county where registered. Proof of such
residence shall be by affidavits of at least two reputable
citizens, whose reliability shall be certified to by any
county or supreme court judge of the State. Any person
desirous of securing the benefits of this act must do so
within one year from the date it takes effect ; but it shall
not be construed to conflict with chapter 661 of the laws
of 1893, tne Public Health Law.
The Governor vetoed an amendment to the Public
Health Law providing that any person who, not being then
lawfully authorized to practise medicine within this State
and so registered according to law, shall practise medicine
within this State without lawful registration, or in viola-
tion of any provision of this article, shall be deemed guilty
of a misdemeanor, and on conviction thereof shall be
punished by a fine of not less than $50 for the first offence,
and for each subsequent offence by a fine of not less than
{100, or by imprisonment for not less than 100 days, or
by both fine and imprisonment. When any prosecution
under this article is made on the complaint of any incor-
porated medical society of the State, or any county medi-
cal society of such county entitled to representation in a
State society, the fine when collected shall be paid to the
society making the complaint, and the expense incurred
by any such society in such prosecution, including neces-
sary counsel fees, may be retained by such society out of
the penalties so collected, and the residue, if any, shall
be paid into the county treasury. In vetoing this bill,
the Governor said : " The Public Health Law was con-
structed upon the principle of excluding from its provi-
sions all but civil penalties, and transferring all criminal
penalties to the penal code, where they properly belong.
It was with this idea that the Statutory Revision Com-
missioners, in revising the health laws, omitted from the
Public Health Law enacted last year the penal provisions
which this bill contains, with the intention of inserting
them in the penal code. As it happened, the Legislature
passed no bill making that transfer, and accordingly the
same provisions are now sought to be re enacted. The
mistake has been made, however, of not attaching them
to the penal code. To enact the bill in its present shape
would be to destroy partially the wise principle upon
which the Public Health Law was framed and to establish
a bad precedent for future legislation."
A law was passed providing that any medical society
now organized in any of the counties of the State set
apart since the passage of the act of 181 3 to incorpo-
rate medical societies for the purpose of regulating the
practice of physic and surgery in this State, shall, upon
complying with the provisions of this act, enjoy the same
privileges and possess the same powers as the societies in-
corporated by virtue of said act now enjoy and possess,
but subject, nevertheless, to the provision of any acts
or parts of acts heretofore passed in relation to medical
societies or to regulate the practice of physic and surgery
in this State. Before any such society shall be entitled
to the privileges and possess the powers as provided in
this act, such society, at a regular meeting thereof or at a
special meeting called for that purpose, after due notice
to all its members, shall make and file with the Secretary
of State a certificate signed and acknowledged by its
president and secretary, stating the name of such society,
the date of its organization, the name and residence of its
members ; that the said society, by a majority vote of its
members, has elected to become and be a body corpo-
rate under and by virtue of said act, and be subject to
the provisions of any acts or parts of acts heretofore
passed, and now in force, in relation to such societies or
the practice of physic and surgery in this State. Upon
filing the certificate such society shall become and be a
body corporate under the name set forth in said certifi-
cate, the same as if such society had been incorporated
under and pursuant to the provisions of the said law.
The trustees of Columbia College were made the legal
successors of the trustees of the College of Physicians
and Surgeons for the executing of all trusts in the city of
New York, and the consolidation was legalized. The
same city was authorized to expend $200,000 for addi-
tional buildings for the Gouverneur Hospital. The Gov-
ernor vetoed a bill changing the name and increasing the
powers of the trustees of the West Side German Dispen-
sary. The city is to pay 38 cents a day for each infant
cared for in the babies' ward of the Post Graduate Hos-
pital, and $15 for each mother in the Mothers acd
Babies' Hospital. The Hahnemann Hospital, the St.
Mark's Hospital, and the Manhattan Hospital Association
were released from certain assessments. A charter was
granted to the Rochester Homoeopathic Hospital. The
law of 1889, relative to the formation of hospital corpo-
rations, was amended so that certificates must be passed
upon by the courts. The Governor vetoed and afterward
signed a bill for the relief of the Goshen Sanitarium
Company, of Goshen. He vetoed a bill forbidding au-
topsies in insane asylums or hospitals unless the author-
ities of the county from which the deceased came had
been previously notified. An appropriation was made
for a homoeopathic insane hospital on the Collins farm
in Erie County. A bill failed to pass providing that in
all hospitals or asylums homoeopathic physicians shall be
appointed equally with physicians of the regular school.
None of the amendments to the pharmacy laws were
successful. One of these provided for a yearly license
fee of $1. Another allowed an applicant to secure an
order for a license from the court if not entitled to the
same within three months after the organization of the
board. The Governor vetoed amendments to Sections
184 and 187 of the Public Health Law so as to enable
persons who have failed to apply for their licenses as
pharmacists within the time prescribed to make applica-
tion hereafter, and also to correct a clerical error in
the existing section by changing the word " resignation"
to ' ' registration. ' ' The only amendment made to Section
187 was to correct the spelling of the word "pepper-
mint," and another clerical error was made in the bill by
changing the word " usual " to " unusual," so as to per-
mit the sale of unusual domestic remedies by retail
druggists in the rural districts without license as pharma-
cists and to prohibit the sale by them of usual remedies.
The Governor stated in his veto that the new clerical
error was worse than the old one.
A bill paying £3,000 a year to the physician to the
coroner of Kings County for autopsies was vetoed. *
Bills did not pass : Providing that $15 shall be paid for
autopsies ordered by coroners ; giving a salary of £3,000
to each of the two coroners in Erie County ; providing
for the appointment of a State dental instructor ; amend-
ing the Public Health Law so that a diploma may be given
to anyone who had been practising dentistry for six
years previous to June 20, 1879 > amending the same law
so as to make examinations for veterinary practice more
stringent, and providing fines for violation of the same ;
extending to January 1, 1895, tne tmie f°r registry of
veterinarians who have no diploma from a college or so-
ciety ; and exempting veterinarians from jury duty. A
State veterinary college was established at Cornell Uni-
versity, and 150,000 was appropriated for the same.
An amendment to the "charter of the New York So-
ciety for the Relief of Widows and Orphans of Medical
Men was passed, stating that the objects of said society
are benevolent, and to afford relief to the widows, or-
phans, and dependent relatives of medical men. An
amendment to the code of civil procedure requires an
examination by a female physician or surgeon in cases
where a female must be examined physically. The pay
of police- force surgeons in New York City was increased
from £2,250 to ^3,000 a year, and the act was made to
apply to Brooklyn also. A fine of $ 100 was ordered for
every omission in reporting deaths, births, and marriages
in New York City. A bill failed to reach the Governor
providing that it shall be the duty of the State Board of
32
MEDICAL RECORD.
[July 7, 1894
Health to make an analysis of all patent medicines and
charge a fee of $50, and providing that patent medicines
shall not be sold unless examined and approved by the
State Board. The Governor vetoed a bill prohibiting
the giving away or selling after October 1st, next, of any
poison or poisonous substances in liquid form except in
fluted bottles labelled in the manner heretofore provided
by law. In his veto the Governor said : " The questions
at once suggest themselves what is meant by ' poison or
poisonous substances/ why the act should be limited to
poisons in liquid form, and what is meant by ' fluted '
bottles. A measure of this kind might be of service, bit
it should b; more carefully worded so that it would not
require a decision of the courts immediately to deter-
mine what it meant. A fluted bottle may be any one of
a dozen or more different styles. Poisons and poisonous
substances are very indefinite words."
Syphilis as a Ground for Divorce —The Supreme
Court of Vermont considers, in the recently decided case
of Ryder vs. Ryder, syphilis as a ground for divorce.
There is in that State, as in miny of the other States, a law
which provides that the marriage contract may be annulled
when at the tim* of the marriage either party was physi-
cally incapable of entering into the marriage state. It
was found in this case that the wife, from whom the hus-
band asked to be divorced, had, at the time of marriage,
chronic syphilis, which was incurable ; that at the time
the mm who mxrried her supposed her to be chaste;
that in about two months she communicated the disease
to him ; that he did not know that she had the disease
until she communicated it to him; that he voluntarily
cohabited with her before and after he knew of her dis-
ease ; that a child was born to them about a year and
four months after their marriage ; that the child was a
mass of syphilitic sores, attributable to the condition of
the mother, and soon died; that, at the birth of the
child and afterward, the mother was in about the condi-
tion of the child from such sores ; that they both con-
sulted a physician, who treated them some time, when
she got better ; that he believed from that time, until
the child was born, she had got well of the disease, and
would not be troubled again with it; that he never had
intercourse with her after the birth of the child ; and
that at no time could he have sexual intercourse with her
without great danger of contracting the disease. Upon
these facts, the question presented to the Supreme Court
was whether the trial court was in error in refusing to
. annul the marriage A majority of the court thought it
was. It was not found that the woman was fully aware
of her condition at the time of the marriage. It would
be presumed that she was not. If it were found that she
was fully aware of her condition, she would have been
guilty of a fraudulent concealment in not disclosing it to
him she was about to marry. It would be an essential fact,
entirely within her knowledge, not within his, nor open
to his observation nor to his inquiry upon any reasonable
principles which do or should prevail in conducting the
negotiations which lead up to entering into the contract
of marriage. — Cincinnati Lancet and Clinic.
The Last Illness of Dr. Brown Sequard — Dr. Ogle
gives in The Lancet an interesting account of the illness
of the late D;. Brown-S6quard. It appears, he says, that
for some years past Dr. Brown-S£quard had not seemed
to his friends to be in good general health. He had, in
1889, teen the subject of severe muscular rheumatism,
aad in the autumn of that year he suffered from some
prostatic trouble. From these ailments he entirely re-
covered. During the following winter and spring, when
at Nice, he had an attack of whooping-cough, as was
mentioned in The Lancet at the time. He was then
regularly using his orchitic fluid injections. During the
next two years he remained fairly well, working very
hard and writing much, sometimes answering as many as
eighty letters in the day. In the summer of 1893 ne suf-
fered great distress of mind owing to the ill-health of his
wife, and in December he was residing at Nice and was
confined to his bed, suffering from phlebitis, when his
wife was dying. TTie consequent grief perfectly un-
manned him, and was quite uncontrollable, and for some
time he took but little food and was unable to sleep, re-
fusing to leave the house. He returned to Paris at the
beginning of March. Then came the vertigo and affec-
tion of sight, followed by the unconsciousness which he
himself wrote about to Dr. Waterhouse, and from which
he recovered. Dr. Dupuy says that at that period the
speech remained " thick " and embarrassed at times, and
that Dr. Brown- Sgquard remarked: "This is an attack
of epilepsy, as you can see." Instead of going to bed as
desired, he wrote several letters, and, no doubt, wrote
the letter to Dr. Waterhouse above alluded to, relating
his symptoms and speculating upon them. During the
following day he was in the same condition as regards
vertigo, hemiopia, and occasional thickness of speech,
but there was no aphasia. He was then visited also by
his friends, Dr. Dej6vine and Professor Potain, together
with Dr. Dupuy, but could not be persuaded to take ade-
quate rest and nourishment. On the next day (Friday)
he consented to take meat, milk, and bread in small
quantities throughout the day, and was comparatively
cheerful. At the close of the day his face became much
flushed, and the vertigo and hemiopia very distressing!
and in consequence of this he walked from one room to
another on " all fours," giving at the time the analysis
of his symptoms and the prognosis of his case, as if he
was contemplating and discoursing on the illness of an-
other person. During the night of that day he was seized
with vomiting, and in the early morning it was found
that he was unable to speak and that the left arm was
paralyzed as to power of movement. Dr. Dupuy found
later on that paralysis of the muscles on the right side ot
the face existed and that the tongue was protruded to the
right side. The left leg and the arm and leg on the right
side were unaffected. There was no muscular spasm in
any part, no interference with sensation, either general
or special ; but vertigo was much increased, and there
was external strabismus of the right eye. The condition
of speech was the same, and there was still no aphasia.
Toward the evening of the day the face became exceed-
ingly congested on several occasions, and the blood- ves-
sels of the forehead much swollen, and there was droop-
ing of the upper eyelid ttf the right eye. During the
morning of the next day (Saturday) he made Dr. Dapuy
understand that he wishea to write on a slate, but the
result was unintelligible, excepting that the word " hy-
peresthesia " was recognized. He then saw some friends
with pleasure. At 2 am on Sunday he became entirely
unconscious, and coma set in. The axillary temperature
rose to 400 C. — i.e., 104° F., and he died without a strug-
gle near midnight. After the cessation of breathing and
of the heart's action all the muscles of the legs and arms
were for several minutes in a state of fibrillary contrac-
tion, and the axillary temperature at the point of death
rose to 41. 50 C. — i.e., 105 90 F. No post-mortem ex-
amination could be made.
Prevention of Iodism — Dr. H. N. Spencer (Jnt. Med.
Mag., December, 1893), recommends the following
mode, due to Professor Hardaway, of prescribing iodide oi
potassium ; the tendency to coryza is counteracted by
the nux vomica and amnion io citrate, while the tonics
prevent depression :
Q . Iodide of potassium J ss.
Citrate of iron.
Ammonium. ftft 3j-
Tincture of nux vomica 3 ij.
Water . Jjss.
Compound tincture of cinchona to make up J iv.
Dose, one teaspoonful in half a glass of water after meals. The
quantity of iodide may be increased to any desired extent by adding,
the necessary amount of a saturated solution.
Insanity is Increasing in Ireland, according to a re-
cent parliamentary report.
The Fee for Medical Witnesses in the London police
courts is half a guinea, or about $2.50.
Medical Record
A Weekly ^Journal of Medicine and Surgery
Vol. 46, No. 2.
Whole No. 1236.
New York, July 14, 1894.
$5.00 Per Annum.
Single Copies, zoc.
TEN YEARS' EXPERIENCE WITH ALEXAN-
DER'S OPERATION FOR SHORTENING THE
ROUND LIGAMENTS OF THE UTERUS.
Sixty- five Operations.
By PAUL F. MUNDE, M.D.,
NEW YORK.
ntOFRSSOR OF GYNECOLOGY AT THE NEW YORK POLYCLINIC AND AT DARTMOUTH
COLLEGE ; GYNECOLOGIST TO MOUNT SINAI HOSPITAL ; CONSULTING GYNECOL-
OGIST IN ST. ELIZABETH AND THE ITALIAN HOSPITALS.
Soon after the publication of Alexander's little book on
the operation revived, and, I believe, first actually per-
formed by him, I, on December 12, 1884, undertook it
siccessfully, following closely the directions laid down in
Alexander's work. I was so much impressed with the
ease of performance and the immediate and subsequent
results of the operation that, during the next two years, I
had six cases to report, in four of which I succeeded in
finding the ligaments, in drawing them out, and attach-
ing them as recommended by Alexander. My experi-
ence with the operation increased so rapidly that in the
American Journal of Obstetrics for October, 1888, I was
able to report twenty- three cases, with but three failures
to find the ligaments, and *rith practically no failure in
the other twenty cases as regards the permanency of the
result of retaining the replaced uterus in the normal po-
sition. In that article I reviewed at some length the in-
dications, results, and technique of the operation, and
concluded by raising my voice very forcibly in its favor
as against the later, more dangerous, less logical, and
permanently less successful operations of shortening of
the round ligaments through the opened abdominal cav-
ity, or ventral fixation of the fundus uteri.
That article was not read before any medical society,
but was simply printed in the above named journal,
where, of course, it was seen by very many members of
the profession, but perhaps did not attract as much atten-
tion as if it had been more widely circulated through the
columns of the weekly medical press, or through the
"Transactions" of the medical society before which it
might have been read. Hence I am afraid that its precepts
and deductions were not so generally appreciated as they
should have been. Of course, I can speak only for my-
self and my own experience, and cannot expect that my
professional brethren will unhesitatingly accept and fol-
low my conclusions. But as I am known to be a con-
servative operator, not only in coeliotomy for diseased
ovaries and tubes, but also as regards other opera-
tions which may possibly be avoided, I felt that I was
entitled, with all due modesty, to more confidence and
belief than if the operative furor had had exclusive pos-
session of me. Nevertheless I am constantly meeting
gentlemen who, with quite as much experience as my own
in all sorts of gynecological operations, still express a
want of reliance in Alexander's operation and a prefer-
ence for abdominal section with intra-abdominal short-
ening of the round ligaments, or ventral fixation, for the
very same objects for which I unhesitatingly prefer Alex-
ander's operation. It seems very difficult to convince
some men that pelvic diseases in the female can be
treated otherwise than by opening the abdominal cavity,
and that, after all, in very many cases, this should be the
last resort, when all other possible means have been ex-
hausted.
Some of these gentlemen base their objections to Alex-
ander's operation on the difficulty of finding the liga-
ments or the impossibility of drawing them out ; others,
again, contend that the results of the operation are not
permanent; and others, again, claim that coeliotomy is
a so much easier and equally safe way of attaining the
same object. It is scarcely necessary for me to say that
I am perfectly familiar, from a theoretical and practical
experience in gynecology of over twenty five years, with
the various methods which are preferred to Alexander's
operation by the gentlemen to whom I refer. I do not
prefer Alexander's operation because I have a particular
hobby in its direction, or because I have anything other
to gain by my preference than supporting what I think
to be best. I can simply point to an experience which
has now amounted to sixty- five operations, and which,
with the increased knowledge of years, still leaves me a
more and more confirmed supporter of the operation.
For minute details as regards the technique and the
indications, I will refer my readers to the article pub-
lished in the October, 1888, number of the Journal of
Obstetrics. I will add but a few brief remarks as to what
is stated there. First, as regards the technique of the
operation I will repeat that if the ligaments are not found
it is always the fault of the operator. It is simply a
question of careful attention to the anatomical landmarks,
namely, the spine of the pubis and the external inguinal
ring, upon which depends the finding of the ligaments.
If the tissues are quickly divided down to the fascia cov-
ering the external inguinal ring, this is lightly pricked
with the scalpel, the knuckle of fat which pops out
through the opening is carefully dissected out bluntly
with the handle of the scalpel, always being careful to
avoid detaching the bundle of fat from the spine of the
pubis ; if then this bundle of fat is entirely lifted up from
the subjacent bone with mouse tooth forceps or an aneu-
rism needle, a slow, minute, and blunt separation of the
tissues thus lifted up will always succeed in revealing the
initial fibres of the round ligament, which usually lie at
the lower surface of the bundle thus lifted up, and run
slightly outward and downward, not entirely outward.
If traction upon the supposed fibres of the ligament
shows that it runs toward the anterior superior spinous
process of the ilium, the operator may be sure that he
has picked up fibres of the external pillar of the ring or
of the oblique fascia. Careful isolation of these fibres,
gentle traction upon them if they prove to run in the
right direction, and dull separation of the strand if it
appears attached in the canal, will usually in a few min-
utes enable the operator to draw out the ligament so that
its identity is at once apparent both to him and the spec-
tators. This point having been reached, it is merely a
question of gentle, continued traction to draw out as
much of the ligament as is allowable, that is to say, until
its increasing size, usually almost to that of a lead pencil,
shows that its attachment to the uterus is approaching.
If traction is too severe and too rapid, or if the liga-
ment is either thin or much adherent, it may easily be
broken, particularly in its lower two-thirds, and may then
be lost to future research, or, if found again, will have
to be picked up within the depth of the canal. I confess
that I still have the impression, which I had years ago, that
this operation requires all the wit and dexterity of the
operator in order that by some oversight or carelessness
34
MEDICAL RECORD.
[July 14, 1894
the ligament may not be lost, broken off, or pushed aside
and thus lost.
The one unvarying landmark is always the spine of
the pubis, where I have repeatedly succeeded in picking
up the ligament, which at first I had failed to isolate in
the bunch of fat lifted up according to direction. By
non-attention to this landmark the operator may get to
one side and manage to pick up some other cord, even
drawing it out to a small extent, as in one case operated
on by one of my house surgeons, until I, coming to the
rescue, satisfied myself and him that it was the femoral
artery, which of course was very hastily dropped, fortu-
nately with no evil results. By returning to the spine
of the pubis and proceeding thence forward, I in a mo-
ment, picked up the terminal fibres of the round liga-
ment, isolated them, and drew out the ligament.
There will always be in this operation one drawback,
and that is the possibility that the thinness of the liga-
ments, their very diffuse attachment to the spine of die
pubis, and their uncertain appearance in the suprapubic
fat, further, the adhesion of such a thin ligament in the
Nuckian canal, may result in failure, either through the
inability of the operator to isolate them or in their break-
ing during his attempt to draw them out In my last
case the ligament on the left side appeared to be unusu-
ally friable, for it broke close to its uterine origin, the
only instance where I have seen it torn so high up. By
passing the first suture very deeply I managed, how-
ever, to keep the left horn of the uterus close to the an-
terior abdominal wall and the result was perfect. This
accident, the breaking of the ligaments, is, in my experi-
ence, the only drawback which this operation possesses.
And I think by extreme care in traction it also can often
be avoided.
I always stitch as much of the ligament as is not
drawn entirely out of the external inguinal ring into the
canal by passing a number of silkworm-gut sutures
through each pillar of the ring and the ligament be-
tween, cutting off the supra abundant portion of the lig-
ament. I have very seldom found it necessary to split
up the inguinal canal to the internal ring to find the lig-
ament, and then only when the ligament had been torn off
during my first attempts at traction. I can see no use
in opening the whole inguinal canal at first to perform
the operation. It strikes me like a confession of timidity
at the very outset to see this done. I am sure that out
of the sixty -five cases which I have performed I have not
been obliged to open the whole inguinal canal in more
than half a dozen cases. The usual length of my in-
cision is not more than two inches.
Suppuration has occasionally resulted, particularly if
much tearing and manipulation was required to find and
draw out the ligaments. I formerly employed a split
bone drainage-tube, but have for some years entirely dis-
carded it, and cannot say that my cases have done any
worse. Even if suppuration did take place in the wounds,
the adhesion of the internal end of the ligament seemed
to be quite firm enough to keep the uterus in position.
None of my patients have ever shown the least dan-
gerous symptoms in consequence of the operation, al-
though several times convalescence was prolonged to four
and six weeks in consequence of suppuration. Never
have I seen an inguinal hernia follow the operation. On
the other hand, I have cured an inguinal hernia by the
operation. I have always introduced a pessary into the
vagina immediately after the operation, in order to pre-
vent undue strain upon the newly attached ligaments,
and have had it worn for from three to six months. Of
course if perineorrhaphy was done at the same sitting a
pessary could not be used.
As regards the length of time required to perform
Alexander's operation, I would say that much depends
upon the character of the case. In an easy case without
adhesions I have frequently succeeded in completely
drawing out both ligaments in from five to ten minutes
for each side. The stitching, of course, must be care-
fully done, and the whole duration of the operation will
probably not be less than thirty minutes. I need scarcely
say that it is always imperative to draw out both liga-
ments, since to shorten only one ligament would result
in placing the uterus in an oblique position.
Second. As regards the indications for the operation I
would say that I consider the lines very closely drawn.
Only a sharply retroverted or retroflexed uterus, with
more or less descensus, with more or less relaxed vaginal
walls, with perfect mobility of the uterus and adnexa,
justifies Alexander's operation. I say justifies, but I do
not necessarily mean that these conditions are an ab-
solute indication for the operation, since in many such
cases perfect relief may be given the woman by a prop-
erly adjusted pessary. It is only when a pessary cannot
be fitted or comfortably worn, which will retain the
uterus and ovaries in their normal position, or when the
patient insists upon being cured instead of being merely
temporarily relieved by a pessary, that we can say that
Alexander's operation is indicated.
Whenever the uterus or appendages are adherent,
Alexander's operation is absolutely and positively con-
tra-indicated. We can, therefore, not compare the in-
dications for Alexander's operation and those for ventral
fixation, in my opinion, since the latter is justified and
indicated only when adherence of the appendages or of
the uterus warrant our opening the abdominal cavity and
detaching the adhesions. Then, of course, it is scarcely
worth while to do an Alexander's, since it adds very little
to the danger to sew the uterus to the anterior abdominal
wall. In such cases of adherent uterus and appendages,
however, where they have been detached through an
abdominal incision, the operation of shortening the
round ligaments by doubling them upon themselves, as
recommended by Wylie, A. P. Dudley, Mann, and
others, should be considered. I have but one experience
with this operation, which is still too recent to enable me
to offer a positive opinion on the subject. Technically
it is exceedingly pretty, logical, and easily effected. In
prolapsus uteri I am not in favor of Alexander's opera
tion, except in so far as it is one in a series of operative
measures by which a retention of the uterus in its normal
position in the pelvis is to be attained. Alone, Alex-
ander's operation is, in my opinion, of no permanent
benefit for prolapsus uteri. Neither do I consider it ap-
plicable to cases of anteversion and anteflexion in which
it is thought advisable to lift up or straighten out the
fundus uteri by drawing it up. In prolapsus uteri my
experience is that the round ligaments are not able to
withstand the constant downward strain upon them of
the large body of the uterus. In anteversion and ante-
flexion the direction of elevation of the fundus produced
by shortening the round ligaments would be such as to
drag the fundus against the symphysis pubis and produce
uncomfortable pressure on the bladder.
Third. In a very large proportion of cases where Alex-
ander's operation is indicated, there exists, besides the
retroversion and retroflexion and descensus of the uterus,
a want of tone or an absence of the inferior uterine and
vaginal supports, namely, the perineum is lacerated, the
bladder and anterior vaginal wall and the rectum and
posterior vaginal wall are prolapsed. While we can very
easily lift up, and even retain in position, the backward
displaced uterus and appendages by Alexander's opera-
tion, it stands to reason that a permanency of the result
will be more assured by restoring to their normal condi-
tions the inferior supports of the uterus and vagina ; and
often also a laceration of the cervix exists at the same
time which maintains a chronic enlargement of the
uterus. I therefore always combine with the Alexander's
the restoration of these various organs, so far as possible,
to their normal conditions. Thus if there is a laceration
of the cervix, a retroflexion with descensus, a lacerated
perineum, a cystocele, and a rectocele, I proceed in the
following order : 1st, trachelorrhaphy ; 2d, Alexander's ;
3d, cystocele, Stoltz's operation (if still necessary after
the uterus is replaced); 4th, rectocele with perineor-
rhaphy (Hegar's operation) ; or, if there be no rectocele
July 14, 1894]
MEDICAL RECORD.
35
bat simply a lacerated perineum, I restore the perineum
by the flap-splitting method. I have frequently been
able to perform this series of operations in less than an
hour and a half, and I have yet to regret having done so,
both as regards the immediate result on the patient (long
duration of anaesthesia, loss of blood) and permanent
results.
Fourth. After the technique and indications of the op-
eration naturally comes the question as to its results,
that is to say, does the uterus which has been successfully
placed in its normal position by the shortening and
attachment of the round ligaments to the inguinal canal
remain in that position for the rest of the woman's life,
in spite of the daily influences which tend to again dis-
place it, and particularly in spite of the occurrence of
pregnancy and parturition ? This question would be an
exceedingly easy one to answer if we were able to retain
all, or even the majority, of our patients under observation.
Manifestly this cannot be the case, since even in private
practice comparatively few operative cases again present
themselves, especially not if they are doing well. It is
usually only those in whom the condition for which they
were treated returns from whom we hear in an unpleasant
sense, either personally or through friends. Compara-
tively few show their sense of gratitude by presenting
themselves for the purpose of giving us the satisfaction of
seeing how well we have succeeded ; hence I can only
refer to a certain number of my sixty-five cases of this
operation in support of my statement that the operation
has been a permanent success. Still the old saying, that
" Straws show which way the wind blows," may possibly
be applied to this operation. I can but say that of all
those women upon whom I have operated during the
last ten years for shortening the round ligaments, but
two have come under my personal observation in whom
the operation eventually proved a failure. In one of
these the operation was performed for prolapsus uteri, the
uterus being very large and heavy, a case in which I now
consider the operation contra-indicated. In the second,
the ligaments had been torn during their attempted extrac-
tion, and primarily the operation must be considered to
have been at least a partial failure. I must add to these
two cases three others in which, in my earlier days, I
failed to find the ligaments ; here the want of success
must not be attributed to the operation, but to the op-
erator. As regards the permanency of the success, I
have had the opportunity to examine probably about one-
half of my cases for a period varying from six months to
as many years after the operation, and in none of them,
I can honestly say, have I found the uterus to have devi-
ated one iota from the position in which I put it. At
the time of my last article, six years ago, I had not had
the opportunity to see any of my cases undergo the cru-
cial test of pregnancy and parturition ; but since then not
only have Drs. Coe and Boldt reported to me, if I re-
member right, each two cases, and Dr. Henry S. Stark
one instance of that occurrence which had come under
their observation, in which the uterus retained after con-
finement the normal anteverted position ; but I myself
have seen four such, in one of which I saw the patient in
consultation for puerperal septicaemia in her fifth con-
finement, the other also for puerperal septicaemia in her
first confinement, six years after the operation, and in all
these cases the position of the uterus was absolutely nor-
mal. I do not suppose that it is necessary to say that
the septicaemia in these cases had nothing to do
with the Alexander's operation, but was merely acci-
dental. Some of my operations performed during the
last six months are of course too recent to enable me
to draw conclusions as to their permanency. I would
say that during the past eighteen months I performed
twenty-one Alexander's operations, every one success-
fully.
In conclusion, while I do not undervalue the difficul-
ties of the operation, and the uncertainties which will
always be attached to it, I still must assert my unquali-
fied belief in it, in properly selected cases, in prefer-
ence to the other dangerous, and, as regards permanent
results, no more certain, operations of ventral fixation and
intra-peritoneal shortening of the ligaments.
A CASE OF CASTRATION FOR PRIMARY TU-
BERCULAR EPIDIDYMITIS IN A PATIENT
AGED EIGHTY ONE.1
By C. L. GIBSON, M.D.,
NBW YORK.
ATTENDING SURGEON ST. LUKE'S HOSPITAL *, ASSISTANT SU1.GBON 6T. MAKY'S
FREE HOSPITAL FOR CHILDREN.
It is with a certain misgiving that I offer to your atten-
tion the description of a single case, presenting neither
an extraordinary rarity nor novelty of treatment.
The subject of genito urinary tuberculosis, especially of
the testicle, presents many points of interest in the way
of frequency, etiology, pathology, exact diagnosis, prog-
nosis, and treatment. Every one of these points has
been and is the subject of widely varying opinions. The
literature is simply terrifying. A glance at the pages in
the " Index Catalogue of the Surgeon- General's Library,"
on the article " Tubercular Testicle," led me to think it
highly presumptuous on my part to try to add to this
wealth of material. And yet it is most disappointing to
find how often this material fails to enlighten us on any
one particular point on which we seek information.
Perhaps it is still more astonishing that a work bearing
the promising title "The American Text Book of Sur-
gery1' should dismiss the consideration of tubercular
testis in exactly nineteen lines.
The subject of this paper does not pretend to settle
the many disputed points. I wish to emphasize some of
the facts of this case as a possible support for the radical
treatment of tubercular testicle, which I favor, although
in a general way I am ready to fall into line with the
present moderate plan of treatment of surgical tubercu-
losis in general, which has followed as a healthy reaction
against the furor of attempted radical measures of the
previous decade.
The following is a resume of the case as furnished by
the hospital records :
Henry W , eighty-one years of age, born in New
foundland, formerly a nurse, was admitted to St. Luke's
Hospital, New York, August 13, 1891 ; service of Dr.
F. H. Markoe, Attending Surgeon. To his great kind-
ness I am indebted for the opportunity of treating and
reporting the case.
Family history : Good.
Previous history : No rheumatic, malarial, cardiac, pul-
monary, or renal history. No previous disorder of the
genito urinary organs, save a single attack of gonor-
rhoea forty to fifty years ago. Double reducible inguinal
hernia for fifty years.
Present history: Nine days previous to admission,
while carrying a man down-stairs, he stumbled, sustaining
a strain referred to left groin. In a day or two the left
testicle became swollen and there was tenderness run-
ning up into the abdomen. (He thinks the organ has
always been a little the larger.) The symptoms described
increasing, he sought relief in hospital treatment.
Examination : The left half of the scrotum is occupied
by a globular mass, diameter three inches, tense, elastic.
At the upper and posterior portion the thickened and
hardened epididymis can be made out. The cord is
somewhat thickened, but smooth. Tumor translucent.
Examination per rectum negative. No urethral dis-
charge. Double reducible inguinal hernia. Pigmented
scars on both legs.
On admission the temperature was 980 F.; pulse, 84 ;
respiration, 20. Urine: Acid, clear, specific gravity
1.020, two per cent, albumin ; no glucose. Microscopi-
cally a few red blood-cells and leucocytes.
Treatment : Regular diet, salts, suspensory bandage,
» Read at the meeting of the Harvard Medical Society of New
York, January 27, 1894. The patient was also presented at this
meeting.
36
MEDICAL RECORD.
[July 14, 1894
and counter-irritation by Paquelin cautery. The next
day it was noted that he was comfortable.
August 1 8th. — Pain continues. Ordered ung. hydrarg.
locally daily.
August 26th — Condition unchanged, explored with
hypodermic needle, clear fluid. Stop ung. hydrarg. Re-
sume cautery.
August 28th. — Fluid about an ounce and a half en-
tirely evacuated, giving considerable relief.
August 31st. — Swelling has returned, with further evi-
dences of inflammation.
The diagnosis of a tubercular epididymitis had been
established for some time. The increasing acuteness
of the symptoms seemed to indicate operative inter-
ference, which was accepted by the patient. Accord-
ingly, September 1st, the preparations for thoroughly
cleansing the skin of the operative field were begun.
Examination of the chest showed heart sounds distant
and feeble. Lungs emphysematous, urine (previous to
operation) acid, clear, sp. gr. 1.016, one per cent, albu-
min, many leucocysts and epithelium, hyaline casts.
September 4th. — I operated, having the kind assist-
ance of Dr. Markoe. Previous to etherization atrop.
sulph. gr. y^, and whiskey 3 vj., were given. An inci-
sion one and one-half inch long, subsequently enlarged
to two inches, from a point over body of pubes down-
ward. Spermatic cord isolated, apparently normal. It
was transfixed and tied high up with catgut ligatures,
and divided. Constituents of cord isolated, and five
fine catgut ligatures applied. Coverings of testicle sepa-
rated and organ turned out, during which purulent con-
tents escaped into the wound to a very slight extent.
About one-third of scrotum ablated with testicle. Mod-
erate hemorrhage. Union by mattrass and continuous
suture of catgut. No drainage. Sterilized dressing
over protective tissue.
Ether was very well borne; no nausea followed.
There was considerable depression in the first few days.
Stimulating food was diligently given, and he was gotten
out of bed into a steamer chair in two days ; this I think
doing much to prevent him from getting into that hope-
less state of apathy when old people are confined to bed.
Five days after operation the dressing had to be in-
spected, as it got disturbed by moving him about daily.
There was primary aseptic union. A second dressing
for protection reapplied. He gradually regained his
strength ; for several days his mind was pretty feeble,
but he was able to leave the hospital eleven days after
the operation in pretty good shape.
The testicle removed was thus reported on by the
pathologist, Dr. J. S. Thacher : " Microscopical exam-
ination shows typical tubercular changes. There are a
large number of giant-cells, many tubercles, some tuber-
cle tissue, and a little cheesy degeneration." There is
no record of the microscopic changes. Six months ago,
two years after the operation, I saw the patient again.
He was waiting in my office for me one very hot day,
feeling very comfortable indeed, while I was absolutely
done up. Of the two he seemed by far the most vigor-
ous. The scar was almost imperceptible, and save some
disturbances of vision he was absolutely free from evi-
dences of disease of any kind. His mental condition
was as clear and vigorous as you could expect of a man
aged eighty three.
This result of this case is exceedingly gratifying and
has some points of interest. I think there are not a few
surgeons, even to-day, who would have refused this elderly
patient the radical operation of castration. Certainly
the majority of practitioners, unfamiliar with the actual
possibilities of thorough modern surgery, would not have
suggested it to the patient. There is a good deal of
superstitious horror still prevalent about the dangers of
castration; sepsis, prolonged suppuration, secondary
hemorrhage do not or should not exist, and these former-
ly made the operation hazardous. In this case we real-
ized that the operation must be speedy and the conva-
lescence smooth. The elaborate preparations of the skin
prior to the operation sought to overcome one of the
most frequent causes of wound suppuration, and rendered
unnecessary any half-hearted and inefficient cleansing on
the operating-table, which adds to the time. The opera-
tion was done quickly, and with scrupulous regard for the
details of surgical cleanliness. The close approximation
of the divided tissues made drainage unnecessary, obvi-
ating frequent change of dressings and pain and leaving
no indolent sinus. The administration of atropine
before the operation gave a certain protection against ex-
hausting nausea after etherization. The immediate
operative shock was not marked. I have already pointed
out, in a paper in the Annals of Surgery for October, 1893,
that the occurrence of shock in operations in advanced
age is more theoretical than real.
The result in this case seems to point to the occur-
rence and radical cure of a primary tubercular epididy-
mitis by castration. This statement at once brings us
into a controversy as to the pathology and consequent
indications. There is the older view that a tuberculosis
of the geni to-urinary system is only a part of the evidence
of a general constitutional infection. This is true only
to a certain extent.
Admitting, then, that there is a genito urinary tubercu-
losis while the remainder of the body is free, there are
two views, the one, strongly upheld among others by
Guyon, that a tuberculosis of the epididymis is never lo-
calized to it, but is accompanied by, or secondary to, some
other tuberculosis of the genito-urinary system, notably
the seminal vesicles. On the other hand there is the
view, supported by one of the latest and best works, Jacob-
son's " Diseases of the Male Organs of Generation," that
the epididymis is usually the first seat of the affection.
The figures indicating the relative frequency of phthisis
in connection with tubercular testis are hard to estimate.
In a series of 102 cases, of Terrillon and Reclus, of tuber-
cular epididymitis, 57 cases also had phthisis. Reclus* s
thesis of 1876 found that only one case in three had
phthisis ; the same ratio is given by Wilson. Again, from
the observations in the Pathological Institute at Prague
we find that in 1,317 cases of phthisis the testicle was in-
volved in the tubercular process only thirty-seven times.
Guyon denies the existence of a localized tubercular
epididymitis. In 26 cases of autopsies of the genito-
urinary tract the occurrence of foci confined to the epi-
didymis was never observed. His observations of 222
cases of genito-urinary tuberculosis showed the following
relations :
Forty cases of isolated genital tuberculosis ; 74 cases
of genito-urinary tuberculosis ; 108 cases of combined
genito-urinary tuberculosis. Now if it were true that tu-
bercular epididymitis never occurs except as part of a
diathesis or as part of a tuberculosis of the genital or
genito-urinary system, the indications for castration
would be pretty limited.
The evidence both of everyday clinical observation
and the statistics quoted above, and, finally, the case un-
der consideration, show that a genital tuberculosis may
exist independent of phthisis. At once the indications
for operation increase. Guyon's statistics are those of a
specialist who sees the late case when a tubercular pro-
cess has spread. Early radical treatment would much
lessen the gloomy statistics of such specialists. For it is
evident that removal of a diseased testicle, if complicated,
wej will say, with disease of the seminal vesicle, would
only be a palliative operation with very narrow indica-
tions. The truth of the matter is, we do not accurately
know just how the process develops. It seems apparent
that in some cases it must develop primarily in the epi-
didymis, the seminal vesicle being secondarily involved,
and vice versa. My personal feeling is that the view
which always makes the seminal vesicle the source of in-
fection of the epididymis cannot be true ; certainly not in
the case under consideration (I take it for granted that
the epididymis is attacked before the testicle, which,
however, is almost invariably attacked with the progress
of the disease). If it were possible to establish what
July 14, 1894]
MEDICAL RECORD.
37
part of the epididymis is first attacked, some light might
be obtained on the subject, although Mr. Jacobson says,
" this is a point which has been much and needlessly
discussed." In the majority of cases the first evidence
of disease is found in the head of the epididymis where
the spermatic artery breaks up and one branch enters the
epididymis. The vessels of the epididymis are smaller
and more tortuous than those of the testicle or vas def-
erens. This would point to infection from the blood-
supply and show the priority of the process in the epi-
didymis and not the seminal vesicle. The tendency of
tubercular processes to become localized- where the con-
dition of blood-supply is most abundant and complex is
well known, especially in the epiphyses, while on the
other hand in tuberculosis of the tendon sheaths the
poorly vascularized tendons remain unaffected although
buried in tubercular tissue. I think on the whole we
can accept this theory of infection by the blood supply
to show that the process is primary to the epididymis
and therefore admits of conditions favorable to operative
relief. The question of infection from coitus, and con-
sequently of the epididymis secondarily to infection of
the seminal vesicle, has but little to support it, and
is in the main fanciful. Mr. Jacobson says that if the
theory were true, tubercular disease of the sexual organs
should be more common than it is. That tubercular
testis is at times congenital, that it follows upon injury
as in our case, certainly are decided arguments against
the coitus theory.
What guides have we in general for the treatment of
tubercular testis ? We have to consider the classes of
cases and the classes of treatment available. I propose
the following divisions :
1. Tuberculosis of the testicle (or epididymis or both),
all other tubercular lesions being wanting. 2. Tubercu-
losis of the testicle and other portions of the geni to-uri-
nary tract. 3. Tuberculosis of the testicle and chronic
pulmonary tuberculosis. 4. Tuberculosis of the testicle
and other portions of the genito-urinary tract and chronic
pulmonary tuberculosis. 5. Tuberculosis of the testicle
forming part of a general acute miliary tuberculosis.
To combat these conditions we have at our disposal :
1. General constitutional treatment — hygienic, dietetic,
climatic, and medicinal. 2. Palliative measures — evacua-
tion of pus, curetting, caustics, thermo-cautery, resection,
castration. 3. Radical measure — castration.
In all forms of the disease, save the rapidly fatal cases
of acute miliary tuberculosis, the general constitutional
treatment should be pushed to the fullest extent possible.
It puts the patient into the best possible condition for
repair of damage and checking of further invasion. To
specify rally a judicious course of treatment would be to
write a good-sized work. That constitutional treatment
per se is curative, forever stamping out the disease, I do
not admit — many early cases are apparently cured, many
severe processes are temporarily ameliorated. A tuber-
cular focus in any part of the body is likely to light up
again at any time, although remaining dormant for years.
The literature gives many such cases. The favorable ab-
solute reports that have been quoted from time to time,
to support the curative effects of constitutional treatment,
either are issued too early or admit of doubt as to exact
diagnosis.
I have said before, it is indicated in every one of the
^ve phases just described. Are there any forms in which
it becomes the only treatment? How far it will be em-
ployed in the fifth form is a matter of expediency. In
the first form it will play a secondary part, the chief fac-
tor of success being early and radical removal of the pri-
mary focus.
In the next three forms it comes to the front, as here
the operative measures can only be palliative ; but in none
of them is the possibility of improving the patient's con-
dition by interference excluded, though the benefits grow
less with the increasing complexity of the lesions.
We come now to the application of the paViative
method. One of these methods, resection of diseased
nodules in the epididymis, is quasi-radical, but presents
no particular advantage, as it will scarcely maintain the
function of the gland intact, and, being probably incom-
plete, is a waste of time when delay is dangerous.
The other varieties, incision of abscesses, use of sharp
spoon, packing with iodoform gauze, cauterizing with
chloride of zinc, burning with thermo-cautery, can never
be indicated in Class 1, of localized primary tuberculosis
of testis or epididymis. The remaining three forms may
all be benefited but not cured by this means of treat-
ment. (Strictly speaking, Class 3, localized tubercular
epididymitis with phthisis, might be included with Class
1, although tubercular disease would not be banished
from the body by an operation.) How far minor pallia-
tive measures, properly speaking, are to be preferred to
castration, even as a palliative measure, will be discussed
in the consideration of that operation.
We come now to the application of castration. In
Class 1, where our diagnosis is absolutely trustworthy as
to the limitations of the disease, and we can put the pa-
tient in a condition to withstand or avoid new formation
of tubercular deposits, the result will be exceedingly
gratifying. There are many cases of total cures persist-
ing for many years which are on record to bear out that
statement.
Great care must be taken, though, to assure ourselves
that we are actually dealing with a localized process. If
we grasp the spermatic cord above the tumor, and find
that it is entirely free from enlargement and localized
swelling and painless, we have not yet assured ourselves
as to the condition. A most careful examination of the
seminal vesicle per rectum is necessary; this requires
considerable knowledge of the normal condition to de-
tect the abnormal in early cases. The seminal vesicle
may be recognized as diseased, while the cord appears or
is normal. This peculiarity is explained by the usual
limitation of the process at one or both of two points,
the testicular end just above the tail of the epididymis,
and at the distal end where it joins the seminal vesicle.
As to the application of castration in any of the three
remaining forms, it seems to me, broadly speaking, to be
indicated as a palliative measure in those, two forms
which I have made of the trouble in the genito-urinary
tract. The indications are even more positive in the
form of localized testicular trouble complicated by
phthisis, provided the patient's general condition war-
rants doing an operation requiring general anaesthesia.
In this case, if the patient can be brought under favor-
able circumstances, the process in the lungs may and can
be arrested for a long time. In any of these conditions,
as Mr. Jacobson very judiciously remarks, the patient is
relieved from one of his two burdens — tuberculous lungs
and suppurating, crippling, perhaps painful testis.
Guyon goes so far as to counsel invariably (within
limits of reason, of course) the use of castration as a
palliative measure, although he absolutely rejects its use
in the early stages before the testicle is materially in-
volved. Believing as he does that the process is con-
veyed from the seminal vesicle to the epididymis, he re-
jects the operation as curative, but indorses it most
warmly as a palliative measure. After removal of the
testis, where there is a geni to urinary tuberculosis else-
where, the relief from the acutely suppurating focus may
give the system more vigor to combat the remaining
process and possibly retard it.
The presence of a localized suppurating focus was long,
and is yet, in some quarters, considered as a noli me tangerc%
for fear that interference with it may cause a general out-
burst of tubercular trouble. On this point Guyon ex-
presses himself very positively as follows: "The most
scrupulous surgeon may in all conscientious security at-
tack a suppurating tubercular focus (provided that indi-
cations exist), without the slightest danger of injury to
the general system.' '
That such an outbreak of general symptoms may occa-
sionally arise as a result of localized operative interfer-
ence, I am not prepared to deny. I have never seen it
38
MEDICAL RECORD.
[July 14, 1894
occur after any operation for the relief of surgical tuber-
culosis.
Being relieved of a distressing local complication the
patient is better able to go about, to live an outdoor life,
to indulge in proper exercise, all of which are so necessary
for improvement of the general health. Moreover, he is
able to return promptly to work : of great importance to
a poor man with a family. In one case I castrated a
man for a pretty advanced process, and he resumed
work as porter in a wholesale house in ten days.
As opposed to castration are dangers of an operation,
apparent loss of virility, and consequently danger of hy-
pochondriasis.
The surgeon must judge in each individual case how
much advantage is to be obtained from an operation,
how much any given patient can stand. As to the ap-
parent loss of virility, the disappearance of both testicles
may produce a marked effect on the mind. Perhaps here
amputation of the worst, and mild palliative measures on
the other might be indicated. Or, as has recently been
most successfully done by Dr. R. F. Weir, a cylinder of
celluloid resembling a testicle might be introduced into
the scrotum and allowed to become embedded. Cer-
tainly, fear of mental changes ought not to deter us from
removal of one testicle ; it is more likely that a better
effect is to be looked for by the removal of an unsightly
and disagreeable condition which of itself would natur-
ally be an obstacle to sexual relations.
The more carefully we weigh the results of castration,
the little danger of the modern operation properly done,
the wider seems to be the field for it. Of the further
operation of removing diseased seminal vesicles, although
some few brilliant results are beginning to be recorded,
it is not within the province of this paper to discuss ; the
operation being still sub judtce, and at present offering
little in its favor. Of course, if it come to receive general
recognition the indications for castration would be mark-
edly increased.
The treatment of tubercular disease by injection of the
substance known as Koch's tuberculin, which was re-
cently hailed by the profession with such hysterical en-
thusiasm, has to day no standing, and need only to be
mentioned to be condemned.
As to the sclerogenic method of treatment by injection
of chloride of zinc, which is now on trial, I can say
nothing in this connection as I am unaware of its employ-
ment in the form of disease under consideration.
Just as in malignant disease, early interference must give
the best chance of effecting a cure. The responsibility
of this rests chiefly on the recognition of the disease and
the possibilities of treatment by the general practitioner.
It is to be hoped that our resources of exact diagnosis
may be multiplied to allow of treatment of the disease by
knowledge of its nature, without waiting to be compelled
by urgent symptoms. The bacilli may be recognized
sometimes in the fluid of the hydrocele, which occurs in
about one-third of the cases. The centrifugal machine
may be of use in facilitating the accumulation of solid
particles. If there is pus, the bacilli will probably be
found readily. Any of these fluids may be used to inoc-
ulate suitable culture media. Or the fluid may be used to
inoculate animals susceptible to tuberculosis, e.g., guinea-
pigs. The semen is occasionally found to contain bacilli ;
other means failing it might yet afford a clew to the exact
nature of the disease. And exactness is what we want to
enable us to move early. #
From consideration of some of the elements presented
by the case reported, the following observations seem
justified : That tubercular testis may occur as an idiopathic
primary condition ; that it may first appear in advanced
age ; that advanced age is no obstacle to successful in-
terference.
I know that many interesting points have not been al-
luded to — the present paper has no pretension to exhaust
the subject. Though I have made no extensive search
on this line, I think that the great age of the patient and
the result make the case unique.
THE TRANSMISSION OF THE CHOLERA SPI-
RILLUM BY THE ALIMENTARY CONTENTS
AND INTESTINAL DEJECTA OF THE COM-
MON HOUSEFLY.1
By THOMAS C. CRAIG, M.D.f
PASSBD ASSISTANT SUKGSON, U. S. NAVY, NAVY YARD, NSW YORK.
While working with cholera in the Hoagland Laboratory
of Bacteriology, it occurred to the writer to undertake a
series of experiments to ascertain whether it were possible
for the common house fly to carry the cholera spirillum
and deposit it, in a living state, and thus be one of the
factors in the contagion ; and also to ascertain whether
cholera was fatal to flies within the time necessary for
them to carry it to distant parts.
A fresh bouillon culture was made from the stock cult-
ures in the laboratory, originally obtained from cases of
cholera at Swinburne Island in 1892. Three large flies
were caught and placed in a small wide mouthed bottle.
A small piece of bread was then moistened with the beef-
tea cholera culture, and put into the bottle along with
the flies. They eagerly alighted on the bread and fed
ravenously on it. A small amount of water was given
them, and they were thus left for three days.
At the end of that time they were found to be alive
and as active as ever. They were taken out and killed,
and their intestinal contents squeezed out on to a clean
cover-glass, care being taken not to let their feet come
in contact with the cover-glass. Some of the expressed
material from the intestine of each one was transferred to
sterilized beef- tea, and placed in an incubator. Smear
preparations were also made of the expressed intestinal
contents, stained, and examined. In one slide were found
a number of fine bacilli and spirilla. The spirilla re-
sembled very closely in size and appearance those of chol-
era ; yet one could not be sure until the separation and
further testing and growth. At the end of two days
the tubes in the incubator were examined and found to
be cloudy, and to have a film very similar to the film
seen on cholera cultures.
Mounted specimens were made from the film and
under liquid, and the field found to be filled with bacilli
of varying sizes, micrococci, and spirilla, the latter to all
appearances identical with the cholera spirillum. Dilu-
tions were made from the film, and under liquid ; and
then rolled in tubes. Acid was then added for the chol-
era red reaction, but with negative results.
At the end of two days the rolled tubes had grown
numerous colonies. In two of the rolled tubes the cult-
ures were very much mixed, while in one tube (the one
made entirely from the film) the colonies were all uni-
form in appearance — small, round, grayish white, slightly
refracting, liquefying colonies with crenated borders.
Several beef-tea inoculations were made from these
latter colonies and placed in the incubator ; stab cultures
in gelatine were also made. Specimens mounted from
these colonies showed long and short spirilla, also the
comma shaped bacillus. The spirilla showed a remark-
able form in arrangement. The microscopic field ap-
peared to be filled with long, curved, intertwining, and in-
tricately arranged hair like masses, having the appearance
of a tuft of curled hair like that used in a mattress. This
appearance and arrangement was only found in those
specimens mounted from the colonies. It was perhaps
the arrangement of spirilla just as they grew. A colony
fitted into the wire loop ; it was then touched lightly in
half a dozen places to a cover-glass, and dried ; no other
disturbance being made. Invariably this same curled-
hair arrangement of these exceedingly long spirilla was
found.
At the end of two days the test-tube beef-tea inocula-
tions were found to be cloudy and to have a film.
Examination of the hanging drop showed the field to
be filled with comma shaped bacilli and a few spirilla —
all in extremely active and lively motion.
The stab cultures in gelatin showed, at the end of two
1 Read before the Brooklyn Pathological Society, June 14, 1894.
July 14, 1894]
MEDICAL RECORD.
39
days, growth along the whole line of puncture, with
commencing liquefaction at the top. Specimens mounted
from the beef tea culture showed characteristic comma
bacilli and spirilla.
Sulphuric acid added to the beef tea culture gave an
intense cholera red reaction.
Bacilli and spirilla of the same shape and size were
found in all the beef tea inoculations.
Hydrochloric acid and nitric acid each gave the chol-
era red reaction ; the reaction with hydrochloric acid
being the most intense and lasting the longest without
fading — at the end of ten days being almost as red as on
the day it was made.
The stabs in gelatin continued to grow and liquefy
the gelatin in the peculiar glass funnel shaped way at the
top of the stab — while the lower part of the stab extended
out into the gelatin as a thin, velvety, needle-like growth.
Specimens mounted from the gelatin culture showed
the comma bacilli. Thus the recovery of the living spi-
rillum of cholera from flies fed on a culture of cholera
proves beyond any doubt how potent and important an
agent the common house fly may be in the carrying of
this spirillum.
From the fact of the flies not dying within three days,
it goes to show that they are able to withstand the toxine
of this culture, now two years old, certainly long enough
to carry the infecting material great distances, and to
deposit it in many places, each of them becoming
a focus for infection.
Investigations relating to this subject were conducted
by Simmonds, and are recorded in the Deutsche medizin-
ische Wochenschrift, 1892, No. 41. Simmonds placed
flies in a bottle with cholera faeces for a few minutes, and
then allowed the flies to walk over gelatin plates. A series
of about nine plates was arranged, and over each the flies
were allowed to walk. In nearly all the plates the cholera
spirillum was recovered. No attempt was made to isolate
the spirillum and grow it in gelatin stab cultures and
beef-tea, or to try for the cholera red reaction.
It might be argued that the cholera spirillum, which I
recovered from the flies, was conveyed from their feet or
their bodies on to the cover glass, the same as Simmonds
recovered his spirillum, and thus never entered their intes-
tinal canals. I was very careful that this accident should
not occur. Before the flies were inoculated their wings
were cut off; and before their intestinal contents were
expressed their legs were pulled off and destroyed. The
intestinal contents were forced out with sterilized forceps,
and only the small drop of liquid at the end of the rectum
was used for inoculating the beef tea.
It may be interesting here to note that I was unable to
get the cholera red reaction in any of the mixed cultures
in beef tea, but never failed to get it in the pure cultures
of the spirillum recovered from the flies fed on the
cholera.
During my work with this subject I was greatly aided
by the many valuable suggestions of Dr. £. H. Wilson,
the director of the laboratory, under whose directions all
the manipulations were made. I intend to continue my
investigations in this line further, and to ascertain
whether other bacteria, such as the typhoid, anthrax,
diphtheria, and tubercle bacilli, can possibly be carried
and deposited in a living state by flies.
Alcohol and Sunstroke. — The late Surgeon Parke,
medical officer of the Emin Pasha Relief Expedition,
wrote shortly before his death a " Guide to Health in
Africa.1 ' In speaking of sunstroke he says that he has
met with comparatively few cases of it in his African
service, and that " he has seen more cases of sunstroke
occur during one ' field-day ' at Aldershot than during
seven years' medical experience in Africa." This im-
munity from thermal fever he attributes naturally to the
use of precautionary measures, the most important of
which is abstention from alcohol. " Drink," he says,
" is certainly the most powerful predisposing cause of the
development of the symptoms of sunstroke."
TWO HERNIOTOMIES IN A CHILD UNDER FIVE
YEARS OF AGE— BASSINrS METHOD.
By SAMUEL E. MILLIKEN, M.D.,
NEW YORK.
The following case, Stanley H , who first came to me
from Newburgh, N. Y., on May 22, 1890, when a baby
of seven months, illustrates some of the difficulties met
with in the mechanical treatment of hernia, even at such
an early age. Although exceptionally intelligent care
was given the case at home, the hernia being retained
for some months at a time, and with an otherwise healthy
child, the rupture would protrude occasionally almost
to its original size.
At the first visit there existed a left oblique congeni-
tal inguinal hernia, the size of a small egg, which was
easily reducible, but was retained, only after some diffi-
culty, with a " Hank " truss. A celluloid " Hood " tnws
was applied May 31st, as the worsted truss failed to hold
the hernia. The mother was instructed not to remove
the truss, even to give the child a lath. Sufficiently
frequent visits were made to my office, as would enable
me to readjust the truss, and see that the pressure over
the inguinal canal and around the pelvis was uniform.
To show the weakened cordition of the inguinal re-
gions the child acquired a hernia on the light side, Feb-
ruary 29, 1892, when a double truss was applied. This
second hernia could not be accounted for by any other
reason than the above, as the general health of the child
was excellent. The congenital hernia did not improve,
and it was decided to perform the radical operation ;
the right or acquired hernia, however, was easily con-
trolled by a truss.
On June 20, 1893, the reconstruction of the inguinal
canal was performed after Bassini's method. The hernia
being congenital, the sac was cut of! about one inch
above the testis, and again flush with the internal ring.
The conjoined tendon, and the shelving process of Pou-
part's ligament, were brought together with interrupted
sutures of kangaroo tendon, posterior to the cord struct-
ures, while the aponeurosis of the external oblique was
closed with a continuous suture of the same material, an-
terior to the cord structures, thus re-establishing the
obliquity of the canal. The skin wound was sutured
with interrupted catgut, without drainage. The wound
healed under one dressing, without any complications,
and the child was sent home on the tenth day after
the operation, with instructions to be kept in the recum-
bent posture for ten days longer, so as to insure firm
union of the deeper structures, only a light bandage be-
ing worn.
The hernia of the right side, which had been held for
so long, was apparently cured, and the truss was therefore
left off. However, in a few weeks after the child began
to walk, the right hernia reappeared, and a truss was re-
applied. With such an unsatisfactory result from con-
servative measures, I advised a radical operation for the
right side, which was not performed until June 21, 1894,
one year and one day after that on the left side, which
had proven so successful, without any apparatus being
worn afterward.
During the administration of the ether for the opera-
tion on the right side, the hernia protruded to the mid-
dle of the scrotum, and was the size of a large egg. The
only difference in technique in this operation, from the
one on the left side, was the total extirpation of the sac,
as the hernia was acquired and not congenital. The
first dressing was changed on the seventh day, when it
was found that the catgut sutures in the skin were ab-
sorbed and complete union had taken place. The pa-
tient was sent home on the ninth day after the opera-
tion, with a light bandage, and the parents were in-
structed to keep the child in the recumbent posture un-
til three weeks had elapsed after the operation.
Conclusions. — 1. When any difficulty is met with in
the mechanical treatment the radical operation should
be performed even in young children.
40
MEDICAL RECORD.
[July 14, 1894
2. If, after six months or a year, the truss has been
steadily worn, and there still exists a flabby condition of
the inguinal region, the operation is also indicated.
3. The risk of operating on children, where strict
asepsis is observed, is little, if any, more than in adults.
4. The chances for a radical cure in children are
greater than in adults, because of the more perfect repa-
rative process at that age.
5. The reconstruction of the canal is, par excellence,
the operation, and, as shown by Bassini's statistics, has
stood the test of time.
6. To obtain the best results a great deal depends
upon the surgical technique, and the suture material em*
ployed.
7. Drainage should not be employed, if the surgeon is
careful to observe the modern rules of cleanliness ; for if
the wound is infected during the operation it must heal
by granulation, and the drainage tube is always an addi-
tional source of danger.
8. After primary and complete union of the whole
wound no truss is necessary.
36 Wmt Firnr-NiNTH Street.
IS THERE A NORTHERN REMITTENT (NON-
MALARIAL) FEVER?1
By NELSON RICHMOND, M.D.,
PitEDDNIA, N. Y.
The importance of the above subject and the interest
manifested induce me to write a paper with the same title
as that presented to this Society a year ago. In that
paper, a year ago, the claim was made that there was a
type of fever common to Western New York, and, as I
have since learned, more or less common to the entire
State, which, in my best judgment, was not typhoid, and
to which there was no settled name accredited by all.
It was asserted that some physicians did call this type
of fever a mild form of typhoid, others named it gastric,
another bilious, another malarial, another remittent,
and still another simple continued fever. It was believed
that this heterogeneity of names was applied to one and
the same fever, and that the lack of text-book informa-
tion concerning it, coupled with the astigmatism of the
observer, made confusion worse confounded. Various
authors were quoted to show that either the names had
no foundation in fact, or that the symptoms, as por-
trayed, were not applicable to the fever in question.
This paper will confine itself strictly to the discussion
of the identity or non-identity of this type of fever with
typhoid.
The burden of proof seems to be that it is not typhoid.
But the writer is very anxious to be entirely satisfied in
his own mind, either that he is right or that he is wrong.
He is the more anxious, after having had nearly fifty
such cases, all recurring, and which he never intimated
were typhoid, to be clear in his own mind as to the fu-
ture. These cases carried a period of thirteen years.
The fever in question is usually gradual in its onset,
protracted and uneventful in its course, and as gradual in
its subsidence. It is confined to neither sex. It has, in
my experience, varied in age from five to sixty years. It
has a duration from twenty-one to thirty -five days. It
seems to run in cycles of seven. The temperature gradu-
ally increases in height, day by day, rarely going above
1030 F., maintains the highest mark for a few days, and
as gradually fades away. The tongue is usually covered
with a yellowish-white coating. Sometimes the tongue
is clean throughout the entire illness. The countenance
is sometimes dull and stupid ; again it is little changed.
Constipation is usually present, or the bowel may be regu-
lar in its evacuations.
The patient is incline! to take things very easy, and
not to worry about himself, his convalescence, or things
in general.
The skin is usually dull in color or jaundiced in ap-
1 Read before the State Medical Society, Albany, N. Y., February
6, 1894.
pearance. There is as much emaciation during the prog-
ress of the disease as in typhoid.
The pathology of the disease, as far as I am concerned,
is a sealed book, for I have never lost a case. There is,
moreover, seldom, if ever, any anxiety on the part of the
attendant. It is a very comfortable sickness. Errors of
diet, during the early stages of convalescence, cause a re-
turn of the fever for a few days.
Osier, under the heading " Mild and Abortive Forms
of Typhoid Fever/ ' says : " It is very important for the
practitioner to recognize the mild type of typhoid fever,
often spoken of as gastric fever or even regarded as sim-
ple febricula. In this form the symptoms are similar in
kind, but altogether less intense than in the grave attacks,
although the onset may be sudden and severe. The tem-
perature rarely reaches 1030 F., and the fever of onset
may not show the gradual ascending evening record.
The spleen is enlarged ; the rose-spots may be marked ;
often they are very few in number. The diarrhoea is
variable; sometimes it is not present. In such cases
the symptoms may persist for from sixteen to twenty
days."
I have given this very liberal quotation, not to
strengthen my own argument, but to be perfectly fair to
those who believe that the fever in question is typhoid.
It would be very easy, after reading this description, to
argue after this fashion : " What is the use of trying to
prove that a disease is less to be feared than it actually is
— that it has a much less dreaded name than some con-
tend. Osier is good authority ! His description fits
nearly enough ! Go on and call it typhoid ! Your pa-
tient will get well and you will get the credit of having
excellent success in treating typhoid fever. They will
say you never have lost a case, perhaps."
But the above course of reasoning does not satisfy the
honest, conscientious practitioner. I will admit, how-
ever, that one of the weakest points in the line of argu-
ment is the description of the fever. It is so monoto-
nous. Crises and destructive symptoms are conspicuous
by their absence.
Let us attempt to portray the symptoms which are ab-
sent in this disease, and which are so inseparably con*
nected with the name typhoid.
You will please remark that I said nothing about rose-
colored spots in this disease. If they ever have been
present they have escaped my observation. There is
never any right iliac tenderness. I have seen cases where
there was tenderness in the left iliac region. There is
seldom any diarrhoea — never any of the pea soup charac-
ter.
There is never an anxious countenance, rather the
reverse, as noted. There is never any sordes on the
teeth, never any brown, dry, or cracked tongue — trem-
bling on protrusion. In fact, gentlemen, what is ty-
phoid, and what are typhoid symptoms as generally un-
derstood ? What does the name convey to your minds
but the above line of symptoms — one or all ?
We are free to admit, however, that the name typhoid
is unfortunate. Should "enteric fever" be generally
adopted, and admission made that enteric fever meant
an involvement of different portions of the alimentary
canal ; that Peyer's glands were involved in the serious
cases — those accompanied by high temperature, brown,
dry tongue, or delirium — then the agitation of this ques-
tion might be considered unnecessary.
There is no doubt that the South furnishes a habitat
for typhoid fever and malarial fever in all its subdivision
types of remittent and intermittent varieties. There is
no doubt that new sections of the North present the
same forms of malarial fever. Malarial fevers were more
or less common when this country was new. Cities and
ceitain regions, well defined, present them more or less
clearly at present. But the Lake Erie region of Western
New York, where this fever has been studied, is a region
entirely exempt from malarial influences. The first
malarial disease is yet to be treated ; the first malarial
complication is yet to be observed in years of practice.
July 14, 1894]
MEDICAL RECORD.
4i
This, moreover, has been the testimony ot physicians who
have had a long practice here.
This region may have had malaria fifty or a hundred
years ago. It may naturally be inferred that it did. If
malaria prevailed and is now absent, may it not have left
some disease in its wake ? Some disease with its actual
malarial germ eliminated ? A disease subsequent to the
former and depending upon it, but not similar ?
If the South is to be credited with these different types
of fever ; if bilious, gastric, typho malarial, and malarial
— without meaning malarial — simply naming it malarial
for want of another name — are to be consigned to the
Shades, what is the North going to do to offset the ma-
larial types in the South ? Is it to be argued that we live
in the Garden of Eden ? A place where they have only
one type of fever and that (under your breath) is typhoid.
It does seem reasonable to me that, as the country is
developed and civilization advances ; as diseases, under
better hygienic conditions and more wisdom in guidance,
assume a less serious form, it is a natural inference that in-
stead of losing the type of disease entirely, we should
effect a modification of the disease. In this case it would
be a change, the true malarial remittent with the germ
of Laveran to a remittent of the present time without the
presence of the germ. Delay in announcing a positive
diagnosis in fevers until the tenth or twelfth day, is
always a wise precaution, unless typhoid symptoms pro-
claim themselves so unmistakably as to admit of no ques-
tion. A disinfection of the stools of all fever patients is a
precaution simple and easy of observance, and restful to
the conscience, when a case which admits of doubt de-
velops symptoms unmistakably typhoid.
Desirous of getting many individual opinions upon
this question, of being firmly settled in my own mind by
a consensus of opinion of the gentlemen present that I
am correct ; or of being fully convinced, by a full and
frank discussion, that the position I have taken is not a
tenable one, I stand before you for judgment.
As stated before, I am firmly convinced that terms ma-
larial as loosely applied — typho-malarial, gastric, bilious,
and simple febricula — should be blotted from our text-
books. The nomenclature should be simplified.
And yet the very fact that these names have crept into
our text-books is one of the strongest proofs that there is
a fever not typhoid, not malarial.
As suggested a year ago, I believe the name Northern
Remittent Fever describes this fever in question, simpli-
fies nomenclature, and is worthy of adoption.
Frkdonia, N. Y.
VALUE OF THIRD BLOOD- CORPUSCLE l IN
TUBERCULOSIS.
By ROBERT L. W ATKINS, M.D.,
NEW YORK.
In a paper read before the Pan-American Medical
Congress at Washington, in September, 1893, * stated
that the third blood-corpuscle is a pathological product.
The statement has given rise to criticism, both favorable
and adverse. At that time, in my paper, I gave the
proofs and reasons for my belief, and will not go over
them again here. Arguments and statements deduced
from another's experience are never as convincing as
one's own, and this is a thing that any physician can test
for himself if he has a good microscope.
The granular masses, or third blood- corpuscle, can
readily be seen, either alone or in groups. When in
groups they are often so pressed together that it may be
confusing at first to detect their shape, but a little ex-
perience will soon overcome this difficulty, and you will
be able to make valuable use of this means of diagnosis.
The third blood -corpuscle is the first indication of
tuberculosis, and I assert that tuberculosis in any form is
impossible without its presence in the blood. It makes its
appearance long before the cough, or before any of the
formerly recognized signs and symptoms appear. Not
* As defined in Landois and Sterling, Physiology.
only is it found in pulmonary tuberculosis, but in Pott's
disease, hip-joint disease, chronic abscesses, and lupus,
which diseases are recognized by the best authorities as
tubercular. It is also found in some cases of rheumatism
and asthma, and often in people who appear perfectly
well; but it is always the forerunner of tuberculosis.
If it had been present in my own blood I should never
have ventured to inoculate myself, as I did some time
ago, with tubercle bacilli ; and if it had appeared after
the inoculation I should have had reason to leel worried.
It did not appear, however, and the event has proved
that I was justified in my confidence that tuberculosis
would not develop.
In an article written recently by Dr. Charles Deni-
son,1 on " The Diagnosis of Tuberculosis by Tubercu-
lin Injections," he says : " There is an active tubercular
state — pre-tubercular state if you wish to call it so — be-
fore the tubercle makes its appearance as a factor in the
case." (This statement has been made by many others,
and, of course, has been known for a long time.) But,
still further he says : " Reference is intended to those in-
tricate, slowly acting blood- changes which come under
the classification of dyscrasia, which may be, for all I
know, the sine quanon of the bacillus of tuberculosis."
From my experience I believe the third blood corpuscle
to be the sine qua non of the tubercle bacillus, and the for-
mer to be the means of diagnosticating this dyscrasia
which it constitutes ; and still further, I believe it to be one
of the foods of the tubercle bacillus, and the only seeable
one in the blood, for I have demonstrated that this germ
will live in acute tubercular blood, and have published
the same in previous articles. The following cases well
illustrate the diagnostic value of this corpuscle.
A few days ago a young lady called upon me to have
her lungs examined. She had been staying indoors a few
days on account of a cold, but the night before something
red came up in her throat like blood. As she had taken
some wine that day it was thought it was possibly that,
but she was frightened. I examined her chest, and so
did another physician. Nothing was found except a little
rough breathing. On examination of the blood it was
found loaded with these corpuscles, and on that sign I
settled my diagnosis of hemorrhage and tuberculosis.
Two days after, when going up the Elevated stairs, she
had a severe hemorrhage and has had several since.
Temperature went up, and now, about two weeks after,
she is in bed with high temperature and night- sweats.
In my experience these cases are not uncommon.
Mrs. H came to me with a supposed case of can-
cer on the forehead. It was a round ulcer about one and
a half inch in diameter, one edge looking squamous
like, it bleeding very easily, and most painfully sensitive.
The neuralgia was quite extensive, radiating from it all
over the head. There were also little nodules here and
there over the forehead. This had been coming on one
year, I believe. A microscopical examination of the blood
showed the tubercular third blood-corpuscle present. I
then made a diagnosis of tubercular ulcer or lupus, and
not cancer. The sore is now healed fairly well, after
two months' treatment.
Mr. H , a single man, came to me only a few days
ago, complaining of a cough with expectoration and
pains in the chest, most of his family having died of tu-
berculosis. He only recently buried a sister, to whom
he was very much attached, which fact worried him in
regard to himself. A physical examination of his chest
revealed evidence, in connection with the history, to say
that it was the old story of beginning consumption. But
on examining the blood no corpuscles were found ; and
he was put at ease at once, for it could not be tubercular.
Many other cases might be given, but I will only em-
phasize its value as a means of making a negative diag-
nosis, i.e., to say that the absence of the third blood-cor-
puscle from the blood establishes the fact that no
tuberculosis is present. The disease with which the pa-
tient is affected, therefore, must be of some other nature.
1 New York Medical Journal, February 3, 1894.
42
MEDICAL RECORD.
[July 14, 1894
Clinical gepartment
THREE CASES OF NERVOUS DISEASES.
By PHILIP S. ROY, M.D.,
WASHINGTON, D. C.
Case I. Raynaud's Disease. — A colored boy, twelve
years of age, complained now and then for three months
of numbness of the right foot followed by burning pain,
particularly marked in the big toe, with occasional at-
tacks of neuralgia in that foot. About two weeks be-
fore I saw him he also complained of its feeling very
cold — swelling commenced, and he suffered intense pain
most of the time. Upon my first examination I found
the big toe as black as ink — pressure upon it lessening
the discoloration — and voluntary motion seemed lost.
On my second visit nutritive alterations had occurred —
blood-blisters had formed and several had broken, leav-
ing raw surfaces. The nail was loose and the tissue un-
derneath ulcerated. The asphyxia had continued, and
to all appearances gangrene was about to occur.
I had ordered the foot to be elevated and wrapped in
cotton-batting, and a soothing ointment applied to the
toe. Internally I gave the elix. phosph., iron, quinia,
and strychnia, with the twelfth of a grain of morphia to
each teaspoonful. I did not see the case again, as the
parents could not furnish either the drugs or the proper
diet — and I advised that he be sent to the Children's
Hospital, or else that one of the physicians to the poor
be sent for. He had no fever when I first saw him, but
three days afterward, on my second visit, his temperature
was 1030 F. I never compared the temperature of the
two feet.
Case II. Affaire's Disease. — A white man, forty
years of age, gave me the following history : About a
year before I saw him, while at work, he was seized with
violent vertigo and fell to the ground. Upon attempt-
ing to rise he found it impossible to do so. He was
told that his face was very pale and covered with a cold
perspiration ; was taken home, and for two days, when-
ever he opened his eyes, all objects seemed to whirl
around him. He vomited some the first day.
After two days he could walk about, but found he was
very deaf in the right ear, with constant noises in that
ear. Since the first attack he has had two others, and in
the last of these I saw him ; he was then unable to rise,
and the slightest movement of his head caused the ver-
tigo to return. His face was pale, with a cold perspira-
tion, and the right ear very deaf. % Between the attacks
the deafness is much better, though hearing is never en-
tirely restored. I examined the throat and external ear,
and could find no disease to account for the vertigo. I
therefore conclude that his is a case of true Meniere's
disease. He had been told by his former physician
that he had bilious attacks.
Case III. Angioneurotic (Edema. — A woman, forty-
five years of age, was suddenly attacked with (edematous
swelling in one foot, accompanied with gastric pain and
nausea. On the following day the other foot became
swollen ; this lasted three days, when the swelling left
the feet and the hands became affected in the same
manner. In two days the swelling disappeared from the
hands and appeared in the face. At the end of a week
all swelling had subsided. The woman looked delicate,
but said her health was good. Upon examination I
found no disease either of the heart or kidneys. She
told me she had had slight attacks of a similar kind. I
afterward saw her daughter with a similar attack, except
that the swelling was confined to the face and hands and
accompanied with nettle-rash, and the gastro-intestinal
symptoms were more marked. The daughter's attack
lasted ten days — first one part and then another of the
face and hands becoming swollen. She had had several
attacks in the three years previous. I could find noth-
ing in the diet to account for the nettle-rash, nor did the
remedies used for nettle-rash relieve her. In both cases
I gave the elix. of iron, quinia, and strychnia, until
they were well I do not know that I have had suffi-
cient opportunity, either from study or observation, to
express an opinion upon the subject, but it seems to me
that if this disease is sufficiently definite to justify giving
it a separate description in medical literature, it is only
because in so doing we emphasize the importance of con-
sidering the nervous system in sudden attacks of oedema.
The urticaria which sometimes accompanies the dis-
ease (as it did in one of my cases) would, a* Osier says,
make one believe that the patient had simply a case of
urticaria — while, as in my other case, purpuric spots
would cause one to fear some serious organic disease.
These cases of nervous disease, the clinical histories of
which differ so widely, are all due, according to our best
light at this time, to vaso-motor influences. In the case
of Raynaud's disease I exclude all other causes that might
produce similar conditions. The more persistently we
keep in mind the nervous system in making diagnosis,
the oftener are obscure cases made clear to us.
SUMMER COMFORT FOR BABIES: WITH A
HINT ON COLDS AND HAY FEVER.
By CHARLES E. PAGE, M.D.,
BOSTON, MASS.
" Man is not by nature a clothed animal," said Carlyle
in "Sartor Resartus," and the writer has three little ones,
aged respectively nine months, two and a hal£ and four
years, who seem to agree with the Sage of Chelsea ; they
are never so happy as when they are naked. Four years
ago (June 14, 1890) the eldest, a girl, was born, and dur-
ing all the hot weather we kept her comfortable and
happy "in her figure," literally. She was sufficiently
blanketed at night and during the cool of the morning
and evening, of course; but in spite of Mrs. Grundy she
was kept naked much of the time, and with unfettered
limbs she was creeping, or, at any rate, hitching, her way
across the floor before she was four weeks old. Her un-
usual strength was due to our practice of non-tending, as
well as to die freedom of body and limbs.
The more intelligent of our visitors, to whom she was
exhibited, were delighted with the evidence of absolute
comfort they beheld, and they straightway manifested a
disposition to help their own little relatives as much as
they could by stripping off some of the extra folds of
flannel under which the little wretches were sweltering
and half-smothering. But someone, we never learned
who, informed the S. P. C. C. of the outrageous treatment
of the little innocent, and looked for our arrest and sum-
mary punishment doubtless, and perhaps the adoption of
the babe by the State ; but it so happened that my little
Nursery Guide, " How to Feed the Baby," published in
1882, was dedicated to the Society for the Prevention of
Cruelty to Children, and so the President smiled be-
nignly on the good soul who lodged the complaint, and
assured her that if Dr. Page's baby died of frost-bite dur-
ing the summer the case should be carefully investi-
gated !
Something like ten to twelve thousand children have
died, under the age of five years, in this city, since the oc-
currence of the little episode referred to, while our little
girl continues to thrive, and to pull off her shoes and
stockings the instant she enters the house from her out-
ings, and both she and her little brother have time and
again distressed the maid by cutting up that caper and
going barefoot on "the Avenue." Numbers two and
three have since come to us, and they share their elder
sister's dislike for clothes. All three go barefoot in the
house all the year around, and much of the time when
out, and wear very slight rig at all times.
Next to a bad inheritance — many children being born
too tough to kill, while some are so frail by nature that
no kind of management will enable them to pull through
— the principal causes of infant mortality are : (1) Exces-
sive feeding, digestive capacity being lessened by lack of
July 14, 1894]
MEDICAL RECORD.
43
exercise and overwrapping ; (2) constant tending, and
constant lack of natural exercise, so essential to vigor of
body and digestive power ; (3) excessive clothing, so de-
pleting in many ways to the animal organism, the skin, a
breathing as well as an excreting organ, being forced to
get on with foul air, instead of fresh, while the pressure
of clothing, all the worse if a belly-band is used, inter-
feres seriously with the circulation of blood in the skin,
etc ; (4) lack of fresh air in the home, very few homes
being sufficiently ventilated.
" Why don't they catch their death o' cold?" Perhaps
one reason is that, H the truth were known, none of us
catches the disease in that way ; it is rather a disease of
accumulation of foul matters from the causes already
named, and when the system becomes surcharged with
frith and certain symptoms appear, we say — those of us
who know no better — " He has caught cold ! " The fact
of the matter is that it is rather a lack of cold, and hence
the prediction of Dr. Felix Oswald, that the time will
come when every sanitarium wiliAbe supplied with an im-
mense refrigerator for the treatment of "colds" (I can
never bring myself to repeat the name except with quota-
tion marks). The adult victims of flannels and a diet
unsuited to the season, hundreds of whom (physicians as
well as laymen, it must be confessed) flock to the White
Mountains every summer to avoid "hay fever," might
take a hint here and live in comfort in any part of the
country. They might go to the mountains for fun, but
not as a lot of sneezing, overgrown infants, to babble
about the hoped-for specific. How often I have ob-
served a babe who could not suck and breathe at the same
time for " snuffles," completely relieved within a half-
minute by removing a large share of its clothing, and
having a cold, damp towel pressed over the forehead,
temples, and top of the head, sending a cool wave in to
relieve the congested parts. It should be a cool, damp
towel, by the way, not ice-cold for an infant ; but the
grown snuffling may employ more vigorous measures.
867 BOYLSTON STSBKT.
NOTES ON BRAIN SURGERY.
By W. E. PUTNAM, M.D.,
WHITING, INP.
Case I. Depressed Fracture of Skull — Amputation at
Shoulder Joint — Recovery. — Andy P , a Pole, aged
nineteen, tried to board a freight train and was thrown
under the cars. I saw him two hours after the accident,
no effort had been made to check the hemorrhage. The
left arm was fractured in three places between the wrist
and shoulder, and the skin and subcutaneous tissue were
destroyed well forward on to the chest. The patient did
not complain of pain, and I took it for granted that the
railroad shock was to blame for this. After carrying him
two miles to my office I amputated the shoulder-joint by
a mixed method, using a peculiar-shaped posterior flap
and sliding some skin over tfre pectoral muscles. Am-
putation completed, my patient continued to sleep on and
on, and I began to look for " new worlds to conquer,"
when I found a three-inch half circular depressed fracture
in the left parietal bone. No ether was needed, as the
compression had caused what I supposed to be railroad
shock. I used a carpenter's chisel (for trephine) and a
monkey-wrench (for a mallet). After chiselling away
enough of the bone, I used the same chisel to raise the
depressed bone. By keeping a continuous stream of
water playing on the seat of operation one can see per-
fectly just how to hold his chisel, there being then little
or no danger of injuring the dura mater. The bone was
raised, and a strip of iodoform gauze was used as drain-
age. One hour after the operation the patient sat up and
drank a cup of coffee, after which he slid off the operating-
table and walked half a dozen steps unaided. In three
weeks he was out again looking for work.
Case II. Compound Fracture of Skull, Opening into
the Superior Longitudinal Sinus% with Loss of Two Ounces
of Brain Matter — Recovery. — Swede, aged twenty-three.
Two laborers were wrestling for an iron hook, and the
hook came down on top of the patient's head, the sharp
point entering the superior longitudinal sinus. The pa-
tient was comatose when brought to my office. There
was a swelling the size of a goose egg on top of the head.
A free incision released the pressure on brain, and the
patient's heart and respiration improved immediately.
When he coughed he literally spat blood from the top c f
his head, throwing blood fully four feet against the wall
of my office. He lost at least two ounces of brain matter.
I had not seen very many cases of brain surgery out here
in the country, so I packed the wound loosely with iodo-
form gauze and took my patient twenty miles to the Rush
Medical College, in Chicago. Dr. N. Senn put a snap
forceps on each of the divided ends of the superior longi-
tudinal sinus, and held them in place with a p] aster- of-
Paris dressing enveloping the whole head. In four days
the snap forceps were removed. In twelve weeks the
patient left the hospital, partially paralyzed on one side,
but able to walk by the aid of a cane. I wish to re cot d
these two simple cases for the benefit of young surgeons
who, like myself, are located in country towns, where we
are compelled to use our little knowledge and all our
courage to save a human life.
AN EASY METHOD OF BATHING IN TY-
PHOID FEVER.
By WILLIAM B. NOYES, M.D.,
NKW YOUC.
Every new medical text-book and periodical accumulates
statistics testifying to the brilliant results following the use
of cold baths in typhoid fever. The hospitals in which this
method is chiefly carried on are almost, without excep-
tion, showing a higher percentage of recoveries than ever
before under any other plan of treatment.
Why is it, then, that this method is not universally
adopted and carried out in private practice ? The an •
swer is simple. Easy as it is in a hospital with an abun-
dance of skilled assistance, there is no method of treat-
ment in use so difficult to carry out properly as tubbing
in typhoid fever in private families.
As the family bathroom is generally out of the ques-
tion on account of its inconvenient location, and use by
others of the household, it becomes necessary to buy a
large portable bath-tub.
Even in cases where there are two trained nurses it is
necessary to call in the clumsy assistance of some mem-
bers of the family to help in the lifting of the patient to
and from the tub, and this is a strain on them, and not
unattended with risk to the one who is sick.
There is undoubtedly still a widespread opposition
among the laity, both educated and uneducated, to the
use of "cold baths" in fever. A young physician must
have a very strong hold on the family, and enjoy their
most complete confidence, to take the risk of the respon-
sibility, if the disease takes a bad turn later from any
accidental complications, and even older men will seme-
times hesitate.
A physician of high standing and extensive practice in
the city recently said to me, " I do not find that tubbing
is practicable in private families, much as I would like to
make use of it I have to content myself with sponging
and packs, and have had some success with constant use
of an ice-coil over the abdomen as a substitute. If the
ice-coil acts so well in lesions of the peritoneal coat of
the intestines, why should it not have a similar result in
lesions of the mucous coat ? "
But all these three methods, sponging, wet pack, or
ice coil, while they add to the comfort of the patient, do
not cause very decided or long continued lowering of the
temperature.
Again, one who has had bad results from necessary
changing of the position of a patient in an advanced
stage of typhoid to examine the back of the chest, or
something equally simple, causing disagreeable heart
symptoms, will rather dread the process of lifting a pa-
44
MEDICAL RECORD.
[July 14, 1894
tient out of his bed for any reason whatever, especially
if the patient is large and the bed a double one.
The following method, which I once saw used in a
hospital in Buffalo, commends itself as a simple solution
of the whole problem. I have never seen it published
in any medical journal or work, and am sure that it has
not often been tried.
It is a very easy thing to slip a rubber blanket under
the patient, and raise the two sides and the ends at the
foot and head of the bed, nine or ten inches, by a row of
pillows, bolsters, sand -bags, or simple boards.
The rubber blanket ought to be of double thickness,
as large as can be purchased, and special care must be
given to the arranging of the corners. When this is
done you have the patient at the bottom of an impromptu
bath-tub, into which you can pour water at any desired
temperature, and in sufficient quantity to partially or en-
tirely cover his body.
Only two inches of water would be enough to give a
cool sponge-bath ten times as efficacious as the gingerly
sponging possible under ordinary circumstances, and if
the sides and corners are firmly fixed you can easily
make this tub hold all the water you desire. The water
may be run from the nearest faucet by a rubber tube.
I have found it a simpler and equally successful method
to carry it in pails and pour it over the patient, starting
with tepid and gradually cooling it down to the desired
temperature.
The neatest method I have found by experiment is to
use a large " watering-pot " with a sprinkler, such as is
used for watering plants. This is a method which will
not commend itself to those who dislike humble and com-
monplace methods to accomplish something that more
complicated and more impressive methods might do.
I believe this kind of a bath will always be grateful to
the patient, and if it is found necessary to use water at a
decidedly low temperature, would give rise to less shock
than a sudden plunge into a tub filled with very cold
water. The effect on the temperature is the same as it
would be under the other method with a stationary tub.
The water can be removed, without spilling a drop on
the bed, by siphoning with a rubber tube, or dipping with
a small pitcher or cup, or sponging. Then the blanket
can be dried and left in place, covered by a clean sheet,
or better yet, removed and dried in the sun.
All this needs a little care, for it would be a very seri-
ous and troublesome accident to soak the patient's bed-
clothing and mattress, but the difficulty and risk to the
patient cannot be compared with that attending the use of
the ordinary tub. And best of all, in those cases where the
family or friends must do the work, and the employment
of trained nurses is impossible on account of expense, this
method can always be successfully used when tubbing
would be out of the question.
I have not found one single objection to the employ-
ment of the method in private cases, and cannot see
why it could not be used in hospitals. .
164 West Seventy-thud Stxbkt.
HISTORY AND TREATMENT OF A CASE OF
TRAUMATIC TETANUS AND SEQUELAE.
By CHARLES J. MONTGOMERY, M.D.,
AUGUSTA, GA.
N , colored, male, aged thirty-two ; occupation, hostler
and yard boy. Previous history : No sickness for nineteen
years, with exception of one or two attacks of grippe
{keeping at work, however, in spite of it), and generally
in winter has more or less of bronchitis. History and
treatment of case : With a razor he cut a corn with a cer-
tain amount of healthy tissue from fifth toe of left foot,
causing some bleeding. Kept at work for several days,
becoming by degrees very lame. By January 24, 1894, a
few days after the injury, lameness and pain in the foot
were so great that discontinuance of work was necessary
and he went to bed. I was called to see him January
26th. At my direction, before I reached his house, a
flax-seed poultice was applied to the foot and fifteen grains
of quinine were given. On reaching the bedside I found
him suffering considerable pain in the foot, which was
somewhat swollen. Fever was present. A simple febri-
fuge mixture was prescribed containing a small amount
of acetate of morphine, and directions were given for him
to be sponged with cool water and his bowels moved with
a blue pill followed by castor-oil
January 27th. — He was found to have passed a restless
night, and suffered pain not only in the fobt, but at the
base of the spine and in the left hip. Some pain about
the jaws. In addition to the febrifuge mixture he was
ordered to take chloral, ten grains, that night, and the same
amount the next morning.
January 28th. — Morning of January 28th the jaws were
set, but not too close to take liquid food and medicine.
Physostigmine salicylate, gr. ^, was given internally, re-
peated once an hour and again in three and four hours
(this being the only preparation of calabar been obtain-
able), and a hypodermic of morphine sulphate, gr. ^, was
given. Chloral was given again that night, and another
hypodermic of morphine. Temperature at this time was
102 j° F.
On the morning of the 29th the patient seemed to feel
slightly easier, with temperature 1010 F. Fever mixture
was ordered stopped, but physostigmine continued. Later
in the morning he had a violent convulsion, and, having
been sent for, 1 reached the bedside during a second
convulsion. Having brought with me a mixture contain-
ing chloral, gr. 15 ; bromide of potassium, gr. 30, in each
tablespoonful, I forced his teeth slightly apart with a spoon
and gave him a dose of this medicine. I ordered that it
be repeated every four hours, and that immediately after
each dose he should take morphine, gr. ^, internally
Physostigmine was discontinued. He began to improve
immediately after the first dose of the above mixture, and
never had another convulsion during the whole progress
of the disease. That night he felt comparatively easy
and his temperature was 102° F.
On the morning of the 30th the temperature was ioif °
F., the man having passed a comfortable night. That
evening the temperature was io2|° F., pulse about no
and weak, and on the morning of the 31st, though a com-
fortable night had been passed, the temperature was found
to be 103 F. I now began to administer infusion of
digitalis, in teaspoonful doses, fifteen minutes after each
dose of the chloral mixture. The temperature had fallen
on the evening of the 31st to ioi|° F., and never again
rose above that point, which I attribute largely to the
continued use of infusion of digitalis. By February 2d
the temperature had fallen to 99!° F. in the morning, to
rise only to 99$° F. in the evening, with pulse 100. At
this time the patient was free from pain and could open
his jaws about one inch.
The treatment, in addition to that mentioned, consisted
in local hot applications, both wet and dry, to the neck
and spine, dressings containing laudanum to the foot, and
later in the course of the disease, massage, with hot cocoa-
butter, and to move the bowels a rectal injection was
given every three days.
Diet consisted of a glass of milk every hour, with
whiskey, and when he became able to chew, semi-solid
and then solid food was taken.
On February 3d the dose of the chloral mixture was
reduced, a dessert-spoonful (or gr. 7j^ of chloral, 15 gr.
of bromide) being taken at each dose instead of a table-
spoonful, except the last dose at night, which was a table-
spoonful. Soon the daily amount was still more dimin-
ished, though not entirely discontinued, till the end of the
third week. About the end of the second week the pa-
tient was in a low state of delirium continually, and seemed
to be growing weaker, and question of amputation was
presented. I decided not to amputate, but dissected
away a portion of the scar tissue at the site of the ori-
ginal wound, which had never been an open wound since
I had been attending the case. The wound which I thus
made, as well as a large portion of the foot, which was
July 14, 1894]
MEDICAL RECORD.
45
still swollen, was dressed with iodoform gauze saturated
with laudanum, and this dressing was continued about a
week.
About the fourth week the patient showed evident signs
of improvement, which, though slow, were continuous, till
the nth of March, when he complained of passing blood
at the end of urination, which was accomplished with a
great deal of tenesmus. This condition was followed by
pain over the pubes. Suppositories of opium and bella-
donna afforded great relief, poultices but little ; ergotole
and fluid extract of cannabis indica were given by the
stomach, flax-seed tea prescribed, and the diet reduced
again to milk. Examination of the urine, which was
very turbid, showed it to contain a large amount of
albumin.
Pain in the back and over the kidneys developed later.
(Edema of the feet and ankles with great tenderness was
present. Dry cups were applied to the loins, and later
hot-water cloths, and digitalis and acetate of potassium
administered internally ; also a few doses of pilocarpine.
The temperature during these complications ranged be-
tween 990 and 1010 F.
The temperature on March 19th had fallen to normal,
with pulse at 82, fairly strong, and the urine, though
cloudy and containing an abundant sediment, was found
to be free from albumin. Improvement from this time
has been practically continuous, and the patient now
(April 7th), is able to walk about the house and a lit-
tle out of doors every day, and is steadily gaining
strength.
AN UNUSUAL CASE OF TOXIC AMBLYOPIA.
By F. E. D'CENCH, M.D.,
NEW YORK.
M. G , aged forty, came to my office on account of
the sudden failure of his sight, which had taken place
eleven days previously. The evening before he had been
reading fine type without difficulty, whereas the follow-
ing morning he could not even see the large capitals in
the name of his newspaper. As his sight had grown
rather worse than better, he sought medical advice.
I found that, even with the aid of his glasses, he could
not count fingers at a greater distance than four feet.
Distinct sector-shaped atrophy of the temporal side of
the optic nerve. Pupils somewhat contracted, but re-
spond promptly to light. Visual field good. There is a
marked central color-scotoma, especially for green and
red.
The patient has smoked cigarettes since he was eleven
years of age, generally about ten or twelve a day, and
has also used alcoholic stimulants, though he has not
indulged in them to excess. The diagnosis was there-
fore easy, and the treatment generally adopted in such
cases begun. Tobacco and alcohol were entirely with-
drawn, and strychnine in increasing doses was injected,
at first every day, afterward every other day. Improve-
ment in sight began almost immediately. In a week it
was Y%nt *a two weeks £fj, in three weeks j^, and so
on, until after two months it was Jjj -f , which, in view
of the fact that there is a myopia of \, with an additional
astigmatism of fa, may be regarded as normal sight.
Faces seem slightly dark still, but he has no difficulty in
reading even small print. There has been no change
since that time.
Cases of toxic amblyopia are not uncommon, and if
sight has not fallen to too low a level, the prognosis is
usually favorable. Loss of vision is gradual, and the pa-
tient will therefore generally consult a physician before
it is too late. The peculiar feature of this case lies in
the rapidity with which vision failed, dropping within
twelve hours from normal acuteness to counting fingers at
a distance of a few feet. Such a rapid loss is seen in acute
glaucoma and a few other diseases, but not in amblyopia
due to tobacco and alcohol, and so this case seemed to
me to be worthy of being put on record.
NOTES ON PELVIC AND GENERAL MASSAGE.
By SARAH E. POST, M.D.,
NEW YORK.
Pelvic Massage. — I have recently attempted this treat-
ment in three cases, in all with a satisfactory result. I
have found it possible to propel the contents of the tubes
down through the uterus and to secure its discharge with-
out the usual recurring cramps. By cramps, I mean tu-
bal colic. In one case this returned every second or
third day ; in another it was constant. The pain is in
the inguinal region and down the front of the thigh. It
seems to be due to traction upon the peritoneal attach-
ments in the inguinal region. It is, I think, not located in
the tube itself, for this may be found upon a higher level.
The pulling is, of course, to be referred to the contrac-
tions and movements of the tube. To secure discharge
without contraction and to thus relieve pain became after
this discovery the main object of the treatment. In a
case of simple catarrh of one side the tube was about the
size of the ureter. In another case both tubes were
easily found. After treatment they were softer ard might
escape the touch. This last case had in addition num-
erous nodules the size of a bean or pea, extending from
the side of the uterus, as I recall the case, into the iliac
fossa. These nodules also disappeared in the course of six
weeks9 massage.
In working upon the tubes I move the index-finger of
the right hand back and forth transversely across their
lumen, beginning at the distal end, carrying the skin,
possibly, the whole of the abominal wall, with the finger
in this motion, gently persisting over each accumulation
where convolution of the tube has occurred. The tips
of the two first fingers were used upon the uterus, the
kneading being generally restricted to the horns them-
selves. At the same time the index- and middle-finger
of the left hand straightened the uterus and held it up-
right where there was displacement of the body or neck.
In this manoeuvre the index-finger was passed in front of
the uterus and the middle- finger behind it. In a case
without serious displacement no vaginal manipulation
was required.
The cases treated had the tubes in place at the sides
of the uterus. I would not expect to benefit prolapsed
tubes, especially if adherent in Douglas's space.
Incidentally I was made to recognize an unexpected
position of the oigans. The body of the uterus was en-
tirely above the symphysis, and the distal extremity of the
tube pointed toward the anterior iliac spine. This position
is, I think, to be traced to our present modes of dress.
Many young women have discarded the corset, and all
probably hang the skirt from a skeleton waist, giving
freedom to the diaphragm, and, as a consequence, eleva-
tion of all the abdominal and pelvic organs. In my expe-
rience, however, this alteration is recent. Six >ears ago
I found this high position and regarded it as a deformity.
General Massage — Effleurage. — Another matter noted
since the publication of my book seems to me of consid-
erable importance. In the course of a bath it has oc-
curred to me to be given the usual long rub, the hands
being carried from the distal end of the extremity up-
ward, and from thence downward by a return stroke,
equally firm pressure being used. When applied to the
arms, I found the heart affected as follows : With the
up- stroke came two slow, full beats ; with the down-stroke,
two feebler beats or two rapid beats followed by an in-
termission. I am not giving positive details, not at the
time having access to a graphic apparatus. The sensation
was, however, unpleasant, and, upon my request for up-
rubbing only, I secured the results of increased heart
pressure — a slowed, strengthened, comfortable pulse.
The work upon the lower extremities did not so much
affect the heart. Still the influence of the down-stroke
was perceptible, and I had it omitted throughout. An
element so influential ought, however, to have some use-
ful application. Possibly this may be found in cases of
cyanosis, pulsating jugulars, and an overloaded heart.
46
MEDICAL RECORD.
[July 14, 1894
Ovaritis. — Wintcenilz's treatment is the following:
Rest in bed ; vaginal injections of hot salt-water; scari
fication of the os uteri twice daily ; rubbing of the abdo-
men with an ointment composed of ichthyol and lanoline
in equal parts ; and a teaspoonful at bedtime of this mixt-
ure for constipation :
9. Sulphate of sodaA 3 iv.
Sulphur 3 j.
Sugar 3 v.
Ess. of peppermint q. s.
In principle this is exactly GoodelTs teaching of years
ago. In his " Lessons in Gynaecology," p. 386, he says
of Weir Mitchell's rest-cure for ovaritis : " I have seen
wonderful cures from this treatment, and can recommend
it with the utmost confidence. Bedridden patients have
been restored to health, and chronic invalids returned to
society."
Gout of the Intestine. — Many cases of colic, enter-
algia, enteritis, and typhlitis, are really gouty manifesta-
tions located in the intestine, according to Haig, who
uses salicylate of soda with great success for such cases,
in doses of about fifteen grains every three or four hours.
Drugs like lead, mercury, zinc, and even cocaine, when
given to gouty patients, form insoluble urates, and an in-
testinal crisis may be produced. Buckworth observes
that persons do not die of gouty intestinal troubles, and
therefore direct ocular pathological proof is wanting.
At the same time he emphasizes the fact of their exist-
ence. From Haig and Buckworth's observations it
may be inferred that in women who have gout or rheu
matic gout the so-called recurrent peritonitis, occurring
most frequently just after menstruation, is in reality gout
of the intestine. There is slight fever or a subnormal
temperature, intense pain that gradually diminishes,
marked tenderness on pressure, great anxiety and fear of
moving or being touched, complete loss of appetite,
general prostration and mental depression following, the
cycle completing itself in about two or four weeks.
Remedies directed to the underlying constitutional state
are the only ones that permanently relieve and cure.
Tissue Metabolism in Chlorosis. — There is a transla-
tion in the International Medical Magazine for April,
1894, of a lecture delivered to a private class by Carl
von Noorden on "Tissue Metabolism in Chlorosis."
The cause of poverty of haemoglobin in the blood must
be due to increased destruction or diminished new for-
mation of the coloring matter of the blood, or to a com-
bination of the two processes. Not one positive sign is
known which proves that in chlorosis more haemoglobin
is destroyed than in health. Some distinct points lead
to the belief that the normal quantity, and probably
much less, is all that is destroyed. The defect is due to
some error in new blood-formation. Some restricted ex-
ceptions exist in anaemia caused by profuse acute hem-
morrhage and by acute nephritis. Here there is an
oedema of the blood. The plasma is so diluted that the
blood-corpuscles swell up and appear relatively poorer in
haemoglobin. In all processes which induce much de-
struction of this constituent of the blood, as infectious
diseases and numerous intoxications, there is principally
a destruction of cells (erythrolysis). For a time iron as
a remedy fell into disrepute, in consequence of experi-
ments on animals, and a few observations on man.
These doubts were more often expressed by physiologists
and pharmacologists than by practising physicians. As
there was no increase of iron in the urine after the ad-
ministration of various iron preparations, it was argued
that no iron was absorbed. The weak point of this rea-
soning is of interest. The intestinal mucous membrane
is the place of excretion for the iron and not the urine,
which is capable of removing only a few milligrammes.
Iron which gets into the blood-current accumulates in the
liver and spleen, these organs, magnet-like, attracting it.
They are the warehouse of the body for superabundant
iron, which is given off very gradually by these organs,
and is removed by the intestinal juice from the body.
How do the iron salts which are absorbed act as reme-
dies ? Is the chlorotic organism wanting in atoms of iron
around which the haemoglobin molecule can be built
up ? Every girl developing chlorosis takes up in daily
food more iron than the most extravagant estimate de-
mands. But this iron is exclusively contained in nucleo-
albumins. There is no doubt that the healthy organism
takes up iron from nucleo albumins and employs it for
the manufacture of haemoglobin. Why does not the
chlorotic patient do the same ? Is absorption at fault ?
On the contrary, absorption is excellent. Iron is ab-
sorbed, but is not used. There is diminution of the
energy of growth in the haematopoietic organs (bone
marrow), resulting in the non utilization of the ferrugi-
nous nucleo-albumins which are brought by the blood.
So far everything is proved. Now for the region of hy-
pothesis. Let us suppose that the iron salts circulating
in the blood effect a stimulation of the haemopoietic cells
of the medulla of bones, and that the result of this stim-
ulus is an amelioration of the constitution of the blood.
On the other hand, the nucleo-albumins containing iron
which are circulating in the blood exert but a weak
stimulus on bone marrow. Experience proves that in
the treatment of chlorosis any iron salt is more effica-
cious than the ferruginous nucleo-albumins, like haemo-
globin, hsemotogin, haemogallol, etc, which pure theor-
ists have tried to foist on the profession. Arsenic gives
good results. Yet success is much greater when com-
bining arsenic and iron. Practical experience proves
this is the best plan. At health-resorts where there are
carbonated ferruginous springs, resident physicians do
not recommend these waters to chlorotic subjects, but
advise the mineral waters of Levico or Roncegno, which
contain arsenic and iron. These substances are closely
allied chemically, and exert on the cells an effect that is
only quantitatively different.
Idiopathic Hypertrophy of the Heart and Degenera-
tion of Heart-muscle. — An address upon the foregoing
subject, given in abstract form in the British Medical
Journal, April 7, 1894, was delivered at the Internation-
al Medical Congress, in Rome, by Dr. S. Laache, oi
Norway. Idiopathic hypertrophy is defined as enlarge-
ment of the heart without obvious anatomical, or rather,
mechanical obstacles to the circulation. The valves
are either intact or affected only by lesions in no-
wise proportionate to the clinical symptoms. The eti-
ology presents some points of hygienic or social interest.
The chief predisposing causes are heredity, and those
conditions which betray their influence by defective nu-
trition. Among determining causes the most important
are alcoholism and excessive muscular exertion. Beer-
drinking is the chief cause of pure idiopathic hypertro-
phy. Athletics has been considered the origin of much
cardiac hypertrophy. It is now conceded that if the
athlete is of proper age, properly trained, and abstains
from alcohol, trouble with the heart does not necessarily
follow a reasonable amount of indulgence in sport.
Physical overstrain weakens the heart, and so does intel-
lectual overpressure. Modern life in cities is not con-
ducive to that mental repose which is necessary to se-
cure normal circulation. The hygiene of the heart is
sadly neglected. Sudden death from cardiac trouble
seems to be increasing in frequency. Yet often the dis-
eased heart possesses a power of resistance that is almost
incredible, and which led Haller in his day to apply to
it the epithet ultimum moriens. In Pepper's "System
of Medicine?1 Osier states that symptoms are not neces-
sarily present in simple cardiac hypertrophy, since this
is a conservative process and almost always an unmixed
good. The pulse of hypertrophy not dependent on val-
vular lesion is usually firm, full, and strong, of high ten-
sion, and regular. It may be increased in frequency,
but often is normal A frequent symptom is an unpleas-
July 14, 1894]
MEDICAL RECORD.
47
ant feeling about the heart, a sense of fulness and dis-
comfort. Flushings of the face, noises in the ears, flashes
of light, and headache are not uncommon. The course
of an ordinary hypertrophy divides itself into three
stages : the period of development, which varies with the
nature of the original factor in development ; the period
of full compensation, the latent stage, during which the
heart's vigor meets all the requirements of the circula-
tion, and this second stage may last indefinitely ; and
the third period is what is called the breaking of a com-
pensating hypertrophy. It may come suddenly during
extra exertion, and death follow from acute dilatation ;
or more commonly it takes place slowly, and results from
degeneration and weakening of the heart-muscle, with
consequent dilatation and all its evils. The treatment
of hypertrophy consists largely of measures directed tow-
ard its maintenance in a degree proportionate to the ex-
tra work which the heart has to do. The utmost moder-
ation in food, drink, and exercise must be enjoined.
Quiet and regular habits are imperative. Excesses of all
kinds quickly lead to impairment of the heart's action.
In the hypertrophy associated with arterial and renal
disease a special danger exists in the tendency to rupture
of vessels. Vigorous heart-beat with very high tension
in the peripheral arteries indicates mischief which may
be met by prompt measures to reduce the high pressure.
A brisk cathartic may avert apoplexy, and the old-fash-
ioned method of bleeding is often justifiable.
The Treatment of Pruritus. — Leloir recommends elec-
tricity in pruritus of all types — anal, vaginal, and general
— and uses the electric breeze of the static machine
with the happiest results. Mercurial ointments give im-
mense relief for the time being. Crocker speaks in
praise of ammoniated mercury, gr. xx. to | j. of benzoated
lard; also the yellow oxide of the same strength, and
calomel, gr. x. to 3ss. to § j. External treatment is of
great service in alleviating the itching, even if it does
not cure the disease. Jackson advises general baths with
soda ( % viij. to x. to 30 gallons}, or nitric or hydrochloric
acid ( § j. to 30 gallons). After the bath the body is
to be dried by wrapping it in a warm sheet and patting
it dry ; then the skin should be smeared with vaseline
and powdered with corn- starch from a dredger. Bulkley
first suggested cannabis Indica, ten minims three times a
day, in water after meals, gradually increasing the dose
to twenty or thirty minims. For children Ellis recom-
mends the daily use of tepid alkaline baths; quinine
and cod-liver oil for the strumous ; nitro muriatic acid in
sarsaparilla, taraxacum, and Fowler's solution. Bron-
son finds a solution of hydrogen peroxide of great value
in general pruritus ; also an aqueous solution of ozone,
used as a toilet wash, and known commercially by the
name of "aquozone." Faradism is often successful in
senile pruritus, applied only to the spine by means of a
brush electrode. The cold douche is another remedy in
the same line that is sometimes of benefit, and is best
used in the morning. In local and general pruritus the
following formula for external application has given ex-
cellent results :
3. Acid, carbolic 3j. — ij#
Liq. potass. 3 j.
Ol.lini I'y
M. Sig. : Shake before using.
Dust Diseases and their Prevention. — The relation
of dust to pulmonary affections is a subject the investiga-
tion of which has already led to many valuable practical
results, and which is still far from being exhausted.
Dust of a non -irritating nature is necessarily inhaled into
the lungs of town-dwellers, where it causes the dark and
mottled aspect so familiar on the post-mortem table.
The irritating dust, on the other hand, which is en-
countered in many occupations, leads to more or less
serious pathological conditions of the pulmonary organs.
Thus it may cause bronchitis, acute and chronic, em-
physema, asthma, bronchiectasis, fibroid conditions,
hypertrophy of bronchial glands, and phthisis, with a
whole chain of attendant vascular disturbances. These
dust diseases, or pneumokonioses, are met with, as every
one knows, among millers, masons, miners, grinders, and
others who follow occupations which habitually expose
them to a dusty atmosphere. This injury is, in the first
place, mainly mechanical, and usually has a direct rela-
tion to the texture of the material which furnishes the
dust. In this way steel particles are more deadly than
stone, and the latter than flour. In other cases the in-
jury to workmen is partly mechanical and partly chemi-
cal, as in the lead enamel grinding trade. So much for
the evil, which is obvious enough, and needs little more
than the above passing reference. A great deal more
discussion is wanted, however, when we inquire as to
what has been done in the way of prevention. The two
great preventive measures are undoubtedly free ventila-
tion and the introduction of wet processes. It is a well-
known fact that the substitution of wet for dry grinding
in Sheffield was followed by a great fall in the number of
deaths from phthisis. A similar principle might be ap-
plied with advantage in other trades. For instance, the
dust raised in grinding lead enamel is of a peculiarly
deadly nature, since it acts both as a mechanical and a
poisonous irritant. Lead enamel is practically insoluble,
and there is no doubt that many of the steps in its
manufacture could be carried out equally well by elutria-
tion and other wet methods. Ventilation, again, is
often defective in the enamel factories. The beneficial
action of a free circulation of air is probably due to the
dilution and the removal of noxious particles. Nowhere
has the improvement of ventilation been followed by bet-
ter results than among our mining population. To take
a single instance : it has lately been officially reported
that in the mining division of Cornwall the proportion
of deaths from phthisis or " miner's disease " has of late
years decreased. This satisfactory result appears to be
due chiefly to the better underground ventilation, conse-
quent on the introduction of boring machinery and of
other improved conditions. Some years ago the whole
question of miners' phthisis was closely investigated by
the Royal Cornwall Polytechnic Society, who offered
prizes for sound information, and obtained a quantity of
valuable matter, which is to be found in their annual
reports of that time. This public-spirited action affords
an excellent illustration of the good that can be effected
by local bodies, if they will only be content to confine
their scientific ardor to subjects at their feet, so to speak,
and within the grasp of an average comprehension.
Conducted on such lines the work of provincial associa-
tions is likely to afford substantial help in arriving at
precise facts and figures with regard to dangerous employ-
ments. They will be also in a position to acquire exact
information as to methods, and to suggest improvements
in trade processes. Their data would then be simply
invaluable to the scientific man, in whose hands the appli-
cation of preventive measures must ultimately be placed.
When thoroughly sound conclusions have been arrived at
it is the duty of legislators to frame laws in accordance
with the facts submitted to them. It is a well marked
tendency of modern legislation to make compulsory all
measures that have been shown to be clearly preventive.
Bearing this in mind, one may safely assert that the com-
pulsory legislation of the future will find a large and
useful field, so far as the happiness of many members of
the community is concerned, in the control of dust-pro-
ducing occupations. Whatever may be done, it is un-
likely that the whole of the mischief could be abolished
in each particular trade. The risk, however, could and
should be reduced to its minimum. The steady aim of
the sanitarian in dealing with dust diseases will be levelled
at the preventable margin, and he will not fail to make
due allowance for the unavoidable residuum. — Medical
Press.
Dr. Baillon, the well-known botanist of Paris, has
been elected to foreign fellowship in the Royal Botanical
Society of London.
48
MEDICAL RECORD.
[July 14, 1894
Medical Record:
A Weekly Journal of Medicine and Surgery.
GEORGE F. SHRADY, A.M., M.D., Editor.
Publishers
WM. WOOD & CO., 43, 45, & 47 East Tenth Street
New York, July 14, 1894.
THERAPEUTICS AT THE INTERNATIONAL
MEDICAL CONGRESS.
It may happen that the most successful and largest med-
ical congresses are not particularly rich in therapeutic
work. Yet, after all, when the heat and smoke of the
day are cleared away, one feels that the important
query is this : Has anything been said or read which
will make the treatment of diseases more sure and ef-
fective ?
We have been looking over the records of the Interna-
tional Congress at Rome, and have tried to find what
practical therapeutical suggestions were made at that
time.
The results of our study, which has been facilitated by
a critical review in the Gazette des Hopitaux, have not
been very fruitful, nor yet altogether barren. For ex-
ample, Dr. Petresco, of Bucharest, comes forward again
with further facts regarding his treatment of pneumonia
with large doses of digitalis. He has employed his
method now for thirteen years and treated 1,192 cases,
and he has reduced the mortality to 1.22 and 2.66 per
cent., while under other treatment the mortality ranges
from 7.15 to 35-50 per cent.
A year ago we discussed Petresco's method, which con-
sists of giving eight or ten or even twelve grammes of
digital leaves in twenty-four hours. According to the
author, it invariably jugulates acute lobar pneumonia in a
few days.
Dr. Goffredi, of Naples, calls attention to the value of
lactose as a diuretic, particularly in heart disease. It is
not so effective in nephritis. Diarrhoea is sometimes
caused by the lactose.
Dr. Pucci praises very highly the use of phenocoll in
malaria. He gives from one -half to one gramme a
day.
After having broken up the paroxysms, the drug is
continued five or six days in association with qui-
nine or arsenic. It is also very useful in malarial neural-
gia.
A curious contribution to therapeutics is that of Dr.
Sanchez Herrero, of Madrid, who recommends a solution
of bromide of potash, 50 ; iodide of potash, 5 ; and water,
500, in the treatment of epilepsy. Dr. Herrero is evi-
dently not familiar with some of the very ancient formu-
las for epilepsy, including that of Brown S6quard. We
should add that the doctor adds to his treatment hypnotic
suggestion twice a week, and that he has cured 19 cases
out of 30.
Dr. A. Murre, of Bologna, makes a protest against the
abuse of cold water in the treatment of chlorosis, but at
the same time thinks that cold water properly used is
better than drugs in this condition.
Dr. Tison thinks that the nitrate of aconitine is useful
in facial erysipelas, shortening the attacks and lessening
the pain. He gives gr. Tfo ten times a day.
Von Ziemssen, of Munich, would have us return to the
use of transfusion of blood, particularly in grave anae-
mias.
The best method is the arm-to-arm one without de-
fibrinating, but if this is not practicable he recommends
subcutaneous injection of nondefibrinated blood. This
ought to be given under chloroform and followed by
massage, as the process is very painful. It is safe to say
that a treatment involving regular anaesthetization of the
patient will hardly become popular, and certainly is not
safe.
DR. MITCHELL ON INSANE ASYLUM MAN-
AGEMENT.
The address of Dr. S. Weir Mitchell before the American
Medico Psychological Association, at their meeting held
in May last, has just been published {Journal of Nervous
and Mental Disease), and it promises, we believe, to ex-
cite wide attention. Dr. Mitchell, with the consent of
the Association, took the opportunity to arraign, in the
severest manner, the present methods of caring for aDd
treating the insane in America. He undertook the task
evidently with reluctance, but with a keen sense of the
duty before him and of the opportunity offered by the very
generous attitude of the asylum superintendents. The
speaker fortified himself well for his work, not only by a
personal knowledge, but by letters sent to him from
nearly thirty of the leading neurologists and alienists of
this country, giving opinions and suggestions regarding
the present methods of managing asylums.
It is unnecessary to say that Dr. Mitchell's address
is throughout an interesting and scholarly one, full of
wit and satire, yet withal not unkindly or in any way
unjust or offensive. And, after all, it is the Boards of
Managers, the public, and the politicians which receive
the severest castigation. We wish we had space to quote
the criticism upon managing boards, their make-up and
their methods. There are, of course, good as well as
bad managers, but it is true that in the majority of cases
the modern asylum trustee has not the slightest concep-
tion of the higher and truer needs of a hospital for the
insane. The prevailing idea is to look after the farm,
the kitchen, and laundry, and to get materials for a sat-
isfying annual report with forty per cent, of "cures"
and a balance to the credit of the institution.
As for the medical superintendents : their weakness, he
says, lies in this, that they work apart from their fellows
and are not in touch with the medical profession as a
whole ; that they aim only to run smoothly a great hotel
or boarding-house, knowing little and contributing noth-
ing to psychology or psychiatry, and least of all to
therapeutics. Dr. Mitchell's final words furnish us a
picture of the ideal hospital for the insane. We read it
July 14, 1894]
MEDICAL RECORD.
49
with delight at the skill of the writer, as he portrays what
to his fancy the present should, and the future may, fur-
nish us. But we feel also a sense of sadness at the dif-
ference between the ideal and the real. And we think
of our own State Lunacy Commission laboriously aiming
to cut down the price of brooms, and utterly forgetful of
the higher needs of hospitals for the insane.
We trust that Dr. Mitchell's address will awaken not
only the conscience of those now responsible for asylum
management, but will stir the public heart until the poli-
tics, penuriousness, aid incapacity that surround so much
of American asylum work are abolished.
THE POWER OF A DIPSOMANIAC.
Peter the Great was an enormous consumer of brandy,
and, to drop to modern times, Webster was not strictly
temperate, and Lincoln had some very able whiskey-
drinking generals ; but history furnishes no account of
dipsomaniacs who were sound in judgment or great in
action. Dipsomania is a morbid condition, character-
ized by the irresistible obsession and impulse to drink,
coming on in attacks during which the patient abandons
himself entirely to the craving for liquor. Dipsomaniacs
may appear perfectly rational between their seizures, and
may transact business with apparent soundness of mind.
Nevertheless, they still possess something unbalanced
and false in their mental make-up. Dipsomania always
occurs in persons who have a psychopathic constitution ;
they belong to the class called by the French the degen-
erate. Consequently, one will always find in their char-
acter some peculiarity which puts them out of the ordi-
nary, and among a class which we cannot entirely trust.
Their eccentricities may be harmless, or may be shown in
some moral perversion or monomaniacal enthusiasm. A
person who has dipsomania is essentially one whose
judgment is weak and whose actions may be erratic,
perhaps picturesque; or, on the other hand, foolish,
cruel, or criminal. ^
The reports of the present extraordinary riots and dis-
turbances which have paralyzed trade, destroyed property,
and terrorized whole communities, is shocking, yet, under
the circumstances, not so very surprising. Such men some •
times have a power of eloquence and organization suffi-
cient to accomplish at times a great good, but more
often enormous evil. But it shows something vitally de-
fective in the local government of some of our cities and
States, when an irresponsible enthusiast can bring about
such things as we have witnessed in and about Chicago
during the past fortnight.
ANOTHER NEW HOSPITAL.
The Chambers Street Hospital is about to move from its
present quarters into a new and larger building at the
corner of Hudson and Jay Streets. The present hospital
has been occupied since 1875. I* was formerly a police-
station, and has become quite inadequate for the work de-
manded. The Chambers Street Hospital has for many
years done an immense amount of valuable work, more
particularly in surgical and accident cases. The annual
number of visits to it is over sixty-five thousand, and
three ambulances are kept busy night and day. The
new hospital is a large five-story building, fire- proof, and
equipped with every modern convenience.
Along with the excellent philanthropical results of the
Chambers Street institution, there is another which most
wiU consider minor and incidental, viz., it has rendered
a down town practice impossible. In other words, acci-
dent and emergency cases are all taken promptly to the
hospital and never to a private office, however well able
to pay the patient may be. Of course, if this is the best
thing for the people as a whole, the physician must sub-
mit. At any rate, institutional medicine has full swing
in the down town district.
fJjeMja of Ifce WLtek.
Dr. Solomon Van Etten, one of the oldest and best-
khown physicians in Orange County, died suddenly at
his residence in Port Jervis, July 7th, of apoplexy. He
was sixty-five years old. He was a graduate of the Al-
bany Medical College, class of '55. During the civil
war he was brigade surgeon in General Terry's division,
and retired from the service with the rank of Lieutenant-
Colonel. He practised medicine in Port Jervis until his
death. He ran twice for Assembly on the Republican
ticket, was United States Medical Examiner for, the
Orange and Sullivan district during the administrations
of Grant, Hayes, and Harrison, and two years ago was
elected Medical Director of the Grand Army for the de
partment of the State of New York.
Dr. W. B. Adamson, of this city, died on July 6th at
his summer residence at Lake George. He was forty-
two years of age, and was born in Stockton, England.
Births and Deaths The Southern Medical Review is
a new monthly that comes to us from Houston, Tex.
It is edited by Dr. N. J. Phenix, but arises from no ashes.
The Railway Surgeon is the title of a new monthly.
The National Medical News, the Epitome of Medicine,
the Country Doctor, the Weekly Medical Bulletin, the
American Gynecological Journal, and the Atlanta Jour-
nal of Surgery, Gynecology, and Obstetrics have ceased
to appear.
Tho Plague. — The bubonic plague, the terror of Eu-
rope even to the close of the seventeenth century, has
again made its appearance in China, where it is more or
less endemic, as it is in Asia Minor. The British Medi-
cal Journal, while admitting the vividness of the picture
drawn by Defoe, points out that " while there is much ex-
aggeration in his ' Plague of London,' his description of
the phenomena of the disease is fairly accurate. The pres-
ent title is derived from the swelling in the groin. In the
earlier plague, a similar swelling in the axilla was a frequent
symptom. The disease is a rapid, malignant, contagious
fever, accompanied by buboes, carbuncles, and livid
spots. At least two thirds of its victims die. Its symp-
toms are violent headache, accompanied with violent
tremors alternating with intense heat. The eyes become
red and assume a ferocious aspect, resembling those of
victims of hydrophobia. The pain extends from the
head to the spine, joints, and limbs. Then follow ver-
tigo and delirium. The tongue is dry and yellowish.
Respiration is difficult, nausea occurs, but rarely vomit-
5°
MEDICAL RECORD.
[July 14 1894
ing. The disease runs its course in from three to seven
days. The patient often dies in a few hours. The first
known appearance of the plague in Europe occurred 430
B.C., when it depopulated Athens, reaching there from
Egypt by way of Libya. It was brought into Europe by
the returning crusaders, and has frequently appeared
since, always coming from some part of the Turkish do-
minions. It appears in lower Egypt, Syria, and Turkey
about every seven or ten years. It has often made its
appearance in London, the most frightful visitation being
in a.d. 430, when there were scarcely enough living left
to bury the dead in all England. In a.d. 716 Constan-
tinople lost 200,000. In 1348 Germany lost 90,000.
It has scourged various parts of Europe from time to
time since, carrying off hundreds of thousands at each
visitation. In Egypt 800,000 died in 1792. The latest
visitation of which we have an account at hand was in
1 813, when it was exceedingly fatal in Egypt and in
Malta."
American Academy of Medicine— The nineteenth
annual meeting of the American Academy of Medicine
will be held at the Waumbek, Jefferson, N. H., on
Wednesday and Thursday, August 29 and 30, 1894.
The greater part of the time is to be devoted to the dis-
cussion of certain problems relating to the medico-social
relations of the medical profession to the " dependent
classes." Arrangements have been made for a special
excursion from New York and Boston and return at re-
duced rates. A choice is offered of an eleven days' ex-
cursion, including most of the expenses, or of returning
immediately at the close of the meeting, and is open to
anyone desirious of attending the meeting, whether mem-
ber of the Academy or not. Any additional informa-
tion about the meeting or the excursion may be obtained
from Charles Mclntire, Secretary, Easton, Pa.
American Electro Therapeutic Association. — The
fourth annual meeting of the American Electro-Thera-
peutic Association will be held in New York, September
25th, 26th, and 27th, at the Academy of Medicine.
8alicyd Chloroform is a combination of chloroform
with salicyd. It is a crystallized substance, which on
warming gives off perfectly pure chloroform. Dr. Hans
Schmid has used it in one hundred and sixty-six narcoses,
and recommends it as being safer and more pleasant than
the ordinary preparations.
The German Commission of Anesthesia. — At the
Twenty- third Congress of the German Surgical Associa-
tion it was voted to continue the general investigation
into the statistics of anaesthetics which the society has
been engaged in for the last four years. Reports are de-
sired until March 15, 1895. Consideration of the fol-
lowing points is especially urged : Specification of the
time of observation, of the anaesthetic used, and the num-
ber of times exhibited ; reason for administration ; ap-
paratus used; duration of unusually prolonged nar-
cosis ; amount of material used ; the concomitant use of
other drugs, as morphia, and the amount; undesirable
phenomena or sequelae.
The Faculty of Port Wayne College of Medicine
have adopted a three years' graded course, the work
done in which is based upon the four years' graded
course recommended by the College Association.
A Death from Hydrophobia. — A case of death from
hydrophobia has occurred at the Pasteur Institute ; but
the patient was already in a hopeless condition at the
time he was admitted. Mr. Walter E. Orcutt, a hotel
keeper of Northampton, Mass., was bitten on the wrist
by a pet dog on May 23d, and although the wound was
very slight, he took the precaution of having it cauter-
ized. It healed perfectly, and he thought no more
about the matter until June 23d, when he was seized
with alarming symptoms, and was at once brought to the
Pasteur Institute in New York. His friends were as-
sured by the physician in charge, Dr. Labadie (Dr.
Gibier's assistant), that no treatment would now be of
any avail, and he died on June 26th. In this instance,
the more violent manifestations of rabies were in a great
measure lacking, but the patient rapidly succumbed to
paralysis of the nervous centres.
American Public Health Association. — The Twenty-
second annual meeting of the American Public Health
Association will be held in Montreal, Canada, on Sep-
tember 25 to 28, 1894, under the presidency of Dr. E.
P. Lachapelle, of Montreal.
The Massachusetts 8tate Board of Registration of
Physicians and 8urgeons. — The governor has made the
following appointments for the first Board of Registra-
tion under the new Medical Practice Law : E. J. Fors-
ter, of Boston, for seven years ; W. P. Bowers, of Clin-
ton, for four years ; D. B. Whittier, of Fitchburg, for
five years ; A. C. Walker, of Greenfield, for one year ;
S. H. Blodgett, of Cambridge, for three years; C. Ed-
win Miles, of Boston, for two years ; A. L. Chase, ot
Randolph, for six years. Drs. Forster, Bowers, and
Walker are members of the Massachusetts Medical So-
ciety ; Drs. Whittier and Blodgett are members of the
Massachusetts Homoeopathic Society; and Drs. Miles
and Chase, of the Massachusetts Eclectic Society.
Harvard Medical 8chool. — The graduating class of
the Harvard Medical School this year contained one
hundrdt and twenty- seven men, and was the largest class
ever graduated.
Unsanitary Edgewater. — The Richmond County (N.
Y.) Medical Society, in a series of resolutions, declare
that small- pox is prevalent there in consequence of the
neglect of the health authorities, that the village for the
same reason is in an unhealthful and filthy condition,
and appoint a committee to co operate with the president
of the village, that the necessary reforms may be made.
The Colorado State Medical 8oeiety.— At the recent
meeting of the Colorado State Medical Society, held in
Denver, June 19, 20, 21st, the following officers were
elected for the ensuing year: President, Dr. Hubert
Work, Pueblo, Col. ; First Vice-President, Dr. J. R.
Robinson, Colorado Springs; Second Vice-President,
Dr. E. Stuver, Rawlins, Wy. ; Third Vice-President,
Dr. Laura Liebhardt, Denver, Col. ; Treasurer, Dr. W.
F. McClelland, Denver, Col. ; Corresponding Secretary t
Dr. C. K. Fleming, Denver, Col.
Strophanthus is a valuable and safe remedy. It is
a cardiac tonic, a diuretic, and quickly relieves pre-
cordial pain and dyspnoea. The tincture is the best
preparation. It should be given in small (TTlij) doses,
gradually increased and combined with stimulants and
July 14. 1894]
MEDICAL RECORD.
5i
antispasmodics, such as ammonia and ether. It is a
most useful drug in aortic regurgitation, as its power of
lengthening diastole is not so great as digitalis, nor has
it so marked a cumulative action ; and any danger which
may lurk in its administration is considerably lessened
by its combination with ether. — Dr. Taylor.
Hew York Polyclinic— Dr. J. Riddle Goffe has been
appointed Professor of Gynecology in the New York
Polyclinic.
On Periodical Tasting of Eyesight in Sohools.— Mr.
Priestley Smith read a paper on this subject recently be-
fore the Ophthalmologic Society of the United King-
dom. Authorities, he said, were agreed that advantage
would accrue from an annual testing of the eyesight of
school children, and several commissions had spoken to
this effect, and formulated definite proposals. Hitherto
no considerable advance had been made toward this end,
for the proposals usually put forward had been that the
refraction of every scholar should be ascertained once a
year by the school doctor. It would be a long time be-
fore every school had its school doctor and every school
doctor was an efficient oculist. The necessities of the case
could be met more easily, and would, he hoped, be so met
in a large number of schools throughout the country before
long. The governors of King Edward VI.'s schools in
Birmingham, which comprised about twenty-two hun-
dred boys and girls, aged from eight to nineteen, had
established three years ago a periodical physical exami-
nation of the scholars in regard to height, weight, chest
measurement, eyesight, and hearing. The eyesight test
was carried out by certain teachers appointed for the
purpose. It made no pretence of being a scientific pro-
ceeding ; there was no attempt to estimate refraction or
diagnose disease. Any such attempt was worse than use-
less unless the examiner were an ophthalmic expert. In
every case in which the vision in either eye was less
than six-eighteenths, an intimation of the fact was
sent to the parent, and with him rested the responsibil-
ity of obtaining the necessary advice and choosing the
adviser. The Anthropometric Committee appointed at
the last meeting of the British Association for the Ad-
vancement of Science, having Professor Cleland and
Professor Windle for its Chairman and Secretary, had
lately issued an inquiry to a large number of schools as
to whether and to what extent periodic physical exami-
nation of the scholars was in force. From the replies re-
ceived it appeared that the eyesight was tested in eight
out of four hundred and eighty-three boys' schools in
England, Scotland, and Ireland (Whitaker's list) ; and
in six of one hundred and twenty-nine girls' schools
in England ; while color vision was tested in three only
of the whole number. Many of the principals, however,
expressed willingness to take up anthropometric work
on receiving directions for carrying it out. The speaker
laid before the meeting the printed directions which had
been drawn up, and which were to be sent, in the first in-
stance, to about two hundred schools. The eyesight test
included in this scheme was practically the same as already
in operation in the King Edward schools in Birmingham.
It involved practically no expense and very little trouble
to the school authorities, and It interested at least one
teacher in every school in the eyesight of the scholars.
In advocating this system, the speaker did not in the
least undervalue the importance of a thorough medical
examination of schools, and he knew that many schools
already had duly appointed medical officers competent
to deal with errors of refraction, but these were excep-
tions. By making this simple eyesight test a part of the
anthropometric scheme now being so energetically
pushed by the Committee of the British Association they
would, he was confident, attain the desired end in a
large number of schools where it could hardly be attained
in any other way.
Lightning Stroke.—" Ball lightning," the fulmen
globulare of the older meteorologists, is the most danger-
ous and destructive of the forms which lightning is known
to assume. Fortunately, however, it is the rarest. A
narrow escape from death by its stroke occurred lately in
the person of a distinguished surgeon of the Belgian school,
Dr. L. Dandois, Professor of Surgery in the University of
Louvain, who had gone to the neighboring town of Linden
to visit a patient, and on his return, having alighted from
the train to continue his homeward journey by road, was
overtaken by a heavy thunderstorm. The sky became as
dark as at midnight, so as to make it difficult for him to
avoid the telegraph-poles standing at intervals along his
path. In a few minutes a fire-ball, as he described it,
descended on him, its stroke hurling him off the road,
across the ditch that ran parallel to it, and landing him
in the adjacent field. He was holding a large umbrella
at the time, holding it with both hands by its wooden
stick, which was of uncommon thickness. On coming to
himself after the shock, he found the umbrella cover com-
pletely burnt off its steel framework, the steel itself being
twisted into every sort of shape. The wooden handle
had, no doubt, saved his life ; had it been of metal Dr.
Dandois is convinced that he must have been killed in-
stantaneously. As it was, fully ten minutes elapsed be-
fore he recovered the use of his arms and legs, benumbed
as they were with the shock. Ultimately he was able to
resume his walk homeward.
The Treatment of Typhoid Twenty-five Years Ago.
— The late Sir William Gull gave the following sensible
directions two years after he had attended the Prince o
Wales during his illness. 1. Typhoid fever is a disease
which runs a more or less definite course. It cannot be
stopped or cured by medicines. 2. The chief thing to
be done at the outset of an attack is to send the patient
to bed, so as to save strength from the beginning. 3. No
strong purgative medicines are desirable. 4. As the fever
develops and the strength grows less, light food should
be given at short intervals — /.*., water, toast water, bar-
ley-water, milk and water, light broths (not made too
strong or too gelatinous). 5. If there be restlessness or
much agitation of the nerves, wine (port, sherry, or
claret), or brandy in moderate doses at short intervals.
This must be directed medically, but in general it may
be said that the amount required is that which induces
repose and sleep. 6. The bowels may be left to them-
selves. If unmoved for twenty-four or thirty-six hours a
lavement of warm water may be necessary, but this will
be directed medically. 7. The restlessness or wakeful-
ness in fever is best remedied by the careful giving of
wine or spirit with the food, or in hot water. Sedatives
such as opium are inadmissible — mostly injurious. 8.
The bedroom to be kept at a temperature of 62 to 65 ° F.
5*
MEDICAL RECORD.
[July 14, 1894
9. Great care is necessary to keep the bed clean and
sweet. This is most easily done by having a second bed
in the room, to which the patient can be removed for two
or three hours daily, while the other is thoroughly aired
and the linen changed. 10. All fatigue to be sedulously
avoided. No visitors admitted, and no other person but
a nurse and one attendant to help her. 11. Patient's
room never to be left unattended for a moment, as in the
delirium of fever patient may jump from bed and injure
himself. 12. As to medicines and the treatment of com-
plications, the immediate medical attendant must be re-
sponsible. 13. As it is possible that the discharges from
the bowels in typhoid fever may be a source of conta-
gion, it is desirable that before being thrown down the
closet they should be largely mixed with Condy's fluid
or some other disinfectant. On the same principle the
strictest cleanliness must be observed in the sick-room.
14. There is no reason to believe that typhoid fever is
contagious from person to person, in the ordinary way.
The largest experience shows that it does not extend, like
an ordinary contagious disease, to nurses or others attend-
ing upon patients suffering under the disease.
What Small-pox Can Do.— At the time of the an-
nouncement of vaccination by Jenner small-pox caused
more than one-tenth of all the deaths of the human race.
Fifty million people died in Europe from small pox dur-
ing the eighteenth century. In the sixteenth century
the disease appeared in Mexico, and 3,500,000 of the
population yielded up their lives in a few years, leaving
some provinces almost depopulated. In 1707 in Iceland
18,000 died in one year, the entire population being but
50,000. Seventy per cent, of the people of Greenland
died of small- pox in 1734. Small-pox is the most fear-
ful disease with which the human race has ever been
scourged. Macaulay tells us it was always present, fill-
ing the churchyards with corpses and leaving on those
whose lives it spared the hideous traces of its power.
"If a modern traveller," says Dr. Hyde, "could be
transported to London in the early part of the present
century, no peculiarities of architecture, dress, or behav-
ior, would be so conspicuous as the enormous number of
pockmarked faces he would encounter at every turn."
It spared neither rich nor poor, and even invaded the
palace of the king.
Awards at the International Exposition of Hygiene
in Rome. — The German exhibitors figure prominently in
the official list of awards made by the jury of the Inter-
national Exposition of Hygiene held concurrently with
the International Medical Congress in Rome. From the
report of the Exposition already given in our columns,
the reader will be prepared to find that the Imperial Ger-
man Gesundheitsamt received the highest award (the great
diploma of honor) ; while minor honorary diplomas were
given to the Prussian War Office, to the city of Berlin,
to the Bavarian Ministry of the Interior, to the city of
Munich, to the Home Office and War Office of Saxony,
and to other bureaux (government and municipal) of the
Fatherland, as well as to Professors Salkowski, Kossel,
and Brieger, of Berlin ; Jaffe, of Konigsberg ; Kiihne, of
Heidelberg ; Drechsel, of Bern ; and C. Zeiss, of Jena.
The gold medal was obtained by the Anilin-Fabrication
Company of Berlin ; by Schering, of Berlin ; by Merck,
of Darmstadt, and by two other German houses ; while
silver medals were literally showered on exhibitors of the
same nationality for contributions to sanitary matSrieL
Among the recipients were professors in the various seats
of learning throughout the Fatherland — Berlin in point
of numbers heading the list. Italy, again, is well satisfied
with the appreciation of her mineral waters embodied in
the awards of the jury. On the court representing the
Hydrological Department were the "Dean of French
Hydrology," Professor Labat, of Paris, and the head of
the German hydrological societies, Professor Winternitz,
of Vienna, while Italian jurymen were the Senator Dr.
Giulio Bizzozzero, Professor of General Pathology in the
University of Turin, and Dr. David Borelli, Professor of
Clinical Medicine in the University of Naples. Among
mineral waters, Italian and foreign, the highest award
was given to that of Fiuggi, which received the silver- gilt
medal ; silver medals were adjudged to Decref (Madrid)
and Perrin (Vichy) for their waters ; and the Giesshubl-
Puchstein, the Franz Josef Bitterquelle, and the Tuscan
Cinciano received bronze medals. Fiuggi, to which the
place of honor has been assigned, is a water of great an-
tiquity, which, like many good things Italian, has been
allowed to fall into desuetude till now, when a vigorous
effort is being made to reinstate it in the popularity it
enjoyed in mediaeval and classic times. Its source is in
the Hernican country to the south of Rome, a beautiful
tract of the Apennines celebrated by Virgil, and its effi-
cacy in subjects of the uric diathesis is attested by clini-
cians of the stamp of Dr. Guido Baccelli, President of
the Eleventh International Medical Congress, the Senator
Dr. Mariano Semmola, Professor of Clinical Medicine in
the University of Naples, and, indeed, by nearly every
consultant of note throughout the peninsula. It ought
certainly to be better known in this country, as its vir-
tues, especially in gastro intestinal catarrh, notably,
such as proceeds from uric and oxalic concretions,
have been attested by British medical men practising in
Italy.
M . Pasteur on Babies. — MT Pasteur addressed the fol-
lowing reply to a lady who recently wrote to him for in-
formation respecting the symptoms of rabies : " M. Pas-
teur has had pleasure in receiving your letter of May 31st.
The bite of a dog is only dangerous when the dog has
got rabies. If there is any doubt in respect to this, the
manner in which it may be found out is the following :
Put the dog that has bitten where it can do no further
harm. Have it examined by a vet., and if it has the
rabies its characteristic symptoms will not be long of
being observed, and the animal will certainly die in
eight days. If at the end of that time no symptoms of
rabies has been observed, the bite cannot cause hydro-
phobia, and there is no reason that the animal should be
destroyed."
Attending Physicians and Consultation-fees. — An es-
teemed correspondent recently inquired :
" In consultations, is not the attending physician e; -
titled to a consultation-fee in addition to his ordinary
visiting-fee ?"
We answered, " Yes." — Medical News.
All the same, the attending physician rarely gets it, and
we see no particular reason why he should, though he
might reasonably charge double his ordinary fee if much
of his time is consumed.
July 14, 1894]
MEDICAL RECORD.
53
jftrcietg Reports.
(ZougzeeB at &roettfara ffftijstciatia
and ^urgeoua.
7Xi></ Triennial Meeting, held at Washington, D. C,
May 20, jo, ji, and June 1, 1894.
(Contkuiad from page a*.)
AMERICAN PHYSIOLOGICAL SOCIETY.
Seventh Annual Meeting, held in Washington, D.C.,
May jo andji, and June i, 1894.
President Henry P. Bowditch, M.D., of Boston,
Mass.. in the Chair. Warren P. Lombard, M.D.,
of Ann Arbor, Mich., Secretary.
First Day, Wednesday, May 30TH.
A motion was made to appoint a committee of three to
consider the advisability of publishing an American Jour-
nal of Physiology , and to report at the next meeting in
December, 1894. Committee appointed by the presi-
dent, consisting of Drs. Lee, Porter, and Donaldson.
Effect of Fatigue on the Bate of Transmission of
Hervous Force. — Dr. Henry P. Bowditch, of Boston,
read a paper with this title. The most important results
obtained were by noticing the results of prolonged stim-
ulation. Thus far there has been discovered no produc-
tion of heat, nor chemical change, nor any great amount
of fatigue produced by prolonged stimulation ; shown in
regard to the last point, for example, by the continuous
action of the vagus on the heart ; and, in Sensory nerves,
by long continued pain. But is there not some change?
The best understood phenomenon of nerve force or
function is, perhaps, the rate of transmission, the gener-
ally accepted average of which is about thirty metres per
second. Is the rate affected by prolonged stimulation ?
The method used by Dr. Bowditch in his experiments
was the nerve-muscle method. To use this effectually,
there must be some method of " blocking " the current,
or interrupting it between the nerve and the muscle, so
as not to wear out the muscle. Of the various methods
of doing this, by interrupting the current, by chemical ac-
tion {e.g., by action of atropia or curare on the muscle,
or local application to the nerve, at point of entrance into
the muscle, of ether), or by pressure (which latter Dr.
Bowditch found entirely useless), he chose the use of
ether, using a mixture of so parts of ether, 8 parts of six-
per-cent. salt solution, and 2 parts of alcohol.
He found the current, or connection between the nerve
and muscle, blocked after application for from one to six
minutes ; and on removal of the ether, the nerve recov-
ered its conductivity in from two to four minutes. His
first effort was to obtain an average effect on a number
of different specimens, in order to compare with the
normal.
He found, however, that there was a very wide range
of results obtained by experimenting with frogs' nerves,
and that the different nerves acted very differently. He
showed by diagrams that the different effects showed a vari-
ation of from 10 to 15 metres up to from 45 to 53 metres,
after use of ether or stimulation, or both, i.e., in the
lowest of his experiments the rate of the first nerve was
15 metres, and after use of ether or stimulation it was re-
duced to 10 metres; and in the highest case was 53
metres, afterward reduced to 43 metres per second.
In most cases the range of each individual experiment
was not large, being from 5 to 10 metres ; but in some
was very large, being in one case from 20 to 40 metres
per second. Dr. Bowditch had found a similar range in
the experiments of other investigators, e.g., in Helm-
holtz's a variation from 4 to 20 metres. He therefore
feels that with the methods at present at our command,
that we cannot hope to arrive at the true normal stand-
ard, the great variations depending upon conditions
which we cannot control.
Dr. Bowditch conducted his experiments in the usual
moist chamber, at a nearly uniform temperature. He
found that rest did not affect the results, i.e., the prepa-
ration did not deteriorate after keeping from one to three
hours. In general he found that after use of ether alone
the rate was somewhat lower than the generally accepted
normal, viz., eighty-two per cent, of normal rate; that
after stimulation it was slightly lower still; and after
both, still lower, being about seventy-six per cent, of
normal. But he considers the decrease comparatively
slight; and that thus far he must conclude that pro-
longed stimulation, i.e., fatigue, does not markedly affect
the rate of transmission. He hopes to continue the in-
vestigation of this interesting question by photographic
and electro-metrical methods.
The Physiological and Therapeutic Action of Nuclein.
— Dr. Victor C. Vaughn, of Ann Arbor, read the pa-
per. Physiologically nuclein may be said to form the
chief chemical constituents of the lining parts of cells,
the element by virtue of which the cell grows, develops,
and reproduces itself. It is its function to utilize the
pabulum within its reach. It is evident, then, that those
tissues containing a large number of cells must contain
the relatively largest amount of nuclein. It would also
seem that it is by virtue of their nuclein that the different
organs manifest their individual peculiarities and func-
tions; and therefore that the nucleins from different
sources would be very different, e.g., that from yeast dif-
ferent from that from the spleen or the thyroid gland,
etc., the number of kinds being limited only by the num-
ber of different cells.
It is the chemical basis of the nuclei of the cells, some-
times called by the histologists chromatin, from the ease
with which it takes up staining materials. Chemically,
the nucleins are proteid bodies containing a large amount
of phosphorus, existing in the form of nucleinic acid,
this acid being the same in all nucleins ; but, combined
with different bases gives us the different resulting nu-
cleins. On reduction and recomposition they yield some
of the so-called xanthin bodies. In general they are in-
soluble in dilute acids and soluble in dilute alkaloids, and
resist peptic digestion.
Some substances histologically nucleins do not yield
any xanthin base, and such are now called para-nucleins,
and some of these are the antecedents of the true nu-
cleins.
Some nucleins are combined with albumins forming
nucleo albumins. Miescher was the first to study appre-
ciatingly the nucleins, and was the one who named them.
He prepared his specimens for investigations from pus
corpuscles, and later from the yolks of eggs.
In 1874 he made his most important contribution to
the knowledge of nucleins by working with the spermato-
zoa of salmon. In a fresh state these were found to be
very resistant to most chemical reagents, but were found
to be destructively affected by dilute salt solutions (ten to
fifteen per cent).
The head of the spermatozoa was found to be practi-
cally free from albumin, and to consist of nuclein and
small quantities of lecithin, cholesterine, and fat.
The nuclein molecule is wonderfully retentive of life,
and possesses marked powers of self recuperation after be-
ing partly decomposed ; as shown by the fact that after
being partly decomposed by salt solution, if this solution
be diluted by the addition of large quantities of water,
the nuclein is restored to its original form and constitu-
tion.
Nuclein maybe very markedly changed in chemical
composition and functional powers, without changing its
visible properties or form, which would readily account
for the failure oftentimes to find, by macroscopical or mi-
croscopical examination, lesions distinctive enough or of
sufficient character or extent to account for the severity
of symptoms observed during life.
An artificial nuclein has been prepared by Lieben,
which, however, is not a true nuclein, but a para- nu-
clein.
54
MEDICAL RECORD.
[July 14/1894
A close relation seems to exist between nuclein and uric
acid, judging from the close relation of both to the xan-
thin bodies. Thus spleen nuclein when oxidized yields
uric acid.
This origin of uric acid from nuclein will explain the
origin of uric acid in the mammalian body, showing
really the number of nucleated cells in the body which
are being recomposed and not* as heretofore believed,
being the result of imperfect oxidation of food stuffs, the
complete product of which is urea.
Some of the. nucleins have germicidal properties
more powerful than corrosive sublimate. The germicidal
constituent of the blood is nuclein, furnished by the poly-
nuclear white corpuscles. Being thus germicidal can they
be used to prevent or arrest the growth of germs in the
animal body ; and if so, in what manner do they act ?
Nuclein seems to be entirely non poisonous, large doses
having been injected and administered by mouth in
human beings with little or no unpleasant reaction. In
some cases it caused a temporary elevation of tempera-
ture and a slight local reaction, but neither to any dan-
gerous extent. He has used it in membranous tonsillitis,
in streptococcus diphtheria, and in indolent ulcers ; and
in all cases with good effect. The action of nuclein in
giving immunity from certain diseases is marked, as
shown in some cases where it was used on rabbits, ren-
dering them immune to the diplococcus pneumoniae;
but this is not due to its direct germicidal action, but to
its power of stimulating some organ whose duty it is to
protect the body against bacterial invasion.
Dr. Vaughn thinks that for immunity and cure of in-
fectious diseases we must look for, ist, Non- poisonous ger-
mides of cellular origin; and 2d, substances which stim-
ulate the activity of those organs whose function it is to
protect the body against those diseases. He thinks that
nuclein fills both of these demands.
From the investigations of Dr. Huber he finds that,
" 1, The subcutaneous injection of nuclein increases the
number of white blood corpuscles; 2, this increase oc-
curs in both healthy and tuberculous persons ; 3, the in-
crease varies with the individual ; 4, the increase is most-
ly in the polynuclear cells ; 5, it generally appears with-
in three hours, and disappears after forty-eight hours."
Action of Calcium on the Heart— Dr. W. H. How-
ell then made an interesting demonstration of the effect
of calcium salts on the contractility of the heart. He
had the heart of a turtle in a bulb, connected with a very
delicate water manometer ; and having connection by a
stop cock with three flasks containing : 1 , Normal sheep's
blood ; 2, sheep's blood with the calcium salts precipi-
tated by excess of sodium oxalate ; and 3, sheep's blood
with excess of calcium chloride. In the first instance
the heart was fed with the normal blood, showing nor-
mal contractions ; then it was fed with the decalcified
blood, upon which the contractions became less frequent,
the diastole being lengthened, and also irregular and
jerky in its action, finally coming almost to a complete
standstill, practically a potash paralysis. Then the blood
with excess of calcium chloride was turned into the heart,
which very soon began to beat more frequently and regu-
larly and was finally restored to a practically normal con-
dition.
Dr. Howell said it had been so far impossible to decide
absolutely whether it was the absence of the calcium salts
or the presence of the excess of the oxalates which caused
the paralysis, it being at present practically impossible
to precipitate all of the calcium salts without an excess of
the oxalates. We cannot exactly neutralize the calcium
salts, as we do not know in any particular sample of
blood just how much is present in soluble and ergo pre-
cipitable form, and how much is in composition more or
less stable with proteid and other bodies.
Ptyalinogen and Pexinogen.— Dr. J. W. Warren then
made some remarks on the qualitative determination of
ptyalinogen and pexinogen. The best way of determin-
ing the presence of pexinogen or the forerunner of the
mUk curdling ferment was by chloroform water. Ham-
merstein, he said, had found pexinogen in nearly all ani-
mals ; but in the mucous membrane of the ox it was not
found, the pepsin being there already formed. Dr. War-
ren had found the opposite condition present in his ex
periments with the ox.
Ptyalinogen, the forerunner of the salivary ferment,
ptyalin, he also determined by the chloroform-water
method. He had found it present in almost every case
excepting in the cat. The principal objection to the
chloroform method was the difficulty of entirely remov-
ing the chloroform, and the fact that, if present, it gave
a reaction with Trommer's test, simulating that of sugar.
The quantity of ptyalinogen is small and yet it was al-
ways genuine. In some cases, of sheep and rabbits, he
could get no results either for ptyalinogen, or for ptyalin
itself in watery or chloroform- water extracts.
Dr. Warren used a one per-cent. solution of sodium
fluoride, which acts as an excellent preservative of the
different ferments of the body, and which does not re-
duce the reagents used for testing for sugar.
Ptyalinogen is not very soluble as compared with the
forerunners of the other ferments of the body; and is
apparently not so stable and permanent. No result was
considered satisfactory nor reported where the action did
not appear within one hour.
Chemistry of Muscle.— Dr. G. N. Stewart then read
a paper on this subject. He stated that his first experi-
ments had been to get information as to whether the
proteid substances usually said to be present in muscle
tissue, and which had all been derived chemically from
dead muscle, existed as such in living muscle.
He differed from and criticised Halliburton's theories,
as to the presence of myosinogen in the muscle tissue,
and the fact of its clotting to produce the rigor mortis ;
and also criticised Halliburton's conclusions from his
method of practical precipitation of the proteid borders
of muscle tissue.
Following, however, Halliburton's methods to a cer-
tain extent, he found the quantities of myosinogin and
the other proteids quite different in the different muscles
of the body ; e.g., those in heart muscle different from
those in the skeletal muscles and some differences in the
different groups of the skeletal muscles ; the larger per-
centages of easily coagulable proteids being as a rule in
the more active and more easily irritated muscles. The
rigor mortis being different in different muscles, are not
the extracts of the different muscles also different in the
quantities and coagulability of their proteids and is the
myosinogen of one different from that of another ? Dr.
Stewart thinks that such differences do exist.
In a series of experiments on fifty frogs' hearts and
skeletal muscles he found slight difference in the tem-
perature at which the proteids of these heart-muscles
coagulated and that at which proteids from skeletal
muscles from the same frogs coagulated.
In the case of rabbits' hearts he found the same result.
Also by direct application of heat to the muscles, it
needed a higher temperature to cause a " rigor mortis "
in the heart than in the skeletal muscles.
In the following tables, which illustrate these results :
I. Is the percentage precipitate occurring between 470 and 49° C.
II. Between 560 and 580 C.
III. Up to 650 C.
IV. The balance of coagulable proteid with boiling.
Also according to Halliburton's results of fractional pre-
cipitation and his nomenclature :
I. Is para myosinogin.
II. Is myosinogin.
III. Is myoglobulin.
IV. Is serum albumin.
Halliburton claimed that para-myosinogin did not clot ;
but according to the fractional precipitative method Dr.
Stewart found it present in muscle clot in large quantity,
and therefore judges it essential to the formation of the
clot, and fully as much so as myosinogen.
These tables show percentage of different proteids, as
July 14, 1894]
MEDICAL RECORD.
55
per above explanation, in the heart and skeletal muscles
of a rabbit :
Heart. Skeletal.
Per cent. Per cent
1 76.I 70.9
II Slight 19.7
III * * Slight
IV 23.9 9.41
In one experiment Dr. Stewart heated a muscle from a
cat's leg at 42 ° C. for ten hours. " Then made extract of
it, and found that all the proteids excepting serum albu-
min were precipitated at about 420 C, showing that the
rigor mortis (thus artificially produced) causes some
change in the muscle proteids, if Halliburton's method of
fractional precipitation, as precipitating pure chemical
bodies, be accepted.
In another case Dr. Stewart prevented rigor mortis of
a muscle by pressure, and then upon making extract and
comparing it with results from a muscle in which rigor
mortis had taken place found very little difference be-
tween the two, as will be seen from the following table.
"A" being the one in which rigor mortis had taken
place ; " B " being the one in which it had been pre-
vented :
A. B.
Per cent. Per cent.
1 70. 68.2
II 21.4 24.8
III 8.7 6.9
He thought that, theoretically, if muscle were exam-
ined after rigor mortis had passed off, there should be
found a difference in clotting power as compared with
muscle examined before rigor mortis ; but had not found
it so.
Dr. Stewart concluded that the methods at present
available for investigation of this subject were incomplete
and faulty and hoped for better ones soon.
Second Day, Thursday, May 31ST.
Circulation Time in Organs.— Dr. G. N. Stewart,
of Harvard University, read the paper. As to method,
it was necessary to cause some condition of the blood
which could be easily noted, would disappear quickly,
and which would admit of new and repeated observa-
tions.
Of various possible methods, Dr. Stewart used that of
injecting a quantity of salt solution into an afferent ves-
sel, and then determining, by the difference in conductiv-
ity of an electric current, caused by the presence of the
salt in the blood, the time at which the salt solution had
reached the efferent vessel, thus giving the time of cir-
culation through the organ. The electrodes may be
placed upon the vessel, and do not need to be inserted
into the vessel nor into the blood-current.
He found the time of circulation longest in the kid-
ney (occasionally about as long in the spleen), the aver-
age of many experiments being 11.58 seconds. The pul-
monary circulation time he found the shortest of any
organ in the body (excepting sometimes the coronary cir-
culation), being from two to four seconds. It was also
more constant than that of any other organ, and might
well be used as a sort of unit or standard.
The liver circulation was from four to seven seconds ;
the thyroid gland, five to six seconds, and capable of re-
duction by section of the cervical sympathetic ; in the
spleen the average time was 10.95 seconds. In one case,
using an animal which had been used previously to dem-
onstrate the motor areas, and which had spasms during his
observation of the pulmonary circulation, he found that
time much shorter.
In another case, where an overdose of chloral had been
given, he also found the time much reduced, probably
due to the marked dilatation of the whole vascular sys-
tem. For measuring the circulation time in the intes-
tines and the coronary vessels, Dr. Stewart used the
method of pigment injections, using two per cent, so-
lution of methylene blue. In the intestines the time was
a trifle longer than the lungs, and about one- third as long
as in the liver. The coronary time was short, being about
three seconds, very little, if any, change being caused by
stimulation of the vagus ; if any change, it was a decrease
of time, not an increase.
Dr. Stewart claimed that the results were not affected,
as some had claimed, by the diffusion of the salt solution,
as the time during which any one observation was made
was not long enough for any appreciable diffusion td take
place.
Soma Experiments upon Keflex Vasoconstriction and
Vaso dilatation. — Dr. W. H. Howell sent a paper with
this title, which was read by Mr. R. Hunt. The object
of the experiments was to study the conditions under
which a reflex fall of the general blood-pressure can be
obtained.
If chloral be administered to a rabbit, and the central
end of the cut sciatic nerve be stimulated, a fall of press-
ure occurs, instead of the usual rise.
It is generally held that the sensory nerves contain
both pressor and depressor fibres, and that upon fatigue
of the vasomotor centres they are more influenced by
the depressor than by the pressor fibres.
Recently Kleen described that a pure muscular stimu-
lation, as by kneading a muscle, caused a fall ; whereas a
cutaneous stimulation caused a rise of pressure.
Dr. Hamell also has shown that, by cooling the sciatic
and stimulating the nerve peripherally to the cooled por-
tion, a fall was caused, which was followed by a rise if the
nerve were warmed and again stimulated.
Dr. Howell and Mr. Hunt found that when the nerve
was cooled that anaesthesia had a marked effect upon the
pressure under anaesthesia, caused by pressure on the cere-
brum, in cats, the vagi being cut ; mild stimulation of
the sciatic at the temperature of the room caused a
marked rise of pressure. At io° C. the same stimulation
caused a fall, while at the same temperature a strong
stimulation caused a rise of pressure.
At 50 C. both strong and weak stimulation caused a
fall. At 1 50 both strong and weak stimulation caused a
rise. The change from a fall to a rise was often very
rapid after changes of the temperature.
Ether, alone or with other anaesthetics, seemed to have
a marked influence in bringing out the depressor effects ;
under ether a rise was usually caused by moderate stim-
ulation at the temperature of the room, but a fall at
lower temperatures. Curare seemed to have an opposite
effect to that of ether, i.e., bringing out more promi-
nently the pressor effects. At low temperatures no fall
could be obtained in the curarized rabbit, and at higher
temperatures the rise was very marked.
Under acetone chloroform the vaso-motor centres
seemed to be not very irritable and the changes in press-
ure not great. Upon rhythmical stimulation under press-
ure anaesthesia, only a rise was obtained varying directly
with the strength and rapidity of the stimuli. Local ap-
plication of drugs to the nerve had little or no effect, ex-
cepting that some, e.g., ether, completely blocked the im-
pulses.
The cause of the above effects cannot yet be fully an-
swered. Dr. HamelTs method seems good evidence of the
existence of two sets of fibres, pressor and depressor, the
conductivity of the former being more quickly diminished
than the latter by local causes. When drugs are injected
into the circulation, probably, or perhaps, the centres
themselves are affected.
Brain Centres of the Bladder. — Dr. Isaac Ott, of
Easton, Pa., gave the results of a few preliminary ex-
periments on the cerebral centres of the bladder. Pre-
vious experimenters had noted that electrical stimulation
to the corpora quadrigemina caused a contraction of the
bladder. Dr. Ott found that, on cross section of the aura
cerebri, a flow of urine followed ; also that when the sur-
face of the exposed crura was touched the bladder con-
tracted. If small doses of atropia were administered he
still got contraction, but failed to get any after large
doses, e.g., gr. ij. of atropine sulphate in an ordinary sized
56
MEDICAL RECORD.
[July 14, 1894
adult cat. He used only mechanical stimulation. His
conclusion was that the centre or centres lie in the
crura cerebri, the exact portion of the crura, however,
being not yet determined.
Volume Changes in Muscle during Activity and
Best. — Dr. G W. Fitz, of Harvard University, read a
paper with this title. He used a plethysmograph on
the arm, with indicators giving tracings showing the ra-
pidity, length, and force of the contractions of the mus-
cles, the pulse-beat, and the changes in volume. He
found changes in both pulse and volume, but directed
attention particularly to the changes in volume. On
contraction of the muscles, i.e., in state of activity, the
volume was markedly diminished^ in quantity varying,
in different arms and in different experiments, from 20
to 75 c.c.
He found the crura indicated by the plethysmograph
quite different when repeated contractions were rapidly
made, as in the milking motion, from that where there
was a single long-sustained contraction.
In the stage of fatigue there was a large variation in
the volume of the arm, a marked filling up, or increase
of volume. With each arm of same patient in a plethys-
mograph, one exercising and the other quiet, there were
slight effects noted in the quiet arm as well as the marked
changes in the active one.
The time taken to get the maximum effect was from
fifteen to twenty seconds, and a similar time was taken
for the arm to refill. These changes, Dr. Fitz claims, are
changes in the quantity of fluid in the arm, probably en-
tirely in the amount of blood in the vessels, the quantity
of lymph in the lymphatic spaces not being much affected,
as the time necessary to cause the change is so short.
Also when the shape and relative bulk of the muscles are
considered, and the relatively small amount of other tis-
sues in the arm, it seems likely that the change is lim-
ited to the muscles.
By the contraction of the muscles the blood is
squeezed out of the vessels, both arteries and veins ; and
there is thus a change in volume and an anaemia of the
arm, because for the time being the blood pressure is not
enough to overcome the force of contraction of the mus-
cles. When, however, the muscle becomes fatigued, the
blood can force itself into the vessels, causing an increase
in volume, and a congestion of the arm.
Dr. William H. Howell, of Johns Hopkins Univer-
sity, exhibited some very interesting " plethysmography
curves taken during sleep." He found the arm con-
gested during sleep, and contracted or anaemic during
waking ; and, taking account of the already known the-
ory of the absence of vasomotor control in the brain,
the quantity of blood there depending upon the condi-
tion of the circulation of the other parts of the body, and
varying inversely as the quantity in other parts, he
brought out a very suggestive indication from the curves,
of the probable parallelism between the amount of blood
in the brain and the condition and intensity of con-
sciousness.
Upon stimulation of any of the centres, e.g., the au-
ditory centre by any noise, the person experimented up-
on being asleep, the arm became anaemic, indicating a
corresponding congestion of the brain, this change being
in direct proportion to the strength of the stimulus.
These experiments led Dr. Howell to suggest a pos-
sible theory as to the cause of sleep, viz., that the anae-
mia known to exist in the brain during sleep, and
which has so far been considered to be a secondary con-
dition, is really the cause of sleep. The explanation of-
fered was that the circulation of the brain, or the
amount of blood, varies inversely to that of the balance
of the body ; the vaso-constrictor centre is in a condition
of tonic activity during waking, thus keeping the quan-
tity of blood reduced in the body and increased in the
brain; this centre becoming fatigued, the body vessels
dilate and* fill up, those of the brain empty themselves,
and when a certain level is reached sleep ensues.
The Cardiac Planrogram.— Dr. S. J. Meltzer, of
New York, read a paper on " The Cardiac Pleurogram
and the Nature of the Cardio- pneumatic Movements."
If a manometer or other recording apparatus be connect-
ed with the mouth, nose, or trachea, while respiration is
suspended, respiratory oscillations can be observed coin-
ciding in time with the cardiac movements.
These were explained by Voit in this way: During
systole an inflow of air into the lungs occurs to counter-
balance the effect of the diminution in size of the heart ;
the opposite occurring in diastole. Later Ceradini rec-
ognized the fact .that the change in pressure could not
take place as long as the blood thrown out by the heart
reniained in the thoracic cavity; but it is only when it is
leaving the thoracic cavity that the respiratory move-
ment occurs. Therefore the cardio-pneumatic undula-
tions are due not to change in size of the heart, but to
change in the quantity of blood within the thorax.
Landois found a short but distinct expiration preced-
ing the main inspiratory movement, and after this main
movement two more small respiratory undulations oc-
curred before the new cycle commenced. Registration
of the respiratory undulations may also be made by means
of apparatus placed in the oesophagus, as done by Martins
and by Dr. Meltzer. Many tracings were obtained of
the cardiac movements, to which Dr. Meltzer gave the
name of cardio-mediostinograms. The distinctness of
these tracings seems to depend upon the depth in the
oesophagus at which they were taken, least distinct in
the cervical region, sharp and clear in the thoracic por-
tion, excepting in the immediate vicinity of the dia-
phragm, where they were sometimes wholly absent. The
results showed the same general feet, viz., an inspiration
at the systole, an expiration at diastole of the heart.
Dr. Meltzer showed a number of tracings taken by the
oesophageal method, showing the curves of the cardio-
respiratory movements very distinctly. In general, in
dogs, in each cardiac cycle there appeared a steep systolic
down-stroke, followed by a gradually ascending diastolic
line with some fine oscillations, showing that during sys-
tole the pressure is suddenly lowered, and during dias-
tole gradually returns to its former level This, as in all
the oesophageal-cardiac tracings from the dog, showed a
so-called negative pulse.
In experiments on himself Dr. Meltzer found also a
negative pulse in the oesophagus down to twelve centi-
metres from the beginning of the oesophagus ; below
fourteen centimetres the pulse was positive, showing an
up stroke of the indicating lever, or an expiratory move-
ment.
Dr. Meltzer referred to Haycraft and EdieV experi-
ments, from which they claimed that the cardio-respira-
tory movements disappeared upon lifting the heart away
from contact with the lungs, and that the lungs really
acted as an oncometer placed about the heart, and that
the air in them is affected by the cardiac impulse just as
the air in a cardiograph placed against the chest.
To test this explanation Dr. Meltzer made tracings of
the cardiac movements directly from the pleural cavity,
calling them cardio-pleurograms.
From these he obtained in general the same results as
before, with slight modifications due to the different con-
ditions and methods, and therefore argues that since both
heart and lungs were far from the openings leading to
the tambour, the movements are not due to the lungs
acting as an oncometer for the heart, and that they are
due, as at first stated, to the change in the quantity of
blood in the thoracic cavity.
Dr. Meltzer thought that Haycraft and Edie's results
were perhaps due to their method of opening the chest,
which caused a very abnormal condition with relation to
its surroundings. In rabbits free access of air to the
chest cavity caused the cardiorespiratory movements to
disappear; in dogs they were diminished, but did not
disappear. This, Dr. Meltzer thought, depended upon
the different arrangement of the organs in the posterior
mediastinal space, in rabbits and in dogs. His conclusion
was that these cardio-respiratory movements were nor-
July 14, 1894]
MEDICAL RECORD.
57
maly and undoubtedly caused, as above stated, by the
changes in the quantity of blood within the thoracic
cavity.
Third Day, Friday, June ist.
Beflaz Time of Winking.— Dr. W. P. Lombard, of
Johns Hopkins University, read a preliminary report of
experiments to determine this point. He used a very
ingenious apparatus for producing the stimulus — a plunger,
worked by electricity, striking the cheek about one inch
from the outer canthus of the eye, the stimulation being
mechanical An electric current is broken at the blow
of the plunger, and immediately closed by a spring, and
again broken by the movement of the eyelid in winking;
the time between the two breaks being measured gives the
time of winking. Tracings were taken on a drum, of the
stimulus and the wink, and parallel with these, of the vi-
brations of a tuning-fork, of known rapidity of vibration.
The time varied somewhat in different persons, and in
the same person at different times ; but in general was a
little shorter than that determined by previous experi-
ments, being about 0.04 second. If from this be sub-
tracted the time of transmission and the latent period of
the muscles, the time will be probably reduced to about
0.03 second.
An Improved Hematocrit.— Dr. Judson Daland, of
Philadelphia, showed, by request, his improved hema-
tocrit, for examination of the blood by the centrifugal
method. He claimed for it, as advantages over the in-
struments at present in use, its greater compactness,
higher speed of revolution of the frame or spindle carry-
ing the capillary tube ; the shorter length of the tube,
and its lens face, making the reading easier; the new
scale, reading the normal amount of corpuscles in the
blood as one hundred per cent. ; and the fact that by it
the blood could be used in its normal condition direct
from the circulation without dilution.
A Short-circuiting Commutator.— Dr. W. P. Lom-
bard, of Johns Hopkins University, showed an ingenious
and very simple short-circuiting commutator, affording,
making, or breaking induction shocks.
It consisted of two hard-rubber wheels or disks, set on
a brass shaft, and having in the circumference of each a
brass plate connecting by contact with the shaft. One
of these wheels rotates on the shaft. Against these
wheels the usual brush rests, and by rotating one of the
wheels upon the shaft the current of the short circuit can
be made to precede, or follow, the primary current at will.
The device can easily be attached to any apparatus.
Dr. Lombard also showed an improved hand-rest for
use with the ergograph, whereby the usual variations
caused by the unconscious and involuntary withdrawal
of the hand and arm from the ordinary hand-rest, and
the use of other muscles than the particular one desired,
can be avoided.
He also showed a " non-oxidizable mercury key," con-
sisting of a hermetically sealed " U " tube in two parts,
a segment of rubber tubing connecting the two parts ;
the tube is partly filled with mercury, the balance being
filled with nitrogen (for which may be substituted hydro-
gen or other non-oxidizing gas), no air being in contact
with the surface of the mercury ; into each end of the
tube is soldered a platinum wire ; and pressure on the
rubber segment of the apparatus causes the column of
mercury to come into contact with the wire at one end
of the tube, thus completing the circuit ; on relaxation
of the pressure on the rubber tube the mercury falls of its
own weight away from the wire, thus breaking the circuit
Anaeithesia by Cerebral Pressure. — Dr. G. T. Kemp,
of Johns Hopkins University, read a paper on this sub-
ject. Of the various methods for producing pressure,
e.g., injections into the subdural space, direct pressure
after trephining with blunt instruments, the air-bag, etc.,
he used a thin rubber bag inserted through a cannula,
which is put into a trephine hole, and distended this with
salt solution.
His object was to find if the production of anaesthesia
was practical and practicable, especially when anaesthesia
by other means was contra-indicated, as in long-con-
tinued laboratory experiments on animals, or where it
was desirable to avoid, in any particular experiment, the
effects, other than anaesthesia, produced by the drugs
ordinarily used for that purpose.
He used chloroform for the primary operation of tre-
phining and applying the pressure apparatus, then allow-
ing the effects of the chloroform to pass off, noted the
effects of the cerebral pressure. The effects of slight
pressure were pain and stimulation, especially of the
medullary centres.
Ail these centres were stimulated early, and this was
followed by exhaustion, and later still by paralysis. The
vagus centres responded first, and respiratory centres
became exhausted first. He found that it was the auto-
' maticity of the centres that was exhausted, and not the
centres themselves ; as after the suspension of their auto-
matic action they still responded promptly and vigorously
to any direct stimulation. He found that he could not
use pressure enough to cause complete anaesthesia with-
out doing some damage to the medullary centres, this
fact being probably due to the anaemia of the medulla
caused by the pressure.
He concluded, however, that for many experiments it
was a means of causing anaesthesia that was of great prac-
tical value for laboratory work.
He exhibited a number of beautiful tracings showing
the results in several experiments, some of them of sev-
eral hours' duration, with the curves of the respiration,
blood pressure, and the artificial cerebral pressure.
Respiratory Paths in the Cord. — Dr. W. T. Porter
presented a paper with this title. He noted Rosenthal's
work on the automatism of the respiratory centre, and
the fact that the exact location of the centre had not yet
been determined. He showed, however, by the fact
that, although some irregular movements of the dia-
phragm take place after separation of the cord from the
medulla, no full, regular, respiratory movements occur,
that there is no automatism in the cord so far as respira-
tion is concerned.
He then detailed many experiments made to trace the
path or paths of respiratory impulses from the centre
through the cord.
His first experiment was to make a hemi-section of the
cord on one side at the level of the second cervical verte-
bra ; then a hemi-section on the other side at the level
of the point of the calamus scriptorius, of all excepting
a very small portion of the outer part of the lateral tract.
Breathing stopped at once, but after a few minutes of
artificial respiration the breathing began again and con-
tinued.
Later the remainder of the lateral tract was cut, and
then breathing stopped again and could not be restored
by artificial respiration, showing that the respiratory im-
pulses descend in the lateral tracts, and that they do not
cross between the two points above mentioned, at which
the sections were made.
Dr. Porter detailed many more experiments similarly
carefully made ; and as to the place of crossing, sug-
gested in general three possible solutions, viz., the
crossing occurs between the bulb and the phrenic centre,
or at the level of the phrenic centre, or by no definite
path, but diffusely, anywhere.
From his experiments, which were too great in num-
ber to give in detail, he deduced the conclusion that the
respiratory impulses pass down the cord through the
outer part of the lateral tracts ; that they can and do
cross on their way down without dyspnoea ; that they do
not cross diffusely in any and all parts of the cord ; that
they do not cross between the level of the bulb and that
of the phrenic nuclei ; that they do cross at or about the
level of the phrenic nuclei, viz., in the region of the
fourth cervical vertebra.
He further suggests the following interesting hypothe-
sis : That the fibres descending in the lateral tracts and
58
MEDICAL RECORD.
[July 14, 1894
transmitting the respiratory impulses end at the level of
the phrenic nuclei in arborizations; that each phrenic
motor cell has two sets, or two sorts, of branches, the
axis cylinder and the protoplasmic or dendritic pro-
cesses ; that the latter have two distributions, some, the
greater part, end on the same side, the others cross to the
other side of the cord, and both come into contact with
the end arborizations of the fibres from the respiratory
centres. Thus the end arborizations of each respiratory
fibre are in contact with phrenic cells of both sides.
That ordinarily the impulses will follow the path where
there are the greater number of processes or dendrites ;
but that if this part be disturbed or obstructed or cut off,
they then can take the other one; crossing to the other side
of the cord and following down the phrenic of that side.
Dr. Porter claims that the only point of this hypo-
thesis which does not rest upon established anatomical,
histological, and physiological facts, is the relation of
transmission to the number of dendrites.
Action of Strychnine on the Cord — Dr. A. R. Cushing
read a paper with the title " Some Facts Bearing on the
Action of Strychnine on the Spinal Cord."
He claimed that there is a coincident paralysis and
stimulation of strychnine- poisoning.
His method of procedure was to expose' only a part of
the cord to the action of strychnine at a time.
He first applied strychnine about the branches of the
brachial plexus. The usual tetanic condition resulted ;
but he found that, although if the upper extremities or
upper part of the body were touched fthe usual tetanic
spasm followed ; if only the lower limbs were irritated
there was no response at all, or only a feeble one.
After a few minutes he could obtain the full results
from touching the lower limbs, owing to the fact that the
strychnine had spread down the cord. When the reverse
experiment was tried, i.e., the lower part of cord exposed
to strychnine, the upper part being protected, the results
were similar; i.e., a full response from irritation of lower
extremities and none from the upper, until after some
time had elapsed, and the strychnine had diffused
through the whole cord. He concluded that in order to
produce strychnine tetanus it was not necessary to apply
strychnine to the motor cell itself ; that strychnine acts
chiefly upon sensory cells ; and that the chief resistance
to strychnine lies in the sensory cells.
The Society then adjourned, to meet in Baltimore in
December of this year.
AMERICAN LARYNGOLOGTCAL ASSOCIATION.
Sixteenth Annual Meeting, held in Washington, D. C,
May jo, 31, and June 1, 1894.
(Continued from page a*.)
Second Day, Thursday, May 31ST.
Results of Cutting Operations in the Nasal Septum
was the first paper of the session. Dr. Thomas R.
French, of Brooklyn, directed especial attention to per-
foration oi the septum and membranous adhesions occur-
ring as a result of operations on the nasal septum.
In reperforation he said that as the methods generally
employed to correct deviation of the septum were not al-
ways successful, he wished to present for discussion a
question which had often arisen in his mind, viz. : If a
successful result cannot be obtained in any other way,
are there not conditions under which perforation of the
cartilaginous septum can be made a perfectly justifiable
. procedure ?
From his study of the result of perforation made by
others, and from his own and other experiences with
perforations with unhealed edges, he expresses his belief
that, with proper care in the after-treatment, perforation
can be deliberately made without injury and with great
relief in a certain class of cases ; that if the breath-way
through the obstructed side cannot be obtained without
leaving a hole in the septum, such a procedure is justifi-
able if the patient can be impressed with the necessity of
leaving the parts alone, and it is reasonably certain that
the case can be carefully followed until healing of the
edges has occurred ; otherwise it is an unjustifiable method
of operating.
He, however, excepts from that statement the perfora-
tions made near the entrance of the nostrils, particularly
in a septum bent obliquely across both openings, by the
Blandin punch.
In re membranous adhesions, after reviewing the recog-
nized causes of this annoying sequel of operations within
the nasal passages, the author called attention to a cause,
heretofore overlooked, viz., that cut surfaces on the sep-
tum will become adherent to scar-tissue on the turbinates
made by the gal vano- cautery at some previous time.
Therefore, in patients who present for treatment whose
nares have never been subjected to operative procedures,
and in whom there is need of the destruction of turbi-
nated tissue and removal of obstructing cartilage or bone,
the septum should be operated upon first, when, after a
month or more has elapsed, and it is certain that the
mucous membrane is completely reformed, the turbinates
can be safely destroyed by any method. When, how-
ever, patients object to a cutting operation on the sep-
tum, but are willing to submit to the destruction or re-
moval of turbinated hypertrophy, preference should be
given to the use of the snare or acids in order to avoid
the possibility of leaving a surface which might become
adherent to a wound opposite in the event of a cutting
operation on the septum being performed later.
Without doubt adhesions are frequently occasioned by
saws with unprotected ends, and the unskilful use of .
trephines and cutting forceps in narrow passages. A dis-
tinct advance will be made when all instruments used for
septal operations are constructed with a view to prevent-
ing the possibility of wounding the outer wall of the nose.
It is a good rule, in operating with the saw, to begin
the section by cutting upward, and finish it by cutting
downward. But whether it is begun from above or below,
the section should be finished by a cut from the opposite
direction ; for in this way the maximum amount of tissue
can be removed from the septum with the least danger of
injury being done to the outer wall.
Dr. J. H. Bosworth, of New York, said that he had
been credited with having said that he had only had one
perforation of the septum from the use of the saw.
What he did say, however, was that, up to the completion
of his first 169 cases he had had only one perforation, but
had had many since. A perforation in the antero poste-
rior direction is practically harmless ; but if it is so shaped
that it presents a projecting edge or angle to the current
of air, it is harmful.
Dr. John O. Roe, of Rochester, did not believe that
with perforations in adults there was danger of a falling
in of the nose, but there is a real danger thereof in chil-
dren. Perforation from operation is bad surgery. We
cut through what we should cut away. He believed that
the septal forceps devised by him would prevent this ac-
cident, as, by means of a screw in its handle limiting the
approximation of the blades, this was prevented. The in-
tact mucous membrane on the non-diseased side acts as a
splint to help support the septal fragments till healing
occurs.
Dr. William H. Daly, of Pittsburg, said that perfora-
tion should be mentioned only to be condemned. These
cases don't stay cured. Many minor factors may con-
duce to septal deviation, such as lying on one side, the use
of the handkerchief, etc. He had had poor results from
Roberts's "pin operation."
Dr. C. M. Shields thought that the thickening found
in these cases was nature's protection against further
bending. Removal relieves the symptoms, but nature
reproduces the deformity. He prefers the knife as the
puret communites. He makes parallel antero posterior
incisions above the line of deflection and joins them by a
perpendicular cut over the salient angle. He has seen
perforation result therefrom.
Dr. W. E. Casselberry, of Chicago, would object to
July 14, 1894]
MEDICAL RECORD
59
perforation on aesthetic grounds. We need not worry
where the condition results from accident. He could not
accept Dr. French's view, that adhesions result only where
there is a solution of continuity on both of the oppos-
ing surfaces. Naso pharyngeal tumors often form adhe-
sions from mere pressure on surrounding surfaces. Fur-
thermore, as to hemorrhage from the septum : it does come
at times from the cut surfaces, and not from injuries to
the turbinated bones.
Dr. M. J. Asch alluded to the operation devised by
him and presented to the association a few years ago.
Few failures had resulted therefrom.
Dr. J. W. Gleitsman, of New York, said that the fail-
ure to relieve the symptoms in many of these cases arose
from the fact that, back of the septal deformity, there is
frequently an enlargement of the inferior turbinates.
The latter may swell up in the air, rarefied by the septal
obstruction.
Dr. S. W. Langmaid, of Boston, asserted that our
operations ought to leave the patient in better condition
than the one in which we found him. Adhesions have
frequently resulted from caustics, which produced corro-
sive action, followed by granulation-tissue. Operation
should never be undertaken unless we can keep a careful
watch on the patient until healing has occurred.
Dr: W. Peyer Porcher, of Charleston, had seen
severe hemorrhage follow the breaking up of adhesions.
He thought iodoform gauze incomparably the best ma-
terial for tamponing in these cases.
Dr. M. R. Brown, of Chicago, believed that bleeding
in septal operations sometimes came from an injured tur-
binate ; not always, however, as the septum may bleed
furiously. He has never found it necessary to perforate
the septum intentionally but twice, and did it far back
from the concave to the convex side.
Early Operation in the Diseases of the Antrum of
Highmore. — Dr. W. H. Daly, of Pittsburg, advocated
an exploratory opening for purposes of diagnosis, and
had treated twenty-seven cases since 1882. It was possi-
ble to teach the patients to irrigate the sinuses by taking
water into the mouth, and then, by a sort of bucco-lingual
compression, force the fluid through the opening into the
antrum, so that it would rinse out the latter and escape
through the nose. As the proper site for opening, he
advocates a point just above the second bicuspid tooth of
the size of a small goose quill. Davidson's syringe, with
a small tube nozzle of proper curve, makes the best irri-
gator. Partitions in the antrum should be broken down.
A conical burr-head drill makes the best perforator.
After operations constitutional symptoms may de-
velop. Pain in these cases is often referred to a point
above the eye. In regard to the site of operation, he finds
in many instances a resiliency of the antrum wall just at
this point. The cheek will cover the opening, but not
always prevent the entrance of particles of food.
Dr. A. W. de Roaldes, of New Orleans, said that he
had found but little difficulty in washing out the antrum
through the natural opening. If an artificial one was
necessary, it should be relatively large.
Dr. Brown preferred to make the opening low down
between the roots of the teeth, and thus go through a por-
tion of the alveolus itself. Thereby we enter the antrum
through the floor. We may enlarge the opening, if nec-
essary. We should remove the drainage-tube early, as its
prolonged use keeps up the discharge. Irrigation through
the natural opening is feasible, but tiresome.
Dr. J. H. Bryan, of Washington, made a plea for
conservative surgery on this cavity. A diagnostic open-
ing could be made through the middle or inferior meatus,
according to the method of Moritz Schmidt. Duration
of the case depends on its past history. For irrigation
only the mildest solutions should be used.
Dr. Schields had often found that the discharge
would cease after the tube was removed. The opening
will always close up when the patient is syphilitic.
Dr. Casselberry believed that antrum disease rarely
exists alone. Other cavities are also affected at the same
time. These latter suppurate, and so prolong the case.
Hence, even drainage of the maxillary sinus can never
cure these cases. The pain above the eye, mentioned by
Dr. Daly, may come from coexisting disease.
Follicular Odontoma Invading the Antrum of High-
more. — Dr. A. W. de Roaldes, of New Orleans, read a
paper, entitled " A Case of Compound Follicular Odon-
toma Invading the Right Antrum of Highmore and Ob-
structing the Corresponding Nasal Fossa, with a New
Apparatus for Administering Anaesthetics, especially
Adapted to Operations on the Mouth, Nose, and Throat."
He said that cases of that kind were so rare, and our
American literature so barren on this topic, that every
one deserved to be made public.
The condensed history of the case is as follows :
Young Daniel A , an otherwise healthy boy, aged
nine, was first seen by Drs. Guice and Rembert, of Natch-
ez, in July, 1 89 2. His right upper jaw presented two points
of disease — one a fibrous growth occupying the socket of
the central incisor tooth, and the other a hard osseous
tumor, covering a considerable portion of the palatal
bone back of the missing canine tooth, extending poste-
riorly alongside the internal plate of the alveoli to near the
tuberosity of the maxilla. Both growths were removed,
but in the spring of 1893 the osseous tumor had re-
turned! when it was operated upon again during the sum-
mer. A short while after necrosis of the bone was found
at the seat of operation, and the antrum was found ex-
posed.
When examined by Dr. de Roaldes, a hard bony tu-
mor was found occupying the right cheek, depressing the
vault of the palate, and encroaching upon the right nasal
fossa, fused with the alveolar border, especially at a
point corresponding with the missing canine tooth.
A diagnosis of benign neoplasm was made, probably an
osteoma, but with a possibility of an odontoma ; this
recorded point to be cleared by previous history, as to
eruption of teeth, which history was unobtainable at the
time. A radical surgical procedure was advised, and was
performed March 4, 1894, by a modified Vollet's opera-
tion ; the whole anterior wall of the antrum was removed
from nose to tuberosity, from alveolar border to orbital
floor, and main mass of obstructed growth chiselled out
from place corresponding to canine fossa. On its sur-
face were tufts of hard adherent tissue ; a large number
of smaller masses, to the number of fifty or more, some
of them tooth shaped, were gouged out in all directions.
After thorough curettage, cavity was packed, parts nicely
sutured and bandaged. Patient made rapid recovery, and
returned home March 23d ; and, twelve weeks after, cavity
is two- thirds filled, and photographs show scarcely any
disfigurement. Microscopical examination, made by Dr.
Borden, U. S. A., shows tumor to consist, as shown in
micro-photograph and drawing of pathological speci- '
men presented, of hypertrophic tooth capsule, which
ossified sporadically in places, producing a number of
denticles (50), which had originally probably all been
bound together by periosteum, the denticles being em-
bedded in the fibro -vascular structure, much as plums are
in a plum pudding. The denticles consist entirely of
cementum, and the origin of the tumor was connected
with the unerupted canine tooth. No dentine or enamel
tissue could be found in the specimen. The case, a very
interesting one, resembles closely those of Sims, Bel-
lander, and Mathias, figured in Sutton's work.
The points of interest brought out by the case reported
by Dr. de Roaldes, and on which he insisted, were: 1.
The rare character of the tumor, which contained, as far
as he knows, the largest number of denticles. 2. Its very
uncommon origin in an unerupted canine tooth. 3. Its
location in the upper maxilla, and, as the above-men-
tioned cases, on the right side. 4. Its coexistence at
one time with another fibrous tumor developed in the
alveola of the right upper central incisor, probably itself
a fibrous odontoma. 5. The fact that odontomata have
often been taken for exostoses, fibroid tumors, etc. 6.
The difficulty of the diagnosis, especially when growth is
6o
MEDICAL RECORD.
[July 14, 1894
embedded in the maxilla. The consideration of the
duration of the disease, the age of the patient, and espe-
cially the absence of one or more teeth, will help to ensure
a precise diagnosis. 7. The propriety of avoiding in
those cases dangerous operations, as has been often done,
in removing the maxilla, when proper chiselling and
enucleation will generally suffice*
Dr. A. W. de Roaldes concluded by presenting, in the
name of Professor Souchon, a new apparatus, devised by
him for administering anaesthetics, and which had been
of great service in the present case.
Cookie -Burr in the Larynx. — Dr. Charles M.
Shields, of Richmond, reported an extraction of a
cockle-burr from the larynx. The patient, a farmer
from Halifax Co., Va., had observed one of his hogs being
chased by some dogs. He rode after them until the
bushes prevented farther pursuit on horseback, and, dis-
mounting, he continued the chase on foot. This exer-
tion made him breathe rapidly through the mouth, and
he was suddenly stopped by feeling that he had drawn
something into his throat that prevented easy breathing.
The foreign body was found to be a burr lying in the
glottic space at its anterior commissure and just at the
lower level of the cords. Its long axis was lying antero-
posteriorly, and it was fastened firmly in position by the
closing of the glottis on its spurs. It had been grasped
just in the act of passing through. The patient had a
most sensitive throat, and manipulation was thereby ren-
dered more difficult After being sprayed with cocaine,
Mackenzie's and other forceps, opening laterally, were re-
peatedly tried without success, because of the inability of
getting the blades between the burr and the bands on
either side to which it was so closely adherent. Then a
wire loop through a curved cannula was likewise unsuccess-
fully tried, the rapidly contracting vocal bands flattening
the loop. Cotton twisted on a curved probe, with the
hope of engaging the prickles in its meshes, met with no
better success, and a curved blunt curette passed below
the burr failed to extract it on being withdrawn.
Just before doing a tracheotomy, which had now been
decided on, Schrotter tube forceps were again tried.
This time, after pushing them between the cords closed,
they were forcibly opened as the cords tightened on
them, and, being drawn forward, the blades slipped
over the burr, which was withdrawn entire.
Laryngeal Neoplasms.— Dr. Charles H. Knight, of
New York, reported three cases of this nature :
Case I. Diffuse Subglottic Myxoma. — Partial removal
by the mouth with Mackenzie's forceps. Tracheotomy
under cocaine and radical extirpation of the growth
through the wound. Recovery without a bad symptom.
No recurrence.
Case II. Papilloma of the Larynx. — Removal with
Mackenzie's and the Schrotter -TUrck forceps. Electric
cauterization of the base of a growth attached beneath
the right vocal band. Restoration of voice within three
weeks, complete aphonia having existed for nearly eight
months.
Case III. Multiple Papilloma of the Larynx.— Re-
moval with Mackenzie's forceps. Recurrence and re-
moval in twelve months. Second recurrence and re-
moval in a similar way five years later.
Dr. Arthur O. Bliss, of Philadelphia, reported two
cases of malignant tumors of the larynx.
Case I. Squamous Epithelioma of the Larynx. — Pa-
tient, male, aged forty-six, with negative previous history.
Had been growing hoarse the past two years. Had
gradually increasing difficulty in respiration and en-
larged glands. Refused radical operation. Trachea
opened through two upper ring®. Heart sounds suggest-
ed atheroma. Considerable albuminuria, but no casts.
At the end of the primary anaesthesia (ether) during the
operation, a severe glottic spasm resulted. This might
have been due to accumulation of secretion. After op-
eration, was very weak for a month, suffered much from
angina pectoris, and died suddenly from latter disease.
Specimen wa? shown. During life the left arytenoid
cartilage and vocal band were so swollen that subjacent
cord could not be seen. The right cord was forced into
semi-abductor. There was no odynphagia. Autopsy
also showed chronic nephritis, fatty heart muscle, and
thickened pericardium.
Case II. Small Round Celled Sarcoma of Larynx. —
Patient, male, aged fifty- three. Symptoms practically as
in Case I. Pharynx was normal. The epiglottis was a
fungoid mass. No laryngitis was observed. The right
arytenoid was swollen and (Edematous. There was
swelling in the supra thyroid region, but none over the
thyroid. High tracheotomy was done, as the patient
refused radical operation. Died in one year from ex-
haustion. Both of these cases would have been favorable
ones for partial laryngectomy.
Laryngectomy by a Haw Method. — Dr. Henry L.
Swain, of New Haven, Ct , reported a case of laryngec-
tomy performed on a German, aged forty two, who had
an epithelioma which had followed on a simple fibroma
of the right vocal cord, the latter having been known to
have existed for a year previous.
The epithelioma waxed great and filled the entire
larynx, so much so that tracheotomy was done under co-
caine March 5th. March 18th the larynx was removed
by Dr. W. H. Carmalt Incision was made from the
thyroid bone to sternum. A low tracheal opening was
made, and a sponge Trendelenburg cannula introduced.
Cross-incision made at top of wound to sterno-cleido
mastoid muscles on either side. The .larynx was then
laid bare, and, bleeding being checked, a bistoury was in-
serted back of larynx between it and trachea. The tra-
chea being liberated by a cut from a strong bistoury, the
larynx was hooked up, and dissection begun from below
.upward. The anterior wall of oesophagus was carefully
preserved until the arytenoid cartilages were reached.
A cross cut was then begun, preserving a part of the mu-
cous membrane of arytenoids and ary-epiglottic folds.
The epiglottis was then cut across, its larynx freed, re-
moved, and all bleeding checked. The epiglottis was
then sewed on to the anterior wall of oesophagus, thus
closing in the pharyngeal cavity and cutting off all com-
munication from the wound in neck. Subsequently the
wound in neck was sewed up tight, except enough of the
lower part of median incision to allow of taking in the
upper rings of the trachea, which latter were sewed into
connection with skin flap, making a circular opening
turned upward and forward. The wound was dressed
with plain dry dressing. No tube left in trachea. Pa-
tient stood operation beautifully, although it lasted two
or three hours.
The subsequent healing of wound followed without ad-
venture, save a large stitch abscess above and back of
trachea, which healed in a few days. Temperature got
to 1010 F. the second day, and then went down to nor-
mal or nearly so and remained. The internal wound at
base of epiglottis was observed to heal by first intention
and patient could swallow water from the first, could take
fluid nourishment at the end of a week and regular hos-
pital diet at end of second week. Internal and external
wounds are both in healthy condition. Patient could
make no audible sounds at first ; later, hissing consonants
were to be perceived, and now the briefest sentences and
single words can be distinctly understood with the back
turned, so that lip reading is eliminated. There is noth
ing more than a whisper to the voice, but it has gained
so much of late in strength as to promise more.
Patient's condition at present prime, he working at his
trade of a carpenter, wearing most of the time a tube in
trachea.
Third Day, Friday, June ist.
Exudative Pharyngitis. — Dr. W. C. Glasgow, of St.
Louis, Mo., related the history of a child, aged ten
months, large and robust, who took cold and had an
otalgia without fever. Two days later, coryza came on and
the temperature rose to 1040 F., with morning remissions.
July 14, 1894]
MEDICAL RECORD.
61
Its course was very irregular, like the fever of aseptic proc-
ess. Mucus poured from the nose in torrents, blister-
ing the nostrils and also the skin wherever it touched the
latter. It was so abundant that cloths had to be placed
around the nose to take it up. The excoriations soon
became covered with a whitish pellicle. There was also
the same secretion from the fauces, where, on tonsils, uvula,
soft palate, and pharynx, the exudate appeared. There
was none in the nose. The patches were white, elevated,
and left no raw surface on removal. They looked like
blisters containing solid albumin. The exudation on the
uvula was probably due to mechanical causes. There
was prolonged aphonia and urgent dyspnoea with dys-
phagia. Fluids returned through the nose. The skin
lesions were like those on the membranes, but the edges
were raised. Adenopathies were wanting. The secre-
tion was intensely alkaline. For treatment, sodium
salicylate salve, and brandy were given internally, while
locally peroxide of hydrogen was used. Aristol served
well as a dressing for the skin lesions. A suppurative
otitis occurred as a sequel. The whole duration of the
case was three weeks. The secretion contained strepto-
cocci in large numbers, but no Loeffler bacilli. Dr. Glas-
cow regarded the case as one of the protean forms of in-
fluenza.
Dr. Jonathan Wright, of Brooklyn, thought that, as
streptococci were so very common, it was difficult to
prove their causative relation in this present case. He
had not found in the Eastern cities such exudative forms
of influenza as had been reported from the West.
Dr. Glasgow replied that he had seen cases from East-
ern cities. He had found benzoate of soda most helpful
in all cases of solid oedema occurring in the course of in-
fluenza.
Singer's Nodes. — Dr. F. I. Knight, of Boston, spoke
of the little nodule, as large as a millet seed, or larger, ap-
pearing on one or both vocal cords at about the junction
of the middle and anterior third, after strain of the voice
by prolonged use or wrong vocal methods.
This manifestation should be considered clinically as
a separate entity, although pathologically, as far as ex-
aminations hitherto made have shown, the nodule is of
the same nature as those occurring in the diffuse form, to
which the term trachoma, sometimes applied to the sin-
gle nodule, should be restricted.
Whether the term chorditis tuberosa, which has also un-
fortunately been applied to the diffuse form as well as the
single nodule, should be retained for the latter is doubt-
ful, as often there is no general chorditis ; but if it is, its
use should be restricted to the single nodule.
In regard to treatment, Dr. Knight said that in the
cases he had met with up to this time, by rest, and as-
tringents if there was also inflammation of the surround-
ing mucous membrane, the voice had been so far restored
that he did not feel justified in risking cutting operations ;
but if, after this treatment, there should be in any case
still no useful voice he should not hesitate to employ Dr.
Rice's guillotine and remove the protruding portion of
the growth if it could be engaged, hoping that the re-
mainder would be more readily absorbed.
Dr. Knight said that he had been unable to learn the
ultimate condition of the singing voice in any of the
cases where an operation had been performed, and hoped
that the discussion might furnish some facts in this re-
gard.
Dr. J. W. Gleitsman had used the galvano-cautery
in these conditions and had been well satisfied with the
result. He also advocated chromic and trichloracetic
Dr. S. W. Langmaid, of Boston, looked upon the con-
dition as a circumscribed definite tumor. He had seen
one case more posteriorly than those described by Dr.
Knight. They generally occur in women and do well
unless chorditis ensues The nodule is not vascular and
is often the result of a previous chorditis. He had seen
six or eight cases in all. He expressed some doubt as to
the causative relation of a wrong vocal method, for these
nodules are seen in singers who are able to satisfy the ar-
tistic demands of a critical public and consequently do
sing well. The voice often improves sufficiently to serve
for the dramatic stage, though its finer singing qualities
may be permanently lost. Surgical procedures would
not necessarily impair the voice unless much injury was
done to the edge of the cord. Curetting might suffice.
Dr. Porcher asked if Dr. Knight thought that these
nodes ever developed into papillomata ; Dr. Knight re-
sponded in the negative.
Dr. Murray had seen four cases. One at Stoerck's
clinic was treated with solid silver stick and steam in-
halations with a perfect result. The node disappeared
entirely. One case was in a boy seven years of age, also
a singer.
Dr. Wright had presented the history of a case before
the New York Academy of Medicine and asked if its
members present believed that there was any relation be-
tween the condition and tuberculosis. If such existed it
might be from dyscrasia or direct irritation from the •
lung lesion.
Dr. Swain had treated one case with silver nitrate.
The cord looked fairly well except at one point, but the
voice had not improved.
Dr. John N. Mackenzie had cured one case of the
tuberous variety with lactic acid in concentrated solu-
tion.
Dr. T. R. French spoke of a case illustrating the
value of long-continued treatment. The woman had
greatly overused her voice and several nodules were vis-
ible. One case looked as if the cord had been subjected
to violence. He believed that surgical measures were
contra-indicated. In the first case mentioned, local
treatment had been continued three times a week for
over two years and a half, weak astringents being used.
The voice is now completely restored, though she tires
more easily than before. The edges of the cords look
perfectly straight but aret a little thickened on one side.
He did not believe in the association of the condition
with tuberculosis.
Dr. W. K. Simpson, of New York, thought that the
cause lay rather in the over-use of the voice than in a
wrong vocal method. The nodules might come from
laryngitis or from hemorrhage in the cords, the bleeding
resulting from over-use and leading up to nodule forma-
tion. In one instance a linear hemorrhage on the under
side of the cord came up into the middle line and was
clearly seen where high notes were sounded by the pa-
tient.
Dr. Delavan did not believe in the association with
tuberculosis. The existence of the two conditions is of
course possible. Nodules sometimes appear in acute
laryngitis, but the relation of these to the chronic variety
is unknown.
Sarcoma of the Tonsil. — Dr. A. W. Watson, of
Philadelphia, reported a case of a woman aged fifty-
three who was well till last Christmas. Had a severe
sore throat, probably a quinsy, discharging a little pus
without relief. Severe pain continued, running to the
ear. There was moderate swelling of the left tonsil and
of the anterior faucial pillar, which was adherent. With
this exception, there was no infiltration of surrounding
structures. Considerable pain on swallowing was pres-
ent.
One small gland was enlarged at the angle of the jaw,
and engorged capillaries were seen at the surface of the
tonsils. Medicine did no good. A deep incision was
followed by free bleeding, but revealed no pus. A piece
of the tonsil removed for examination showed the view
characteristic of round-celled sarcoma.
Six weeks later, under cocaine, the tonsil, held out by
vulsellum forceps, was, along with its adherent pillar, re-
moved by successive short strokes with the galvano-cau-
tery knife. Three weeks after, pain in the ear had nearly
gone and the adenopathy had disappeared. There was
no odynphagia. The peculiar features of the case were
the sudden onset and the presence of so much pain and
62
MEDICAL RECORD.
[July 14, 1894
dysphagia in view of the lack of infiltration of surround-
ing structures.
Importance of an Early Diagnosis of Malignant Tu-
mors of the Throat. — Dr. J. W. Gleitsman, of New
York, read a paper with this title. The author stated
that he did not desire to ventilate the question of the
possibility of an operation, in cases so far advanced that
the decision had to be left to the patient as to whether
he would prefer to slowly die after a tracheotomy, or to
take the risk of a probable death by any attempt at re-
moval.
At the present time there are three methods of proced-
ure which have resulted in a certain number of cures.
The endolaryngeal operation allows of temporary re-
moval, but at times effects a lasting cure. If patieifts
only come under observation early enough this method
should be resorted to more frequently than it is. The
first operation done in this way for epithelioma of the
vocal cords was done by Schmitzler, in 1867, with no
•recurrence twenty years later. Reference was made by
the writer to several other similar cases which are record-
ed in the recent literature of laryngology.
A possible relief is promised by the method elaborated
by Coley, of treating these tumors by inoculations of
erysipelas or of its toxic products' obtained by the cold
process.1 One of Coley's patients had sarcoma of the
tonsil which, under the erysipelas treatment, diminished
considerably in size and had not increased after two years.
Reference was also made to the use of methyl blue in
cancerous tumors. In these latter, internal medication
with this agent has given better results than its local ap-
plication.
Regarding modern surgery the larynx and pharynx can
be considered as analogous to the breast and uterus.
But conversation with our leading surgeons elicits the
fact that by far too large a number of cases are seen by
competent men only when the patients have reached a
stage when an operation is either impossible or extremely
hazardous. Excepting trauma and sepsis, delay in oper-
ating is the most potent factor for bad results in surgery.
Early diagnosis is indeed often difficult ; but when once
made, delay is both unjustifiable and unpardonable. It
is better to avoid the use of the word "cancer " in our
necessary conversation with our patients.
As to the operation itself, the case generally goes for
this purpose into the hands of the general surgeon ; and
the laryngologist, therefore, cannot be accused, by his
advocacy of operative measures, of selfish motives. Each
case must be decided on its own merits — as to whether
we shall do a tracheotomy only, or extirpate the larynx
in Mo, or do a modified laryngectomy after Cohen's
method. Preniazek, a Russian surgeon, has had thirty-
seven cases of laryngo fissure with the head hanging
down, and has had only two deaths — one from diph-
theria and the other from tuberculosis.
Of thirteen cases under Dr. Gleitsman's own observation
the pharynx was involved in six, and the larynx in seven.
Of the former four were cancer and two sarcoma (ton-
sil). Of the latter, six were cancer and one alveolar sar
coma. One case of pharyngeal cancer was operated
upon three months ago and feels well now. The others
died. Of the two tonsillar sarcomas one was inoperable,
the other lived two years without recurrence after re-
moval, but died by suicide. Of the seven laryngeal
cases the six cancerous patients are dead and the sarco-
matous case is living without known recurrence. Lar-
yngo fissure, with removal of the diseased tissue, was
done twice ; unilateral as well as total extirpation, each
twice ; tracheotomy alone, once. Death resulted twice
from shock, twice from pneumonia (second and third).
Only one had a recurrence after six months, and died
from exhaustion. One with total laryngectomy did well
for several months, but died of an intercurrent appendi-
citis.
In the discussion on the two preceding papers, Dr.
1 See American Journal of Medical Sciences, May, 1893 ; also
Post-Graduate, August, 1893.
Wright spoke of the difficulty in making an early diag-
nosis in such cases, even with the aid of the microscope,
until the clinical features were well developed. He ex-
pressed a polite scepticism as to the accuracy of Coley's
results. Some people seem to be immune against strep-
tococcus infection. The paper was still further discussed
by Drs. Swain, Simpson, Langmaid. and Casselberry.
Neurasthenic Throats. — Dr. W. Peyer Porcher, of
Charleston, spoke of the intimate relations between the
throat and the lungs, and how lesions in one place might
excite symptoms in the other. Among the most com-
mon symptoms of neurasthenic throats were reflex cough,
aphonia, and a spastic condition of the laryngeal mus-
cles. Many of these cases seem to form the base of a
subsequent phthisis. Illustrative cases are quoted to em-
phasize the main points of the paper.
Carbolic Acid in Cysts of the Larynx.— Dr. E.
Fletcher Ingals, of Chicago, forwarded a paper on
this subject. A case of cyst of the larynx occurred in a
man, forty -three years of age, who had experienced some
trouble with his throat for about two years, but had been
annoyed by soreness for only a month, though there had
been considerable cough for the previous seven months.
When he first presented himself there was hoarseness
and continuous burning pain in the throat. One brother
had died of consumption, but there was nothing in the
patient's personal or hereditary history which seemed to
account for his symptoms. His general health was good ;
weight normal ; temperature and pulse, normal ; he had
a deep, loose cough, and expectorated about half an
ounce of muco-pus daily, which subsequently appeared
to be the result of a subacute laryngo-tracheitis and bron-
chitis. There were no abnormal physical signs over the
chest, but an examination of the larynx revealed a large
swelling of the left ventricular band and aryepiglottic
fold, measuring about one and one-half by one centimetre,
antero posterior and lateral diameters. The surface of
this was uniform and smooth; the mucous membrane
over it slightly congested, and the whole had the appear-
ance of a solid tumor. After a preliminary treatment
with resolvents, it was determined to inject the tumor
with lactic acid. From ten to thirty minims of a thirty
per cent, solution of this medicine were injected deep
into the growth, three or four times, at intervals of two
or three days. As the needle passed in, it had the feel-
ing of passing through four or five millimetres of firm,
soft tissue into a cavity. A laryngeal lancet was subse-
quently used, and a small amount of thick, semi-trans-
parent, grayish fluid escaped, which caused some dimi-
nution in the size of the tumor ; the contents, however,
soon reaccumulated, and it was found that the injections
of lactic acid had no influence upon the size of the
growth. It was then determined to use deep injections
of carbolic acid, which was employed in solutions in
glycerine and water of from eight to ten per cent, of the
acid, from fifteen to twenty minims being used at each
injection, and the injections repeated once in from five
to seven days. These injections were repeated eight
times in all, twenty minims of the ten per cent, solution
being used each of the last six times. At the end of this
time the tumor had nearly disappeared, and the injec-
tions were discontinued with the belief that the cyst had
been obliterated. The patient was subsequently seen at
intervals of three or four weeks for three months after the
last injection, and there had been no return of the
growth. The patient felt that his throat was perfectly
well, and it presented the appearance of a normal larynx.
The especial points of interest in the case consisted of
the deeply seated position of the cyst, and the impossi-
bility of removing it without removing a large part of
one side of the larynx. Its walls were so thick that
crushing, tearing, or cutting operations were out of the
question.
Mycosis of the Pharynx and Tonsils. — Dr. Ingals
reported twelve cases of mycosis of the pharynx and
tonsil in order to place the histories on record. They
offered nothing specially new, but illustrated the great
July 14, 1894]
MEDICAL RECORD.
63
superiority of cauterization with the galvano-cautery over
other methods of treatment.
Four of the cases received practically no treatment.
The other eight were treated by cauterizations with the
galvano-cautery, and all were cured ; in none has recur-
rence occurred so far as the author could determine.
An analysis showed that in fifty-eight per cent, the
patient had for many years suffered more or less from
sore throat, and in sixty six per cent, soreness of the
throat had been present from four to eight weeks imme-
diately preceding the discovery of the mycosis. Symp-
toms of dyspepsia were present in three cases, or twenty-
five per cent, but in fifty per cent, of the cases it was
distinctly stated that the patient was in general good
health.
The plan followed in the treatment had been to burn
off the growth and to pass an electrode, heated to a
bright red heat, about one eighth of an inch into the
tissue beneath it. Two or three patches were cauterized
at each sitting, and the operation was repeated at inter-
vals of about five days, according to the patient's con-
venience, two or three days being allowed to elapse
between the disappearance of the soreness caused by one
cauterization and the repetition of the operation.
The author believes that in some cases the disease had
existed for many years before it was discovered; but in
most of the patients he had seen it had apparently been
of only a few weeks' duration. From his experience in
two of the cases he believed that the disease might some-
times disappear under natural causes.
Etiology of Bheumatic Affections Due to Tonsillar
Diseases. — Dr. H. L. Wagner, of San Francisco, for-
warded a paper with this title : The tonsil has been justly
termed by Gerhard a physiological wound — an inlet into
the system guarded by leucocytes, which we have learned
of late protect the body against the invasion of various
micro-organisms. If through inherited or acquired pre-
disposition the energy of these leucocytes is diminished,
or if the tonsil in a diseased state does not allow these
corpuscles to migrate, then a soil may be given for infec-
tious diseases, such as diphtheria, scarlatina, tonsillitis,
follicularis, etc.
The sequences which sometimes follow these diseases
are important to observe : paralysis of various parts of
the body after diphtheria, and also articular- rheumatic
affections following follicular tonsillitis. The results
gained by clinical studies and bacteriological investiga-
tions in follicular tonsillitis, followed by rheumatic affec-
tions, are what I particularly desire to refer to.
The question which presents itself is : Whether these
rheumatic affections are produced by the germs (staphy-
lococcus albus et aureus, Fraenkel's pneumococcus, etc.)
migrating from the tonsillar tissues into other portions of
the body, causing rheumatism— or whether they remain
in or about the tonsils, sending forth and distributing
their ptomaines or poisonous products into the system ?
The result of my investigations, which I will give you
in brief, show in follicular tonsillitis a migration of these
germs, proving that rheumatism here is not caused di-
rectly by ptomaines.
Clinical observations show that the joints which are
mostly in use are the ones generally affected; for in-
stance, the ary-cartilages of the larynx of singers (5 cases),
the knee-joints of shoe dealers — owing to the constant
kneeling posture (2 cases), and the wrist joint of violinist
(1 case), and bookkeepers (2 cases). Referring to the
two cases above, where rheumatism of the knee-joint de-
veloped, the bacteriological investigation showed that
the synovial fluid obtained by tapping of the joint con-
tained the same micro-organisms as found in the diseased
tonsil. I was also able to identify the same germs in the
urine of nearly all the cases. The family and clinical
history of all these patients showed no signs of rheuma
tism before the attack of this tonsillar disease.
Skulls of Cretins. — Dr. Harrison Allen, of Phila-
delphia, gave a demonstration on the skulls of cretins,
showing the peculiar characteristics of this condition
as influencing the size of the nasal chambers. The hard
palate was shortened, the inferior meatus deepened, and in
one instance the maxillary sinuses greatly enlarged. The
skulls were from the Wistar Museum, at Philadelphia.
He believed cretinism more common in America than is
generally supposed.
Election of Officers. — At the executive session follow-
ing the reading of papers, Dr. John O. Roe was elected
president for the coming year. Rochester, N. Y., was se-
lected as the place of meeting, the date to be determined
by the council.
OUR LONDON LETTER.
{(From our Special Correspondent.)
HOSPITAL SUNDAY — INCORPORATED MEDICAL PRACTITION-
ERS* ASSOCIATION — DEFENCE — PR OTECTION — BUSINESS
AFFAIRS OF THE PROFESSION — SIR B. W. RICHARDSON'S
MISTAKE — COUNTER PRACTICE — THE ANTIS AND THEIR
FADS — EXPERIMENTS IN HOSPITALS.
London, June 9, 1894.
Hospital Sunday is again upon us, and to-morrow most
of the places of worship in London will resound with ap-
peals to the benevolent on behalf of the suffering. The
Lancet, always a warm supporter of this movement, has
this year repeated its plan of publishing a special supple
ment in aid of the work, and one hundred and twenty-
five thousand copies of an abstract of this supplement
have been distributed to the ministers of the various con-
gregations. This supplement was first issued in 1886,
and has been regularly continued since.
The Practitioners' Association has been duly registered
as a company limited by guarantee under the Companies'
Acts, 1 862 to 1 890. Its name is now the Incorporated Med-
ical Practitioners' Association, and its objects apparently
those of protection societies generally, to which is added
the promotion of various reforms. In pursuit of these laud-
able objects, a special issue of the Medical Times and Hos-
pital Gazette y a vigorous little two-penny paper which is
the descendant of the Students' Journal, and the organ of
the Association, has been largely circulated, containing
full particulars of what has been and will be attempted.
Hospital abuses, remuneration of medical men, the ques-
tion of nurses and midwives, and some law proceedings
have occupied much of the attention of this Association,
and there is no disposition to burke any of the burning
questions that other bodies seem to neglect. This Associ-
ation seems really to have had its birth in the House of
Lords Committee on Hospital Management, and several
of its members gave evidence before that committee on
the abuses of out-patient departments.
I do not know if the Council of this newly incorporat-
ed body expect to rival the British Medical Association,
but they certainly promise to do work which has hitherto
been neglected. While they consider that existing or-
ganizations successfully cover the field of scientific work
and progress, they say they intend to be above all things
practical and to carry out schemes of direct utility to the
members. The business affairs of the profession, are there- .
fore to be added to the great objects of protection and
defence. Accordingly they propose to appoint solicitors
to work for members at reduced charges (catch the law-
yers so far imitating the doctors !) ; to act as agents in life
and fire insurance, and for the transfer of practices and
to collect debts. The profits of this kind of business —
which some will think incongruous — are to be added to
the reserve fund. Committees of arbitration are also to
be formed, which may be useful in settling disputes and
preventing scandal. A defence committee would perhaps
prevent some of the prosecutions that have too often been
unjustly brought against medical men, and an ethical
committee might very well warn practitioners who are
guilty of unprofessional conduct. You will see that very
64
MEDICAL RECORD.
[July 14, 1894
much of this programme is the neglected work of the
British Medical Association, and might all be done by it.
While it, however, ignores its duties and opportunities, it
may be desirable to establish another organization. The
British itself began in a small way, and it is impossible to
predict how rapidly the young rival may grow.
One thing strikes me as a mistake : the little society
with its little organ should have pitched its subscription
at a figure in accordance with its size and actual position.
It cannot all at once compete with a huge co operative
journal society which has sacrificed so much professional
honor for the sake of a great advertising connection.
Sir Benjamin Ward Richardson has "put his foot in
it " with the general practitioners. He has actually pro-
posed in his Asclepiad (occasionally pronounced as if
sleepy-head) to legalize counter-prescribing by druggists.
If there is one abuse more injurious to the profession and
dangerous to the public than all others, surely it is this
wide-spread encroachment of men in a province for which
they are unfitted. Bad as it is to endure the competition
of unauthorized and unqualified quacks of every kind,
what would the consequence be of legalizing the practice
of the great shop-keeping quack? Convert every dis-
penser into an authorized prescriber, and the "doctor's
shop " would no longer be a phrase to laugh at. Igno
ranee would prescribe for all minor ailments a pennyworth
of a drug or a shilling nostrum according to the willing-
ness of the patient to disburse. This is certainly a solu-
tion of the problem of cheap dispensaries and out-patient
abuse which no reformer has contemplated. I hope Sir
Benjamin will have the courage to say he repents the
rash proposal, which was no doubt dropped in a thought-
less moment — an error often committed by those who
suffer from attacks of cacasihes scribendi. This is by no
means the first blunder of Sir Benjamin's on medico* po-
litical matters, but he could hardly be betrayed into one
more serious.
Mr. A. Arnold, whose chief distinction is perhaps his
name, has been speaking in Piccadilly on vivisection, and
said if such cruelty to animals were permissible because
good results were obtained we might sanction the vivi-
section of malefactors and children. No doubt he knows
the fallacy of his own foolish utterance, but anything is
good enough for an audience if it will give a little no-
toriety.
Another cry — apparently got up* by the crazy antis
— is against experiments on patients in hospitals. It is
rather too bad of these faddists to attack our hospitals on
the eve of the Sunday collection. But we need not
wonder, for so many falsehoods have been circulated by
the anti this or the antithat egotists, and vouched for
by persons who ought to know better, that the most
monstrous statements excite no surprise, although their
repetition by some cheap newspapers is bringing disgrace
on the editorial function.
OOPHORECTOMY vs. OOPHORECTOMY.
To thb Editor of the Medical Record.
Sir : I have noticed of late, especially among gynecol-
ogists, a mispronunciation which violates all the rules of
etymology, and is excessively offensive to the ear to any-
•one who remembers the origin of the word. The word I
refer to is "oophorectomy " which of course, as your
readers well know, is derived from the Greek word '&6v,
an egg, a word of two syllables and not of one. It would
be just as excusable to pronounce " zoftlogy " " z55logy,M
or " o61ite," " oolite," as to unite the two o's in the pro-
nunciation of oophorectomy. The dictionaries, as your
readers will find, all put the diaeresis over the second " o,"
and I trust that our gynecological friends will be willing
to introduce it into their pronunciation, and not offend
the ear and the taste and violate the proprieties by such
mispronunciation.
Very truly yours,
' W. W. Keen.
Philadelphia, June 28, 1894*
pCedical Sterna
Contagious Diseases — Weekly Statement — Report of
eases and deaths from contagious diseases reported to the
Sanitary Bureau, Health Department, for the week end-
ing Ny 7> x*94.
Tuberculosis
Typhoid fever
Scarlet fever
Cerebro-spinal meningitis
Measles
Diphtheria
Small-pox
Cholera
Varicella
Pertussis
Erysipelas
Leprosy
Caws.
Deaths.
58
102
9
3
52
11
0
2
61
8
201
47
11
4
0
0
0
O
0
0
0
0
0
0
The Orloff-Davidoff Prize. — A prize of 10,000 rubles
(l5,ooo) is offered by Count Orloff-Davidoff for the dis-
covery of a certain cure or preventive of cattle plague.
The efficacy of the remedy is to be proved by the same
standard as those known to science as protective against
small- pox, anthrax, etc. The award of the prize is in the
hands of the Curator of the Imperial Institute of Experi-
mental Medicine of St. Petersburg, acting on the advice
of a committee of experts selected for the purpose. The
competition is open to the whole world with the excep-
tion of active members of the above-named institute.
The description of the proposed remedy must be clear
and complete ; it must be sent in, under the ordinary
conditions as to concealment of the identity on the part
of the author, on or before January 1, 1897. The award
of the prize will be made on January 1, 1899. If no
remedy satisfies the committee, a further competition
will take place, and the award made on January 1, 1902.
This may stimulate the search for the desired remedy,
but it may also lead to the suppression of any such dis-
covery, if made, until the award of the committee is an-
nounced.
Legislators Going to School. — The German Cultus-
Minister has, in response to repeated stimulation by a sani-
tarian deputy, consented to organize systematic courses of
instruction in matters appertaining to public health for the
special benefit of members of the German Legislature.
Lectures are to be given by the professors of hygiene of
the various German universities on the principles of hy-
giene. Probably, in the fear lest the legislators might not
go to the lectures, it has been arranged that the lect-
ures are to come to them, for they will be given
within the precincts of the Legislative Chamber itself.
The idea thus put forth is delightful, and it ought to be
Americanized at once. If we could only have in Wash-
ington lectures on economics for the populists, lectures
on statesmanship, money, and taxation for Republicans
and Democrats, lectures on verbigeration and morals
for all, it would greatly promote the usefulness of our
law makers, and give an enormous impulse to the activity
of our educators.
Cold Baths in Whooping cough. — Dr. Maurice Spring-
er reports, in V Union M'cdicalc of June 2, 1894, a case
of pertussis in a child aged one month, in which the sole
treatment consisted in the giving of cold baths to which
powdered mustard was added. The child recovered.
Living Anatomical Charts.— The British War Office
is considering the advisability of instructing all soldiers
in Her Majesty's service in the principles of first aid to
the injured. Some genius has offered the startling and
original suggestion that every soldier should have the
leading arteries mapped out on his body by dotted lines
tattooed in India ink, so that any of his companions may
be able to arrest dangerous hemorrhage should he chance
to be wounded.
Medical Record
A IVeekly Journal of Medicine and Surgery
Vol. 46, No. 3.
Whole No. 1237.
New York, July 21, 1894.
$5.00 Per Annum.
Single Copies, ioc.
©rigitml QxlitUs.
FEEDING AFTER WEANING.1
By WM. L. STOWELL, M.D.,
NEW YORK.
Feeding an infant after it leaves its mother's breast in-
volves the whole subject of dietetics. We have just
had a course of three lectures (Professor Chittenden,
Cartwright lectures) on one part of digestion, yet are now
to compress the entire matter into a ten-minute review.
The review must be cursory in the extreme.
The infant at birth is a carnivorous mammal, composed
of nitrogenous and fatty matters, carbohydrates, and salts
of lime, potash, etc. To maintain the little creature, all
these substances must be supplied. The mother's milk
is an emulsion of fat containing these ingredients. It is,
therefore, the perfect food. The infant has a simple di-
gestive tract which secretes very little digestive fluid of
any kind. The simple milk is absorbed with little diffi-
culty and little waste.
With the passing months, changes take place, anatom-
ical and physiological. At six or eight months teeth ap-
pear and the salivary glands become active. This sug-
gests the ability to eat a little of the food of adults, e.g.,
starches. From the eighth to the twelfth month the teeth
come more rapidly, the child becomes very active, uses
up tissue, and needs more material to build with. Now
is the time to wean and supply additional food. The
exact time cannot be set. A mother who is not strong,
has become pregnant, or feels nursing a tax on her con-
stitution, should begin weaning at six or eight months.
Should the child not thrive, wean early. If both mother
and child are well, the physiological changes are such
that the baby can leave the breast partly at ten months,
and completely before a year. The transition should be
gradual except in case of acute illness of the mother.
Begin by giving cows' milk once or twice a day, and
nursing only two or three times.
Human milk contains: proteids, 1.78 per cent. ; fats,
3.83; sugar, 6.84; salts, 0.23, a total of 12.68 solids.
(Leeds's average twelve mothers.) Cows' milk contains :
proteids, 3. 76; fats, 3.75 ; sugar, 4.42 ; salts, 0.68, mak-
ing total solids 12.61. (Leeds's ordinary bottled milk.)
Human milk then differs from that of the cow in contain-
ing more fat, 2.25 per cent, more sugar, less salts, and
but half the proteids.
Because of the excess of proteids, cows' milk needs to be
diluted one third or one half with water, depending upon
the digestive power of the infant. The slight acidity of
cows' milk may be disregarded in infants of six months
or over. Lime-water or soda maybe added earlier. Or-
dinary dairy milk contains from ten to twelve per cent,
of cream. When such milk is diluted one half, the fats
are too low ; extra cream must be added. Jersey milk
contains eighteen to twenty per cent, of cream, and hence
requires only the addition of water, and a little sugar,
possibly. I have raised Jerseys, and raised babies on Jer-
sey milk, and heartily approve of it. It is not logical to
declare Jersey milk too rich, and forthwith give directions
for adding cream to ordinary milk until it is of Jersey
standard. One dealer served me with milk containing
eighteen per cent, of cream, another, equally well known,
1 Read before the Section on Pediatrics, New York Academy of
Medicine, May 10, 1894.
supplied milk only seven per cent, cream. Obviously
the two could not be treated alike. Ass's milk is very
nearly the same as woman's milk in composition. ' * Strip-
pings " is also better than Ordinary milk, being richer in
fat. Neither is practicable, so they need no discussion.
In warm weather all milk should be heated to 1680 F.,
i.e., Pasteurized, to destroy ferments and prevent sour-
ing. This temperature kills tubercle bacilli, typhoid,
or other germs that may be lurking in the fluid. The
process of sterilizing renders casein less readily coagu-
lated, destroys milk-sugar, and causes proteid matter to
adhere to fat globules, retarding their digestion. These
changes are of no importance clinically, except in weak
children.
Perfect nutrition demands waste and removal of tissue,
as well as new aliment, i.e., complete oxidation. Sugar
and starch take up much oxygen, and if given in too
great quantity will detract from what should go to the
albuminoids. It is the excess of one ingredient that so
often begins the malassimilation that ends as rickets.
The starches easiest to prepare and digest are potato, oat-
meal, and barley. The two last are added to milk as
diluents and for their mechanical effect on casein, even
in infants only a few months old. They have no food
value, however, until six months, when ptyalin is present
in sufficient quantity to act on them. Oatmeal prevents
constipation by causing increase of peristalsis, whereas
barley tends to check diarrhoea. Choose between them
accordingly.
Condensed milk is a popular substitute for breast milk.
The weight of medical authority is heavily against it.
As ordinarily diluted it contains less than half the albu-
minoids and fat needed, or if diluted to their proper pro-
portion the sugars aje doubled. As a natural result we
have two kinds of babies brought up on it — one plump,
but without any staying powers in case of illness, the other
a starving little skeleton. Condensed milk is only to be
commended when travelling, or as a temporary change
when other food disagrees.
Lactose forms one half the solids of milk. Its oxida-
tion maintains the body heat. If it be deficient, the
little infant wastes and starves. As the infant of ten
months grows stronger and more hungry give him stale
bread or crusts to bite on. Zweibach, and toasted bread
(moistened), or crackers will also supply starch, partly
converted into dextrin and so easy of digestion. In
baked potatoes the starch granules are finely divided, so
they should be preferred to boiled potatoes. By the
twelfth month soft boiled eggs may be given. In the egg
we have fourteen per cent, of nitrogenous, and 10.5 per
cent, of fatty matter. An egg diluted with water and
sweetened makes a good substitute for, or addition to,
milk. Soft boiled it digests in three hours. Additional
nitrogenous food may be had in broths of beef, mutton,
or chicken. Beef-tea to be of any value should be a cold
infusion of a pound of steak to a pint of water, not heated
until just before serving. Prolonged cooking coagulates
the albumin of meat and only extracts the salts. It is
poor food. Meats contain much potash and lime, for
which reason Routh says children need much meat to
build up their bone and muscle.
During the beginning of the second year the anterior
molars appear, an indication that the child is ready to
masticate food. He may now have rare roast- beef to
chew and suck the juice from, not to swallow. Beef is
one of our best nitrogenous foods, containing 20 per
66
MEDICAL RECORD.
[July#2i, 1894
cent, nitrogen ; next comes mutton, with 18 per cent. ;
poultry, with 21 per cent., and nearly 4 per cent, of fat.
Fish is 18. 1 per cent, nitrogen, and 2.9 per cent, fat;
mutton is a little easier than beef to digest but not so
rich. Graham bread, rice, and corn bread can be added
to the dietary now that there are teeth enough to break
them up thoroughly. Bulky food stimulates digestion
by causing increased muscular action of stomach and flow
of juices. Concentrated foods are to be avoided as not
promoting natural activity. However, liquid foods will
often check 'vomiting without medicine.
A thin sandwich of stale bread with scraped beef and
a glass of milk is a good breakfast for a babe of two to
three years of age. A dish of plain meat-soup with baked
potatoes, a boiled vegetable, and bread will be his dinner
at noon. By three o'clock he will want crackers and
milk. At six o'clock a cup of custard, or bread and but-
ter with milk, should be the last meal of the day.
Physiologists say that children absorb three or four
times as much carbon per pound weight as adults. This
accounts for their eating so out of proportion to their
weight compared with their parents.
At two years of age, or thereabout, the child has his
twenty deciduous teeth. He can eat all plain food of a
proper table, and thinks he should have everything he
sees. He should not be allowed even tastes of unsuit-
able articles, only such food as is to form his diet. All
fried food is difficult to digest. Re cooked meats are im-
proper. All so-called rich food is interdicted, as the sys-
tem is not strong enough to wrestle with foreign sub-
stances or excess of natural diet.
During the second year fruit is admissible. Scraped
sweet apples are enjoyed, and digested in one hour and a
half. Baked apples in milk with crackers make a good
supper. Juice of oranges is good in the morning.
Bananas, if very ripe are rich in sugar and much liked by
the little ones. When green or unripe, bananas are largely
starch. If eaten too green and too rapidly by too young
a child it is pernicious food, otherwise good.
In arranging a dietary regard must be had for season,
cold or hot climate, sluggish or active temperament of
the child, etc. The exact weight or exact age of the
child is not a proper criterion. Two atoms of hydrogen
unite with one of oxygen to form a molecule of water;
but you cannot be sure that a given number of grains of
nitrogen will produce a definite number of foot pounds oi
force, or that so much sugar will produce so many heat-
units.
It is often forgotten that the child needs a large
amount of water, even if his diet be chiefly fluid. I have
therefore included water rn the table below, which I
have compiled as a summary of dietetics in the young.
The following dietary may serve as a basis for direc-
tions to parents and nurses :
Frequency and Substance of Meals.
8 Months, 5 Meals.
7 A.M. (a) Milk.
(*) Milk and rusk.
to. 30 " (a) Oatmeal or barley in milk ; sugar or malt.
(b) Beef-tea.
a p.m. (a) Egg in milk, sweetened.
(b) Stale bread and milk.
5.30 " (a) Milk and cracker or zweibach.
\b) Milk and oatmeal or barley.
10 " (a) Milk.1 Total milk, ij pint.
I Year to \\ Year*
7.30 a.m. {a) Rusk or cracker and milk. Banana.
(b) Soft boiled egg ; milk. Orange,
ii 4* (fl)Milk; bread and butter.
{b) Baked potato; milk.
2 p.m. (a) Beef-tea; light pudding.
(b) Bread, butter, bread in meat gravy from a roast.
(c) Meat, roast, to suck on.
5.30 ■' [a) Bread and milk. Prune juice.
(b) Cocoa; custard.
10 " {a) Milk, if awake. Total milk, 2 pints.
Two later periods in childhood deserve a moment's
consideration.
Table of Food Values.
Food.
I Nitrogen. Tis-
I iiue - forming
Protcids.
Human milk (Leeds).
Cows' milk (Leeds) . . .
1. 78
3-76
Eggs (Pavy) 14.00
Bread (Letheby)
Potatoes (Letheby)
Beef cooked (Ranke), lean. . .
fat....
Turkey (Letheby)
Fowl
White fish (Letheby)
Apples (Freseninus)
Bananas, ripe (Corenwinder).
8.10
19.
14.
Carbon. Fats.
3.83
3-75
10.50
I.60
0.20
3.60
29.80
Carbohydrates.
Heat-giving.
Sugar. Starch.
6.84
4.43
Salts. Water. I Total solids.
How pre- Hours for
pared. dxges-
0.23
0.68
I.SO
2.30
Raw.
37.00
3.20 18.80 . 0.70 75- co
87.32 12.68
87.39 12.61
74.00 1 Soft bM'd.1
( HardbTd.
\ Stale
*. ,Hot
\ Baked....
) Boiled . . .
5.10
4.40
72.00
51.00
C'
21. CO
l8 IO
0.22
4.82
3.8o
2.9O
Pectine, 2.72
Fat. 0.63
7.85
19.65
Traces.
1.20 74. co
1. 00 78.00
°«44 I 85.04 I Insoluble, 2.96
°«79 73.90 Cellulose, 0.20
2.00
2.00
1 -So
300
3.15
2.00
3.15
a. 30
330
3.00
2.30
4.00
2.00
Water, Croton (Chandler) (grains per gallon) sodium chl., 0.40; sulphates of potash, soda, and lime, 0.617 1 carbonates of lime and magnesia,
2 74 ; silica, 0.62 ; organic matter, 0.67. Total solids, 5.03.
Stimulants. — The testimony of physicians is almost
unanimous against alcohol for children in health. The
small percentage of sugar or oxidizable material in
wines and beer is more than offset by the injuries to di-
gestion and the nervous system. All the wisest men use
stimulants guardedly, even in infantile disease. Tea and
coffee have a very considerable value in checking tissue
waste, and indirectly supplying nitrogenous matter and
salts ; but these virtues are entirely counterbalanced by
the ill-effects of tannin and thein ; the one causing colic,
etc., the other making the child nervous, fretful, and
peevish. Still the children of the poor consume great
quantities of both. The millionaire's pet and the labor-
er's youngster start with the same anatomy, but are
rarely reared on the same diet.
At the sixth or seventh year, when the deciduous teeth
fall, the child must be urged to chew his food thoroughly.
If he begins to attend school that will form an excuse for
bolting meals.
Still later, at puberty, unusually rich or highly spiced
food should be avoided lest it increase sexual excitement
in the immature.
Bring up the child from the beginning to eat slowly
and at regular times as much as he wants. The rules of
time and quantity will be on a sliding scale in different
families. In feeding infants, as in the whole practice of
medicine, we must fix the principles, and prescribe with
common-sense according to the case in hand.
38 West Thirty-sixth Strbbt.
» All milk Pasteurized, if Jersey, or in warm weather.
July 21, 1894]
MEDICAL RECORD.
67
TYPES AND METHODS OF RESPIRATION.1
By J. GARDNER SMITH, M.D.,
NEW YORK.
PHYSICAL DIRECTOR HARLEM BRANCH Y. M. C. A ; SPFCIAL INSTRUCTOR IN PHYS-
ICAL TRAINING PUBLIC SCHOOLS ; MEMBER COUNTY MEDICAL SOCIETY ; VICE-
PRESIDENT HARLEM MEDICAL ASSOCIATION ; MEMBER A. A. A. P. E., ETC.
We are told by the best authority (Genesis ii. 17) that
when the Lord breathed into his nostrils man became a
living soul. Ever since that time respiration and life have
been closely related. In all forms of animal life air seems
a necessary factor. In man we know that through the
lungs air enters the blood. Passing through the nostrils,
the pharynx, the larynx, the trachea, the larger bronchial
tubes, the smaller bronchial tubes, the more minute air-
passages, and finally the delicate air-cells, the oxygen of
the air by a process of osmosis passes through the micro-
scopic wall of these cells into the blood ; and carbonic-
acid gas passes from the blood in the reverse direction
till it is exhaled again through the nostrils. Each breath
then carries oxygen to and eliminates carbon dioxide from
the blood.
This interchange depends upon the demand by the
body ; the extent of breathing surface within the lung ;
the elasticity and action of the thorax (or chest) ; upon
the nervous mechanism controlling each, and, not least,
upon the purity of the air we breathe. Bodily demands,
of course, depend upon mental or physical exertion.
The man who never makes much physical or mental effort
may live to a good old age, but he is never prepared for
an emergency, such as injury or disease of a portion of
the lung, nor can he enjoy any violent effort with safety ;
and in his later years his general health, if it has not
done so already, will deteriorate.
The extent of breathing surface within the lung varies
with the individual. His heredity, his early years, acute
or chronic disease of the bronchial tubes or lung sub-
stance determine this condition to a certain extent. He
may, however, materially improve and increase this func-
tion by judicious respiratory exercises (so-called " pul-
monary gymnastics"). This practice should be begun
early, the earlier the better, and be continued throughout
life.
The capacity of the thorax, too, may be increased by
judicious exercise in breathing. The passive individual
in a healthy condition at each inspiration inhales perhaps
thirty cubic inches (Kirke) of air. This is called " tidal "
air. The average individual without special practice in
breathing or vigorous physical exercise of some kind can
inhale a variable quantity over and above this, called
"comple mental " air. Again, this individual can exhale,
by forced expiration, a variable quantity over and above
the ordinary tidal air called "supplemental" or "re-
serve." There still remains in the chest after a forced
expiration a certain quantity of " residual " air, estimated
(Kirke) at one hundred cubic inches. This quantity also
varies with the ability of the individual to contract all the
diameters of the chest In my statistics of 2,000 men of
average age, about twenty-three years, the total capacity
of the chest ("complemental," "tidal," and "supple-
mental" air) was about two hundred and fifteen cubic
inches, and this quantity is about the same for 2,000 men
since that reckoning. This capacity by practice was in-
creased by fifteen cubic inches (average) within one year.
The interchange of air within the lungs and the chest
capacity depends largely upon an intelligent understand-
ing of the mechanics of respiration and persistent practice
of the methods of respiration. Proper co-ordination of
the muscles of the thorax is highly important. Many
men of ordinary intelligence, and many more with " thin
gray matter," have no control of the chest. Some do
not even know how to inhale, to say nothing of the prac-
tice of the various types of respiration.
There are three main types of respiration in man —
superior thoracic, diaphragmatic or "abdominal," and in-
ferior thoracic — illustrated by the following photographs.
1 Read before the Harlem Medical Association, March 7, 1894.
Mechanically, the thorax is a conical box bounded
laterally by the ribs ; the sternum and costal cartilages
anteriorly; the ribs and spinal column posteriorly ; the
diaphragm, a dome-shaped muscle with a tendinous centre
forming the base. This conical box is capable of move-
ment in every direction. Muscles raise the ribs upward
and forward, increasing the an tero- posterior diameter;
muscles rotate the ribs outward and upward and raise
them laterally like the bail of a pail, inci easing the lateral
diameter ; the diaphragm moves downward, increasing
the vertical diameter.
The size of the chest thus increased the air within the
lungs becomes rarefied ; the pressure within the thorax
becomes less, and immediately the external air, with its
continual pressure of fifteen pounds to the square inch,
rushes in to fill this a tendency to a vacuum." Of course
it is highly important that the nostrils and other air-pas-
sages and the chest and abdominal wall be free from con-
striction or obstruction.
Upper chest or superior thoracic breathing (see Fig. 1,
"
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Fig i.
a to b) may be practised on command 4< inhale " and
" exhale, * or "one," "two," and "three," "four." On
the first command, or first two counts, raise the upper
chest, upper and forward, to the fullest extent (see a to b).
Do not raise the shoulders. On command " exhale," or
"three," "four,1' the chest should recede (fee b to a) ;
keep head erect. Pupils will grasp the idea more quickly
and better by placing the left hand on the upper chest,
inhaling and exhaling through the nostrils. This may be
done to music (count of sixteen). The photographs show
the proper movement of the chest.
Abdominal or diaphragmatic breathing (see Fig. 2, a
to b). On command " inhale " and <( exhale," or " one,"
"two," and "three," "four," lower and raise the dia-
phragm. This action presses the abdominal organs down-
ward, and thus, on the first command of "one," "two,"
the abdomen protrudes (see a to b). Do not move the
chest wall or bend the body.
68
MEDICAL RECORD.
[July 21, 1894
To aid in understanding this exercise, press upper chest
with left hand and place right palm just below lower end
of the sternum. At every inhalation the right hand
should be pushed forward, and on second command, or
" three," " four," the abdomen should recede underneath
the hand.
Practise to count of sixteen or more or to music. Al-
ways breathe through the nostrils.
Lower side chest or inferior lateral thoracic breathing
(see Figs. 3 and 4, a to b). On command u inhale" and
" exhale, " or "one," "two," and "three," "four," dis-
tend and contract the lower chest laterally. On the first
command, or "one," " two," the ribs are rotated outward
and raised laterally (see a to b\ as one would raise the
bail of a pail. Thus the broadest part of the chest is en-
larged and much air is inhaled. The writer examined one
man with this part of the chest extraordinarily developed,
who had a chest capacity of over four hundred cubic
inches. (The spirometer recorded no higher.) On count
" three," " four," or " exhale," expel the air by contract-
ing the lower chest. In this exercise the upper chest
and diaphragm should remain passive. The backs of the
fingers or point of index fingers pressing lightly at about
the ninth rib will enable one to understand this rather
difficult exercise. The best singers have almost com-
a / 2 3 *f 5 (
f 7 S 9 t$ if tZ /j
\fvt§ hints tf
3 -
< .
':
JBr *?
*L
--
| r
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tf'l ■
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. * Y
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r-rf ■ * t-
fife';- ' i-
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y or
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9BL-
Fig. a.
plete control of lower chest and diaphragm and breathe
but little with upper chest.
Obstacles. — Of course it is highly important in dia-
phragmatic and inferior thoracic breathing that there be no
constriction about the waist or lower chest. Many ladies
cannot run or exercise vigorously mainly because of such
constriction. Again, some children find difficulty in breath-
ing with the mouth closed. In most of these cases there
is some deformity or disease within the nostril, which should
receive surgical attention. Another very important con-
sideration is pure air. The air of a well-ventilated room,
class-room, or gymnasium may be beneficial, but every
opportunity for practice in the out-of-door air should be
improved. Running or other vigorous exercise stimulates
respiration, because the blood demands more oxygen.
The individual who understands how to use his chest is
able to meet this demand more readily. In the indi-
vidual with a large chest capacity, who understands how
to breathe, who is free from disease of bronchial tubes or
lung-tissue and without heart disease, shortness of breath
is seldom seen. Breathing exercises are most beneficial
Figs. 3 and 4.
when practised after muscular exertion. They should
occupy an important place in physical training.
The effects are better development and control of the
thoracic muscles ; more power in speaking and singing ;
a healthier condition of the lungs ; improved circulation
of the blood within the lungs ; more rapid and efficient
aeration of the blood ; better general health.
307 Lbnox Avrnue.
New Drugs and New Names. — Our esteemed English
brethren must be especially keen on new drugs, and in
particular on new names of a proprietary character. A
casual glance through the advertising columns of The Lan-
cet (which is sometimes considered a conservative jour-
nal) gives one quite a new idea of modern materia medica.
The following list of " new drugs " is taken from a single
issue: "nepenthe, malakine, virol, pepsalia, pumitine,
cactina, celerina, antinervine, cerebrine, papain, anestile,
opiatine, lintus tussi, kreochyle, vapo-cresoline, chiralta
liq. cocoatina, izal, bynol, bovril liquor sedans. "
These are not all, but they are sufficient to show the
pharmaceutist's fancy, and the appreciation of it by the
British mind. To the student, and even the recent grad-
uate of medicine, all these things must appear quite unin-
telligible, and he must feel that having learned the materia
medica of his text- books, he must begin again and learn
that of the manufacturer.
July 21, 1894]
MEDICAL RECORD
69
A FEW APHORISMS RELATING TO OBSTET-
RICS.1
By A. C. EWING, M.D.,
SALT LAK« CITY, UTAH.
What to do, and what not to do, in the management of
labor — that is the question.
No branch of a physician's practice requires more self-
poise; and where so many complications arise command-
ing our sympathy and demanding our skill, as that of ob-
stetrics, and when disease and death follow a normal
case of labor, the cause can be traced to none other than
to ignorance or mismanagement.
With these preliminary remarks, I shall advance a few
aphorisms relating to obstetrics.
1. Examine the urine a week or so before the ex-
pected confinement. Albumin need not cause alarm,
unless present in large quantity, in which case the
woman should be restricted to milk diet, given one-tenth
grain sulphate spartein four times a day, and bowels kept
open with cream of tartar; the object being of course
to relieve congestion of the rt nal veins.
2. Make no digital examination without first cleansing
the hands and nails, together with the external genitals,
with a solution bichloride mercury, 1 to 2,000 and ethe-
real soap.
3. Empty the rectum thoroughly with an injection of
warm water.
4. Make as few examinations as possible during prog-
ress of labor, and each time dip the hand first in the
antiseptic solution.
5. If presenting part emerges slowly from the womb,
do not allow your impatience to so get the better of your
judgment as to induce you to "assist nature" by pulling
upon the os. I am strongly of the opinion that about all
the deep pathological tears, calling for surgical interfer-
ence, found on the right and upper anterior sides of the
cervix, are caused by the ringer of the accoucheur.
6 If " pains " are sluggish, change the position of the
patient.
7. Do not rupture the "bag of waters" too soon, as
it, when intact, favors, I believe, the posterior rotation of
the face.
8. Should a posterior rotation of the occiput occur,
and nature fail after a reasonable length of time to effect
a delivery, apply the forceps and turn the occiput to the
front, by rotating either to the right or left, as the posi-
tion of the babe would indicate.2 This manoeuvre of the
forceps can be executed without danger ir care be exer-
cised, turning the head not more than a quarter of a cir-
cle at a time, then pausing a moment for the shoulders
to follow. After this is accomplished the instruments
should be removed and re-applied.
9. In making traction on the child's head with the for-
ceps, unlock them about every thirty seconds, else the
engorgement produced by continued pressure of the in-
struments might cause a hematoma of the brain or
dura.
10. To prevent a rupture of the perinaeum.
When the occiput is emerging from the vulva, remove
the right hand from the forceps and with it support the
soft parts, while with the left you continue slight traction
upward until the bridge of the nose reaches the anterior
border of the perinaeum, when the instruments are quickly
removed ; now, in order to avoid a rupture, especially if
an expulsive effort is being made, hold the head in statu
quo until a relaxation takes place ; then, with the thumb
and first two fingers of the right hand, push the perinaeum
down and under the chin, allowing it to rest on the palmar
surface of the fingers. The next pain will expel the
head, which is grasped by both hands and pulled up-
ward— delivering the under shoulder first.
1 Read before the Salt Lake Medical Society, April, 1894.
9 E.g.f when in a right O. P. Iliac position, turn the forceps to the
right, and when in the left O. P. I. position, turn to the left. The child
can be turned, however, and without danger, even when in a direct
0. P. position.
11. Should a rupture occur, repair the injury at once,
using the large iron- dyed silk.
12. Do not become impatient if the placenta does not
follow quickly, but wait, say a half or even an hour, be-
fore an attempted forcible delivery is made. Should,
however, a violent hemorrhage occur, empty the uterus
at once, by disinfecting the hand, introducing it into the
womb, detaching the placenta, and allowing it .and the
hand to be forced out together.
13. The source of uterine hemorrhage following labor
arises almost always from the open and now no longer
useful utero-placental vessels. Nature, ninety-nine times
out of a hundred, prevents hemorrhage arising from this
source by filling up these tortuous vessels and plastering
over their open mouths with coagulated blood. Therefore:
14. Do not use Crede's method, and for two reasons:
first, that the act of squeezing out the placenta dislodges
at the same time from the anfractuosilies and vessels
this plastic coagulum, inviting streamlets of blood to fol-
low the non-pressure of the hand, causing in all prob-
ability a hemorrhage instead of preventing it. The
second reason is, that a hemorrhage following after this
method of forcible expulsion, necessitating, as it usually
does, a constant hand-pressure over the uterus for half an
hour or more, while it may not prevent absolutely the re-
formation of nature's cement, would, in my opinion, cause
paralysis of the contractile fibres of the womb, rendering
them incapable of responding to the stimulus of ergot or
to anything else. (When I see a woman who is suffering
from uterine subinvolution, I unhesitatingly lay it to the
undue paralyzing pressure it has received.)
15. For these passive hemorrhages where, so soon as
the hand is removed the hemorrhage goes on, I rely on
one teaspoonful of laudanum rather than two or three of
ergot.
16. After the birth of the child, gently knead the ab-
domen with the finger tips of the left hand, using barely
force enough to feel the uterus beneath. This gentle
friction excites uterine contraction far better than rough
massage, expelling the placenta almost as quickly, and is
rarely, if ever, followed by unpleasant hemorrhages or
after pains. This slight finger- pressure should be con-
tinued a short time after the placenta is expelled.
17. In early abortions, before atrophy of the blood-
vessels of the mucosa lakes place, the hemorrhage comes
greatly from this engorged mucous membrane instead of
entirely from the placental surface, as in full term. To
stop it, do not use ergot or compression, but approximate
the inner surfaces by removing the decidua with the
placental forceps and dull curette. This is to be fol-
lowed by a hot antiseptic (preferably carbolic acid) intra-
uterine douche.
1 8. Have the vulva kept well covered with sublimated
cotton to catch the lochia and prevent hetero-infection ;
and, in addition, if a clean and competent nurse is in at-
tendance, order given, night and morning, for five days,
warm antiseptic vaginal douches.
19. Wash the babe's eyes the moment it is born; and,
in dressing the navel, use borated cotton saturated with
glycerine.
20. Restrict the diet the first three days only, after
which have the bowels moved either by an enema or the
compound licorice powder. (If there is much flatus, use
instead a full dose of castor oil and turpentine.)
2 1 . Keep the woman in bed two weeks if possible, and
the first four days give a capsule containing y2 gr. eigotine
and 2j^ grs. quinine morning, noon, and night. This
tends, I believe, to prevent fever and hastens the process
of involution.
22. If surgery is your specialty, and you are called to
a case of confineme nt, use extra precautions in cleansing
the hands and nails ; in fact, it would be wise, if your
practice in surgery is extensive, to let obstetrics alone,
for I care not how skilful you may be (and surgeons as a
rule are skilful), you will, sooner or later, lose from septic
infection the wife of some one, and it may be, alas ! the
wife of your dearest friend.
7o
MEDICAL RECORD.
[July 21, 1894
THE DYNAMICS OR POWER OF THE
INTERNI.1
By FRANCIS VALK, M.D.,
PROFESSOR OF THE DISEASES OF TUB EYB, NEW YORK I'OST GRADUATE SCHOOL
AND HOSPITAL.
In the static condition of the external muscular apparatus
of the eyes, we find these organs directed forward, slightly
downward, about fifteen degrees below the horizon, and
slightly convergent, so that the visual lines are directed
toward a point about twelve feet distant in front of the
eyes. In this position the visual lines will form an angle,
whose base extends from each centre of rotation in the
eyes and whose apex lies at the point mentioned above.
This angle is called the muscular mesoropter ; and when
the eyes are fixed in this position, the external muscular
apparatus is supposed to be completely at rest, with bi-
nocular vision.
Starting from this position of rest, the eyes are, by the
active force of the straight muscles of the eyes, moved
consensually, in different directions, according to the
sensations produced on the retina by the rays of light.
It is this active power of the muscles, particularly that of
the interni and its antagonist, the externi, which I offer
as the object of this paper.
In the examination of the eyes and the muscular appa-
ratus, by which we may endeavor to draw certain conclu-
sions or arrive at any specific results, we are accustomed
to compare the examination of one hundred cases. I
have therefore selected this number, from the last cases
on my note-books, in the hope that this examination may
be of some service in the correction of asthenopic troub-
les. For the past year or more I have been interested
in the active power or dynamics of the interni, and so
have tested that power as well as that of its antagonistic
muscle in this series of cases, and I have been somewhat
surprised at the result. All these cases have been exam-
ined in my office with, I think, reasonable care, and I
feel satisfied the results are very nearly accurate, and
will leave the final results to speak for themselves, as I
am not prepared to say just on what lines all these cases
may be treated.
When we study the refraction of the eye, with all its
complex apparatus, each part of which works so beau-
tifully in conjunction with the other, and the complica-
tions that may arise, we are apt first to consult Bonders
and note his remarks. So as I turn to him I find that
even before his work was published, or some forty years
ago, many bold surgeons, at that time, were performing
tenotomy of the externi for the relief of asthenopia, not
only in myopic cases, but in all others. In many cases
they must have been successful, but in others, with the
usual enthusiasm of the profession, it was carried too far,
and the results were far from successful, even disastrous
in some cases. Still, it was continued, more or less,
until Donders found that most of the cases of asthenopia
were due to a shortening of the optic axis, or hyper-
metropia, and the tenotomy of the externi passed into
"innocuous desuetude." Then for many years we fol-
lowed the teachings of Danders, and gave convex glasses
to all our asthenopic cases, until the present day, when
we have two questions presented to us. Firstly, that
of insufficiency of the straight muscles, either in their
actions vertically or horizontally, as advocated by Dr.
George T. Stevens. And secondly, since we have used
that excellent instrument of precision, Javal's ophthal-
mometer, we find astigmatism, due to the curvature of
the anterior surfaces of the cornea, unless neutralized by
the curvature of the posterior surface (Tschering) or that
of the crystalline lens. This is the active cause of all
asthenopia, and must be corrected.
I propose, at present, to take a conservative view of
both propositions, and believe we will find cases where
relief will depend on either condition. Correcting the
last proposition of astigmatism first, and then, in case of
1 Paper read before the Ophthalmological Section of the Academy
of Medicine, New York City, November 19, 1893.
failure, turning to the first proposition, where I believe
we may find success for the relief of the asthenopia.
In looking over the literature of this subject in our
text-books, I failed to find any positive statement in ref-
erence to the dynamic power of the straight muscles.
In Saelberg Wells's last edition, I find the active power of
the interni as about twenty to thirty degrees, and that of
the externi as six to eight degrees. In Noyes's work on
" Diseases of the Eye," I find the best exposition of this
subject ; but in his table of one hundred cases his results
seem very different from my own examinations. He re-
ports seventy-fiVe per cent, with insufficiency of the ex-
terni, with nearly fifty per cent emmetropic, while I
have only two per cent emmetropic. I cannot consider
a low degree of hypermetropia as an emmetropic eye.
Dr. Stevens considers that the active power of the mus-
cles should be respectively about fifty degrees for the in-
terni and ten degrees for the externi, or in the proportion
of five to one ; but in my examinations I have never found
them as high as Dr. Stevens, except where the muscular
power has been exercised by prisms, when this result may
be obtained.
From my own examinations, I am inclined to think
that if the power of the interni stand to that of the ex-
terni in the proportion of four to one, or even three to
one, we will have no muscular asthenopia; in other
words, the interni should be three or four times stronger
than the externi, for comfortable work at the reading
distance. This will give sufficient reserve power accord-
ing to Landult, for all useful purposes.
In my examinations, I regret to say, I have been dis-
appointed in the tests for the dynamic power of the
muscles of adduction and abduction ; as with Von
Graefe's vertical diplopia test, Stevens's phorometer, and
Maddox's rod test, I have found some cases exactly op-
posite to that of the prism test. Hence, I have confined
my tests to the simple power of each individual muscle to
overcome the deviation of a ray of light from a candle
placed at fifteen feet, passing through a prism with the
apex placed over the muscle to be tested, using the
test without a colored glass placed over the other eye.
This method may have its faults, but I think we should
have the eyes in the best possible conditions to develop
the full muscular power, that is, the power to fuse the
images by causing them to fall upon the macula in each
eye.
I do not think we maintain that condition when we
reduce the retinal impressions by a disk of colored
glass or by a vertical displacement of the images, so that
the rays may fall upon a less sensitive part of the retina,
and in both instances we lessen the stimulation for a cor-
rect fusing of the images.
As an instance of my preference for this simple test, I
find that, in forty- eight cases, the vertical diplopia test
agreed with the prism test in only twenty-nine, and was
exactly opposite in the remaining nineteen; in other
words, the first test would show esophoria or homony-
mous images, indicating weakness of the externi, while
with the prism test we would find that the dynamic
power of the externi exceeded that of the interni, accord-
ing to the proper proportion. Either one or the other
must be wrong, and I think we may depend on that
which allows the eyes to be tested under the same condi-
tions as exist when the eyes are used at their daily work.
In compiling the result of one hundred cases of as-
thenopia I have used the following tests. Refraction,
phorometer, vertical diplopia, prism test. Also record-
ing the treatment, as the correction of refractive errors if
present, the prism ordered, operations, if any, performed,
with the final result as far as possible.
As regards the refractive errors, I have used atropine
in some doubtful cases, otherwise not, as I agree with
Roosa that at the present time it is not necessary to put
our cases to the inconvenience of blurred vision, from
paresis of the accommodation, but I have verified my trial
by glasses, with the retinoscope, the ophthalmoscope, and
the ophthalmometer of Javal. I believe, when these four
July 21, 1894]
MEDICAL RECORD.
7i
tests agree, we cannot be very far from the exact condi- shall be coincident with the rays of light passing through
tion of refraction in our cases. I place the examination a prism.
with retinoscopy first, as I have found that the most re- You are, no doubt, all familiar with the simple test of
liable and correct objective test in reference to the final placing the apex or angle of the prism over the position
results of the vast majority of cases. It gives the refrac- of the muscle to be tested, and increasing the size of the
tive condition of the dioptric apparatus, showing any astig- angle until the muscle loses its power to form a single
matism and the axis very rapidly and correctly. I use image, and diplopia results.
the plain mirror only at a distance of forty inches and Taking this as our test and then as our standard power,
read my results, as shown by the retinal reflex, without that the muscular power of the interni shall be to that
reference to any so called shadows, or by using a lens of of the externi as at least three to one or, better, four to
one dioptry placed before the eye. I may differ with one — Noyes says six to one, I found in this series only six-
some of my colleagues in this respect, but I am satisfied teen cases with that result. In the largest number, I
my examinations are correct, as they have been con- found the power of the muscles equal, or as one to one,
firmed by the examination under atropine. In many the total number being thirty-seven of this series. The
cases I have noted the existence of an astigmatism of one- rest of the cases varied in the proportionate power of the
fourth of a dioptry by this simple test. two muscles, in some the power of adduction was too
The ophthalmoscopic test I consider a very valuable great as compared with abduction, and in otheis exactly
and useful one, but I have not been able to confirm an the reverse condition, and the power of abduction ex-
astigmatism of less than one half dioptry, while in the ceeded that of adduction. To place my results in tabular
use of the ophthalmometer of Javal I have fully published form I found.
my result, but I now depend more upon the approxima- Taking the power of the externi as one, then we
tion of the mires and the size of the image, reading off have : one to one, 37 ; to one and a half, 5 ; to two, 20 ;
the radius and the degree of the astigmatism in dioptries, to three, 12 ; to four, 4 ; to five, 4; to twelve, 1 ; to
on the arc, than I do upon the overlapping of the image fifteen, 1; and to fifty, 1. In all of these the interni
of the mires. I find these markings much more correct, exceeded the externi, except the first thirty-seven cases,
while in most cases it is not necessary to allow the usual Now taking the power of the interni as one, and we
one-half dioptry. It is also difficult at times to tell the have : one to one and a half, 3, and one to three, 1, while
exact overlapping, but we can readily see when the edges in three cases there was a very decided difference in each
of the mires touch in the primary and secondary posi- eye. Of the entire number only sixteen were within the
tions. My rule is, in all refraction cases, that these ob- standard limits ; showing that in a vast majority of my
jective examinations shall agree, and I expect to find the asthenopic cases there was an insufficiency of the interni.
same result in the trial by glasses. " Noyes on Diseases of the Eye," p. 195, says : " In this
In all these cases as tabled, the refraction was correct- proving, great diversities will appear according to the
ed by glasses first, and a fair trial given ; and I believe, condition of refraction, especially will weakness of adduc-
in a large majority, they were relieved of their asthenopia, tion appear, with myopia. On the other hand, defective
even though the active power of the interni was found abduction will more frequently be found in emmetropia
far below that of the normal standard ; but if they were and hyperopia and astigmatism. ' '
not relieved, then I felt that I must seek some other I was surprised at the above result, as I expected it
cause for their asthenopia, and endeavored to correct what- would be similar to Noyes' s examinations; yet they
ever muscular insufficiency I could find, relying in all seem to be just the opposite. We have only forty-nine
cases on the simple prism test. in which the power of adduction exceeded that of abduc-
The refractive conditions of this series of cases also tion ; but in only one half of these cases did it reach any-
seem to present some features of peculiar interest, as they where near this normal standard, as I have suggested ; and
do not agree with any tables I have noted. Taking the when it was near this normal, then I find that in all my
cases in their sequence of frequency I find : cases they were relieved by glasses.
c. . . ... . « Case8, In four cases I found the power of the one eye differ-
£ S^TK^^ -t from that of the other, b£h the interni and the ex-
3. Compound myopic astigmatism, axis 1800 8 term being different m their proportions to each other ;
4. Hypermctropia 5 also in three cases there existed a constant diplopia,
5. Simple myopic astigmatism, axis 1800 4 two showing esophoria, or weakness of the externi, of 50
7. SrJTsrs-^is:::::::::::::::::::::::::::: J and v*>- respectively; with one case * exophona, or
S. Simple hyperopic astigmatism, axis 1800 2 weakness of the interni Of 15 .
9. Emmetropia 2 My treatment of this series of cases has been as fol-
ia One eye, Ah. , the other Amh 1 lows : In all, the refraction was first corrected by glasses.
11. One eye, Ah.,_axis 900, the other Ah. 1800 : ........ • " When this did not prove satisfactory, I then examined
12. One eye, II. w. Ah., axis 90 , the other same, axis 180 .... 1 .• „_A_ ^r lua M.*\m„ „„ j :« ^;«u*-^« MMM. **» _~A*u.
13. Compound myopic astigmatism 1 the P°wer of the muscles, and in eighteen cases, or nearly
14. One eye, Ah.f axis 900, the other M. w. Am., axis 900 1 twenty per cent., ordered pnsms combined with the cor-
» . , recting glasses. In four cases the interni was exercised
Total IOO , 9 ° A, 1 »^i_ f r r
by prisms three times a week, with relief for various
In most tables of refraction we are accustomed to note periods. In two, partial tenotomy was advised and re-
hypermetropia as the prevailing condition ; x but now, fused. In the three cases with constant diplopia, I did
with the improved methods of examination and perhaps a complete tenotomy ; and in six cases I did a partial
increased proficiency, I find that the largest number tenotomy, with relief and decided improvement in the
have simple hyperopic astigmatism, and the next largest power of the muscles to overcome the prism test; so that
the same condition, associated with hypermetropia, in one-fourth I thought it advisable to correct the insuffi-
these two classes forming more than sixty per cent, of ciency as I found it, before I could get relief from their
the entire number, and evidently the prime factor in the asthenopic symptoms.
causation of asthenopia. My indications for the extent of my tenotomies has
Passing now to the test which forms the object of this been as follows : If I find there is a constant diplopia,
paper, I noticed, in many of my cases, examined in tjje with a deviation of the visual lines of ten to fifteen de-
past year, that the tests before mentioned for insufficiency grees or more, I find the muscle I decide to cut, with
did not give satisfactory results, so that I have been com- as slight a laceration of the conjunctiva and capsule of
pelled to rely entirely upon the simple prism test. This Tenon as possible ; then with a very small hook beneath,
shows the power of the straight muscles of the eye to I cut the tendon completely free from the eyeball, and
turn it on the centre of rotation, so that the visual line allow the wound to heal without sutures. I believe the
, e w e *v e. * ** j- i o • ^ « r results of such an operation, when the vision is normal in
1 See my paper before the State Medical Society, on Our Refrac- 1«*"1» v* ° . " , v/pwi»MVu, A -A , Tr T ,
tion Cases. y each eye, will be about ten to fifteen degrees. If I de-
72
MEDICAL RECORD.
[July 21, 1894
cide to perform a partial tenotomy, then I find my indi-
cations in the preponderance of power in one muscle
over its antagonist, as compared with what I consider
the normal balance as before stated.
So if I find the proportion as one to one, and the case
is not relieved by glasses after a fair trial and thorough ex-
amination, I proceed to operate. This operation I per-
form by finding the muscle with a very small strabismus
hook ; then with a very small pair of scissors I cut the fi-
bres of the tendon above and below, always leaving one
small fibre in the centre of the tendon intact. I have
found the results of that operation about three to five
degrees as shown by the prism test.
We now come to the conclusions that these series of
cases seem to present :
1. That in more than fifty per cent, of our asthenopic
cases we will find that the power of the externi exceeds
that of the interni, in comparison with the usual pro-
portions that should exist between these muscles ; in other
words, that insufficiency of the interni is much more fre-
qient than is stated in the text books. I found only
three cases of insufficiency of the externi.
2. That I place very slight reliance on any test for in-
sufficiency of the muscular power, when we reduce the
visual impressions of one eye by any means. Conse-
quently, I can only rely upon the old test of the actual
power of each individual muscle to turn the visual axis
of the eyeball, coincident with a ray of light, deviated
by a prism, from a candle placed at twenty feet from the
person examined. In forty eight cases the vertical di-
plopia test did not agree, and was exactly opposite to that
of the prism test in nineteen cases.
3. That in cases where the proportions of the muscles
are as one to one, we may exercise the weak muscles for
a reasonable time or as long as their power will increase,
but I would state that I have found this exercise useful
only in weakness of the interni. Or we may order
prisms, combined with the glasses, with the base over the
weak muscles. They may afford relief, and I have not
found any of my cases develop a latent insufficiency from
their use. In some cases these means afford, for a time,
complete relief; but there may be a return of the muscu-
lar weakness ; in other words, the improved power ob-
tained by exercise or prisms is not constant.
4. That in all cases the error of refraction, either sim-
ple or with astigmatism, should be corrected by suitable
glasses, and these should be worn for a month at least,
before we attempt to correct any muscular insufficiency.
5. That, in diplopia, we should do a complete tenot-
omy, carefully performed, with as slight a laceration of
the tissues as possible.
Lastly, that, in insufficiency well marked, after the
results of several trials with the prisms are the same, we
miy then perform a partial tenotomy, as stated, with full
confidence of a good result.
Yeaslei in Samoa. — Dr. Davies, of Savaii, Samoa,
writes to the British Medical Journal an account of the
first invasion of measles into that island group. The
disease was brought there in September, 1893, aQd in
the following three months about 1,000 of the entire
population of 34,500 died from its effects. The epi-
demic was mild and few died during the period of fever
and eruption, the great mortality being due to the se-
quelae and complications. The deaths were principally
from gastritis, enteritis, diarrhoea, and dysentery. A
few died from suppressed measles. The craving the na-
tives manifest for raw fish, unripe or over-ripe fruit, and
especially half cooked fresh pork, became morbid during
the period of convalescence. Many, lest they should be
told to avoid these, abstained from procuring foreign
medicine. Nine-tenths of the deaths could have been
prevented by care in diet, and even the worst cases of
diarrhoea and dysentery yielded readily to treatment.
Those patients who placed themselves under intelligent
medical supervision, and who followed out the directions
as to medicine and diet nearly all recovered.
(Mittical §tpnxlment.
HYDRONAPHTHOL IN PHTHISIS PULMONA-
LE.
By CARL B. SMITH, M.D.,
BIKGHAMTON, N. Y.
Since January 1, 1893, * nave ^en using hydronaph-
thol hypodermically in the treatment of phthisis pul-
monalis with the following results : Out of 31 cases, in all
stages, that I have treated I have had only 9 deaths, 8
are enjoying fair health to day but are incurable and
14 have been cured completely. I use it in the
strength of grs. v. to 3 j , and the following are the effects :
The hectic fever disappears, the appetite returns, the
cought lessens, the lungs clear, and the patient com-
mences to gain in weight, some having gained as much
as four pounds in one week.
In one case which I tested with the microscope (Ehr-
lich staining) the bacilli were found to disappear from
the expectoration.
In all my cases I did not give either creosote or cod-
liver oil, and can only give the credit of my success to
the judicious use of hydronaphthol.
At the present time, after having practised this treat-
ment for more than a year, I look for a cure, in the in-
cipient stage, inside of three weeks ; in the second stage,
fifty per cent, cured inside of five weeks ; in the last
stage, life prolonged and some cures, but I will have to
work further in this stage.
Working from the germ theory I used hydronaphthol in
three cases of lobar pneumonia, and in each case the
temperature dropped from 1020 and 1030 F. to normal;
after the first treatment the cough loosened, and after
the third treatment they were cured.
REPORT OF A CASE OF FRACTURE OF THE
PELVIS, FRACTURE OF THE FEMUR, AND
LACERATION OF THE BLADDER; RECOV-
ERY.
By W. B. CUNNANE, M.D.,
SANTA BARBARA, CAL.
Fracture of the pelvis is said to be uncommon in men,
rare in women, and almost unknown in children. It is
usually produced by a crushing force, such as a caving of
earth or stones in a mine, catching the body between
two objects moving in opposite directions, or the passage
of a heavy wheel across the pelvis.
There is usually a great deal of obscurity attending the
diagnosis ; and, even when the fact of the fracture is clear-
ly made out, it may be very difficult, or almost impossible,
to locate the exact line of separation. Examination by
rectum, and in females by the vagina, may enable one
to arrive at greater certainty, but frequently the most
careful exploration may fail to determine the extent of
the injury.
The gravity of these fractures usually depends upon
the number and extent of the complications present,
rather than the injury inflicted on the bone.
This fracture, especially when it takes place in children,
occurs so infrequently that I deem the following case
sufficiently interesting to the profession to make a re-
port of it.
G. M was a native of California, female, aged
five years, copper color, black hair and eyes ; well de-
veloped but small for her age. She had measles when
three years of age ; and one year ago was confined to
fed four weeks, on account of an injury to the head,
produced by a fall ; recovery complete.
Her present injury was caused on April 5th, by the
wheel of a truck, heavily loaded with hay, passing diag-
onally across the anterior surface of the body, from the
middle of the right thigh to the lower margin of the ribs
on the left side.
July 21, 1894]
MEDICAL RECORD.
n
On inspection : Dorsal decubitus ; the left eye ecchy-
mosed and the surrounding skin abraded ; the left hand
presents a contused appearance, and there is lateral
bending of the second finger. There is a contused mark,
about two inches wide, passing diagonally upward from
right to left, across the pelvis, just to the left of the
symphysis pubis. The left lower extremity is lying on
its outer side flat upon the bed, and drawn up toward the
trunk. The right lower extremity presents a shortened
appearance, with some deformity about the middle of the
thigh ; the foot rotated outward and lying with its ex-
ternal margin flat on the bed.
On superficial examination I made a diagnosis of
contusion of left eye ; fracture of second phalanx of sec-
ond finger of left hand; oblique fracture of right femur
at junction of upper with middle third ; fracture of the
left os innominatum, or a separation of its primary cen-
tres, and probable injury to some of the pelvic viscera.
The fractures are all simple.
The pain incident to making a careful examination
and applying treatment was so intense that it was nec-
essary to administer an anaesthetic. Therefore I re-
quested assistance, and at the suggestion of the family
Dr. R. J. Hall was called. Having to wait about two
hours for his arrival, during the interval I gave morphia
sulphate for the relief of pain.
As soon as the doctor arrived the little patient was
placed under the influence of an anaesthetic, and with
the finger in the rectum a careful examination was
made ; but we were unable to secure distinct crepitus,
neither could we make out the exact line of fracture of
the os innominatum. The fractured femur was placed in
a plaster-of- Paris bandage without extension, the plaster
enveloping the hips and trunk to the axillae. She was
then returned to bed and instructions given the parents
to maintain perfect quiet, to preserve the urine for future
inspection, and administer light nourishment.
April 6th. — Pulse, 120; temperature, 1010 F. ; res-
pirations, 28. She maintains the position originally
assumed ; the kidneys acted three times during the night,
and the urine contained a quantity of blood. She did
not sleep much during the night, and is crying with pain
in the left inguinal region. There is extensive swelling
in and around the hip joint extending downward al-
most to the knee. The inner side of thigh, high up, and
the left labia are very much ecchymosed, swollen, hard,
and painful to the touch ; the swelling and ecchymosis
extending from the symphysis pubis, anteriorly, to the
anus, posteriorly, not passing beyond the median line,
nor above Poupart's ligament. The eye, hand, and right
lower extremity are doing very nicely, no swelling or
pain.
We cut the plaster bandage where it encircled the hips
about two inches up its middle, anteriorly, for the pur-
pose of relieving pressure on the ilium. Not finding suf-
ficient injury of the external genitals to account for the
discharge of blood in the urine, we came to the conclu-
sion that it was produced by laceration of the bladder, or
internal portion of the urethra. Having arrived at the
above inference we desisted from further examination,
agreeing to await developments, and should the symptoms
indicate the necessity of it, perform laparotomy.
April 7th. — Pulse, 100; temperature, normal ; respira-
tions, 25. The kidneys acted frequently during the past
twenty-four hours, but the urine did not contain any blood.
She is resting quietly now, and slept moderately well
during the night. She maintains her original position ;
the swelling of left hip and thigh increasing, ecchymosis
more marked, and cries with pain if disturbed. The eye,
hand, and right lower extremity progressing nicely toward
recovery.
From April 7th, to the date of discharge, May 5th, con-
valescence was progressive and uninterrupted, except by
a mild attack of rubella, which produced a slight rise of
temperature, sick stomach, and looseness of the bowels,
lasting about twenty- four hours.
The dorsal decubitus ; the entire extremity lying on its
outer side flat upon the bed, the thigh flexed to its extreme
limit upon the trunk, and the leg on the thigh, which
position was maintained during the first three weeks pa-
tient was confined to the bed ; the extensive exudation
and effusion existing in and around the hip joint ex-
tending downward almost to the knee ; the deeply sit-
uated ecchymosis and exudation into the left labia, its
adjacent and subjacent tissues, not passing beyond the
median line ; the pain incident to the pressure of the
plaster of Paris on the ilium disappeared immediately
after it was divided up the middle, anteriorly; the
intense pain which was produced whenever an attempt
was made to move the limb or pelvis, and the dis-
charge of blood in the urine, all combine to form an
aggregation of symptoms which point to the correctness
of the diagnosis. To be sure, we were unable to trace,
with the finger in the rectum, the line of separation, but
all of the other symptoms, subjective and objective, indi-
cate fracture of the os innominatum, or separation of its
primary centres, and laceration of the bladder or internal
urethra.
At the present writing, June 2d, she walks with a per-
ceptible limp in the right leg, which is due to about two
ctm. shortening ; there is, also, a sort of a shuffling move-
ment similar to that of a woman after an unusually hard
confinement ; otherwise recovery is complete.
A NEW CARDIAC TONIC DOSIMETRIC GRAN-
ULE.
Indicated in Cases where the Heart's Action is
Irregular, Weak, or Diminished in Tone and in
Nutrition.
By EDWARD C. MANN, M.D.,
MEDICAL SUPERINTENDENT SUNNYSIDB SANATORIUM, NBW YORK J MEMBER
MBD1CAL SOCIETY OF THE COUNTY Or NBW YORK ; MBMBBR BROOKLYN PATH-
OLOGICAL SOCIETY ; HONORARY MBMBBR MEDICAL SECTION IMPERIAL UNIVBR-
SITY OF KHARKOPP, RUSSIA; PRESIDENT OF NBW YORK ACAD* MY OF ANTHRO-
POLOGY, ETC.
In the treatment of nervous and mental diseases, and
especially of inebriety and the morphia habit, we find me-
chanical difficulties and nutritive disturbances associated
with valvular and neurotic affections of the heart. We
cannot use digitalis in these cases without the great dan-
ger of getting up a condition of defective nutrition and
secondary degeneration of the heart. We have in these
cases to properly tone and increase the nutritive condition
and working capacity of an enfeebled or irregular heart.
We want a remedy that will at the same time nourish
the heart- muscle and slow a rapid and quicken a slow
heart. We want a remedy the physiological action of
which will be to establish a regular rhythmical action of
the heart. This we can obtain very satisfactorily by the
cardiac tonic dosimetric granule which we present to
the profession. We are in a position to day to get a
much higher degree of certainty in the administration of
medicinal agents by the use of alkaloids, glucosides,
resinoids, or organic acids, as medicinal agents, instead
of the often complex and variable crude drugs which
characterized old methods of treatment. These "active
principles " are in many cases transmutation products,
that is, they are obtained from the native substance by
the action of a series of chemical reagents, and sometimes
by the additional action of heat. Some of the alkaloids
do not exist in the plant, apomorphia, for instance, which
cannot be extracted as such from the opium, but is made
by the action of heat and hydrochloric acid, from mor-
phia. In this new method of dosimetry, and particularly
by hypodermatic dosimetry, we can, by our knowledge of
the exact chemical identity of our remedy, and of the
precise quantity injected into the system, determine the
nature and degree of the effects of this definite substance
upon the physiological processes, both in health and dis-
ease, with a degree of accuracy hitherto unknown in the
science of medicine. We know, furthermore, that an
exact amount of the active principle reaches the lymph
spaces and circulatory channels, when from its chemical
74
MEDICAL RECORD.
[July 21, 1894
nature we can give it hypodermatically. Never before
in the treatment of disease have we been able to treat it
so exactly and obtain such certain and permanent relief
as we can to day, by dosimetry, and particularly by hypo-
dermatic dosimetry. What we need now is better adapt-
able chemical forms of the " active principles/' alkaloids,
glucosides, or other definite active principles, and then we
shall be in a position to have a new, exact, and scientific
system of therapeutics. Hand in hand with this must
go an exact system of feeding our patients (proteid diet)
which shall require the least vital force and oxygen to
digest, assimilate, and appropriate the food ingested, and
give the most force and energy.
The formula for the cardiac tonic dosimetric granule
which I use is as follows. Each dosimetric granule con-
tains:
R. Morphia gr. -ft
Strychnia gr. 7^
Atropine gr. ¥JT
Caffeine gr. Vf
We have here a granule with a fixed therapeutic activ-
ity which can be used hypodermatically, if desired, by sim-
ply dissolving it in water, and which, clinical observation
proves most satisfactorily, will impart to the heart a bet-
ter nutritive vitality, increased working-power, and a reg-
ular rhythmical action. It is well to bring the patient
down to a restricted diet of milk, buttermilk, eggs, or
raw oysters, and to correct all gastric or hepatic disturb-
ances, to relieve the alimentary organs of their engorged
condition, states which I always have to direct my atten-
tion to in the affections of the heart in cases of alco-
holism, and very often in cases of the morphia habit. The
use of this dosimetric granule we have always found
followed by a rapid improvement in the strength and
rhythm of the heart's action ; and we recommend con
fining the use of digitalis to those cases where we need a
powerful cardiac stimulant, in cases of threatened collapse,
when one or two of the cardiac tonic dosimetric granules
may be dissolved, and a hypodermatic tablet of ^ gr. of
digitaline added to it, as the most appropriate heart stimu-
lant. Nitroglycerine and sulphate of sparteine would
also be indicated in such extreme cases, TJT to -fo of the
former by the mouth, with £ to £ gr. of the latter hypo-
dermatically. I keep a solution of the sulphate of sparteine
made up of the strength of 16 grs. ad aquse $j., and
standing by this a bottle of nitro-glycerine tablets -fa gr.,
and always use them simultaneously in emergency cases.
In the treatment of the morphine habit also I have for
years been accustomed to rely upon this latter combina-
tion for two or three days after complete withdrawal of
the morphine to obviate and antagonize the psycho so-
matic suffering of the patient.
ANOMALOUS FCETAL NUTRITION IN TWIN
GESTATION.
By JOHN C. HUPP, M.D.,
WHEELING, W. VA.
On the second day of May, 1894, I encountered a phe-
nomenon not heretofore observed in an obstetrical ex-
perience of forty-seven years. The mother of four chil-
dren, in the seventh month, she alleges, of her fifth preg-
nancy, gave birth to very decidedly decomposed twins,
one foetus being very many times smaller and more com-
pletely decomposed than its twin sister. There was only
one placenta, which was attached to the ordinary-sized
cord of the larger foetus, which was not larger than a
thread, encircling its neck three times, and after tracing
one end to the umbilicus I traced the other end to its
attachment to about the middle of the cord of the larger
foetus, and around this attachment there were three or
four cherry-like projections. The smaller foetus, with or
without a placenta, notwithstanding its anomalous con-
nection, could not have been nourished through a cord
so diminutive, and this, to me never-before- heard- of
union, doubtless caused the death of the larger foetus.
My impression is that the insufficient nutrition of the
smaller foetus caused its death, and the resulting pyogenic
material was conveyed to the larger one with fatal re-
sult.
REPORT OF THE USE OF CRUDE TUBER-
CULIN ON COWS.
By IRWIN H. HANCE, M.D.,
SARAMAC LAKE, N. Y.
Being desirous of having the cows in the Adirondack
Cottage Sanitarium free from any tubercular taint, a test
was made on the herd with crude tuberculin. The herd
consisted of eight cows such as are found on the ordinary
country farm ; to all outward appearances they were free
from any disease. The day preceding the first test in-
oculations their morning and evening temperatures were
taken per vaginam for comparison and were as follows :
May 2 1st. a.m. p.m.
1 100.5 102.6
2 101. 0
3 101.0 101.0
4 100.8 100.8
5 101.5 101.4
6 101.4 101.8
7 loi.a 101.4
8 100.5 IOI-8
In looking over the literature at our command Dr.
Hewetson, of Montreal, was unable to find any detailed
account of dosage and temperatures; it was therefore
deemed advisable to use a small dose to begin with ;
double the amount was given six days later to make the
test reliable. The solution used contained 0.1 of Koch's
lymph in each c.c. The inoculations were all made in
the loose folds of the neck, just in front of the fore-
shoulder. Needles with very strong shanks are needed
because of the thick hide.
May 2 2d, 8 a.m. — 0.050 was inoculated in each cow.
The temperatures in degrees Fahrenheit were :
May 22d. 8 a.m. 2 p.m. 8 p.m.
1 100.6 101.8 102.4
2 101.0 101.5 100.8
3 101.4 100.8 100.8
4 101.4 100.8 100.2
5 101.4 101.2 100.6
6 101.0 101.6 101.0
7 101.6 101.2 100.6
8 101.4 101.6 100.8
A comparison of the temperatures for the two days
shows a negative result.
May 28th, 7 a.m — One decigramme was administered
to each cow. During the day the temperatures were
as follows :
May 28th. 7 a.m. 2 p.m. 8 p.m.
1 100.6 101.8 100.8
2 101.0 101.4 ZOI.2
3 iox.4 101.0 100.8
4 101.4 100.8 100.6
5..... 101.8 101.2 101.0
6 iox.6 iox.2 101.0
7 102.2 101.6 101.4
8 101.2 101.6 101.0
On this occasion the results were equally satisfactory.
A single glance over all these temperatures shows that
the normal temperature of a cow per vaginam is about
1010 F. The only exception was cow number one, which
was an old matron ; her afternoon rise of temperature
cannot be considered reactionary since the evening tem-
perature of the day on which she received one deci-
gramme of lymph was only one-fifth higher than that of
the morning.
The ease and simplicity of the administration, with
the thoroughly practical and efficient results of this test,
places in the hands of everybody a simple means of dis-
covering this very prevalent disease.
Two Deaths under Anesthesia occurred recently in
two successive days in Birmingham.
July a i, 1894]
MEDICAL RECORD.
75
Medical Record:
A Weekly Journal of Medicine and Surgery.
GEORGE F. SHRADY, A.M., M.D., Editor.
Publishers
WM. WOOD 8l CO., 43, 45, & 47 East Tenth Street
New York, July ax, 1894.
SYPHILIS OF THE EPIDIDYMIS.
In affections of the testicle, as they are usually spoken
of, the diagnosis is ever a matter of great interest, and,
indeed, often of much importance, and it is not enough
for the physician to pronounce the case one of " swollen
testicle " and order rest and hot poultices. Many of the
diseases which attack the various structures contained
within the scrotal envelope have been carefully studied,
their salient features pointed out to aid in arriving at
just conclusions regarding them, and their etiological
bearings definitely traced. There are others which, it
would seem, have not received the attentive study their
more or less frequent occurrence demands. According
to Dr. C. W. Allen, this is true of the syphilitic changes
which take place in the epididymis while the testis proper
remains unimplicated. In a paper just published in the
American Journal of the Medical Sciences, he writes his
views upon what we must acknowledge is a relatively little
discussed question. The first writings of importance con-
cerning the early syphilitic epididymitis are attributed
to Engelstedt (1861), and to Drow two years later.
" Since then," the writer says, " little has been added
to the literature bearing upon it if we except the brief
writings of Szadek."
We would here like to call attention to a Paris thesis
published by Cuilleret, in 1891, entitled " £tude sur
I'^pididymite syphilitique secondaire," which has evi-
dently been overlooked. Since it touches upon some
points which have been omitted in Dr. Allen's paper,
we will review its chief features and conclusions. The
writer believes that epididymitis by itself is a frequent
manifestation of the secondary period, especially at its
beginning, but that it passes unperceived, for the double
reason that it occasions no discomfort and has a marked
tendency to spontaneous regression. Habitual examina-
tion of the organs alone can determine its relative fre-
quency, for its chronic course is benign and has no ten-
dency to permanent alteration or destruction of the
tissues. The opinion is, however, expressed that its
presence indicates a rather pronounced attack of syphi-
lis, which should be carefully treated, and that the prob-
abilities favor serious manifestations in the after-stages.
The matter of differential diagnosis does not appear to
present many difficulties. Gonorrhoeal epididymitis is
certainly much more frequent, but its acute and painful
symptoms would exclude this affection, though it would
that, as an exception, a case may be acute. The
induration is located in the head of the organ and is ex-
tremely hard. Diagnosis from beginning tuberculosis
must offer greater difficulties where all other signs of
syphilis are absent, and the element time, and possibly
test treatment, it seems to us, would have to enter into
the problem's solution. The first mentioned paper takes
up a rather different phase of the question, and the prop-
osition is advanced that syphilis attacks the epididymis
at almost any stage as well as in the early secondary
period, in the absence of any other evidence of the dis-
ease, and when there have been no symptoms, perhaps,
for many years. This view is supported by a number of
clinical observations, several of which add decided weight
to the arguments, while some of the others are not so con-
vincing. One difficulty which stands in the way of ac-
cepting the results of treatment as strong proof of the
syphilitic nature of a pathological condition, is that mer-
cury and the iodides are so often beneficial where there is
not the least suspicion of a specific taint. This may be
true even of tuberculous processes, as the writer admits in
commenting upon the last of his series of cases, and says
coincident evidence of tuberculosis in other organs must
be looked for.
A point in differential diagnosis between this and the
chronic enlargement so often left after gonorrhoeal epi-
didymitis, is that in the latter the tail of the organ is the
part involved, while syphilis implicates mostly the head.
There is no doubt that castration is still cow and then
performed for supposed tuberculosis or malignant growth,
where syphilis is the real cause of the abnormality.
For this reason alone such clinical studies of the ques-
tion are not amiss, for while they aid in saving an occa-
sional testicle by means of the iodides, they tend to
bring about a better understanding of the whole subject
of enlargement of the epididymis ; and so far as syphilis
is concerned, it must be confessed the field has not been
overworked.
THE RISE OF APIUM GRAVEOLENS.
It is with considerable interest that we have watched the
rise into therapeutical prominence of that toothsome ad-
junct to the dietary, celery. Without any adventitious
aids from the physiological laboratory or critical clinical
studies, it has become a formidable rival to the mystic
sarsaparilla and ginseng as a popular remedy. It does
not pretend to purify the blood, to be sure, but it calms
the nerves, a task of even greater magnitude in these
fin de siicle days. Apium graveolens, or celery, is, we
believe, a close cousin to apium petroselinum, or pars-
ley, but somehow it is petroselinum alone that has won
serious medical attention. This latter plant is aperient
and diuretic, and helpful in amenorrhoea, dysmenorrhea,
and allied female complaints. Some years ago Dr. Ran-
som asserted that celery also had some influence on the
urinary secretion. But nowhere is it shown that it has
the slightest effect on the nerves. Yet we must believe
that it does have much effect, or discredit a very large
percentage of medical advertisements in the daily presr.
We are prepared to take a most impartial view of the
situation, and will be glad to learn that celery has power-
ful therapeutic effects in various directions. But we pro-
test that the burden of proof is with the populace and
not with the professors. At present all that medical
76
MEDICAL RECORD.
[July 2i, 1894
science can say is that celery is an agreeable weed to eat
when cold and white and crisp and clean. Indeed, it
seems a pity to put it into a tincture and grade it down
with sarsaparilla.
TRANSPORTATION OF THE INSANE TO HOS-
PITALS.
While reform in the care and treatment of the insane,
during the past decade or two, has been rapid, and, in
some respects, radical, the manner in which they are
carried to hospitals has received but little attention. In
this State, for some time past, a mild under-current has
been running in the direction of reform in this matter,
but so far but little good has been accomplished. The
time came long ago, when the insane person should have
been differentiated absolutely from civil offenders ; but
as a matter of fact, the two are sadly confounded to-day
by many persons who have to do with the insane in one
way or another.
The reason of this is perfectly plain. When a person
becomes insane (and we are speaking now of persons in
the humbler walks of life, who cannot afford private at-
tendance and skilled nurses), he promptly falls into the
hands of the local constabulary or police, and especially
does he meet this fate if he manifests the least tendency
to disturb the public peace, or in any way show violence.
Dr. Stephen Smith, in a very able paper entitled " More
Rational Treatment of the Insane," that appeared in the
American Journal of Insanity, January, 1894, says :
" When a person is alleged to be insane, our laws place
him in the category of persons who have been accused
of civil offence. In many of the States the term, ' The
Accused/ is employed in the statutes when such a per-
son is referred to. This feature of our law is a relic of
the old method of arresting the violent and disturbed
insane under the common law of England.1'
We need not attempt to portray the ill-treatment often
received by the insane, man or woman, at the hand of
these ignorant and harsh petty officers of the law. Too
often they are manacled, or laced in a straight jacket,
put in prison, and fed on prison food, or not fed at all,
if, by reason of some delusion, they refuse to eat. The
grossest of indignities, however, is left for them to suf-
fer when in process of transportation to the hospital to
which they have been committed for care and treatment.
Ttie superintendent of a hospital for the insane in a
neighboring State recently described the manner in
which an insane woman was brought to the hospital,
as follows : " She was brought twenty miles or more
(in a wagon) in a drygoods box. The box was just
large enough for her to sit in, and this had a blanket
thrown over it, and tacked all around. Ropes had been
placed on the sides to form handles. She had not been
taken out of the box, and had not been able to change
her position from the time of starting until she reached
the hospital, several hours. Imagine the condition in
which I found her when I tore the blanket covering off."
In the same State, not long since, a man was carried
half a day's journey to the hospital, strapped hard and
fast to the top of a coffin. He was in this excruciating
position for many hours. When released in the hospital
he could not stand or move hand or foot.
It is difficult to give credence to the two instances
cited above, but the fact of their occurrence is vouched
for by a correspondent in whom we have every confi-
dence. Of course, those in charge of our public hospi-
tals have absolutely nothing whatever to do with the
manner in which patients are brought to them. Their
jurisdiction begins only when the patient has crossed the
threshold of the hospital door. There would certainly
appear to be room for reform in this direction.
CEREBRO SPINAL MENINGITIS.
During the past year cerebrospinal meningitis has been
epidemic in several localities in this country, and among
them in New York City. Dr. Henry W. Berg has
made a clinical study of this latter epidemic {Archives
of Pediatrics), and a discussion of his paper took place at
the Academy of Medicine in April. The disease was
also seriously epidemic in Maryland, and at the instance
of the State Board of Health, an investigation of it was
undertaken by Drs. Simon Flexner and L. F. Barker, of
Johns Hopkins University {American Journal of the
Medical Sciences, February and March, 1894).
Dr. Berg shows. that the mortality from cerebrospinal
meningitis in New York City rose from 230 in 1892 to
469 in 1893. The majority of the cases occurred in per-
sons under the age of five, and there was no especial
difference between the sexes. The greatest mortality
occurred in May, but as the disease took a somewhat
chronic type, it is assumed that it was actually most
prevalent during the late winter and early spring. At-
tention is called to the fact that the epidemic followed in
a measure the wake of the influenza, and corresponded
with a great prevalence of pneumonia, facts which have
been observed before. There seems to be nothing in the
New York epidemic to point to cerebro spinal meningitis
as distinctly a filth disease, nor were there any evidences
that it is ever contagious. The cases on the whole, ran
a very chronic course, and there were few instances of
the foudroyant type of the disease. The attacks began
with a chill and fever or with convulsions, often accom-
panied by propulsive vomiting and headache. Very
soon the characteristic symptoms of pain and rigidity in
the back of the neck, with muscular tenderness and pain,
appeared. As a rule, there was a herpetic eruption on
the skin, and nasal catarrh was frequent. As the disease
progressed, symptoms of irritation and compression of
the brain and cord developed, delirium, photophobia,
pupillary and retinal changes, ptosis, strabismus, and
other paralyses appeared, ending finally in stupor.
In discussing the pathology of cerebrospinal menin-
gitis, Dr. Herman M. Biggs was positive in stating that
the disease presented no distinctive bacteriology or
etiology. Cultures are sometimes sterile, or bacteria of
various kinds may be found. The pneumococcus of
Frankel is oftenest present, and after this the strepto-
coccus and the staphylococci albus and aureus. Dr.
Biggs also asserted that cerebral meningitis was always
cerebro-spinal, and that there were no facts to warrant a
separation of the two diseases.
Dr. Biggs's views are not in accord with those of Drs.
Flexner and Barker. These gentlemen say that the epi-
demic and sporadic cases of cerebro spinal meningitis are
due to a particular micro-organism, the micrococcus
lanceolatus, discovered by Eberth in 1880, and by
July 2i, 1894]
MEDICAL RECORD.
77
Wechselbaum in 1886. This microbe is considered to
be the cause of those forms of meningitis developing
epidemically or in association with pneumonia. There
is, however, aD other class of cases in which it is caused
by injuries, or appears in the course of other infections
such as typhoid fever, arthritis, sepsis, etc. Drs. Flex-
ner and Barker report cases which corroborate their view.
MEDICINE AND MODESTY.
The Cincinnati Lancet- Clinic insists that the medical
profession is just as big as any other calling, perhaps big-
ger. And it wants a medical cabinet officer at Washing-
ton right away. It says : " To-day the success of the
army and navy is more dependent upon the resources of
the medical department of those branches of national
service than ever before." There is a little anti-climax
here, though the statement will not be disputed. But our
contemporary continues, with access of emphasis : " Very
much of the efficiency of the Interior Department is de-
pendent upon its medical staff. The finances of the
country are at the mercy of medicine, while the prosper-
ity of all the people is wholly determined by their condi-
tion of health.'1
This we think is really putting it rather strong. We
yield to no one in appreciation of our calling, but it
seems to us that the prosperity of our country depends on
the ingestion of adequate food, the observance of law, and
the prosecution of our industries, as well as upon sanita-
tion. Let us insist on acknowledgment of our true
merits, and upon the high functions which public medi-
cine fulfils. They are of sufficient weight without the
adventitious trappings of an expansive fancy such as our
esteemed Cincinnati contemporary seems to possess.
But let us look at what our country needs first, and our
professional advancement later. The country would be
benefited by a national control of matters of public
health. This can be gotten best by not asking at the
same time for a cabinet officer.
PROFESSOR WILLIAM JAMES'S PLEA FOR
THE MIND-CURERS.
Professor James, after denying that he holds any brief
for the "healers/' makes this extraordinary plea : — He
says: "The facts are patent and startling; and any-
thing that interferes with the multiplication of such facts,
and with our freest opportunity of observing and study-
ing them, will, I believe, be a public calamity. The law
now proposed will so interfere, simply because the mind-
curex? will not take the examinations. They return to
science disdain for disdain; and nothing will please
some of them better than such a taste of imprisonment
as might, by the public outcry it would occasion, bring
the law rattling down about the ears of the mandarins
who shall have enacted it.
" And whatever one may think of the narrowness of
the mind-curers, their logical position is impregnable.
They are proving by the most brilliant new results that
the therapeutic relation may be what we can at present
describe only as a relation of one person to another per-
son ; and they are consistent in resisting to the uttermost
any legislation that would make ' examinable ' informa-
tion the root of medical virtue, and hamper the free play
of personal force and affinity by mechanically imposed
conditions."
The mind-curer has surely an eloquent advocate in the
Harvard professor. But no one except those daily fa-
miliar with the aspects of disease can understand how*1
specious and silly such talk is. First, let us ask where
are the " facts " that are so " patent and startling." Is
there a single disease in our nosology which the "heal-
ers " heal in larger percentage than does rational medi-
cine? What are the " facts " about pneumonia, fevers,
phthisis, cancer, rheumatism, and all the familiar forms
of suffering which the physician meets and relieves daily ?
Let Dr. James put a " healer " in charge of the medical
ward of a city hospital and see how " the impregnable-
ness of a logical position assists him in pulmonary oedema
or a failing heart. If there are " brilliant new results,"
why are they not collected, authenticated, and presented
to the world in a way that will bear honest inspection ?
At present they are simply rumors that pass from one
fanciful female or over- credulous psychologist to another,
and have about the evidential value of the ghost stories
accumulated by the Phantom Committee of the Society
for Psychical Research.
The medical profession knows well how much its art is
limited, and eagerly accepts any genuine help. But it
has no evidence that mind curers do more than amuse
the leisure of selfish invalids and nurse the introspections
of feeble philosophers.
foetus at tUt 'SSEeek.
The Escape from the Electric Chair. — Governor Flow-
er has wisely respited Mrs. Halliday, the Monticello
woman recently convicted of murder in the first degree
and sentenced by the judge to death in the electric chair.
The commission of experts appointed to examine into
her sanity reported that she was of unsound mind. In
view of the evidence, even on the trial, there was no
other conclusion to be drawn. The sentence was accord-
ingly changed to imprisonment for life as an insane con-
vict. The Governor is to be congratulated on his fairness
and good sense. The Governor of Illinois might have
done the same for Prendergast and with equal propriety,
but it is now too late, as it is with other things he left
undone.
Brooklyn last week had the extraordinarily high death-
rate of 33.4 per 1,000.
Dr. Joseph Pagani, of Boston, died on July 15 th. He
had practised in the North End for twenty years. He
was born in Borgomanero, Italy, in 1836. In 1863 he
was graduated from the University of Pavia. He came
to America in 1865, and after a short stay in New York
went to Boston. For his kindness to Brazilian subjects
he received, in 1882, from Dom Pedro the decoration of
Chevalier de Buenos Ayres. In 1892 he was made Ca-
zique and Baron Hoxley in the Aryan peerage of Rus-
sia. He was a distinguished member of several medical
societies, among which were L'Acad^mie Mddecine of
Paris and the Societa Medicale di Roma.
Dr. John Williams, who attended the Duchess of York
during her recent confinement, has been created a baro-
net.
78
MEDICAL RECORD.
[July 21, 1894
Professor Hermann Helmholtz was taken suddenly ill
on July 12th, with a brain lesion and now has left-sided
hemiplegia.
• The Plague in Hong Kong is reported to be subsiding,
but cholera is on the increase in Canton.
Monuments to Medical Ken. — The work of securing
funds for a monument to Professor Charcot is progress-
ing favorably, and is receiving help from Germany and
other countries. A monument in memory of the great
Russian surgeon, Pirogoff, will shortly be erected in
Moscow. The subscriptions for this object already
amount to 12,000 roubles (about $6,000). The monu-
ment will appropriately be placed on one of the open
places between the blocks of the immense new clinique
in Moscow.
Texas Not the State for a Young Doctor.— A corre-
spondent writes that he left New York to verify the well
advertised chances for the young medical man in Texas ;
but after travelling throughout the entire State he found
every place more than full, with not a few waiting for
chances to earn money enough to get home. He says
there is even a better chance in New York.
The Immediate Repair of the Permanent Cervix —
Dr. H. D. Gardner, of Scranton, Pa., writes: "In the
article of July 7 th on the ' Causes of Diseases Peculiar
to Women/ you say lacerations of the cervix and peri-
neum should be repaired early. Now I, in common with
many others, believe in the immediate repair of the
perineum ; I have never tried to repair the cervix, but
think it might be done, and in order to do this you must
first find the tear. Now I know of no way so good as
to look for it. Turn down the bedclothes and with a
good light, lamp or candle, look and see whether there
is a tear or not. No power on earth could prevent it,
but you can repair it easily and quickly. I look upon
this as the most important duty of the obstetrician."
Bequests to Hospitals. — The late John Crerar, of
Chicago, has bequeathed to the Presbyterian Hospital of
this city $25,000; to St. Luke's Hospital, $25,000.
Medical legislators and Medical Mayors abound in
France. The first to go to the aid of the murdered
President Carnot was Dr. Gailleton, the Mayor of Lyons.
Among the leaders of the medical section in the French
Parliament are Professors Cornil and Lanaelongue and
Dr. Leon Labbe. These gentlemen, says The Lancet,
recently convened a meeting of their fellow (medical)
members, and the outcome of the conference was the
formation of a medical group, whose duty it shall be
to watch over professional interests in the two houses.
M. Labbe was appointed President, and MM. Cornil and
Lannelongue vice-presidents of this new group. The
freshly formed party has already begun work, for it has
discussed a bill introduced by M. Labbe which, if adopt-
ed— and it has every chance of being carried — will pro-
long the limit of age of medical students, with regard to
their military obligations, from twenty-six to twenty-
seven years.
Death of the Smallest Kan in the World.— Dudley
Foster, said to have been the smallest man in the world,
died at Bridgetown, N. S., on June 20th, of heart dis-
ease, aged sixteen years and ten months. He was thirty
inches high, and weighed twenty pounds.
Antieholera Inoculation. — An Indo European tele-
gram states that within the previous few days three
further remarkable instances of the success of M. Haff-
kine's system of auticholera inoculation had occurred at
Calcutta. In the first case four out of the six members
of a family were inoculated last March. The cholera
appeared in the neighborhood lately, and the disease
attacked one of the two who had not been inoculated,
while the inoculated remained free. In the second case,
five members of a family consisting of eleven persons
were inoculated in March. The cholera lately attacked
one of the six who had not been inoculated. In the
third case, six out of a family of nine were inoculated.
When the cholera prevailed in the neighborhood a few
days later the disease attacked one of the three not
inoculated. The Corporation of Madras have passed a
resolution inviting M. Haff kine to visit that city and
introduce his system.
Sir Joseph Lister. — The Council of the Society of
Arts has, with the approval and sanction of the Presi-
dent, His Royal Highness the Prince of Wales, awarded
the Albert Medal to Sir Joseph Lister " for the discov-
ery and establishment of the antiseptic method of treat-
ing wounds and injuries, by which not only has the art
of surgery been greatly promoted and human life saved
in all parts of the world, but extensive industries have
been created for the supply of materials for carrying the
treatment into effect"
Sterilized Milk is becoming a popular hot-weather
drink in this city.
A Political Honor to a Physician. — An esteemed
correspondent writes from San Josl, Costa Rica, to in-
form us that Dr. Juan J. Ulloa, who was a delegate
from Costa Rica to the Pan-American Medical Congress,
and who is a graduate of the Medical Department of the
University of the City of New York, has been appointed
Secretary of State in the Departments of the Interior and
of Public Improvements of Costa Rica.
Dr. V. P. Gibney has been elected Professor of Clini-
cal Surgery in the College of Physicians and Surgeons of
New York City. 4
Prize for an Essay on Tuberculosis.— At the Denver
meeting, just closed, of the Colorado State Medical So-
ciety, the following resolution, offered by Dr. Denison,
was carried, and Drs. Charles Denison, H. A. Lemen,
and S. £. Sally were appointed as such Examining Com-
mittee : Resolved, That this Society offer a prize of $ 100
for the best essay upon the following subject : The Diag-
nosis of Tuberculosis by Microscopic Examination of the
Blood.
Asparagus. — English journals have been actively dis-
cussing the physiological action of asparagus. The con-
clusion reached is that it is a diuretic.
The Caul still seems to have a commercial value. Wit-
ness the following advertisement in a New York daily :
"Caul for Sale, reasonable. Address , box
, World, uptown.' '
The American Electro-therapeutic Association will
hold its fourth annual meeting in New York on Septem-
ber 25 th, 26th, and 27 th, at the Academy of Medicine.
Members of the medical profession are invited to attend.
July 21, 1894]
MEDICAL RECORD.
79
Society ^tpovte.
<&0ugv&&8 at &mtviaxn fPqjsicfcros
and gnvQ&ans.
Third Trienninl Meeting, held at Washington, D. C,
M*y 29> 30, jr, and June 1, 1894.
AMERICAN GYNECOLOGICAL SOCIETY.
nineteenth Annual Meeting, held at Washington, May
29, 30, and ji, 1894
(Continued from Vol. 45, page 769.)
Second Day, Wednesday, May 30TH.
President's Address. — Dr. Lusk chose for the subject
of his address " The Proper Position of Recent Surgical
Methods in the Treatment of Uterine Fibroids." There
is nothing, he said, which in an equal degree marks in
gynecology the boundary line between the old order of
things and the new, as the recent discussion upon the sur-
gical treatment of uterine myomata. Myomata might
remain of small size and produce no symptoms. When
small and the symptoms were slight, the surgeon could
delay a little and control attending menorrhagia by cu-
rettage, etc. The argument in favor of more radical
measures bee rase of the supposed liability of myomata to
malignant changes, especially in patients nearing the
climacteric, clinically had not much weight.
Gottschalk, Franklin, Martin, and others had had
favorable experience in controlling the symptoms and
growth of uterine fibroids in certain cases by tying the
uterine arteries through the vagina. It seemed to the Presi-
dent unwise bigotry to ignore such testimony because
ligation of tfie uterine arteries belonged to the domain
of little things. Certainly the patient would prefer to be
relieved in that way to having the uterus removed.
It .was a question whether sufficient attention had been
paid in this country to the large amount of efficient work
that had been accomplished abroad in connection with
the enucleation of fibroids by the vaginal passage.
Chrobak alone had reported forty-three cases, with but
one death. • The tumors were cervical, submucous, and
interstitial, and varied in size from a child's head down.
The President related one of his own cases of this kind, in
which able men had said.the tumor could not be removed
except by opening the abdomen. After enucleation, en-
tire or by morcellement, the uterus or cervix could be
restored by plastic operation. It might seem a little
thing, but women would prefer not to have the scar left
by abdominal operation, and the danger of hernia was
shown by the fact that, at Jacob's clinic, in 259 cases her-
nia occurred in 38. By the vaginal method better drain-
age was secured, and there was less shock. The results
by the vaginal method were remarkable — P6an, 300 cases
with only six deaths ; Richelot and Doyen together, 88
cases with two deaths. When the tumor exceeded in size
a child's head experience taught that, as a rule, it was ad-
vantageous to attack it from above.
Regarding castration for control of symptoms pertain-
ing to fibroids the views of Martin, Leopold, Gusserow,
Lawson Tait, on their statistics, were quoted to show that
often the procedure gave a satisfactory result. Castration,
however, was no longer advocated in large tumors and
cystic tumors.
In all cases where the abdomen had been opened, the
possibility of saving the uterus and appendages should
not be lost sight of. All pedicled growths should be tied
and removed.
The views of Polk and Martin, particularly, were re-
ferred to in the line of sparing the healthy tissue where
it was necessary to remove disease of structure in the
uterus and appendages. There would still, however, re-
main a certain number of cases in which, owing to the
size of the tumor, cystic degeneration, number of growths,
etc , it would be necessary after opening the abdomen to
do total extirpation.
Dr. Lusk then passed to a consideration of methods of
treating the pedicle. Although good results had been ob-
tained from fastening it into the abdominal wound, the
method had been abandoned; some patients returned
with a fistula, etc. Complete removal and amputation,
leaving the lower cervical segment only, were methods
advocated by the best authority.
Discussion was then called for upon the papers of Drs.
Lusk, E. C. Dudley, and Wathen.
Dr. W. M. Polk thought also there could be no one
method applicable to all cases of uterine fibroids. He
favored conservative measures, retaining healthy struct-
ures, wherever removal of simply the diseased portions
would be likely to terminate in cure. This remark was
especially applicable in disease ot the appendages, for
even pus in the tubes did not necessarily preclude ovula-
tion.
Dr. Baldy thought that if myomectomy was to be
done at all, it should be by the abdominal, not by the va-
ginal, method. It was, however, attended by danger of
hemorrhage, sepsis, and recurrent disease.
Drs. Cushing and Gordon also advocated total re-
moval of the uterus, as opposed to myomectomy.
Dr. W. Gill Wylie believed in suiting the operation
and the method of performing it to the particular case,
and thought the President's paper presented the subject
very justly.
Dr. Byford expressed similar views, and Dr. Engel-
man regretted that some of the gentlemen had seemed to
show prejudice against attacking any cases of fibromata
uteri per vaginam, regardless of their size/
Dr. A. P. Dudley related a few cases illustrative of
the advantage of the different procedures under different
circumstances.
Rupture of the Uterus ; Palliative versus Surgical
Treatment. — The discussion upon this subject was
opened with a paper by Dr. Charles M. Green, of
Boston. He said : It is improbable that any authority at
the present time would advocate any specific treatment as
applicable alike to all cases of rupture of the uterus. The
object of the discussion is rather to arrive at the methods
most suitable for particular classes of cases, according to
the condition and situation of the patient, the availability
of surgical skill, the site and character of the rupture and
manner of its production, the extent to which the child
has escaped into the peritoneal cavity, the presence or
absence of hemorrhage, the condition of the uterus as re-
gards sepsis.
Surgical treatment should embrace, not alone laparot-
omy, with or without suture of the rent or removal of
the uterus, but also the various methods of drainage with
gauze, wicking, or tube, with or without antecedent irri-
gation ; while palliative treatment, included the various
general therapeutic measures for sustaining the patient,
relieving pain, and combating shock, combined with
local 'antisepsis and natural drainage. The two were
often advantageously combined.
To one with limited experience iri abdominal surgery
and severer obstetrical practice, the idea of laparotomy
after rupture of the uterus was an attractive one, but ex-
tended experience could but convince that in many cases
less radical measures gave better results.
Merz's statistics of 230 cases, grouped under ten heads,
were given. Complete rupture, 181 cases, with 63 recov-
eries; incomplete rupture, 46, with 19 recoveries.
Dr. Green divided the cases of uterine rupture for pur-
poses of treatment into three classes : 1. Complete or in-
complete tears of the lateral or posterior walls of the
lower segment, with adequate provisions for vaginal drain-
age, hemorrhage easily controlled, no intestinal hernia;
such cases often recovered under palliative treatment,
drainage, and antisepsis. 2. Complete tears of lower seg-
ment, or moderate tears of uterine body, more or less
blood-clot, etc., having entered the peritoneal cavity ;
treatment might be by peritoneal irrigation and drainage
8o
MEDICAL RECORD.
[July 21, 1894
with gauze. 3. Cases in which extraction of child through
pelvis is impossible or inexpedient, hemorrhage uncon-
trollable per vaginam, rent extensive, irrigation, trans-
verse, or ragged ; in such cases abdominal section is indi-
cated. The propriety of suturing the rents must be
decided according to the condition of the uterus and the
edges of the tears ; when the latter are very ragged and
infiltrated with blood, when the uterus is friable and ap-
parently septic, hysterectomy promises better results than
suture.
The Palliative Treatment of Rupture of the Uterus. —
Dr. Malcolm McLean, of New York, read a paper with
this title.
One of the most constant and characteristic phenom-
ena connected with rupture, the author said, was sudden
recession of the presenting part. After strongly protest-
ing against one allowing himself to be led by modern
radical tendencies in surgery to operate in all cases of
rupture of the uterus regardless of the particular condi-
tions present, the field for palliative measures was pointed
out and an illustrative case cited. The hand was intro-
duced, the child was found, escaped through a rent in
the right anterior wall of the uterus, so that only the head
and right arm were within the uterine cavity. In exam-
ining the edges of the wound it was noticed that the sur-
faces were completely shielded by the amniotic sac,
which was pushed through ahead of the limbs of the
child, forming a hernial sac into the peritoneal cavity.
Without any difficulty the child was drawn back into the
uterus and at once delivered by the feet. The placenta
with the membranes were withdrawn, and a considerable
quantity of amniotic fluid, meconium, etc., was brought
away in the pouch of the amnion which had protruded
through the rent in the uterus. Believing that the peri-
toneal cavity, therefore, had not been invaded except by
purely blood extravasation, the case was left to nature,
using, of course, antiseptic douches, etc. The woman
made a good recovery after a somewhat tedious conva-
lescence while absorbing a considerable hematocele in
the right side of the abdomen.
A year and a half later Dr. McLean delivered the same
patient, and the cicatrix was distinctly felt through her
very thin abdominal parietes.
Stress was placed upon the fact that the amniotic sac
had protruded into the rent and protected infection of
the peritoneal cavity.
The President, Dr. Lusk, being requested to speak,
said he believed that all reported cases of rupture of the
uterus through the anterior wall had terminated fatally.
When the rupture was complete, but the child only partly
extruded, a small proportion of the mothers had recov-
ered under vaginal extraction and subsequent drainage,
but unfortunately nearly all of them had afterward been
hopeless invalids. Therefore, if the rupture were com-
pletely into the abdominal cavity, and the woman was not
moribund, he would feel safer on returning home if he
had opened and cleansed out the abdomen, and either
sewed up the rent or removed the uterus according to
the case.
Dr. Reynolds, of Boston, would not agree with the
President that patients who recovered after palliative
treatment were hopeless invalids, as out of four cases of
rupture of the uterus seen by him only one died, three
recovered, and, under palliative measures were healthy
subsequently.
Dr. E. C. Davis thought the thick uterus in multipara
which had ruptured was likely to be friable, very suscep-
tible to infection, offering little hope of union by suture ;
therefore removal of the organ seemed preferable.
Dr. W. M Polk said he felt, when brought before a
case of rupture of the uterus, that he was between the
devil and the deep sea — that is, death of the patient from
sepsis if he did not operate, and death from added shock
if he did. Usually there was already a state of collapse
which forbade a formidable operation. Owing to the
fact that operations per vaginam caused not more than
a third the amount of shock attending approach by the
abdomen, one should, if possible, ligate the vessels from
below, and close the lower uterine rent at least, or per-
haps do hysterectomy from that direction.
Dr. R. W. Murray, of New York, related four cases
of rupture of the uterus, the last one seen with Dr. Coe —
profound shock, laparotomy, death. This case showed
that removal of the uterus (which was not undertaken)
might prove extremely difficult, if not impossible, owing
to the great thickness, oedema, and vascularity of the tis-
sues. Two cases seen in private practice recovered under
palliative treatment. If there was no doubt of rupture
into the abdomen he thought it best to resort to coeliotomy.
Third Day, Thursday, May 31ST.
The Influence of Laceration of the Perineum on the
Uterus and the Operation for its Repair. — Dr. W. Gill
Wylie, of New York, made the following points in
this paper : The main forces which act on the contents
of the abdomen are the muscles, the diaphragm play-
ing the principal part. When we wish to keep the
abdominal contents quiet, the diaphragm and abdominal
muscles are contracted. The axis of the uterus is nor-
mally in line with the forces bearing upon it from above.
When it is displaced backward or forward those forces
strike it broadside and act much more powerfully in
displacing it. The axis of the rectum is at right angles
to that of the anus, so that when the rectum is full it shuts
the anus. The force which most influences the pelvic or-
gans is straining at stool. The perineum tends to keep
the anus in shape with relation to the rectum. Destroy
the perineal support of the rectum and the straining at
stool will force the rectum forward, carrying the vaginal
walls before it, producing so called rectocele. In repair-
ing the perineal injury Dr. Wylie made it one of the
special objects to tilt the so-called rectocele backward
and bring up the depressed sulci, or angles on either side
over the rectocele. It differed from Dr. Emmet's opera-
tion in one regard at least, that is, the area of denudation
was solid, whereas in Emmet's a central portion was left
undenuded. The external sutures, extending to the nor-
mal place of the hymen, did not exceed four in number,
the internal or those above that point being about the
same in number and of silver wire. They were left in
three weeks, in order to give full time for union to occur
in the white fibrous tissue where the lesion had existed
long enough for muscular fibres to disappear. If the
central portion of the area of denudation were left un-
touched it would not prevent return of the rectocele.
Where there was rectocele there were also haemorrhoids ;
hence the necessity for treating these and of stretching
the rectum, a procedure which he believed was commonly
omitted, accounting, in part, for many failures.
The paper was discussed and criticised by Drs. Noble
and Skene. The latter thought no one procedure adapted
to all kinds of tears.
The Ultimate Results of Retro-displacement of the
Uterus by Pessaries, with Special Referenoe to Alexan-
der's Operation. — Dr. Francis H. Davenport, of Bos-
ton, read this paper. The conclusions reached were, that
in cases of uncomplicated retroflexion or retroversion the
choice of treatment lay between the use of the pessary
and shortening the round ligaments. Where the former
was decided upon a cure could be expected in about
twenty- five per cent, of the cases. Where a cure was ef-
fected by pessaries it was usually within a year or a year
and a half after beginning treatment. A large propor-
tion of the patients not cured could still wear a pessary
without discomfort and did not wish an operation. The
Alexander operation should be limited to those cases in
which a pessary could not be worn and those preferring
it to the support ; to cases in which vaginal support was
inappropriate; also as supplementary to other opera-
tions.
Dr. Cushing thought the paper a very judicious one,
although he must differ from some of the conclusions,
He did not think statistics upon cures effected by pessa-
July 21, 1894]
MEDICAL RECORD.
81
ries of any value in the past. He believed with the
reader, that there were few cases of backward displace-
ment which could not be rendered quite comfortable or
cured by pessary, or else there was a complication which
rendered treatment by the Alexander operation inappro-
priate— usually some adhesive band. Therefore in a
large proportion of cases where pessaries were not suc-
cessful it was best to open the abdomen and discover the
cause, rather than do Alexander's operation.
Dr. Clement Cleveland had had very good success
with the retroversion pessary. If a permanent cure
could be effected by it, it would usually take place with-
in a year. At the end of that time he allowed the
patient to decide whether she preferred an operation,
and if the case were a suitable one and the round liga-
ments were shortened by a correct procedure success
would follow in at least seventy -five per cent, of the
cases.
Dr. G. M. Edebohls, of New York, had had less
success in the cure of backward displacements of the
uterus by pessaries than had been claimed by some other
gynecologists, and since his success with shortening the
round ligaments by the method employed by him had
been practically uniform he always resorted to this or
else let the patient go elsewhere for treatment by the
pessary. A number of these had returned, having tired
of wearing the support although it gave no special dis-
comfort ; then shortening the round ligaments, he had
sent them away permanently cured. Of course he was
assuming that the cases were suitable ones for treatment
by either of these methods.
Dr. Gkhrung thought the percentage of cures by
pessary was greater than had appeared from statistics, for
the reason that, when recurrence of the displacement had
taken place some time after leaving off the use of the
pessary, the case had always been placed among the fail-
ures, whereas it might in reality have been a cure with
recurrence due solely to renewal of the cause. While
the pessary might not give that positive result produced
by fixation, it was at least free from the unnatural state
left by this.
Dr. Dickinson, of Brooklyn, impressed the fact that
a permanent cure of uterine displacement could not be
expected so long as women continued their faulty modes
of dress and occupations which involved an unnatural
position of the body, especially of the abdominal and
pelvic organs, and destroyed muscular tone.
Inflammation of the Ureters from a Medical Stand-
point.— Dr. M. D. Mann, of Buffalo, read a paper,
considering in a systematic manner inflammation of the
ureters, its pathology, causation, treatment, etc. His
knowledge of inflammation of the ureters began only a
few years ago when Dr. Kelly, of Baltimore, called at-
tention to the condition; while the disease was still
scarcely mentioned in the text- books, he believed it was
common and was of great importance. Among the
causes he first mentioned injuries during childbed and
related a case. Of ascending ureteritis from bladder
trouble, he had never seen a case except of gonorrhoea!
origin. Yet gonorrhoeal cystitis in .women did not often
attract attention. It was probable that it might lurk in
the ureters after it had ceased in the bladders, for the
reason that treatment was commonly limited to the blad-
der in gonorrhoeal inflammation which had extended to
this organ or higher. Dr. Mann did not doubt but
what failure to relieve pain after coeliotomy was often
due to unrecognized gonorrhoeal inflammation of the
ureters. Where the ureteritis was due to inflammation
extending downward, the cause, according to his experi-
ence, was nearly always the presence of renal calculi or
renal tuberculosis. He believed that symptoms attrib-
uted to pressure upon the bladder by displacement of
the uterus were commonly due to an abnormal condition
of the urine and its influence upon the ureters.
Pressure was recognized by all writers as a cause of
ureteritis, and the author thought no one would doubt
but what a fibroid tumor of the uterus, an ovarian tumor,
and even cancer of the uterus might exert sufficient press-
ure upon the ureters to cause inflammation. But an ab-
normal condition of the urine was, in the author's opin-
ion, the cause of the great majority of cases. In many
the urine was excessively acid and also scanty. While
containing a variety of crystals, the total solids were apt
to be below normal. It was sometimes called the con-
dition of lithaemia, and was frequently brought about by
reflex neurosis affecting the digestive organs, and some-
times by certain foods, strawberries being among those
which acted obnoxiously in some people. Tuberculosis
of the ureters had been occasionally recognized.
The diagnosis rested upon the symptoms, the examina-
tion of the urine, which should be chemical and micro-
scopical, and upon palpation and inspection. In many
instances the ureters could be felt thickened, and on in-
spection, which could easily be made by Kelly's method,
in the area about the vesical openings of the ureters might
be found the seat of granulations or ulcers, irritation of
which by the abnormal urine caused vesical tenesmus.
The treatment was constitutional, local, and sympto-
matic. Constitutional treatment was specially important.
Diet should be corrected, the urine should be rendered
alkaline and increased in quantity, and diaphoresis in-
duced at the beginning. Sandal wood had had a valu-
able influence through the urine, also some other agents
often given internally in gonorrhoeal urethritis. As to
surgical treatment, the author had a few times catheter,
ized and dilated the ureters, but without special result.
Granulations about the mouth of the ureters could be
treated locally. Ureteritis was apt to affect both canals,
but one more than the other.
Drs. Baldy, A. P. Dudley, Willis Ford, Cushing,
and the author participated in the discussion. Dr.
Baldy had seldom found ureteritis, and thought it must
be a rare condition.
Symphyseotomy Versus the Induction of Premature
Labor. — Dr. C. P. Noble, of Philadelphia, read this
paper. Three questions were propounded : 1. Is embry-
otomy upon the living child and deliberately selected a
justifiable operation ? 2. Is it justifiable in labors not
among cases of contracted pelvis, yet in which there is
considerable obstruction making such violent efforts at
version or forceps necessary as to threaten mother and
child, instead of resorting to symphyseotomy? 3. In
contractions of moderate degree is it better to induce pre-
mature labor sufficiently early to permit of bringing forth
a living child, or to let pregnancy go to term and resort
to symphyseotomy, should this prove necessary ?
Regarding the first question, craniotomy on the living
child, Dr. Noble thought it had been answered in the
negative. The problem was not to save the mother alone,
but to save both mother and child by a procedure which
gave hope of diminishing the mortality of both to that
of the mother alone where craniotomy was resorted to.
Dr. Noble also thought the second question would in the
future be answered in favor of symphyseotomy, but he
did not pretend to express anybody's opinion but his
own.
In answering the third question it was necessary to
consider the mortality of mother and child in premature
labor compared with that in symphyseotomy. The gen-
eral mortality to the mother in premature labor had been
given as five per cent.; in symphyseotomy as ten per
cent. Dr. Noble believed, that in both the figures were
entirely erroneous. Five per cent, was undoubtedly too
high a maternal mortality in induction of premature labor
for contraction; it should not be higher that one per
cent, in goocU hands. Ten per cent, mortality for the
mother under symphyseotomy was also entirely too high,
as it represented the results in all cases, and it was well
known that the operation was likely to be put off until
the mother was in very bad condition from use of for-
ceps, etc. In order to compare the safety of the two
procedures only those cases of symphyseotomy should be
included in which it had been an elective operation, re-
sorted to before injuries had been inflicted by forceps,
82
MEDICAL RECORD.
[July 21, 1894
etc. The maternal mortality from symphyseotomy under
favorable circumstances should be very low. The advan
tages to the child over premature labor were striking, for
many premature children died at birth, and many more
succumbed afterward. The author narrated a case which
he had reported before, the first one in the world in
which symphyseotomy had been resorted to in preference
to premature labor, and the first one in the United States
in which the patient had submitted to a second symphyse-
otomy at a subsequent pregnancy.
The views of the author were substantially agreed with
by Drs. R. W. Murray, Charles Jewett, Engelman, and
Malcolm McLean.
Officers : Dr. M. D. Mann, of Buffalo, was elected
President ; Dr. H. C. Coe was re-elected Secretary. The
date of the next meeting will be the fourth Tuesday in
May, 1895. Place yet to be decided upon.
AMERICAN SURGICAL ASSOCIATION.
Fifteenth Annual Meeting, held at Washington, D. G,
May 29, jo, jr, and June f, 1894,
(Continued from Vol. 45, page 800 )
Third Day, Thursday, May 31ST.
The Sargical Treatment of the So-called Surgical Kid-
ney.—Dr. R F. Weir, of New York City, read a paper
on this subject. He reported the case, he said, in order
to show that the prognosis is not always as bad as we
hitherto thought it. The case was that of a young man
who had an attack of pneumonia some four years ago,
followed by scarlet fever and nephritis. Albumin and
casts persisted, and he never regained his health.
Two months ago he had an attack of urethritis. Gon-
ocjcci were present in great numbers. It subsided under
treatment of creoline, silver nitrate, and zinc sulphate solu-
tion. Twelve days prior to his admission to the hospital,
without any assignable cause, he had a chill, preceded by
a temperature of 1010 F., with vomiting and diarrhoea.
The next day he had pain in the loins, which was thought
to be lumbago, but on the next day there was great ten-
derness over the right kidney.
During the seven days between his admission to the
hospital and the operation, he had four chills, with tem-
perature ranging from 1030 F. to 1050 F., pulse 116 to
120. He passed fifty to sixty ounces of urine daily. It
contained pus. It was thought enlargement of the right
kidney could be made out, but I thought it was an ab-
scess. I did not think he had the ordinary condition
known as the surgical kidney.
Operation. — An incision was made and the kidney ex-
posed. It was twice its ordinary size. It was deeply
congested and swollen, particularly on its inferior sur-
face. Puncture with the aspirating needle gave no indi-
cation of pus, but an incision revealed the nature of the
disease. It disclosed numerous miliary abscesses. The
kidney was rapidly removed and the wound packed with
iodoform gauze.
Result. — Immediately after the operation the temper-
ature dropped from 1050 F. to 990 F., and then remained
subnormal for a few days. The patient made a rapid re-
covery, and was discharged from the hospital three weeks
later. At the time of his discharge the urine was nearly
normal, and no treatment was advised beyond spending
as much time in the open air as possible.
How often Does such Unilateral Renal Trouble Exist?
— The first question this case would naturally suggest to
all surgeons, is how often may such a fortunate condition
of affairs be found in cases of surgical kidney ? That
this form of nephritis is sometimes limited to one kidney,
is beyond doubt. The statistics of one man show that out
of one hundred and thirty cases of surgical kidney, nine-
teen were unilateral. From the hospitals of New York,
out of seventy-one cases of miliary abscess, both organs
were affected in fifty- nine, and only one organ in twelve
cases, or about twenty per cent, of these cases, might have
been treated successfully.
Future Prognosis. — The speaker could not help feeling
more hopeful in the treatment of these cases than in the
past. Even where both organs are involved, something
should be done in the way of evacuating the pus. Where
the patient's condition warrants it, and especially when
there are symptoms pointing to one side, it is justifiable
to make exploratory incisions on one or both sides.
Surgery of the ureters. — Dr. Christian Fenger, of
Chicago, read the paper.
Discussion. — The papers read by Drs. Tiffany, Weir,
and Fenger were discussed together.
Dr. Richardson, of Boston, said the examination of
the urine prior to operation was most important, as it was
often the deciding point in doing operations which were
not absolutely necessary. In removing a kidney he
would prefer to go through the abdomen, which gave you
a better opportunity to avoid or control hemorrhage.
The incision should be large enough to permit the exam-
ination of both kidneys. This would also avoid the dan-
ger, in unilateral trouble, of removing the only kidney
the patient might possibly have.
Dr. Mudd, of St. Louis, thought the low temperature
and the quantity of urine passed to be a better indication
than albumin or casts. He also thought as much of the
kidney as possible should be saved, as the kidney had
great reparative power ; also, that it was disastrous to re-
move the kidney immediately after an injury, before the
patient had recovered from the shock of the accident.
He thought it was very difficult to determine by handling
whether you had good kidney material or not. He did
not approve of the abdominal incision, unless you were in
doubt about the other kidney, as hemorrhage could be
controlled just as well from behind.
Dr. Nancrede was opposed to the abdominal opera-
tion, owing to the danger of infection from the pus which
might possibly escape into it. He insisted upon being
sure the patient had two kidneys before removing one.
Dr. Carmalt, of New Haven, said in searching for
both kidneys you should bear in mind the abnormal po-
sitions which may exist. In one post-mortem case he
found the left kidney low down in the pelvis, and in this
case a possible mistaken diagnosis of one kidney might
have been made.
The paper was further discussed by Drs. Prewitt,
Deever, of Philadelphia; Gaston, of Atlanta; Fenger, of
Chicago ; and Forbes, of Philadelphia. The last-name^
gentleman exhibited an indigo stone weighing one hun-
dred and forty-seven grains, with the interesting state-
ment that the patient had no renal symptoms, showing
an unusual tolerance by the kidney of such a large for-
eign body.
Treatment of Malignant Tumors with the Toxinei of
Erysipelas. — Dr. William B. Coley, of New York, read
the paper. He began this treatment of multiple sar-
coma by repeated injections of living cultures of erysipe-
las streptococci in 1891, and gave the account of ten
cases. Six were sarcoma and four carcinoma.
In four cases erysipelas was produced, but the marked
improvement in the cases where erysipelas was not pro-
duced led the speaker to believe that the curative action
was due to the toxines, rather than to the germ itself.
In 1892 he experimented with bouillon cultures pre-
pared by heating to ioo° C, and the effect was slightly
less than when living cultures were used.
Early in 1893 he began using cultures filtered through
porcelain without subjecting it to heat. The toxines of
the bacillus prodigiosus prepared in the same way were
used in conjunction with the erysipelas toxines which in-
tensified the action of the erysipelas toxines on the sar-
coma, and was much more effective than that of the ery-
sipelas toxine alone.
Toxine Must be Fresh. — The toxine to be of value
must be freshly prepared from very virulent cultures.
All successful cases were from cultures made from fatal
cases of erysipelas.
Results. — Of twenty five cases of sarcoma treated, six
were cured without any recurrence; nine showed marked
July 21, 1894]
MEDICAL RECORD.
83
improvement ; eight, improvement slight ; and two, no
improvement.
Of eight cases of carcinoma, all but one showed more
or less improvement, and in three cases the improvement
was marked.
The diagnosis of all these cases was established by em-
inent surgeons and pathologists.
How do the Toxines Cure ? — No rational explanation
of the action of the toxines on malignant tumors can be
offered, except on the assumption that such tumors are of
micro-parasitic origin. Admitting this theory, explana-
tion would be easy, viz.: antagonistic bacterial action.
The following were the conclusions of the paper: 1.
The curative action of erysipelas upon malignant tumors
is an established fact. 2. The action is more powerful
upon sarcoma than carcinoma. 3. The action is chiefly
due to the soluble toxines which may be isolated and
used with safety and accuracy. 4. The action is greatly
increased by the addition of the toxines. 5 . The toxines,
to be of any value, must be fresh and from virulent cultures.
6. The results obtained from toxines, without danger, are
nearly so, if not quite, equal to those obtained from a fresh
attack of erysipelas, and inoculations should rarely be re-
sorted to.
Dr. Keen, of Philadelphia, had treated seven patients
in the same way and manner, but in not one of these
cases had there been even an arrest of growth. He had ob-
tained reactions as high as 103 ° to 1040 F., while in some
cases no reaction took place. He injected in the tissues
in some cases, and directly into the tumor in others.
In one case there was a breaking down of the growth,
but when the use of the toxines was discontinued, the
case went on rapidly. He had never seen any harm done
further than the rise of temperature. As his experience
with the toxines had been limited, he could not hope to
obtain as good results as Dr. Coley.
Dr. Park, of Buffalo, had inoculated cases with erysip-
elas from patients in the hospital wards, without results.
He got some culture from Dr. Coley, but the results were
no better than those obtained by Dr. Keen. He thought
it a case of different men working in the same manner
and obtaining different results, the most experienced get-
ting the best results.
Dr. Warren's experience was similar to that of Drs.
Keen and Park, but thought the subject should be en-
couraged in every way, and conclusions should not be
jumped at. The question of the character of the reaction
he thought an interesting one. It was thought, where the
injection was in the tissues, a fatty degeneration of the
cells of the sarcoma took place, but when the tumor was
injected it was a necrosis. It should also be remem-
bered that all the cases were selected as inoperable.
Dr. Richardson stated that one of the successful cases
was sent by him to Dr. Coley. In this case there was no
doubt whatever about the nature of the disease, and with-
out this treatment the patient would have died. The
case was a perfect cure.
Venous Tumor of the Diploe was the title of a paper
read by Dr. L. S. Pilcher, of Brooklyn.
History. — The patient, a girl, fifteen years of age, at
the age of five, fell, striking on the top of her head. In
a few days afterward a small, soft swelling appeared, grad-
ually increasing in size, causing no pain or tenderness.
At the end of five years it was lanced and a small quan-
tity of blood evacuated. The swelling immediately re-
filled. It was lanced again in a few years afterward, with
similar results. Nothing further was done until her ad-
mission into the hospital.
When admitted she presented a tumor over the anterior
fontanelle. It was covered with a thin skin, devoid of
hair, and of a bluish hue. It was soft and fluctuating, and
diminished slightly under pressure. It had been enlarg-
ing and was on the point of bursting.
Operation. — On March 14th the tumor was incised.
It consisted of a small blood-clot and fluid blood. The
tumor was fed by several channels leading from the veins
into it. Hemorrhage was controlled by pressure and
tampons. The entire cavity was thoroughly curetted and
tamponed with gauze, and the opening sutured.
• The interesting feature of this case is the fact that it
was not a dilatation of any blood-vessel, but a true trau-
matic tumor; being an adventitious blood-space fed by
channels from the blood-vessels.
Strangulation of Meckel's Diverticulum. — Dr. J. W.
Elliott, of Boston, reported the case. The interesting
features were the symptoms presented by the patient, all
of which pointed to appendicitis. Under manipulation
a large, hard mass was felt in the abdomen. A vertical
incision was made in the abdomen, and the appendix
found to be normal, and the true nature of the trouble
revealed. The patient subsequently died from septic
peritonitis.
The paper was discussed by Drs. C. Fenger, of Chica-
go ; Tiffany, of Baltimore ; and White, of Brooklyn,
N. Y. In the discussion attention was called to the fact
that a tumor near the umbilicus should direct attention
to the diverticulum.
The. Removal of Stone in the Bladder. — Dr. W. S.
Forbes, of Philadelphia, read a paper on this subject and
presented a new lithotrite. Given the problem of a stone
in the bladder, a limited viaduct through which to reach
and remove it without injury to the parts, we have two
unknown factors, viz. : the crushing resistance of the
stone, and the strength of the lithotrite.
Crushing Resistance — How Obtained. — The exact
crushing resistance of a stone has never been stated by
any writer, except in vague terms, as tough, etc. The
same may be said of the description of the strength of the
lithotrite, as strong, powerful, etc., all oT which mean
anything and nothing.
In order to attain the necessary knowledge in the ques-
tion, it is necessary to measure the crushing resistance of
a large number of stones taken from the human bladder.
The conditions of science should be weighed, as it were,
in the fine scales of the jeweller. A very large number
of stones were tested in the lithotrite, which was placed
in and worked by a very powerful machine, so delicately
and accurately constructed and adjusted that every ounce
of force applied in crushing the stone was recorded.
The New Lithotrite has all of the elements contained
in the Bigelow and Thompson, but the construction and
general lines of it, however, are entirely original and
widely different from any lithotrite now in existence.
The penile and vesicle ends consist of a male blade sliding
within a female blade and held within the latter by a
slightly angular undercut slot. This prevents the male
blade rising out of the female blade when under a strain.
The greater the strain the tighter it is held.
The long axis of the shaft is straight to within two
inches of the crook or curve, and here rises to an
angle of about three degrees until it meets the curve.
This accomplishes six important objects: easy intro
duction of the instrument over the urethra; increases
strength of female blade by giving it support higher
up; allows a larger stone being grasped without in-
curring a longer female blade ; places the metal of the
female shaft where it is most needed; prevents side
movement or twisting of the male blade by giving it a
deeper slot to move in, thereby supporting it higher up ;
the angle between the female blade and the long axis of
the shaft is the same as if the shaft was straight all the
way to the curve ; the female blade has its proximal sur-
face concave and prevents calculus slipping out when the
power is applied, and tends to give strength to the instru-
ment ; it is elliptical and uniform in size to within three
inches of the crook, and here increases slightly in calibre
until it reaches the maximum, which is at the crook, giv-
ing great strength to the female, where it is most needed,
and places the extra metal within the bladder and pros-
tatic portion of the urethra, where it is easily accommo-
dated.
The shoe of the female blade is larger than the male
blade, so that all debris is expelled and impaction of the
instrument is prevented, and the wall of the bladder pro-
84
MEDICAL RECORD.
[July 21, 1894
tected from being cut or pinched. The female blade
is elliptical, giving thick septum, without increasing the
calibre of the shaft. The female blade is made thin fore
and aft, taking up less room in the bladder. The proxi-
mal surface of the female blade is in the form of a wedge
of about forty five degrees, in order to penetrate the calcu-
lus with the least power of propelling force. The cross
ridges on the proximal surface of the male blade prevent
the stone flying when broken, and the parallel spillways
permit the debris to escape without causing impaction of
the instrument. The spur rises to a greater height on
the male blade, to give it greater strength. This spur
interferes in no way with the holding of the stone, if it
does not touch it. The great breadth of the septum of
the female blade is permitted by the elliptical shaft.
Handle or Screw Mechanism. — The handle or screw
mechanism is of the interrupted screw type. It consists
of the internal screw throughout the barrel having the
threads cut away for the entire length of the barrel at
alternate spaces of ninety degrees each.
The screw barrel has an end movement in the cylindri-
cal barrel of about one-sixteenth inch. Working In this
barrel is a pair of screw blocks with interrupted screw
threads alternating spaces of ninety degeees each, so that
they may slide up and down the barrel without engaging,
but by turning the handle they engage immediately.
One screw block is rigidly keyed to the screw handle
shaft, and the other so formed that it has a motion of
ninety degrees around the handle shaft. When turned
to the right it locks or engages. When the calculus is
crushed, the instrument may be unlocked simply by
turning the handle to the left until it stops, which is
never more than half a turn.
Owing to the one sixteenth inch play of the screw
barrel, the cylindrical handle readily adjusts itself to en-
gage the threads of the screw block, and the calculus is,
therefore, never dropped, in order to locate the instru-
ment.
Slow Thread. — The screw thread is made slow to in-
crease the crushing strength and for the important factor
of time. A certain pressure may be applied to a stone
without crushing it, which, if allowed to remain acting
upon the stone for a short time, will crumble it without
further pressure, and thus the instrument is not unduly
strained The screw handle is larger than the ordinary
one. It is made of very thin sheet metal ; strong and
light as the lightest handle now employed.
The instrument has broken one hundred and fifty-
eight calculi, of various shapes, sizes, and degrees of
hardness in the testing machine, and been subjected to a
pressure of five hundred pounds between the blades thir-
teen times. Its ultimate strength after this trying or-
deal was six hundred and fifty pounds. Moreover, after
this enormous pressure, the instrument was closed and
could have been introduced and withdrawn from the liv-
ing human bladder with ease, and without injury to the
parts.
Extirpation of the Larynx. — Dr. W. H. Carmalt,
of New Haven, read a paper with this title, dealing
chiefly with the after effects. He operated with the idea
of doing away with the opening into the mouth. Many
had doubtless seen the case of a man whose larynx was
taken out, who was afterward able to sing and speak ;
and this, without any communication between the mouth
and lungs. The opening of the trachea being directly
above the sternum. The man swallows a certain quan-
tity of air and makes a little puffing around the trachea ;
holding this for a few moments he is enabled to speak.
He is able to count up to twenty when he stops and re-
fills his mouth with air. In the speaking case, it was de-
termined to close the upper opening in extirpating the
larynx.
History of the Case. — Two years ago the man com-
plained of hoarseness. Examination revealed only a
swelling of the right vocal cord. He passed out of ob-
servation until four months before the operation, when
he again came under observation with a distinct swelling
of the vocal cords and the parts above. He again passed
out of observation until about two weeks before his ad-
mission to the hospital, when he was threatened with suf-
focation.
The attacks of dyspnoea, under local applications, be-
came less until after five days, when he had an attack of
dyspnoea one night that required tracheotomy to prevent
death. His symptoms subsided, and we were able to wait
and prepare for the necessary steps of the operation.
Operation. — The entire larynx was involved with a
cancerous growth which extended to the trachea, which
condition was not revealed by the laryngoscope.
The entire larynx, together with the first ring and up-
per half of the second and third rings of the trachea, were
removed and the opening into the mouth closed. The
epiglottis was not removed.
Result. — The day following the operation he was able
to swallow his food.
The operation was performed on the 5th day of April,
and his recovery has been uninterrupted. He is achiev-
ing a voice, though it is a poor one. He is able to whis-
per.
The principal object of this paper is to call attention
to the fact that an artificial larynx is unnecessary.
Dr. Forbes called attention to the patient who had
been operated upon in Philadelphia, and said the patient's
ability of speaking was due to his ability of keeping the
air in his throat, on the same principle as the Scotch bag-
pipe j and by practice he will improve in both length
and quality of speech up to a certain point. He cannot
vary his voice, such as elevate or depress it The note
is no more than the same as the bagpipe ; a monotonous
drone, but it is superior to an artificial larynx.
Dr. Hingston, of Canada, said one man had his
tongue removed, and could speak ; another had his jaw re-
moved and could speak ; and now here is a man without
a larynx and also able to speak. He thought it difficult
to say which was the principal organ of speech.
The President closed the session with a short farewell
address, and the meeting adjourned until its next annual
meeting, to be held in New York in the spring of 1895.
The following officers were elected for the ensuing
year: President, Dr. F. S. Dennis, of New York; Vice-
Presidents, Drs. D. J. R. Weist, of Richmond, Ind., and
J. B. Roberts, of Philadelphia; Secretary, Dr. M. H.
Richardson, of Boston ; Recorder, Dr. DeForrest Wil-
lard, of Philadelphia ; Treasurer, Dr. N. P. Dandridge,
of Cincinnati.
AMERICAN PEDIATRIC SOCIETY.
Sixth Annual Meeting, held in Washington, D. C, May
*9> 3°> 31* and June 1, 1894.
(Continued from Vol. 45, p. 770.)
Third Day, Thursday, May 31ST.
Dr. F. Forchheimer in the Chair.
The Vutritional Element in the Causation of Venroses.
— Dr. Christopher, of Chicago, read a paper with this
title. He began his remarks on the triad of hereditary,
anaemia, and local reflex causes, as given by Rachford.
But as neuroses often occur in those not anaemic, i.e.,
oligocythemic, the term malnutrition is preferable.
The chemical composition of the nutritional supply may
be at fault.
As a definition " a neurosis is a group of phenomena
resulting from abnormal action or nutrition." It may
be due to : 1, Chemically abnormal nutrition ; 2, physi-
cally abnormal, as heat or cold ; 3, a toxine ; or 4, occur
under improper trophic influences. Such tissue starva-
tion may be due to deficient quantity of nutrition or a
food incomplete in parts of its composition, e.g., fat-
starvation = rickets ; starvation of salts = scorbutus.
Not all proteids are equally available in digestion, but
milk gives several, all of which are readily convertible.
Complete and incomplete starvation of tissue may coex-
ist Hence we have physiological starvation. We may
July 21, 1894]
MEDICAL RECORD.
85
also have pathological starvation from syphilis, tubercle,
etc.
The author counts the sweating of rickets a neuro-
sis of fat- starvation. Under heredity he says, atavism,
morphologically, is of no account, but chemically it
gives rise to clashing of functions resulting in lithsemia,
for example. Neuroses are due to perverted action, but
as this may occur in various tissues, the term " histoses "
is suggested.
Dr. Rotch endorsed the conclusions regarding fat-
starvation and said that he was making careful analyses
of the salts of milk, which he hoped would prove of much
value in our understanding the management of rickets
and scorbutus.
A Case of Cyanosis. — Dr. William P. Northrup, of
New York, exhibited the heart of a case of congenital
cyanosis, which lived to four and a half years notwith-
standing severe attacks of measles and pertussis. The
heart showed a narrow pulmonary artery, an opening
between the right ventricle and auricle, and hypertrophy
of the right ventricle. The cornus arteriosus was oblit-
erated, the foramen ovale closed. As symptoms the child
had the typical sluggish peripheral circulation, clubbed
fingers, constant dyspnoea, and a purring thrill over the
base of the heart with a systolic murmur in the left third
interspace. The trouble appeared due to early foetal en-
docarditis.
The question for discussion was whether cyanosis, a
symptom, should continue as a name for a disease.
Most of those present seemed to favor calling such cases
malformation of the heart, abandoning the term " cya-
nosis."
nomenclature of Diseases of the Mouth and of the
Gastroenteric Traot. — The committee on revision of
this subject presented its report through the chairman.
The report was adopted, and will appear in full later
in the Archives of Pediatrics. The idea in the revised
nomenclature is to eradicate old and useless names, and
to adopt a nomenclature such as will enable men in dif-
ferent parts of the world to understand what each is
writing about.
Election of Officers. — The following officers were
elected : President, Dr. F. Forchheimer, of Cincinnati,
O. ; First Vice-President, Dr. Lewis Starr, of Philadel-
phia, Pa.; Second Vice President, Dr. August Seibert, of
New York City ; Secretary, Dr. Samuel S. Adams, of
Washington, D. C. ; Treasurer, Dr. C. W. Townsend,
of Boston, Mass.; Recorder, Dr. Dillon Brown, of New
York City; Member of Council, Dr. B. K. Rachford.
The Early Diagnosis of Pott's Disease. — Dr. Dillon
Brown, of New York, then presented a long and thor-
ough study of "The Early Diagnosis of Pott's Disease
of the Spine in Children.' ' The author went carefully
into the differential points between this disease and
others simulating it, or remotely connected therewith.
He cited many cases in which the patients had been
treated for dyspepsia, peritonitis, cold abscesses, rheu-
matism, paralysis, etc., the real lesion remaining long
unrecognized or being only found upon autopsy.
On the other side, cases were recorded having a diag-
nosis of spinal caries, which proved to be sarcoma of
bone, a glioma of cervical medulla, and the like. As
nearly all these cases were reported by men of large ex-
perience, it shows the necessity of great care and exact-
ness in diagnosis as well as treatment. The disease is
now recognized as a chronic tubercular lesion of the
vertebra, and as ninety per cent, of cases occur in child-
hood, we must be on our guard. The presence of syph-
ilis or traumatism as a cause must be sought for. Rheu-
matism is to be excluded by treatment if the symptoms
are uncertain.
Fourth Day, Friday, June ist.
Infantile Myxedema. — Dr. William P. Northrup, of
New York, read the paper, which was a preliminary report
of two cases being treated by thyroid extract. In future
further account will be given of their progress. The
first, a girl, nine years of age, was of good family history,
the parents non consanguineous. She had lived in Ohio
and Pennsylvania. She had grown none since nine months
of age, and had but fourteen deciduous teeth. She pre-
sented the usual characteristics of cretins, puffy look,
parchment like skin, flat nose, swollen tongue, protuber-
ant belly, and umbilical hernia. She could say only one
word, but was of lively disposition. This child was
treated for eighty days with glycerine extract of sheep's
thyroid. The dose, one minim, three times a day, in-
creasing a minim a day until the temperature remained
at ioo° F. At the end of eighty days the child was
much improved, taking more food, and having a brighter
countenance.
The second case was twelve years of age. The same
treatment was employed, but the results were less marked.
Successful Treatment of Infantile Myxcedema — Dr.
Osler, of Baltimore, then read a paper with this title.
Case I. was a boy, aged four years and eight months, who
took one quarter of the thyroid gland of a sheep each
twenty- four hours. After a time this was administered
desiccated. In fourteen months the boy grew four
inches, an unusual increase. He now walks and runs
about, and has gained so much mentally that few would
think him " queer.'1 The myxedematous appearance is
all gone.
Case II. was a male, aged nineteen, who made no
material gain, partly because treatment was omitted for
three months.
The third case was lost track of.
In discussion Dr. Carr referred to Dr. Crary's case,
which is growing rapidly and gaining mentally.
Dr. Forchheimer related three cases under his ob-
servation. In the first patient, a boy, aged nineteen,
the thyroid extract had to be discontinued because of
the maniacal excitement it produced. A second case,
aged eleven months, is improving on the extract. In
Case III., aged four years, there is no change. The
treatment gives promise of benefit, therefore, but is not a
certain cure.
Acute Pyelitis in Infants. — Dr. L. Emmet Holt, of
New York, read a clinical paper on the above topic.
Acute pyelitis may follow any other acute disease. Case
I. was a child, eight months old, nursed. It suddenly
had a temperature of 103.5 ° without any discovered local
cause, pneumonia was suspected. The urine was collected
in a two ounce conical glass and showed three quarters of
an inch of pus and a trace of albumin ; there were no
casts, nor was any treatment instituted. The child is
now well.
Case II. was a female child, aged eight months, who
had been nine days ill. The temperature ranged from
1030 to 1060 F. Symptoms all negative but pneumonia
suspected as before. On the eleventh day the urine
showed pus and albumin with bladder epithelium, but no
casts. There was no dropsy. Two days later the urine
contained-eight per cent, of pus. The child took twenty
grains of citrate of potash daily, and in three weeks all pus
had disappeared.
Case III. was aged nine months ; previously never ill.
The child had repeated chills in one day and a tempera-
ture reaching 1040 F. in the rectum. Between chills the
temperature would fall to normal and all appear well.
Two grain doses of quinine were given every three hours.
On the fourth day the child took fourteen grains of qui-
nine. Little urine was passed, and that with pain. It
contained one-fifth pus and a little albumin ; specific
gravity, 1. 01 2. On the sixth day sixteen ounces of urine
was passed without irritation of the bladder. However,
the child took but half its usual amount of food. The
irregular fluctuations of temperature continued and a few
granular casts were found in the urine. Although the
spleen was at no time enlarged, Dr. Ripley, the con-
sultant, advised more quinine hypodermically. Eighty
grains were thus administered in seventy- two hours
without bad effect. The chills and fluctuation of tern-
86
MEDICAL RECORD.
[July 21, 1894
perature were stopped. Lithia water and hot fomentations
were used as treatment. The urine now was alkaline in
reaction, sp. gr., 1.007, contains albumin, 3.6 grains
of urea per day, a few red and many white blood-cells,
with bladder epithelium.
In review the author noted that the first case was mild
and recovered without treatment. The second case had
a temperature about 1050 F. for twelve days, not affected by
quinine. Though the temperature was higher there was
little prostration. This case occurred during the influ-
enza epidemic, and had no suspicion of malaria about it.
The etiology of Case III. is doubtful ; was it septic or
malarial ?
Dr. Osler mentioned a case, three years of age, who
had recurring chills several months. After each chill the
urine would be turbid, acid, and full of pus. Although
the spleen was not enlarged, the boy had been saturated
with quinine. Treatment was thought of no further
avail, but the boy having a phimosis, the father wished
that remedied. There was no return of the attacks after
the circumcision. The speaker believes that malaria may
be excluded without a blood examination.' It is a rule
that a fever that resists quinine is not due to malaria.
Dr. Seibert suggested vulvo vaginal catarrh extending
into the bladder or farther and causing suppuration.
Dr. Holt, in closing, said it had been his fortune to see
a number of cases of purulent infiltration of the kidneys,
all of whom died. Such cases were quite distinct from
pus in the pelvis of the kidney. The absence of mucus
and of alkalinity assures the case not being cystitis.
Giant Fingers. — Dr. F. Huber, of New York, ex-
hibited a plaster cast and photograph of such a case. The
most enlargement and distortion was of the second fin-
ger.
Medical Septicaemia in Children was the subject of an
address by Dr. W. S. Christopher of Chicago. He
spoke in part as follows : We all see many cases of fever
which do not fit the description of typhoid, malaria,
influenza, or scarlatina. This term is not a scapegoat,
but a term under which these endemic fevers may be
classed until we can properly differentiate them one from
another. Medical septicaemia indicates that it is non-
traumatic. The case was then cited of a child, aged
twenty months, who had a diarrhoea of three weeks. The
temperature was 105° F. but erratic. Scarlatina was
ruled out in a few days, typhoid fever also. Two days
later it seemed surely to be peritonitis. The peritoneal
cavity was then irrigated with a sterile normal salt solu-
tion. The following day pneumonia developed, but all
was recovered from. Here it is fair to infer that the
same micro organism caused the inflammation of bowel,
peritoneum, and lung, whether appendicitis or no mat-
ters not.
In a recent epidemic of twelve such cases three had
laryngismus stridulus, followed by fever for two weeks
and indigestion. Eight similar cases occurred which
must be grouped, and medical septicaemia is a generic
name that suits. Some forms of dysentery would belong
here, but not the amoebic dysentery.
Dr. Caille said he should think it difficult to distin-
guish between a medical and a surgical septicaemia.
True, it might be often hard to locate the source of infec-
tion, but having located it treat accordingly.
Dr. Fruitnight thought such a nomenclature should
be deferred until the cases are differentiated.
Dr. Holt believed that many such fulminant cases
would upon autopsy prove to be pneumonia.
Dr. Adams considered the term evasive rather than
helpful, and thinks most such cases as described are atypi-
cal typhoid.
Dr. Christopher, in closing, declared that an ana-
tomical diagnosis is useless, for we cannot know always
without autopsy. He therefore felt that there was need
of the class medical septicaemia.
Mirror Writing.— Dr. George N. Acker, of Wash-
ington, exhibited a nee;ro boy, aged ten, who is natural-
ly a mirror writer. He writes equally well with either
hand, the left beginning on the right side of the paper
with the letters slanting to the left. In playing marbles
the boy's left hand is the surest. The patient's personal
history and heredity were negative. His mind is quick
and he is rather cunning.
Before closing Dr. Forchheimer made a few remarks
thanking the Society for the honor they conferred in
electing him President for the coming year, and with best
wishes " auf wiedersehen " adjourned the meeting to next
year at Hot Springs, Va.
AMERICAN DERMATOLOGICAL ASSOCIA-
TION.
Eighteenth Annual Meeting, held in Washington, May
29> JO, 31, and June i, 1894.
(Continued from Vol. 45, page 764.)
Second Day, Wednesday, May 30TH.
Adeno carcinoma of the Skin Starting in the Sweat-
glands. — Dr. Fordyce, of New York, exhibited micro-
scopic specimens and photographs showing the structure
of the malignant growth. He stated that, although a
number of pathologists had claimed a sweat-gland origin
for certain clinical varieties of skin cancer, only a few
cases were on record in which such a point of departure
had been proven. In the case in question, the new-
growth is a proliferation of the columnar cells lining the
sweat-glands, which broke through the membrana propria
and infected the surrounding connective tissue. The
tumor was removed from the leg of a man, thirty-five
years old, and was about two- thirds the size of an egg.
Dr. Fordyce also demonstrated the intra-cellular bodies
which are looked upon by many as the cause of cancer.
He expressed himself as a believer in the parasitic nature
of cancer, but was not prepared to admit that its etiology
had yet been made clear.
Dr. Hartzell said that the essential characters of the
cells were not changed. He believes the disease to be
of parasitic origin, and that the growth of the cells was
more rapid when the parasites were in greater number.
Dr. Bronson asked whether the origin in the sweat-
glands had any effect upon the induration of the lesion.
Dr. Fordyce replied that he had found such epitheli-
omas to be quite soft.
Contagiousness of XoUuscnm Contagiosum. — Dr.
Stelwagen, of Philadelphia, read a paper on this ques-
tion. He quoted a large number of clinical examples of
the communicability in households and in institutions.
Among others, that of a nurse who had received the dis-
ease from a child, who had received it from another nurse.
The latter had given the disease to other children. He
quoted an example where there were three cases in one
family who had infected a young friend who played with
them. Also the case where there was an eruption in a
man and his wife about the genitals. A case where a
brother and sister used the same towel and were both in-
fected. He gave a very exhaustive rtsumS of the re-
ported cases of the contagiousness of the disease. In an
epidemic in a hospital for children, two weeks after the
first case was observed, there were forty-one cases in the
hospital. The long period of inoculation is remarkable.
He doubts whether the psorosperm is the cause of the dis-
ease.
Dr. Fordyce believed the disease due to an animal
parasite, probably the psorosperm.
Dr. Hartzell believed in the etiological relation of
psorosperms and this disease.
Dr. White thought that there had been no demon-
stration that the bodies found in the cells were parasitic
and introduced from the outside.
Ichthyosis Congenita (so-called Harlequin Foetus). —
Dr. Sherwell, of Brooklyn, reported a case of universal
ichthyosis in an infant. The parents were absolutely
healthy and had two other children, both healthy. The
child was born at term and weighed two pounds. The
whole surface of body was covered with soft, horn like
July 21, 1894]
MEDICAL RECORD.
87
scales. The scales on the head were more sebaceous.
The flexures were deeply fissured. The mucous surfaces
were only slightly affected. There was slight ectropion.
Alkaline baths and inunctions of vaseline and ung. aq.
rosae were employed in the treatment. When bathing
and inunctions are neglected, extensive scales form on
body. The child has been much improved by the treat-
ment.
Protozoa-like Bodies of Herpes Zoster ; a Contribu-
tion to the Study of Psorothermosis. — Dr. M. 6. Hart-
zell read a paper on this subject, in which he called at-
tention to the bodies resembling protozoa in zoster, vari-
cella, and variola. Pfeiffer was the first to describe them
as protozoa, and thought they gained access by the inter-
costal vessels. There were three varieties. These
bodies have a cell body proper, an internal capsule, and
a cavity containing several small oval bodies. The sec-
ond variety is much larger than the first. The body of
cell stains feebly. The internal capsule stains deeply.
Some of the bodies are found free and show amoeboid
movements. He found in a case of recurrent zoster the
same alterations as in ordinary zoster. He thinks we
have a metamorphosis and increased vital activity of the
epithelial eel If.
Third Day, Thursday, May 31ST.
Angioma Serpiginosum. — Dr. J. C. White, of Boston,
read a paper entitled " Angioma Serpiginosum and Some
Other Dermatoses.1'
In the case of angioma serpiginosum, from the border
of right scapula to nipple there were twenty-four le-
sions of pin- head size and of a red color. They disap-
peared partially under. long pressure. These lesions in-
crease in size and finally undergo evolution in the centre,
the border forming circles or segments of circles. The
skin in the centre appears normal except the red color.
New foci appear and follow the same course. The dis-
ease spreads in an annular manner for an indefinite period,
and appears as pale scar- tissue surrounded by scarlet
rings.
The writer said that small aggregations of cells are
found in the corium in this disease, which are unlike the
round granulation cells. Small places in vessels were
found filled up with small granular masses, resembling
amoeboid forms of lower organisms. There seemed a fu-
sion of degenerated cells in the nodules which appeared
to undergo degeneration by the strangulation of the blood-
vessels. The pathological anatomy of this disease has a
great resemblance to that of the pigmented moles.
Acquired Idiosyncrasy for Quinine Showing Peculiar
Cutaneous Manifestations. — Dr. Charles W. Allen,
of New York, read a paper with this title. He said that
the most frequent eruption caused by this drug is an
erythematous rash beginning on the face and extending
over the whole surface. Other usual forms are the urti-
carial and papular, while the vesicular, bullous, and pur-
puric are less frequently seen.
In the case reported by Dr. Allen the subject had
previously been able to take quinine in moderately large
doses without ill effects. The peculiarities of the case
reported are: 1. That the eruption is developed by a
very small quantity of the drug ; 2. That the lesions are
local and show no tendency to spread ; 3. That the lo-
cation of the individual spots is always the same. 4.
That the eruption was produced four times accidentally
and fourteen times experimentally. The writer says that
the simple erythema of one attack may in another attack
closely simulate an erythema exudativum multiforme.
The patient, in the case reported, took a five-grain dose
of the sulphate of quinine at bedtime. During the
night a general pruritus developed, and in the morning
large erythematous blotches were found on certain parts
of the body — on the next morning the prepuce pre-
sented large excoriated surfaces suggestive of chancroids.
The rest of the glans and prepuce was red and sensitive.
The quinine was discontinued, and in about a week the
spots desquamated and faded in color. Some months
later the patient having taken one " Monsette " pill, not
knowing that it contained quinine (about one grain) de-
veloped within twelve hours itching, burning, and prick-
ling sensations, and the same spots appeared as before.
The whole prepuce was again excoriated. He developed
the same symptoms in the same year after taking a cor-
dial glass of coca wine, although in a less pronounced
way. The quantity of the drug was exceedingly small.
In this patient, a few hours after taking about one third
of a grain of quinine, the glans penis was surrounded by
a ring of redness and the same spots as before developed
on the body. Dr. Allen experimented with various salts
of quinine, such as the hydrobromate, the hydrochlorate,
the bisulphate, dextro quinine, and the bimuriate with
urea. The same manifestations invariably followed.
These investigations prove that the statement which has
been made, that the acid and not the case is the offend-
ing substance, is incorrect.
The writer proved by experiments upon this case that
the theory of reflex dilatations of the vessels of the skin
from stimulation of the sensory nerves of the stomach was
not applicable. General symptoms followed holding
one-fourth grain of the carbamide in the mouth for fif-
teen minutes. Quinine given in a suppository and by
inunction produced a distinct erythema. A weak solu-
tion of quinine in alcohol rubbed into the scalp caused
the same symptoms. Dr. Allen noticed in this patient a
marked tenderness on pressure over the spinous process
of the second dorsal vertebra. Upon this symptom he
bases his supposition that the eruption is due to an an-
gio paralysis of central spinal origin. He believes the
symmetrical distribution and circumscribed features of
the eruption are explained by the theory of nerve origin,
as in large doses the reflex function of the cord is les-
sened and ultimately abolished. The writer thinks it
rational to refer these skin changes to an action upon
the cord.
Symmetrical Cutaneous Atrophy of the Extremities.
— Dr. Bronson, of New York, reported the case, which
was a very rare one, only four of the same variety having
been found in the literature. Buchwald, of Breslau, was
the first to describe this form, and so peculiar were the
manifestations of the disease, and so well delineated were
they, that the term Buchwald's atrophy was suggested.
The affection, which is clearly an idiopathic form, differs
from the ordinary atrophia cutis propria in its symmetry
and in its tendency to gradual progression and in the fact
that the atrophy seems to be of a qualitative kind as well
as simply quantitative or degenerative.
The case described by Dr. Bronson affected a patient
forty-five years of age, who was a working-man of fairly
good family and personal history, and who, except for
the atrophic disease, appeared to be in possession of per-
fect health. The disease had begun about fourteen years
ago, and latterly had remained nearly stationary, at least
so far as the extent of the disease was concerned. It oc-
cupied the entire surface of both lower extremities from
the upper part of the feet to Poupart's ligament in front,
and extended over the nates behind, leaving the cleft of
the nates, however, as well as the genitals, free. The
arms were similarly affected from the base of the fingers
behind, and from the wrists in front to about the junc-
tions of the lower with the middle third of the upper
arms. *
The chief marks of the atrophy were the thinning of
the skin, discoloration, wrinkling of the surface, and a
multitude of shallow depressions scattered over the sur-
face. The skin was everywhere freely movable, and
could be lifted in thin folds from the subjacent struct-
ures,, which folds subsided again to the general level
slowly when released, as though the skin had lost elas-
ticity. Everywhere were numberless fine wrinkles which
followed the cleavage lines of the skin — they enclosed
smooth, shiny interspaces, and gave the appearance of
a crumpled piece of gold-beater's-skin. The wrinkling
was most marked about the joints, especially the knees,
88
MEDICAL RECORD.
[July 21, 1894
backs of wrists, and the nates. The discoloration was
due in part to brownish pigmentation, that was in most
parts punctate, in part to the purple color of the veins,
which showed through the thinned and abnormally
transparent epidermis with uncommon distinctness, and
partly to. a red reflex from the arterioles. In a recum-
bent posture the color of the legs and thighs was more
brown, but after standing awhile the veins became turgid
with blood, and the surface appeared cyanotic. There
was no impairment of sensation in the affected parts, but
rather hyperaesthesia. The hairs had nearly disappeared,
as also the perspiratory function.
Relation of Impetigo Herpetiformis and Pemphigus
Vegetans — Dr. Joseph Zeisler, of Chicago, presented
a communication with this title, in which he said that
to anyone who has carefully studied the literature and
the descriptions of impetigo herpetiformis and of pemphi-
gus vegetans, respectively, it must have become apparent
that while each of these rare disorders seems fairly well
established as clinical entities, they have many features
in common, which occasionally make their differentia-
tion exceedingly difficult even for the expert dermato-
logist. The speaker referred to the writings of Duhring,
Dumesnil and Marx, and of Dubreuilh, who had com-
mented upon a case of impetigo herpetiformis (published
by himself in 1887) in a way which shows that while
some of them accept his case as a typical instance of that
disease, others considered it as an example of pemphigus
vegetans. The points of similarity of the two diseases
are there more fully detailed. The prevalence in women,
the inception on some mucous membrane, the peripheral
extension of the cutaneous lesions, the localization on
certain places of predilection, the occurrence'of vegeta-
tions on places where moisture, warmth, and friction
exert an influence, the fatal termination, the obscurity
of the etiology and pathology are referred to more partic-
ularly. The differentiation in a doubtful case will have
to be made according to the principle de potiore dehomi-
natio fiat, i.e., where miliary pustules form the chief le-
sions during most of the time, impetigo herpetiformis will
be declared, while, if bullous lesions predominate, pemphi-
gus will be the diagnosis. The writer thinks the criti-
cisms of various writers concerning the description of such
rare cases are unjust, for the reason that variations from
the well-established type of any disease are always liable
to occur.
Dr. Bronson showed a combined comedo- expressor
and dermal curette of his invention.
Dr. Gilchrist, of Baltimore, showed some micro-
scopical preparations containing protozoa.
AMERICAN NEUROLOGICAL ASSOCIATION.
Twentieth Annual Meeting, held in Washington, Z>. C,
May jo andji, and June 1, 1894.
(Continued from Vol. 45, page 772.)
Second Day, Thursday, May 31ST.
A Hew Neuroglia Stain. — Dr. W. J. Morton, of
New York, presented some microscopic slides showing
the new neuroglia stain of Weigert, presented to him by
Dr. Weigert on a recent visit to his laboratory in Frank-
fort. The neuroglia fibres are stained blue, while the
nerve elements are either not stained at alltor at least very
faintly. The medullary sheaths do not accept the stain,
and thus the field is left clear for the differentiation of
the neuroglia fibres. Dr. Weigert is not yet quite ready
to publish this new stain, although he has been at work
upon it for five years ; no specimens have hitherto been
exhibited on this side of the Atlantic.
Multiple Neuromata. — Dr. Morton also read a paper
entitled " A Case of Multiple Neuromata, with Exhi-
bition of Microscopic Sections of a Large Neuroma Re-
moved from the Ulnar Nerve.'1 The tumor developed
upon the ulnar about half way between the elbow and the
wrist, and was about the size of a hen's egg. Cutting
down upon the mass with a view of severing and suturing
the nerve if necessary, or of dissecting out so far as pos-
sible its strands, he found that the tumor was lying quite
free, except for a few thread like adhesions, within a cap-
sule, and that the nerve traversed this capsule from end
to end, in five separated bundles. It was therefore pos-
sible to enucleate the tumor and replace the nerve strands
without the slightest injury to the latter.
The tumor was a myxo-fibroma. The encapsulation
of the tumor, and at the same time the confinement of the
nerve bundles to the capsule, was novel and of importance
to bear in mind in further operations upon such growths.
Grossed Knee-jerk. — Dr. Guy Hinsdale and Dr. J.
Madison Taylor, of Philadelphia, presented a com-
munication with this title. It was based on studies of
over one thousand cases of nervous disease observed at
the Infirmary for Nervous Diseases, Philadelphia, and
the institutions for feeble-minded at Carlisle, Pa.,
and Vineland, N. J. In using the term crossed knee-
jerk, it is meant that, the patella tendon being struck,
the opposite leg is instantly made to approach its fellow ;
hence the phrase " in knee jerk," or "contra-lateral knee-
jerk/' may be used to describe this action. The move-
ment observed in the limb opposite to that in which the
patella tendon is struck is not an extension of the leg so
much as an adduction of the thigh (vastus internus and
aureus). The best attitude for eliciting the movement
is not that which permits the freest knee-jerk, such as
sitting on the edge of a table. It demands rather more
ease of lateral motion of the thigh. This is accomplished
very well by seating the subject at ease in a chair with
the body erect and the knees ten or twelve inches apart,
with the knee joint at rather an obtuse angle, the feet
being advanced a few inches.
The phenomenon is observed in a small proportion of
normal persons, and in from twenty to thirty per cent,
of the cases coming to a clinic for nervous disease. It is
observed in a large majority of spastic cases. It is dis-
tinctly proved not to be due to a communicated shock
or jar to the pelvis, by reason of its absence in all cases
of locomotor ataxia, and its production in favorable cases
on suspending the subject from the floor and observing
the adduction of the thigh on tapping the patella tendon
or, as in one case observed, tapping the tendo Achillis
Crossed knee jerk is also found to be reinforceable.
Tracings were shown which recorded, in a normal subject,
an adduction in crossed knee jerk of one-sixteenth of an
inch, in a spastic one fourth of an inch, and in the latter
case, under reinforcement, half an inch. Reinforcement
produces the movement in some cases where it is not
otherwise evident. A case was related in which a very
slight tap on the patella tendon causes violent contrac-
tions of both legs, causing the knees to smite together, or
cross over ; a larger tap will cause, in addition, crossing
of both arms in a sort of lock spasm, requiring aid after-
ward in stretching out the limbs.
The reflex arc involved in movements of this kind is
held to embrace the cerebrum.
Dr. H. R. Stedman, of Boston, asked if this condition
was not somewhat similar to the so-called allocheiria.
Dr. Walton thought that a practical result, bearing
on diagnosis, could not fail to* follow careful and sys-
tematic investigations of these anomalous reflexes. We
have not exhausted the directions in which the reflex im-
pulses may be deflected. He had found not only the
classical reflex, described recently by Remak, of toe
flexion on stroking the inside of the thigh, but had seen
both dorsal and plantar flexion of toes on stroking vari-
ous areas in the lower extremities in case of broken
back.
Dr. Morton spoke of the application of faradism to
the right sciatic nerve as having produced a reaction in
the muscles of the left shoulder.
Dr. George Jacoby referred to a paper read by him a
few years ago in which he had called attention to the
phenomenon of irradiation of the electrical current.
Dr. Mills believed that the best explanation would
be forthcoming from a careful study of the distribution
July 21, 1894]
MEDICAL RECORD.
89
of cells and fibres in the cord and their relation to other
parts of the system.
The President considered the title of the paper an
unfortunate one, and did not look upon this phenomenon
as a crossed knee-jerk at all, but as a contralateral muscular
contraction. He thought its reflex character was quite
doubtful and that there was no difficulty in accounting
for irradiation on anatomical grounds.
Dr. Dercum, of Philadelphia, exhibited a skull which
had been kindly loaned by Mr. Bailey Willis of the
Geological Museum. It belonged to the Peruvian Gov-
ernment, and its origin was traced to pre-historic times.
It was shown as an illustration of the ancient method of
trephining.
Recurrent Oculo-Motor Paralysis. — Dr. Knapp, of
Boston, read a paper with this title. A man of forty-
one, with some nervous heredity, had had severe neural-
gic pain over the left eye, with ptosis, external strabismus,
and numbness of the face, a year before he came under
observation. This lasted seven weeks. In December,
1892, one year later, he had intense pain in the left side
of the head, with nausea and vomiting. There was com-
plete paralysis of the left third nerve, with anaesthesia of
the nose and cheek on the left side, and paraesthesia of
the forehead. Photophobia was present The anaesthetic
region was extremely tender on pressure, and there was
increased discharge from the left nostril. After two
months the paralysis began to diminish, and after four
months it had almost wholly disappeared ; but the sensory
symptoms still continued in a lesser degree. Statistics
were given of forty cases, and of ten other cases of a
doubtful nature. In only six cases has there been com-
plete recovery from the paralysis in the interval between
the attacks, and in four more the pupil remained dilated.
In seven cases there was at first complete recovery, but
in the later intervals there was some paresis. Senator's
division into periodical and periodically exacerbating
cases hardly seemed warranted, and, although some of
the cases resemble migraine, the affection in most cases
is not at all like migraine. Three autopsies have shown
lesions involving the nerve, and most cases are probably
due to such lesions.
Dr. Mills had observed several cases of recurrent
ocular palsy with involvement of the fifth nerve. He
had also seen cases of recurrent facial paralysis. The
only probable explanation in most cases is that of or-
ganic lesion. He thought Knapp's cases were probably
due to lesion of root fibres.
Dr. Morton Prince agreed with Dr. Knapp in be-
lieving that these cases were caused by organic lesion.
He believed that pain as a localizing symptom possessed
very little value. He would rather depend uppn motor
and sensory paralysis.
Dr. Walton thought all cases could not be classed
together. While many were of nuclear or vasal origin,
possibly some of the less grave cases were due to recur-
ring oedema or possibly vascular disturbance at the cor-
tex, which would perhaps explain the coincidence of
motor and sensory disturbance. Possibly some cases
were allied to the severer form of hysteria.
Dr. Knapp, in closing the discussion, said that there
was no case of complete recovery on record where there
had been both motor and sensory involvement. In cases
of syphilitic origin where only one or two branches were
involved, it was more likely to affect the nerve after it
had left the pons.
Circumscribed Softening of the Pons, Internal Cap-
sule, Oandatnm and Lenticula. — Drs. Charles K.
Mills and John Zimmer, of Philadelphia, reported a case
which presented two limited lesions of unusual interest —
one in the pons, and a second involving the internal cap-
sule, and a small segment of the caudatum and lenticula.
The patient, a woman, aged forty- two, had a previous
history of alcoholism and of acute articular rheumatism.
Examination showed slight impairment of mental action,
marked somnolency, and imperfect articulation. At
rest, the right eye turned strongly to the right, while the
left was not deviated. Both eyes could not be turned
together to the left. The lateral movement of the left
eye to the right was also impaired, and slight nystagmus
of both eyes was present. The lids of the left eye could
not be brought fully together. Right facial paresis was
present, but the tongue was not deflected Tendon and
muscle phenomena were much exaggerated in the paretic
limbs. Anaesthesia could not be discovered in any por-
tion of the body. .About eleven days after admission,
she had a second apoplectiform attack. She was now to-
tally unable to articulate, but understood what was said.
She was also unable to expectorate, and there was inter-
ference with swallowing. A thorough and careful au-
topsy made by Dr. Guiteras revealed a circumscribed
softening of the pons. The lesion, at its cephalic ex-
tremity reached to within 1.5 mm. of the ventral surface
of the pons — laterally extending to the raphe, and about
the middle of the pons slightly across the mesial line.
The area of softening became smaller and more deeply
situated as it approached the post-oblongata, which it al-
most but not quite reached. The second lesion was re-
vealed by a vertical transection of the right basal ganglia
and capsule. The widest portion of the lesion corre-
sponded to the plane of the cephalic extremity of the thal-
amus. It was about 1 7 mm. in its antero- posterior extent.
The pontile lesion probably involved the root fibres of the
abducens, and the fibres connecting it with the facial
fibres or nucleus. The position of the lesion was such as
, not by any possibility to involve the cell-nests of these
nerves. The lesion involved the crustal portion of the
pons, including a portion of the pyramidal tracts, and
the deep transverse fibres. The lesion of the internal
capsule was beautifully localized near the genu, probably
involving the geniculate and speech tracts.
Lesion of Thalamus ; Death from Intestinal Hemor-
rhage.— Dr. Wharton Sinkler, of Philadelphia, read
this paper. He referred to the importance of placing on
record all facts relating to the function of the thalamus,
and stated that his attention had been drawn, in con-
nection with the case which he reported, to the observa-
tions of Lussana, Brown-S6quard, Ebstein, and SchifT,
many years ago, in which they produced ecchymoses and
hemorrhages into the mucous membrane of the stomach
and colon of some of the lower animals, by wounding
the corpora quadrigemina and optic thalamus.
The patient was a man aged sixty-seven, who had
worked for many years in a stone quarry, and had re-
ceived frequent slight injuries to the scalp,, in conse-
quence of being struck by fragments of stone. In July,
1892, after having been exposed to the sun, he was sud-
denly taken ill and had to be removed to his home in an
unconscious condition, where he was seized with con-
vulsions, which lasted for the greater part of two days.
After a month he was able to resume his work ; but two
weeks later he began to have epileptiform convulsions,
which recurred at irregular intervals of from one to two
a week. The seizures were always preceded by an olfac-
tory aura, the patient observing the smell of burning
sulphur. After a few months the patient had maniacal
attacks after his fits, and was removed to the Philadel-
phia Hospital in December, 1893.
There was nothing notable about his condition, except
that the attacks of epilepsy were of the precursive form.
He would run violently, and imagined that he was pur-
sued by devils. Toward the end of February he had an
attack in which there was rise of temperature without
any physical reason being discoverable. His intellectual
powers failed ; and he gradually fell into a somnolent
condition, which lasted for nearly three weeks, at the
end of which time he was suddenly, without premonitory
signs, seized with intestinal hemorrhage of a profuse char-
acter, from which he died in about twelve hours.
At the autopsy the mucous membrane of the colon was
found to be softened and deeply injected, but no lesion
was found in the way of an ulceration, or rupture of a
vessel which would account for the hemorrhage. The
brain showed very marked evidence of an old lepto-men-
9o
MEDICAL RECORD.
[July 21, 1894
ingitis over the left hemisphere, and there was atheroma
of the vessels of the base. In the posterior right thala-
mus there was found a small area of softening. It was
about one- third of an inch in length, by one- fourth of
an inch in its transverse diameter. No other coarse le-
sion could be found in the brain.
Cerebral Hemorrhage : Its Causes and Premonitory
Symptoms.— Dr. C. L. Dana, of New York, presented
this paper, based upon the study of 1.00 consecutive cases
of apoplexy with hemiplegia, observed at his clinic at the
Post-Graduate Hospital, and 79 cases of apoplexy, with
autopsy, observed in Bellevue Hospital ; 30 of the latter
came under his personal care and observation. Of 100
non-fatal cases 36 were due to syphilis. The special
characteristics of the attacks due to syphilis are that they
occur in early life ; they are often multiple in character,
and the pathological condition underlying them is usu-
ally a thrombosis and softening. So far as his experience
and records went cerebral hemorrhages are rarely re-
peated, and it seemed as if in many cases the rupture of
an artery changed the vital conditions, as it certainly
does the personal habits, so that the attack exercises a
conservative influence upon the individual and actually
tended to prolong life.
Dr. E. D. Fisher, of New York, presented a report
of 77 cases. Fifty one had one attack ; 16, two attacks ;
9 had three, and 1 had six attacks. All are still living.
These cases were observed in his service at the city alms-
house. The average age at which the first attack oc-.
curred was 44^ years. His observations, he thought,
confirmed what had been said by the reader of the paper.
The longest duration since the attack was twenty-two years.
Dr. Gray, of New York, thought that the fatal defect
in the paper was that many things were confounded. It
told us nothing as to the frequency of apoplexy, but left
us in doubt as to the elements of diagnosis.
Dr. L. Weber, of New York, said that while he be-
lieved Dr. Dana's deductions from his own cases were oi
value, those from other sources did not seem to him to
be applicable.
Dr. William A. Hammond doubted whether life was
in any way protected by an attack of apoplexy, as the
same causes would persist.
Dr. Wharton Sinkler had observed a case in which the
attack occurred twenty-five years ago. The man did not
seem to bs in any way benefited in his general condition.
Dr. Prince thought the fallacy lay in the statistics as to
those still, living, as one cannot say how many attacks
they are going to have.
Dr. Dana, in closing, said it was hardly fair to criticise
his data, as sufficient time was not permitted for the read-
ing of his entire paper.
Lumbar Puncture for the Removal of Cerebro-Spinal
Fluid. — Dr. William Browning, of Brooklyn, N. Y.,
read a paper with this title. He reviewed the main
points in this recently devised operation. Brief notes of
a few cases were given as well as directions for its per-
formance. The following conclusions were reached :
1. The method is simple, easily practised and rather
attractive.
2. In itself it is usually without danger.
3. By it we certainly can draw off cerebro-spinal fluid.
4. The quantity removed at short sittings has been
from one to one and a half ounce in adults.
5. This without doubt represents the amount of free
fluid usually present in the lower vertebral canal even
when occluded above.
6. In internal hydrocephalus the relief, if any, is but
very temporary. In the common form due to tubercular
meningitis the result is not worth the trouble ; while in
the closed or sacculated forms it must rather do harm
than good.
7. As a diagnostic means, e.g., in suspected meningeal
hemorrhage, it is valuable. As an index of pressure it
may also be worth noting.
8. It is worth further trial : — (a) As a passing relief in
brain tumors not complicated by hydrocephalus ; (b) As
a substitute for trephining in progressive dementia ; (c)
In certain spinal troubles ; (d) And possibly as a means
of applying medication directly to the spinal me-
ninges.
9. In conclusion it may be said that, while admissible
in all cases of brain-pressure, there is as yet no estab-
lished indication for this procedure except for diagnostic
purposes.
Dr. Mills said that all operations of this kind are un-
philosophic, and would accomplish nothing, as the fluid
reaccumulates. The same may be said of hydrocephalus.
Some good may be done when the fluid is either blood
or pus ; otherwise it is not indicated.
Dr. Dana had utilized this method in three cases of al-
coholic meningitis (in the so called wet-brain). Two re-
covered and one died. In the adult the operation is dif-
ficult. He agreed with Dr. Mills as to its indications
and utility. He believed that the operation possessed,
at least, some rational foundation.
Hon-Operative Treatment of Brain Tumors.— Dr.
Theodore Diller, of Pittsburg, was the author of this
paper. The writer took the view that not all brain
tumors which could be localized should be operated on.
He cautioned against regarding as successes those which
merely succeeded surgically. The obstacles in the way
of a complete success were many, and the results were dis-
appointing, in spite of the rich and growing knowledge ot
localization. Operations should not be undertaken un-
less the patient was getting worse in spite of medical treat-
ment.
Dr. Starr spoke of the case of a man with a doubtful
history of syphilis and all the symptoms of cerebral tumor.
Its localization was a simple matter. Mercury was used
and iodide of potash was given in doses of three hundred
grains daily. There was marked improvement in all
symptoms; and it seemed to be a case cured without
operation. The patient died suddenly, and at the
autopsy a cysto-sarcoma was found without any evidence
of gummatous infiltration.
Dr. Putnam believed we should only operate when
there were definite indications.
Dr. Sinkler mentioned the case of a man with Jack-
sonian epilepsy and no history of syphilis. Two years
later all symptoms of tumor were present. Mercury and
iodide were used, but he became progressively worse.
An operation was performed but no tumor could be dis-
covered. The wound healed well. Since then, the pa-
tient has improved steadily in all symptoms.
Dr Jacoby said that there was a class of cases present-
ing all of the symptoms of tumor which get well without
operation. He cited the case of a man with many of the
symptoms excepting optic neuritis, where he was unwilling
to make a positive diagnosis. The Plasmodium malariae
was found in his blood and he made a complete recovery
under large doses of quinine.
The President stated that we have all been disap-
pointed more or less in the results after operation. It
may be our own fault on account of the delay in operating.
He had a similar experience to that of Dr. Starr. At
the autopsy there was found a typical glioma. The
symptoms had entirely disappeared for several months.
In. another case with all the symptoms of tumor iodide
had been used, but all symptoms subsided after thorough
mercurial inunction.
An Electrode for Use in Diagnosis.— Dr. W. M.
Leszynsky, of New York, presented an electrode which
had been specially constructed with a view to its useful-
ness in diagnosis.
Stolen Grafts. — A man has brought suit in San Fran-
cisco for $25,000 damages, for the loss of some strips of
skin removed from his thigh and grafted upon the head
of another patient in the hospital. He claims that the
grafts were taken without his consent and knowledge,
while he was under the influence of an anaesthetic, given,
as he was led to believe, to save him from the pain of an
examination that was to be made by the surgeons.
July 21, 1894]
MEDICAL RECORD.
91
ASSOCIATION OF AMERICAN PHYSICIANS.
Ninth Annual Meeting, held in Washington, D. C, May
29 > 3°> J1* and June 1, 1894.
(Continued from Vol. 45, page 80a.)
Fourth Day, Friday, June i, 1894.
The Chemical Products of the Anaerobic Putrefaction
of Pancreatic and Hepatic Tissues, and Their Effects
upon the Tests for Morphine. — Dr. Victor C. Vaughan,
of Ann Arbor, Mich., read a paper with this title. The
chemical products of putrefaction are modified by the
conditions under which the process proceeds. There are
always present, during life, in the upper part of the small
intestines, certain anaerobic germs which produce indol
and its derivatives. When the host dies, these germs do
not necessarily cease to exist. They can grow, multiply,
and produce their special products only in the absence
of air. Pancreatic and hepatic tissues allowed to de-
compose in the absence of air, contain chemical sub-
stances which can be extracted by the methods of Drag-
gendorf, and which give many tests similar to those given
by morphine.
The author had demonstrated these facts by experi-
ment. This being true, new tuethods must be sought
for the detection of morphine in the human body after
death.
No discussion.
Oastro-enteric Rheumatism. — Dr. Henry M. Ly-
man, of Chicago, presented this communication. Gastro-
enteric rheumatism is characterized by symptoms as defi-
nite as those of articular rheumatism.
It occurs among neurotic, arthritic, senile, or prema-
turely-aged people.
It belongs to the erratic and neuralgic variety of
rheumatism.
Its pathology is as indefinite as that of chronic neuro-
muscular rheumatism in general.
It is probably due to acidity of the stomach, or at least
to tie absorption of the products of an abnormal digestive
process. The symptoms come on when the stomach is
nearly empty, e.g., at midnight. The pains are exceed-
ingly variable, but are distinct from gastralgia. It is a dull,
deep-seated pain, not influenced by motion. It shifts
from place to place. It may be in the cardiac region,
it may involve the pelvic nerves and cause rectal or blad-
der symptoms, or the sexual nerves and cause priapism.
Unlike dyspepsia, it does not affect the general health,
though the patient may become anaemic.
The treatment consists in providing warmth and dry-
ness of the surroundings of the patient ; hepatic and re-
nal elimination ; nutritious and easily digested food ;
warm baths, and abundant exercise.
Dr. J. H. Musser, of Philadelphia, deprecated the
introduction of new terms. He would prefer " the gas-
troenteric form of lithiasis."
Dr. J. £. Graham, of Toronto, Canada, expressed
his interest in the paper.
Dr. Victor C. Vaughan, of Michigan, said : We use
the term rheumatism to cover a great variety of things.
We should make a distinction of those pains caused by
uric acid. It might be well to call these pains described
above, gout. He called attention to the fact that the
tendency of investigators was to doubt the former teach-
ing that uric acid was an incompleted stage in the pro-
duction of urea.
Dr. I. T. Dana, of Portland, Me., thought that rheu-
matism is a conglomerate pathological mass. He would
confine the term rheumatism to acute articular rheuma-
tism and give other names to other conditions.
Dr. Vaughan agreed with the previous speaker, and
added that he believed these diseases would ultimately
be distinguished by examinations of the blood.
Dr. Lyman closed the discussion. He was not satis-
fied with the name, but it was the best he could do in the
present state of our knowledge
Osteomalacia. — Dr. George Dock, of Ann Arbor,
Mich., reported the case of a woman, aged twenty-five
years, a native and resident of Michigan, who had a
marked case of osteomalacia. The case was probably,
though not distinctly, of puerperal origin. The case
lasted three or four years, with marked symptoms for
two and a half years, and was characterized by the com-
mon subjective symptoms and softening, spontaneous
fracture, and deformity of the bones, and excretion by
the kidneys of large quantities of lime salt3 (renal colic).
Treatment had no influence on the disease (lime, phos-
phates, etc.).
Post-mortem. — The changes were very marked and do
not throw any light on the pathology of the disease (mi-
croscopic and histological specimens were shown).
He referred briefly to all the cases hitherto reported
in the United States, which, excluding three of doubtful
diagnosis, are very few, and do not add materially to our
knowledge of the disease.
NEW YORK PATHOLOGICAL SOCIETY.
Stated Meeting, January 24, i8p4-
George C. Freeborn, M.D., President, in the Chair.
Carcinoma of the Head of the Pancreas. — Dr. J. S. Ely
presented such a specimen. A man sixty- three years ol
age, a shoemaker by occupation, was seen by him in
March, 1892, with Dr. Ferrer, at the Out patient Depart-
ment of the Roosevelt Hospital. He had been well up
to six weeks before. At this time he began to have pain
in the right hypgehradrium, and detected a lump in this
region. OrvMarch 3d, he rather suddenly became jaun-
diced, and four days later there was a severe attack of
vomiting, the vomitus being whitish and free from blood.
The pain in the region of the tumor continually increased,
the tumor appeared to be growing larger, and he had lost
much flesh and was greatly troubled with insomnia and
constipation. When first seen, he was much emaciated
and deeply jaundiced ; the tongue was dry and clean, and
the arteries hard and tortuous. A physical examination
of the chest gave the signs of pronounced emphysema.
On the right side was a large, irregular, nodular mass
which appeared to be the lower border of an enlarged
liver. The mass was quite tender and slightly movable
on deep inspiration and gentle manipulation. No tumor
could be detected under the enlarged liver, or in the
situation of the pylorus. The stomach was normal in
size. The temperature was 99. 8° F.
The case was apparently one of carcinoma in the sub-
stance of the liver. Because of the absence of marked
gastric symptoms and gastrectasia, and because of the in-
tensity of the jaundice, he had been inclined to the opin-
ion that the primary carcinoma was in the head of the
pancreas, or in the common bile-duct near its entrance
into the duodenum, the former being considered the
more probable on account of the late appearance of the
jaundice. After admission to the hospital the pain was
relieved somewhat by moderate doses of morphia. There
was quite free epistaxis on several successive days, and
this greatly prostrated him, so that on March 23d, after
a short period of unconsciousness, he died of exhaustion.
During the two weeks he was in the hospital, the tem-
perature was not higher than 1010 F., and it only once
reached that point four days before his death.
The autopsy was made by the speaker about twenty-
four hours after death. The body was much emaciated
and extremely jaundiced. Scattered through the mesen-
tery were many small, hard masses, the largest being
about half an inch in diameter. Many of these were sit-
uated at the point of attachment of the mesentery and
intestine. Around the common bile duct was a hard
mass, 1J/2 x 1 x ^ inches, which replaced the substance
of the pancreas. This mass was continuous with a thick-
ened mass around the common bile-duct near its mouth.
Above this point this duct was greatly dilated. Scattered
through the liver were spherical masses — both discrete
and conglomerate — which were very abundant near the
92
MEDICAL RECORD.
[July 21, 1894
lower border of the liver. They presented the character-
istic appearance of carcinomatous nodules in the liver.
Between the nodules the liver substance showed dark cen-
tres and light peripheries of the nodules. The gall-blad-
der was adherent by old adhesions to the under surface of
the liver, to the duodenum, and to the tumor around the
mouth of the common bile-duct. The stomach appeared
normal The spleen showed chronic congestion and in-
terstitial splenitis. The kidneys were of about the nor-
mal size ; their capsules were moderately adherent ; there
were some small cysts, and the markings of the cortex
were indistinct. There were numerous small ulcers, with
indurated bases, situated on the mesenteric attachment of
the small intestine, and continuous with the small tumors
in the mesentery. The hemorrhage was thought to have
occurred from some of these ulcers. The intestine con-
tained much liquid, granular, dark greenish-brown fecal
matter. The heart was of normal size. There was athe-
roma of the aorta. The lungs were excessively pigmented,
and their surface showed considerable old pleurisy.
Specimens were exhibited under the microscope showing
intense athracotic pigmentation, lying in the interlobu-
lar connective tissue. This same pigmentation was also
quite abundant in the liver — a point worthy of note.
Scattered through the lungs were a dozen or more hard
nodules, the largest being three fourths of an inch in di-
ameter. Microscopical examination showed all the
growths in the various organs, as well as the masses in the
mesentery and intestinal wall to be deno-carcinoma, or that
type of carcinoma in which the arrangement of the epi-
thelial cells was such as to suggest the acini of a gland.
This was not the appearance, however, everywhere, the
tumor in many places presenting the typical picture of
small alveolar carcinoma. The structure of the metasta-
ses was much more uniformly that of adeno-carcinoma
than that of the supposed original tumor in the head of
the pancreas. With regard to the intestinal lesions, there
could be no doubt that the ulceration was a secondary
result of the involvement of the intestinal wall by metas-
tases which formed in the mesentery at the point of its
attachment to the gut. The sections showed several
stages of the encroachment of these metastases on the in-
testinal wall, and of the resulting ulceration. Intense
congestion was visible in the floors of some of the ulcers,
and it was undoubtedly from these that a part of the hem-
orrhage occurred, evidence of which was seen in the dark
granular material filling the intestine.
The speaker said that the occurrence of such metas-
tases, with secondary involvement of the intestine and
ulceration, he believed to be rather unusual. The mate-
rial giving origin to these metastases must have been car-
ried by the blood-current.
A tumor of the structure and location here described
might have its origin in the duodenum, in the common
bile-duct, or in the head of the pancreas, and it was usu-
ally impossible to say with certainty from which of these
structures it originated in the present case. But, as the
head of the pancreas occupied the centre of the carcino-
matous mass which, it was evident, was the primary nod-
ule of the tumor, it was believed to have begun its growth
in the pancreas. A measure of support was given to this
view by the following case :
A man sixty-one years of age, a varnisher by occupa-
tion, was treated in the Roosevelt Hospital, during the
fall of 1 89 1, for chronic diffuse nephritis, and was dis-
charged improved. On March 24, 1892, he returned,
stating that soon after he left the hospital he began to
feel weak, and to be troubled with cough in the morn-
ing, and occasionally by bloody expectoration, dyspnoea,
and patpitation. On March 14th, he first noticed jaun-
dice, and this had steadily increased. On admission he
was deeply jaundiced and decidedly emaciated ; there
was oedema of the legs and thighs. The tongue was
coated and dry, the arteries were very atheromatous,
the pulse was 96, regular and feeble, and he had
ascites. The temperature was 990. Physical examina-
tion showed an accumulation of fluid in both pleural
cavities, more on the left side. The hepatic dulness
extended from the fifth rib to the free border of the ribs.
He soon developed orthopnoea, and died on March 26th,
four days after admission. The post mortem examina-
tion was made the same day by Dr. Ewell, the house phy-
sician. The abdominal cavity contained much bile-
stained liquid, and the organs were also bile stained.
The left pleural cavity contained fluid; the heart was
somewhat enlarged, and the left ventricle dilated and
hypertrophied. The mitral valve was thickened and cal-
careous. The lower lobe of the left lung was compressed
and carneous, and contained a nodule of old healed
phthisis, one- half inch in diameter. There was a similar
nodule in the right apex. The peritoneum around the
liver was covered with a layer of loose fibrin, and the gall-
bladder was distended and filled with liquid bile. The
cystic duct was apparently obliterated. The liver
weighed three pounds and eight ounces, and was very
hard, and the interlobular fibrous tissue was increased.
The kidneys were small, the capsules adherent, the cor-
tex thin, and the markings obliterated. The spleen was
small and hard, and showed recent inflammation of its
capsule, similar to that seen in the liver, besides old peri-
splenitis. The stomach, duodenum, and small intestine
were normal. The head of the pancreas was hard near
its tip. Behind this was an abscess-cavity, one and a
half inch in diameter, and a second separate abscess
was found in the tail of the pancreas. Microscopical ex-
amination of the hard mass showed it to be an adeno-
carcinoma. The mesenteric lymph nodes near the pan-
creas showed no involvement, and there was no trace of
metastasis anywhere. The death of this patient from
Bright's disease and peritonitis, revealed a carcinoma in
the head of the pancreas in a very early stage, while still
limited to the original site.
The speaker said that he had reported these two cases
that they might be compared with the one presented at
the last meeting. Where jaundice developed in an old
person in the manner described, and where gall-stones
and inspissated bile could be fairly excluded, carcinoma at
this point should be thought of as an extremely likely
cause of the jaundice. In two of the cases the diagnosis
was made of carcinoma in this region — a more exact
localization would of course be quite difficult. In the
first case, he thought, from the late development of the
jaundice after nodules had formed in the liver, that there
was probably a carcinoma in the head of the pancreas
instead of at the mouth of the common bile-duct, in
which case the jaundice would have probably occurred
earlier.
Dr. J. M. Byron said that he was exceedingly sur-
prised at the similarity of the structure exhibited in the
various organs in which metastasis had occurred. It was
well understood, of course, that in a glandular organ like
the pancreas the growth might take place on the epithe-
lium of the organ, and proliferate and produce a new
growth which would resemble the organ from which it
sprung ; but when the metastasis occurred, for instance,
from the pancreas to the bone, or to another organ not
a glandular organ, he could not understand how a gland-
uloid formation such as was seen in the specimen could
take place. This was the first time he had heard of it.
Regarding the second case, he asked whether the lungs
had been examined, and also the exudation of blood, in
order to determine whether or not there was a primary
epithelioma of the pleural cavity.
Dr. Ely replied that he did not make the autopsy and
had not been able to see the physician who had made it,
but if there had been anything noticeable about the
pleura he felt sure that it would have been noted. There
was a great deal of oedema and advanced ascites, and it
was thought at the time to be not an exudation, but a
simple transudate.
Dr. Byron said he had asked this question because he
was familiar with cases of endothelioma which had been
presented by Dr. H. M. Biggs, and in which the first
symptoms were those of small exudations of bloody se-
July 2i, 1894]
MEDICAL RECORD.
93
rum into the pleural cavity. These had been diagnosti-
cated at first as ordinary pleurisy, but at the autopsy the
pleura had been found to be greatly thickened, and there
were immense numbers of metastases.
General Tuberculosis. — Dr. T. S. Southworth pre-
sented specimens from a case of general tuberculosis.
They were removed from a child of fourteen months, in
the Nursery and Child's Hospital. It was one of twins,
and when born, in November, 1892, weighed 4^ pounds.
It was breast fed, and did well up to the spring of 1893,
when it had whooping cough. At the age of six months
it weighed 16 pounds. Last August it began to have a
slight cough, and since then it steadily foiled, until at
the time of its death, on January 18, 1894, it weighed
only 2>y± pounds. The chest was examined once or
twice by the house physician, but no very definite physi-
cal signs were found. At the" autopsy the emaciation
was very noticeable. The abdomen was distended. On
opening the thorax the right pleura was found firmly ad-
herent over the upper and middle lobes of the right lung,
and there was a yellow, cheesy mass found beneath the
pleura, embedded in the upper and middle lobes on the
anterior surface. It was adherent to the pleura, but not
to the lung tissue. When removed, it left a rough cav-
ity which did not apparently communicate with the
bronchi. The edges of this cavity were sharp and
slightly overhanging. The upper and middle lobes of
the lung were consolidated, and showed tubercles on the
surface. The adjacent bronchial glands were large and
cheesy. The left lung also showed scattered patches of
tubercular infiltration. The pericardium was adherent
over the left border of the right ventricle. The heart
and valves were normal. The liver showed a few tuber-
cles on the surface. There was general adhesive peri-
tonitis binding together all the abdominal organs, but
there was no fluid in the abdominal cavity. The spleen
was covered with lymph, its capsule was opaque, and
there were a few miliary tubercles on its surface. The
kidneys were apparently normal. Both the large and
small intestine were covered with lymph and studded
here and there with tubercles beneath the peritoneum,
and also in the mesentery. In the large intestine were
some superficial ulcerations, and other areas which ap-
peared to be suppurating lymph nodes which had not
broken down. The mesenteric glands were much en-
larged and cheesy. The nodule found embedded in the
upper part of the right lung was about the size of a wal-
nut. Smears were made from the deeper portions of the
mass, and tubercle bacilli found. Small pieces were also
examined microscopically, and showed cheesy degenera-
tion and the remains of giant cells. There was no defi-
nite glandular structure remaining.
A Case of Pyuria. — Dr. F. Tilden Brown presented
a report of a case for diagnosis. He said that he had had
a patient suffering from pyuria under his care for five
months. The patient had been bedridden for the
greater part of this time. There was no abnormal tem-
perature. The cystoscope showed pus coming from the
left ureter. He had not been able to exclude tuberculo-
sis of the genito-urinary tract, although repeated search
had been made for tubercle bacilli. At times there was
also a slight hematuria and some discomfort in the left
side and left testis, suggestive of a renal calculus. The
pain had been accounted for by the discharge in the
urine of certain shreds. The hematuria had been rather
more marked after exertion. The urinary examinations
had been very contradictory. The speaker raised the
question whether we could expect a tubercular process of
the kidney where there was a profuse suppuration, and
yet no associated micro-organisms and no elevation of
temperature. He thought it would be rather unusual.
If due to a stone in the kidney, one would expect more
intense subjective symptoms. The leucocytes appeared
to be well formed. He had examined for filaria, bil-
harzia, and similar organisms, with negative result.
Dr. T. M. Prudden remarked that in making exam-
inations where tuberculosis was suspected, it was desirable
to use the sediment from large quantities of urine.
Lately he had been accustomed to ask for the urine of
two or three days, and after decanting the sediment, it
was placed in the centrifugal machine, and still further
concentrated. By this method tubercle bacilli could be
found in some cases where the more usual methods of ex-
amination gave only a negative result.
The Society then adjourned.
(&oxxz&voxi&mtz.
OUR LONDON LETTER.
From our Special Correspondent
HOSPITAL SUNDAY — MANSION HOUSE RECEPTION — ROYAL
SPEECHES FOR HOSPITALS — THE MIDW1VES' REGISTRA-
TION QUESTION — THE ROYAL SOCIETY'S CONVERSAZIONE
— THE ANNUAL MEETING — A DOCTOR'S LEGACY — OB-
STETRICAL SOCIETY — DIVISION OF BROAD LIGAMENTS —
EFFECT OF THIS AND OOPHORECTOMY ON MENSTRUATION
— OPPOSING OPINIONS — ADENOMA OF CERVIX WITH A
DEPRESSION.
London, June 16. 1894
The Hospital Sunday Fund promises to equal past
years, hut at present only a small proportion has reached
the Mansion House. Up to Thursday evening ^14,000
had been received. The Lord Mayor and Lady Mayor-
ess gave a reception on the 7 th, in connection with the
movement. Our princes have lately pleaded the cause of
our hospitals. On Monday the Prince of Wales spoke
for the Popular Hospital, and afterward inaugurated a
new Home for Missions to Seamen. On Saturday the
Duke of Connaught spoke at St. Thomas's Hospital, and
it is very lately that the Duke of York presided at St.
Mary's. This is good work for royalty.
The Midwives' Registration question continues to agi-
tate professional circles, and Dr. Carter, of Liverpool, has
entered the lists against Dr. Renton, who has so long
waged war on behalf of the profession. Dr. Carter's pre-
vious appearances in medical politics are hardly calcu-
lated to inspire confidence in his proceedings or in those
of the British Medical Association. It matters little, how-
ever, what may be done at present, for no one expects
that the Legislature will find time to deal with the ques-
tion this session, and the Government is not likely to add
to its instability by attempting to pass a measure on a
subject so much controverted.
On Wednesday last the conversazione of the Royal
Society was held with the usual eclat. This function —
sometimes called "the ladies' night" — is the one that
appeals to the uninitiated, and therefore the one occasion
on which the chief scientific society, so to say, unbends.
There were a considerable number of photographs and
other interesting things exhibited in illustration of vari-
ous scientific matters. A curious if sombre exhibit was a
mummy cloth calculated to have been made in the
Fourth Dynasty, and the strands were said to be 300 by
150 per inch — a contrast with the 140 by 140 of present
day fine Irish linen.
On Thursday the annual meeting was held, and the
new Fellows elected. Among them are some whose work
is of much interest to medical scientists, and two are
members of our profession — viz., Mr. Watson Cheyne
and Dr. J. Rose Bradford. The F.R.S. is so highly
prized that I may venture to congratulate these gentle-
men on the recognition of their work. It is always
agreeable to see colleagues obtaining merited distinc-
tions.
Another law case has been settled honorably to the
profession. A will made by a sick patient left Dr.
Ormsby ^3,000, and this will was disputed on the
ground of incapacity and undue influence. The case ut-
terly broke down— " crumbled away," to use the ex-
pression of the judge— and the counsel for the complain-
ants threw up his brief and publicly withdrew all
94
MEDICAL RECORD.
[July 21, 1894
imputations. But what is to compensate Dr. Ormsby
for the expense to which he has been put and the moral
torture he must have endured in the interim ? It seems
a terrible thing that a patient in dividing a property of
^86,000 confers a doubtful benefit on his " dear friend
and confidential adviser " by bequeathing him a moder-
ate legacy.
At the last meeting of the Obstetrical Society a paper
was read by Dr. Remfry, on " Ligature and Division of
the Upper Parts of both Broad Ligaments, and the Re
suit of this Operation as Compared with that of Removal
of the Appendages.1' This plan was adopted in a case
of bleeding fibroid, which did not admit of oophorectomy.
The paper compared the two procedures from an ana-
tomical point of view as well as in reference to the re-
sult. In respect to the theories as to the amenorrhcea
after removal of the appendages, the author, having dis-
cussed several, concluded that changes in the circulation
with diminished blood-supply to the uterus were the
chief factors ; and this conclusion was supported by the
case related, in which menstruation did not return for
three months, and the slightness of the operation was
opposed to the shock theory.
A decided difference of opinion was expressed in the
course of the discussion respecting the amenorrhcea after
oophorectomy. Dr. Horrocks declared that in all his
experience he had never seen menstruation continue for
any length of time after complete removal of both
ovaries. It is difficult to be sure that the ovaries are re-
moved entire. He still held that the ovaries were es-
sential to menstruation, although not to ovulation. He
had never been able to find the nerve which was said by
some to influence menstruation, and would like to see
proof of its existence, but of course he did not doubt the
influence of the nervous system. In contrast with this
opinion Dr. Duncan said he had had four cases in
which, many months after complete removal of the ap-
pendages, the patients had menorrhagia. He could not
account for this unless the ligatures of the stumps were
perhaps exciting irritation. He held that, so long as no
ovarian tissue remained on the proximal side of the liga-
ture, a small amount on the distal side was of no impor-
tance. In several cases he had left portions of firm
ovarian tissue to prevent slipping ot the ligatures, be-
cause the ovaries and tubes were so firmly matted down
in the pelvis that he thought it safer to do so, but in no
instance had menstruation occurred. Dr. Amand Routh
referred to the possibility of hemorrhage from other
causes, and said he had dilated in three cases of persis -
ent hemorrhage after removal of appendages, and in
two he had found a polypus and in the other villous
growths. He believed the ovaries acted through gan-
glionic nerves going from them to the uterus, and, of
course, these nerves were removed in oophorectomy, so
that we cannot absolutely ignore them as a cause of men-
struation.
Dr. Routh's observation as to polypi is suggestive of
the possibility of such cause being overlooked before
oophorectomy, and will no doubt put operators on their
guard against such a mischance. Dr. Remfry' s case,
although interesting, is not unique, since, as mentioned
by the President (Dr. Herman), a case has been recorded
by Dr. Murphy and another by Dr. Kilner Clarke, and
in them menstruation was not arrested. It has also been
proposed to tie the broad ligaments in order to arrest
malignant disease, but I do not remember to have seen it
recorded that the plan has been adopted. Dr. Remfry,
in his reply, did not admit that removal of the append-
ages insured the arrest of menstruation, some published
cases being opposed to this, though it is not easy to. re-
fute the objection that in these cases the removal was not
complete.
Dr. Braithwaite next read an account of a case of
adenoma of the portio vaginalis uteri forming a de-
pressed sore or ulcer. Drawings of the case were exhib-
ited, and it was clearly an unusual one. Among the re-
marks made upon it I may mention that, except for the
depression of the surface of the ulcer, every one would
have taken it for an ordinary erosion and the suggestion
that this depression might possibly be accidental, as ero-
sion might have occurred on a previously depressed area.
In support of this is the fact that the patient had had
three children. Another suggestion was that the ade-
noma had become malignant where the ulceration had
been seen, although the microscope did not show this.
Still it is very common for these cervical adenomas to
become malignant, and this change may begin in a very
limited area.
STATISTICAL FACTS AND INACCURACY.
To the Editor or the Medical Recobd.
Sir : Referring to Dr. Spence's letter in the Record of
July 7th, I must confess Jhat I cannot attempt to un-
ravel the garbling of my statements which it contains.
I may, however, now quote from Dr. Spence's letter :
" Statistics, in order to be valuable, should be, as to their
material facts, correct."
Dr. Spence's doubts, to be euphemistic, hinge upon
my Case IX. To show his correctness and minuteness,
I may state that, on June 20th, the mother brought the
child to my clinic at the Post-graduate School, and the
case was shown to the students as practically cured.
Furthermore, I translate the following letters from
Dr. Voegtle and the child's father (originals inclosed),
lest Dr. Spence continues in his error, which I doubt not
is unintentional.
The father writes : " . . . I never had the remot-
est thought of telling Dr. Spence that my child did not
recover until Christmas. But I did tell him that
the wound was entirely healed toward the end of
July. . . ."
Dr. Voegtle, of Long Island City, writes, under date
of July 10, 1894, " . . . Your dates regarding the
case of empyema in Ravenswood are essentially correct,
varying only in the matter of a day or two. . . .
The child was discharged from treatment on July 16
(1893) > tne wound was healed in the beginning of
July. . . ."
With the expression ot most distinguished considera-
tion to Dr. Spence, I am,
Yours very truly,
Carl Beck, M.D.
July 17, 1894.
Contagious Diseases — Weekly Statement. — Report of
cases and deaths from contagious diseases reported to the
Sanitary Bureau, Health Department, for the week end-
ing July 14, 1894.
Tuberculosis
Typhoid fever
Scarlet fever
Cerebrospinal meningitis
Measles
Diphtheria
Small-pox
Cholera
Varicella
Pertussis
Erysipelas
Leprosy
Cases.
Deaths.
95
100
17
6
57
9
2
3
59
4
190
49
4
4
0
0
0
O
0
0
0
0
0
O
The Lancet's Investigation of the Electrical Treat-
ment of Sewage. — The proposal to treat sewage electri-
cally was received a few years ago with considerable
enthusiasm, and many experts ventured to think that
electricity, which was doing so many wonders in other
respects, would probably also give assistance in the
direction of sanitary affairs, and perhaps afford a
satisfactory solution of the problem of sewage dis-
posal, if not indeed of sewage utilization. But the
July 21, 1894]
MEDICAL RECORD.
95
first attempts to utilize the electric current as a sewage
purifier met with little success, owing to the great prac-
tical difficulties that were encountered. We need not
enumerate them here. Suffice it to say that, of the elec-
trical processes which count for anything now, there are
two which continue to excite considerable interest and
curiosity among engineers and sanitary experts at the
present time. We refer to the Webster electrolysis pro-
cess and the Hermite system of treating sewage with elec-
trolysed sea- water. In the former method the sewage is
actually exposed to the action of the current, while in the
Hermite method the sewage is submitted to the action of
sea- water, the composition of which has been . partially
altered by the action of electricity. Briefly, the Webster
process consists in allowing ordinary sewage to flow
through channels in which are placed iron plates or elec-
trodes, set longitudinally, with the usual battery connec-
tions, with the positive and negative terminals of a dyna-
mo. The sewage in its passage through these channels is
said to become entirely split up by the action of the elec-
tric current upon the chlorides always present in sewage.
At the positive pole the chlorine and oxygen given off
combine with the iron to form a salt, which is probably
hypochlorite, and at the same time carbonate of iron
is assumed to exist in solution, which not only deodorizes
the fecal matter by removing sulphuretted hydrogen
(FeS), but also acts as a carrier of oxygen from the air by
being alternately reduced to ferrous and oxidized back to
ferric oxide. The Webster process, therefore, although
an electrical one, depends upon the production of certain
chemical salts ; but it is probable that the efficiency of
the method depends largely, if not entirely, upon the fact
that the sewage is presented to these chemical bodies
while they are in a very active state — in fact, in statu
nascendi. The Hermite method consists in the electrol-
ysis of sea water and the subsequent flushing of the con-
tents of water-closets with a definite quantity of the
resultant fluid. The Hermite fluid is, therefore, a chemi-
cally active fluid, prepared by electrical means. The sew-
age is never in contact with the current, as in the Web
ster process, nor does the process pretend to secure the
precipitation of organic matters. It claims, rather, to
effect the complete deodorization and sterilization of
sewer contents. Both processes, therefore, have one com-
mon object in view — namely, the healthy • disposal and
not the utilization of sewage.
The Hermite process for the treatment of sewage, with
which the present report proposes to deal, has been con-
ducted on an experimental scale at Worthing during the
early months of the year, with the view of its adoption in
accordance with the plan originated by M. Hermite.
The Lance fs communication has shown that electro-
lyzed sea-water contains probably as its chief active con-
stituent hypochlorous acid, resulting from the partial
dissociation of magnesium hypochlorite, and that it is
fairly stable under ordinary circumstances ; that it is a
powerful bleaching liquid, being superior in this respect
to* bleaching powder solution, but not to a solution of
bleaching powder of equal chlorine value, in which the
hypochlorous acid has been liberated by the addition of a
weak acid (CO, or others, in weak solution) ; that it is also
a powerful deodorizer, and that in all probability these
properties are due to the united action of oxygen in statu
nascendi and chlorine. These, in brief, are the chemical
properties of electrolyzed sea-water, and it remains for
us to consider what effect for good or for evil such a
liquid of definite strength would have when mixed in a
certain proportion with fecal matter. It deodorizes, but
does not destroy or remove organic matters, although
there is little doubt that certain of them are partially
changed, and most probably those which are more readily
putrescible {vide the analysis of effluent). While these
things are true and are so far satisfactory, there must also
be certain drawbacks in the system which are likewise
indicated in these experiments. Electrolyzed sea-water,
for instance, is rapidly reduced in strength by common
newspaper, and as this is an almost invariable accompani-
ment of human dejecta its piesence in the sewer must
seriously affect the activity of the liquid, even if it does
not withdraw the active constituent entirely. Indeed the
entire contents of a sewer rapidly appropriate the chlorine
strength of the liquid. (Compare also in this regard the
bacteriological experiments with stools, urine, culture,
etc.) The same observation applies to soap or domestic
waste, etc., which rapidly " kills " oxygenated chlorine
compounds. Again, it can only be supposed that deo-
dorization, not to say sterilization, is complete when the
chlorinated body is in excess, and an effluent containing
free chlorine or its equivalent is inadmissible to rivers.
The expense, moreover, in inland towns would be greater
since it would be necessary either to carry sea-water or
to prepare it artificially. M. Hermite's proposal is to es-
tablish a producing centre in the towns and to supply the
liquid through pipes into all the streets and houses, much
in the same way that water and gas are at present sup-
plied. The adoption of such a scheme in any place would
no doubt lead to a sanitary condition of things hitherto
unreached, but many excellent advances could be made
in the same direction, it should be remarked, if cost were
not an item which so often bars the way. Apart, how-
ever, from such a scheme, there is no doubt that the pro-
duction from sea-water of a powerful bleaching agent and
deodorant is an innovation which should afford very ma-
terial aid to sanitary progress. Thus for many purposes
the substitution of electrol>zed sea-water for other and
more expensive agents in our sea-side towns and villages
would doubtless confer many advantages. It could be
used, for example — with desirable effect doubtless — to
flush the headings of drains and sewers ; it could be dis-
charged into sewage outfalls; and, lastly, the system
could be applied on a small scale for the sanitary treat-
ment of hospitals, barracks, etc., by means of an auto-
matic electrolyzer worked from a central electric supply.
It should be added that, except as regards what has al-
ready been published in our columns, no particulars in
regard to the actual cost of production have as yet been
furnished by the originator of the main idea.
An Interesting Law Case. — An action for damages
has just been tried in one of the Paris courts which per-
haps is unique of its kind. A gentleman suffering from
anaemia of a very hopeless type was advised by his medi-
cal attendants to submit to the operation of transfusion ;
and having consented, his gardener volunteered to sup-
ply the blood. Consequently transfusion was performed,
and to the great benefit of the patient, who recovered
completely after a short time. However, some time
afterward the gardener fell ill, and attributed his con-
dition to the sacrifice he made for his employer. He
accordingly brought an action against him for damages,
claiming the large sum of 60,000 francs, or nearly two
thousand five hundred pounds. The court ordered an
independent medical examination of the case; but in the
meantime the man died, that is to say, two years and
three months after the operation. The autopsy proved
that the gardener had succumbed to a carcinoma of the
stomach, and the doctors gave their opinion that the
malady was not affected by the transfusion. However, the
widow continued the suit, and last week the court dis-
missed the case with costs against the plaintiff. — Med-
ical Press.
Physicians as Pioneers in Temperance Reform.— At
the annual meeting of the British Medical Temperance
Association on May 2 2d, Dr. Norman Kear said that,
more than a hundred years before the beginning of the
modern temperance reformation, the voice of medicine,
by Dr. Baynard, in 1702, thundered against the milder
intoxicant liquors. He characterized ales as " unwhole-
some and dangerous liquors," and suggested the making
their sale criminal. A quarter of a century later Dr.
George Cheyne, of Bath, commended abstinence as
natural, healthy, and safe, and denounced moderate
drinking as " unhealthy and dangerous/ ' In another
quarter of a century, in the Universal Pharmacopasia,
96
MEDICAL RECORD.
[July 21, 1894
Dr. James (1747) approved the wisdom of Mahomet in
forbidding fermented liquors to his followers. Seven
years before the dawn of the nineteenth century, Ben-
jamin Rush taught that no nourishment and no strength
were found in spirituous beverages, followed a year later
by Erasmus Darwin, who stigmatized wine as a perni-
cious luxury, injuring thousands. In the first days of the
present century Beddoes declared that wine, constantly
taken moderately, was mischievous and enfeebling ; im-
mediately after whom Trotter, while also declaiming
against wine, reprobated beer as a poisonous morning
beverage. Over sixty years ago Physician - General
Cheyne ardently championed abstinence, as did Dr.
Daniel Richmond, of Paisley, who was one of the found-
ers of one of the first teetotal societies in 1832. To
these pioneer temperance champions fell to be added,
prior to 1876, when the British Medical Temperance As-
sociation was founded, among a host of medical abstain-
ers, such outstanding men as Professor Rolleston, of Ox-
ford, Menzies and Burn, of Edinburgh, Kirk, of Green-
ock, Linton, of Aberdeen, McKenzie, of Inverness,
Grindrod, of Manchester, Beaumont, of Bradford, Hig-
ginbotham, of Nottingham, Fothergill, of Darlington,
Collenette, of Guernsey, Clay, of Manchester, Mudge,
of Bodmin, Thompson, of Bideford, and Henry Munroe,
of Hull. Though the medical profession had often been
abused for opposing the temperance cause, it was re-
markable that from the ranks of medicine had gone forth
unsparing condemnation of beer and wine before the
early temperance pledge of abstinence from ardent spirits
alone had been publicly proclaimed. In proof of the
sympathy of medicine and surgery with temperance, Dr.
Kerr cited the three great medical declarations on alco
hoi, the first in 1839, given by Julius JefFreys, the sec-
ond in 1847, by J°^n Dunlop. the third in 187 1 by Mr.
Ernest Hart and Mr. Rae. — British Medical Journal.
Therapeutic Wisdom.— The American Druggist says
that among the queer collection of stolen and confis-
cated goods, in the private office of Police Inspector
McLaughlin, is a medicine chest containing six compart-
ments, each with five small bottles from " Caswell &
Massey." On the inside of this case, written in Gothic
text, was this stanza :
For every ill under the sun
There is a remedy or there's none.
If there's one, try and find it ;
If there's none, never mind it.
Some New Methods of Treating Diseases of the
Stomach and Intestine. — Rosenheim (Bert. Klinik, May,
1894) first discusses the stomach douche. He uses a tube
with numerous side-openings and one larger terminal
opening. Under pressure the water issues from all these
orifices, and in this way all parts of the stomach are acted
upon. The douche is used morning and evening. By
this method syringing with force against the stomach-wall
is avoided, and by using the douche when the stomach is
empty, matters serving for nutrition are not abstracted.
The douching is more easily done by the patient, and the
tube does not get blocked. Besides warm douches,
which are sedative and but slightly stimulating, water
containing common salt, chloroform, silver nitrate (1 in
1,000) may be used. The douche is useful in nervous
dyspepsia, chronic gastric catarrh of moderate severity,
and in severe affections of the sensory and secreting ap-
paratus of the stomach, as in gastralgia, hypersecretion.
The addition of sodium chloride to the fluid is said by the
author to increase the HCl production, and that of silver
nitrate to diminish it. After the stomach is washed out
once or twice, the silver solution is run in and allowed to
remain half a minute. The procedure is unattended with
danger provided the pylorus be not incompetent. The
pylorus is rarely incompetent, and this is readily ascer-
tained by blowing the stomach up. As regards the elec-
trical current, the exact indication as to the kind is still
in doubt. For motor insufficiency, the value of electrical
treatment is unquestionable. The author thinks it also
allays sensory irritation symptoms ; galvanism should be
used here with the negative pole in the stomach. He
then speaks of recto-abdominal galvanization in cases of
motor weakness of the intestine. A case is cited to show
the value of electricity even when the irritation symptoms
and pain in the stomach are due to organic disease, prob-
ably a cicatrized ulcer The author then discusses the
treatment of gastric ulcer with large doses ofbismutb. He
gives ten grains of bismuth subnitrate in two hundred
grains water in the morning on an empty stomach, and
fifty grains of water are drunk a little later. Finally, the
author speaks of the treatment of spastic constipation by
large oil clysters ; four hundred to five hundred grains of
pure oil are injected, and this is followed, if necessary, by
a water enema later; the injections are given daily at
first. Instances are given of the good results of these
various methods of treatment. — British Medical Journal.
The Cause of Cancer.— The weight of evidence seems
to point, then, to the " sporozoa " as nothing more than
degeneration products of the epithelial cells. This view
is held by the majority of those who have studied them,
and is supported by the irregular shape and occurrence
of the bodies, by the well recognized tendency of the
cells of carcinoma to undergo degenerative changes, by
the more abundant occurrence of the bodies in the medul-
lary variety of carcinoma in which the degenerative
changes are most frequent, and in the epitheliomata (flat-
celled carcinomata) of the skin in which more or less
ulceration and degeneration have been present. The
nature of the degeneration is undoubtedly different in dif-
ferent cases. Some of the appearances are explained as the
result of degeneration of the nucleus, some as the result
of degeneration or vasculation of the cell body, and some
as the result of penetration of leucocytes, red corpuscles,
or other cells into and between the bodies of dead or
degenerate cells of the tumor. Stroebe concludes that,
while a possible parasitic origin of carcinoma cannot be
definitely denied, there is as yet no positive evidence
whatever in favor of such a view. — American Journal of
Medical Sciences.
Worse than the Climate of Colorado must be that of
the Himalayas, if one may generalize from the experi
ence of Mr. Conway in that region. In a recently pub-
lished book on "Climbing and Exploration in the
Karakoran Himalayas," in speaking of the rapid changes
of temperature, he relates the experience of his party.
One morning, on the way from Gargo to Gilgit, they en-
countered a violent storm. The wind blew a gale, the
snow was so thick as to darken the sky, and the cold was
intense. Suddenly " the wind ceased, the sun came
over the edge of the hill and drove the frost away ; the
brook began to tinkle again, a cuckoo called from the
birch scrub across the glacier, and a bumblebee droned
around the tents. A more sudden change it would be
impossible to imagine. The sun was soon too hot, and
within two hours the temperature — which had been down
to 150 F.— rose to 8o°."
A Good Pee.— The barber who cut Louis XIV. for fis-
tula in ano received a present from his grateful patient
of $60,000, a fine estate, and a patent of nobility.
Woman Is Not Pit to Practise Medicine ; she is not
fit for the elaboration of the arts and the enlargement of
the sciences, nor is she fit for politics. To prevent mis-
conception we hasten to add that these are the words of
Dr. Abeken, of St. Louis, and not ours.
The Prenoh Language in Japan. — The foreign pro-
fessors in the medical department of the University of
Tokio are chiefly Germans, and the students are obliged
to learn that language. Until recently, says i9 Union
Mtdicale, they were also required to learn English, but
they have now requested the government to allow them
to learn French instead of English, giving as the reason
for the change that " Pasteur and Charcot have no equals
in England, and they (the students) wish to be able to
read the works of these two savants."
Medical Record
A Weekly yournal of Medicine and Surgery
Vol. 46, No. 4.
Whole No. 1238.
New York, July 28, 1894.
$5.00 Per Annum.
Single Copies, zoc.
CASES OF OSTEOPLASTIC RESECTION OF
THE SACRUM.
By FRED. KAMMERER, M.D.,
SURGEON TO THB ST. FRANCIS AND GERMAN HOSPITALS, NBW YORK CITY.
It is now generally admitted that the only way of deal-
ing effectively with certain ailments of the rectum, espe-
cially its upper parts, is by approaching the seat of dis-
ease from the posterior wall of the pelvis. It is possible
that after greater experience with the technical difficulties
of the methods based on incision of the soft parts only
has been gained, the latter may rival those procedures,
which require the permanent or only temporary removal
of parts of the bony structure of the pelvis as a prelimi-
nary measure. At present this is not the case. The ex-
posure of the rectum from behind, with removal of the
coccyx and part of the sacrum, is still regarded by most
surgeons as better adapted to the end in view than sim-
ple incision in the parasacral region (Woeffler) or
through the soft parts lying between both tuberosities of
the ischium (Schelkly).
Since Kraske's publication, about eight years ago,
quite a number of modifications of the original have been
proposed.
At first the plan of removing permanently parts of the
sacrum and the coccyx seemed to be most in favor,
some difference of opinion existing among surgeons
as to the line of incision through the bone. Thus
Kraske originally removed besides the coccyx that
part of the sacrum on the left side lying below the third
and including the fourth sacral foramen, but not ex-
tending to the middle line (<* b c). Hochenegg modi-
fied Kraske's incision to include part of the right half of
the sacrum (a d), and Bardenheuer recommended trans-
verse section of the bone below the third sacral fora-
mina (a e, Fig. i). Even after removal of so large a
Fig.
piece of bone as in Bardenheuer's operation, very little
discomfort, if any, has been experienced by the patients
who have recovered from these operations. As draw-
backs of these methods by which parts of the bone are
sacrificed, have been mentioned weakening of the floor
of the pelvis, interference with the functions of bladder
and rectum, loss of the point ot attachment of the
sphincter ani muscle at the tip of the coccyx with con-
secutive disturbance of the function of that muscle .and
kinking of the rectum, due to contraction of the cicatri-
cial tissue about the end of the divided sacrum. In
a former article l I mentioned that I had not myself
observed any of these symptoms after removal of the
lower end of the sacrum, but others have occasionally
seen them. On the whole, I believe they are very rare.
We should therefore demand of the osteoplastic methods
that they possess technical advantages, if they are to be
preferred to the more radical measures just mentioned.
Is this really the case? It does not seem to apply to the
methods of Hegar, Kocher, and Levy. These are techni-
cally more difficult, and are said by others to unnecessarily
complicate wound treatment. I cannot, however, speak
of them from personal experience. I was, on the other
hand, more favorably impressed by the plan, which Ryd) -
gier ' recommended about a year ago, and after giving it
a trial in six cases, prefer it to either the methods of
Kraske, Hochenegg, or Bardenheuer, which I have for-
merly employed. Fig. 2 shows the various incisions
through the sacrum for temporary removal of the lower
end of that bone and the coccyx. Hegar's incision,
dh bf, separating the bone but not the soft parts in the
line bf, has for its object the elevation of the flap bfh
on b/zs an axis. Kocher splits the coccyx and sacrum
in the median line and then adds a transverse section of
the bone (h gf, h g b), turning the flaps thus formed to
both sides. Levy makes a transverse incision (bf) over
the sacrum and from its ends adds two further incisions
running downward and outward (b c, fe). After divid-
ing the bone in the line bftht flap is turned downward.
Rydygier incises the soft parts, beginning at the posterior
superior spine of the ilium on the left side and running
down to the tip of the coccyx, thence in the median line
to the anus (a b h a). After division of the sacro-sciatic
ligaments, the soft parts are removed from the anterior sur-
face of the sacrum by the hand of the operator. A trans-
verse incision is then added below the third sacral fora-
» Mrdical Record, February 20, 189a.
2 Centralblatt flir Chirurgie, No. I, 1893.
9»
MEDICAL RECORD.
[July 28, 1894
mina (£/) and the bone divided along this line with a
chisel. The flap /d his now turned to the right side,
upon h /as an axis. With a retractor inserted at the tip
of the flap (6) the latter can be easily held aside and
manipulations about the rectum can be as readily carried
on as when the bone has been entirely removed.
Case I — M. A. S , aged forty-two ; native of Ire-
land. In the summer of 1892 she began to suffer from
tenesmus and bloody stools, and was treated for hemor-
rhoids. The nature of her complaint being later on
recognized, she was sent to St. Francis Hospital for
operation. On examination a cancer of the rectum was
discovered, beginning immediately above the sphincter
ani on the posterior wall, occupying the lateral walls ot
the rectum, but leaving a small portion of the anterior
wall of the gut intact, into which the exploring finger
could be barely placed. The upper end of the neoplasm
was not reached.
March 22, 1893. — Rydygier's osteoplastic resection of
the sacrum in the knee-elbow posture, in the presence
of Dr. E. W. Cushing, of Boston, and Drs. William Polk
and George EdebohLs, of this city. Very slight hemor-
rhage during incision of the soft parts, only a few liga-
tures being necessary. Division of the sacro sciatic liga-
ments. It was then a very easy task to separate the soft
parts from the anterior surface of the sacrum with the
aid of the index-finger, keeping the latter well against
the bone. The transverse incision was carried imme-
diately down to the bone, and a chisel about an inch
wide was employed in severing the latter, beginning
at the left border and moving the instrument over the
posterior surface of the sacrum to the right With a
few strokes of the mallet the bone was very quickly di-
vided. After elevation of the flap to the right and dissec-
tion of the tissue covering the rectum, it now became
apparent that it was impossible to save the sphincter ani.
The anus was, accordingly, circumscribed by a new in-
cision and the entire lower end of the rectum separated
from the surrounding tissues. After free incision of
Douglas's pouch and further separation of the rectum as
far as the promontory of the sacrum, more especially
after incision of the lateral folds of the peritoneum,
forming the reflection from the sacrum upon the rectum,
the gut was easily drawn down, so that the tumor lay
well outside the anal opening. After the closure of the
peritoneum with interrupted catgut sutures, amputation
of the rectum was done about three fourths of an inch
above the border of the tumor and the end of the gut
sewed to the margin of the wound at the site of the nor-
mal anus. Iodoform gauze tampons were then placed
upon, and to each side of, the new rectum, their ends
protruding from the wound-cavity just above the new
anus. The flap was now returned and everywhere united
by sutures of silk-worm and cat-gut, excepting the parts
where drainage was to be established by the gauze lead-
ing from the wound-cavity. Dry aseptic dressing exter-
nally. The tampons were removed for the first time on
the fifth day, the external dressings having been changed
quite frequently. Primary union occurred throughout
the sutured area. Recovery uninterrupted. Complete
cicatrization at the end of the sixth week. Length of
the amputated portion about five inches.
September, 1893. — Removal of a small recurrence be-
tween rectum and vagina.
April, 1894. — Patient in fair health (Fig. 3 shows
condition of external parts). There is now a recurrence
on the posterior wall, for which the patient will allow no
further operative interference. There is apparently firm
union of the bone at the site of division and the appear-
ance of the parts externally is, but for the line of union,
normal.
Case IT. — G. R , aged sixty eight. Has been
complaining of rectal trouble for the past two years
(pain during defecation and hemorrhages). Large cir-
cular cancer of the rectum, mostly on anterior wall, sev-
eral inches above the anus. Cachetic appearance. Very
marked atheromatous degeneration of arteries.
April 26, 1893. — Osteoplastic resection. Flap dis-
sected up, as easily as in first case ; no hemorrhage to
speak of; resection of rectum after enucleation of the
same from the surrounding tissues ; division of the rec-
tum below the tumor, leaving about two inches at the
anal end ; incision of the peritoneum ; resection of
about four inches of the gut ; suture of the divided ends
Fig. 3.'
with catgut; extirpation of many sacral lymphatics
which are involved ; drainage with gauze ; flap replaced
and sutured as in first case. Profound collapse after op-
eration, from which the patient rallies well in a few hours.
Early the next morning he very suddenly expires shortly
after drinking. Autopsy not allowed.
Case III. — A. B , aged twenty ; married. Nine
months ago, double salpingo-oophorectomy was done in
this city, in consequence of which a fecal fistula remained.
When first seen at the German Hospital in September,
1893, was in poor general condition. Several fistulous
openings, from which pus and faeces came away, were
found in the cicatrix of the abdominal incision. They
all led to a subcutaneous abscess cavity, which in its turn,
when incised, communicated at the lower end of the
original incision with the gut through a long fistulous
track, leading downward and backward into the pel-
vis. A probe introduced into the fistula passes to the
left of the uterus and vagina, but the point of com
munication with the rectum cannot be found. Feeling
assured, however, that it did exist and that, on account
of probable adhesions, it would prove a hazardous under-
taking to attempt reaching the seat of trouble by an an-
terior incision, I decided to do osteoplastic resection
of the sacrum and thus to get to the opening in the
gut.
The operation was conducted as in the other cases,
with the only exception that the patient was placed on
her right side, with flexed lower extremities and elevated
buttocks. Considerable hemorrhage occurred and there
was a good deal of delay on this account in elevating the
flap. Introducing a probe into the fistula, the point of
which could be felt from the posterior wound high up on
the anterior surface of the rectum, I attempted to reach
this point by dissecting off the rectum on the left side.
While thus occupied, the patient went into a deep col-
lapse, which necessitated immediate interruption of the
operation, from which she only fully recovered after
many hours. The wound cavity had been hurriedly
tamponed and no sutures were applied to the flap. In
the course of the following two months the cavity gradu •
ally filled with granulations and the flap fell into place.
At the end of this time the flap was again raised and the
1 Dr. Fischlowitz, house-surgeon of the German Hospital, has very
kindly taken the photographs used in this article for me.
July 28, 1894]
MEDICAL RECORD.
99
same plan pursued in attempting to reach the opening in
the rectum. After much labor I finally came upon a
small cavity, the size of a walnut, on the anterior surface
of the rectum, far above the plane of Douglas's pouch.
There I found the point of the probe. I could just reach
the cavity with the tip of my finger, but could not find
the intestinal lesion. A tampon was pushed down into
the cavity in the hope that it might heal by granulation
and the fistula thus close. The entire line of incision
was again left unsutured. The wound has filled with
granulations. No more faeces have escaped during the
last two months, either by the anterior or posterior fis-
tula, both of which still exist, however, but are apparently
closing. The incision along the left border of the sa-
crum is still open for about two inches, and several at-
tempts to close it by secondary sutures have failed. The
general condition of the patient is excellent.1
Case IV. — J. F , aged forty-five, recto vaginal fis-
tula in the upper part of vagina after extirpation of the
uterus for cancer. An attempt to close the same from the
vagina failed and the patient was transferred to my ser-
vice at the German Hospital for osteoplastic resection of
the sacrum. Knee elbow posture ; after elevation of the
flap the fistula was exposed by separating the tissue to
the left of the rectum. Considerable difficulty was ex-
perienced in separating the rectum from the vagina;
when this was accomplished the edges of the large open-
ing in the vagina were excised and the opening itself care-
fully sutured ; an iodoform tampon was introduced, but
the opening in the rectum was left unsutured. The flap
was returned, and the transverse and the vertical incision
below the coccyx were united by sutures. That part of
the incision lying to the left of the sacrum was left open,
and from it the tampon protruded. The latter was left
undisturbed for eleven days, when the bowels were moved
for the first time. Very soon the introduction of the tam-
pon to the site of the old fistula became difficult, as the
wound-cavity began to cicatrize very rapidly. However,
while there appeared to be union in the vagina, some
faeces were naturally discharged by way of the tam-
FlG. 4.
pon through the wound-cavity and opening in the rec-
tum.
At this time it became apparent that a small fistula had
again formed in the vagina. Fig. 4 shows the condi-
tion of the external parts three months after operation.
The opening to the left of the sacrum for the tampon is
the only portion of the original incision which has not
closed. I now intended to make an artificial anus and
to again elevate the flap later on, but I abandoned this
idea on discovering extensive secondary infiltration of
the lymphatic system of the pelvis. The wound has not
1 The posterior incision is now about entirely closed, three months
later.
entirely closed yet, about four months after operation,
but no faeces escape from it, and only when the move-
ments are liquid does fecal matter escape from the va-
gina.
Case V.—H. B , aged fifty-eight. For the last two
years blood in stools and lately great difficulty in defeca-
tion ; general condition poor. Two and a half inches
from the anus a cancerous growth, almost entirely oc-
cluding the lumen of th^ rectum, through which the ex-
amining finger cannot be passed.
December 21, 1893. — Left inguinal colotomy. Follow-
ing this for several weeks irrigations of the rectum, three
or four times daily, from anus through the colotomy-
wound.
January 18, 1894. — Osteoplastic resection of sacrum
in knee-elbow posture. Resection of three and one-half
inches of the rectum, after incision of Douglas's cul-de
sac; about one and one- half inch of the anal end is left,
which is sutured to the upper end of the rectum in its en-
tire circumference ; flap returned and sutured throughout,
with exception of opening for drainage below the coccyx.
The peritoneal cavity was not closed by sutures in this
case, but tampons of gauze, placed to each side of the
rectum, were brought well up to Douglas's pouch. Unin-
terrupted recovery. Primary union, with exception of
posterior circumference of the sutured gut, where separa-
tion and slight sloughing occurred (Fig. 5) At the end
Fig. 5.
of March a small opening was still present below the coc-
cyx, which communicated with the rectum and marks the
spot at which the rectal sutures gave way. Here there
is a stricture of the gut.
March 30th, flap again raised. Excision of stricture.
Finding it impossible to unite the two ends of the rectum
on account of tension, the plan, recommended by Dr.
Lange of this city, of transplanting the anus upward and
backward after a transverse incision in the perineum be-
tween both tuberosities of the ischium was adopted.
After carrying the incision well up between vagina and
rectum, the anus could be moved for about one and one-
half inch, making suture of the approximated ends pos-
sible. The transverse incision in the perineum was
united with silk-worm gut in a longitudinal direction.
After the flap was again returned the anal orifice was
found immediately below the coccyx. The anus has
remained in situ, but some separation occurred in
the perineum. The artificial anus still remains to be
closed.
Case VL— S. R , aged seventeen. Always well
as a child. Four years ago severe attack of diarrhoea,
with frequent repetitions of the same during the follow-
ing two years ; then constipation, with much straining
during defecation and loss of blood ard mucus. Anae-
IOO
MEDICAL RECORD.
[July 28, 1894
mic and emaciated girl. Beginning about three or four
inches above the anus and extending upward, as far as
the finger could reach, were a large number of polypoid
growths. Left inguinal colotomy on December 18,
1893. Jus* below the longitudinal incision into the gut
a polypus about one and one -half inch long and
measuring about one-half inch in its widest part, with
a very slender pedicle, is found and removed. Micro-
scopical examination by Dr. Schwyzer, assistant pathol-
ogist to the German Hospital, Showed it to be an ade-
nomatous polypus.
January 20, 1894. — Osteoplastic resection of sacrum in
knee elbow posture. Longitudinal incision of the rec-
tum, beginning about four inches above the anus and run-
ning upward for two or three inches. The entire mucous
membrane lined with small and large growths of the
kind described, as far as the finger can be passed upward
in the gut. Finding it impossible to remove the growths
individually, on account of hemorrhage and, above all,
their location, I removed what I could with a long and
large Volkmann spoon and tamponed the rectum, as
hemorrhage during this manipulation was quite alarming.
No suturing of the flip ; tamponade of the wound cavity
with sterilized gauze; marked collapse, but patient ral-
lied well. Iodoform tampon in rectum removed on the
fourth day for the first time, after which the temperature,
which had ranged from 1010 to 102. 8° F., dropped to
normal.
March 2, 1894. — Closure of the artificial anus and of
the longitudinal incision in the rectum. For the latter a
good deal of dissecting out of the rectum was necessary;
Kic. 6. •
silk sutures, tampon of sterilized gauze. On April 6,
when it is evident that perfect and firm union has oc-
curred in both places, the resection flap is finally re-
turned to its original position and retained there by sev-
eral strong silk sutures. These sufficed to keep it in
place, the anterior surface of the sacrum having mean-
while become adherent to the rectum. The original in-
cisions are still granulating, but will no doubt soon close
(Fig. 6J.
The improvement in the patient's condition is very
marked. The hemorrhages from the rectum have ceased
entirely, and there is no pain during defecation, which
occurs normally. The patient has gained very much in
weight.1
In all these cases I have been impressed by the rapid-
ity with which this preliminary operation can be done.
1 1 have just seen the patient three months after the above was writ-
ten. She continues in excellent health. "} There is still a point of gran-
ulation to heal, but no fistula.
While deprecating in general any time limit in surgical
work, it is surely an advantage to accomplish something
in from five to ten minutes, which otherwise requires a
longer time, at least in my own experience, and that with
decidedly less hemorrhage. I fully endorse Rydygier's
claim, that his osteoplastic resection is a much less bloody
operation than the permanent removal of coccyx and sac-
rum by any one of the other methods with dissection of
the soft parts from the posterior surface of the sacrum.
In only one instance of osteoplastic resection did I meet
with considerable hemorrhage, in Case III., where I
operated in the lateral position. I consider the knee-
elbow posture, which I employed in all the other cases,
with distinct elevation of the pelvis, especially of the
sacral region, as the most desirable one for rectal surgery,
since it controls hemorrhage through elevation, gives ex-
cellent access to the field of operation, the surgeon stand-
ing between the slightly separated thighs of the patient,
and facilitates manipulations with the chisel, the pelvis
being supported by sand bags placed under the anterior
iliac spines.
When the flap, including the coccyx, part of the sac-
rum and the integuments, can be, from the nature of the
case, returned to its place and sutured, the result will be
an ideal one as regards restitution of the normal contour
of the sacral region, as shown in Figs. 3 and 5. In suturing
the transverse incision I have always passed the needle
down to the bone, but have never included the bone itself
in a suture, by any device whatever. Notwithstanding,
in several cases in which I have had to elevate the flap a
second time, I have always found firm union of bone sur-
faces, either fibrous or partly osseous. It is unfortunate
that secondary operations so frequently become necessary
in rectal surgery, for, even when we have resected the
rectum and made a circular suture of the ends, we fre-
quently find that the latter gives way on the posterior
circumference of the bowel. Such, at least, has been my
own experience and the experience of others as well, I
believe. I have not, however, found the operation of
raising the flap a second time any more tedious than the
first. Greater care must only be exercised to avoid the
rectum, which now has been drawn close to the anterior
surface of the sacrum by cicatricial contraction. But I
think, when we are dealing with cases, such as fistula for
example, where tamponade of the wound* cavity becomes
necessary for some time, we should resist the temptation
of suturing the flap and we should leave the wound- cavity
entirely open. My attention was forcibly directed to
this point by Case IV. (Fig. 4), where I got very good
union of the transverse and vertical incisions, but in
which case a successful tamponade of the deep wound-
cavity (about six inches) was not easily effected through
the small opening corresponding to the unsutured part of
the original incision. I think this fact was responsible
for the ultimate re establishing of a small vaginal fistula.
Such wounds ought to heal from the bottom of the
wound-cavity to avoid even the slightest retention, en-
dangering the object in view, and the best guarantee for
this is a wide opening, allowing free inspection and tam-
ponade.
Where no sutures are used some retraction of the flap
develops after a time. This is no doubt much less than
in flaps that are without a bony substratum. Even when
only the lateral incision to the left of the sacrum has re-
mained open (Fig. 4) a distinct elevation of the soft parts
over the sacrum results from the same cause, a deformity
which can, no doubt, at the proper time be very readily
remedied by an insignificant plastic operation. This is
not so readily accomplished when no suturing at all has
been done. There is another fact worthy of considera-
tion in this connection. It is this: After some time
secondary operations on the rectum are even more diffi-
cult than the original ones, owing to the development
of much cicatricial tissue about the gut, which makes the
latter more rigid and does not in consequence permit the
approximation of such parts which we may desire to unite
by sutures. From all this we may conclude that it will
July 28, 1894]
MEDICAL RECORD.
101
be wise to do secondary operations as soon as the condi-
tion of the patient will permit.
The cases of fistula which I have reported have not
been entirely cured. They have been much benefited,
however, and one of them is very likely closing. I firmly
believe that in no other manner ought these cases to have
been approached, certainly not by an anterior laparotomy.
While technically difficult, the sacral route is still the
easiest way to get at the seat of disease when the rectum
is affected, and also in some cases in which the uterus is to
be dealt with. Rydygier's preliminary operation is cer-
tainly well devised, and being as simple as the permanent
resection of the sacrum, while not disfiguring, assuredly
deserves preference.
A CASE OF ACUTE SOFTENING OF THE
BRAIN.
By PHILIP ZENNER, A.M., M.D.,
CINCINNATI, O.
CONICAL LECTUBSR ON DISEASES OF THE NERVOUS SYSTHM III THE MEDICAL
COLLEGE OF OHIO.
Dr. Diller's case of acute softening of the brain, pub-
lished in the Medical Record of April 28th, leads me
to report the following case, which was also, for a time,
believed to be one of hysteria, and in which, as in Dr.
Diller's case, the paralytic manifestations were very slow
in onset. I regret that my notes of the case are not
more complete.
Mrs. S , aged fifty-three. A brother and sister
died of paralysis. She was always in good health until
forty-six years of age, the time of the menopause. At
this time, too, her husband had a long and serious ill-
ness, and underwent a dangerous operation, all of which
doubtless assisted in developing her subsequent nervous
malady.
One of the first physicians whom she consulted for her
nervous symptoms — headache, vertigo, etc — told her
that she had a brain tumor, a diagnosis which was sup-
posed to have had a permanently ill effect upon her ;
at least she was thereafter in constant dread of organic
nervous disease. She never regained her former good
health.
It is difficult in a few words to give a clear idea of the
varied symptoms presented during the seven or eight
years of her invalidism. Her chief complaint was of
various paresthesias, tingling sensations or the like,
which never left her altogether. At first they were only
in the left hand and arm, subsequently they were in the
right arm or both arms, and in the face. Such sensa-
tions in the mouth prevented her from wearing her false
teeth with comfort, so that for several years she did not
wear them at all Very often she would say there was
no strength in her hand, she would not cut her meat,
etc., though there was no evidence of paralysis.
At one time when I was called to see her I was informed
that for months she had been unable to write. On ques-
tioning her she could not tell why, could only say she was
unable to write ; and seemed very much rejoiced when
by a firm order on my part I succeeded in getting her to
write. The same was true of reading. Often for months
she said she could not read She often had a peculiar
disturbance of speech, something similar to aphasia ; she
would have to grope for words or sentences, speak only
short sentences or only a word or two, and then halt as
if unable to proceed farther. She would sometimes use
the wrong word. But she could always give the name
of an object or individual This speech defect was much
worse when emotional, and very much less when she
was calm* She had also various vaso-motor disturbances,
redness, swelling, and perspiration, in various parts.
With her nervous symptoms there was a complete change
in her whole being, from a cheerful active woman inter-
ested in and interesting to everybody, to one who at-
tended to and was interested in nothing, crying, despond-
ent, her mind dwelling only on her many ailments.
The symptoms, of which only a few have been men -
tioned, varied much in intensity. At times they were so
severe as to make life a burden to herself and her
family ; again, after a sojourn at the sea-shore, or in the
South, she improved so much as to be comparatively
well, though still far from being her old self. Her
health was thought to be the best it had been since she
first took sick, just before the occurrence of her last and
fatal malady.
About January 6 or 8, 1894, she began to complain
of pain in the right arm. A few days subsequently she
said to her physician : " You see my arm is paralyzed."
On examining her he found that she could move the arm
freely. He saw no evidence of paralysis, and tried, in
vain, to convince her of this fact. But it was soon ob-
served that she could not move the right hand, and in a
day or two the. right elbow, and after an interval of a
day or more, the right shoulder also became affected.
1 saw her January 14th. She walked with difficulty,
leaning upon an attendant for support, but the strength
of the different groups of muscles of the legs appeared to
be good, a rough test indicating that the muscles of the
right leg equalled in strength those of the left. The
right hand was altogether powerless, and there was but
little strength in the muscles of the right elbow and
shoulder. She felt a light touch everywhere on the right
arm and leg, but on the arm the touch was not quite so
well localized as on the left arm. Tendon reflexes nor-
mal, cranial nerves, fundi oculi normal, no headache. '
The patient was in an hysterical emotional state,
cried and laughed alternately, the feelings appearing
to be very superficial. On account of either mental
confusion, or inattention, or impaired speech, there was
little satisfaction to be obtained from her statements.
She spoke little spontaneously, often seemed not to grasp
the meaning of a question, or paid no heed to it. When
she spoke it was in a faltering manner, seeming to have
difficulty in finding and arranging her words. This men-
tal state did not appear to be a new feature. Like con-
ditions had frequently been observed in bad periods in
former years. But the apparent mental confusion was
greater; this and the appearance of a new symptom,
paralysis, was all that distinguished her condition now
from what was often observed in her before.
I saw her again January 17th. Her mind was more
blunted. She scarcely spoke any, and paid little heed
to questions, so that the examination of subjective states
was not satisfactory. She was now confined to her bed.
She apparently could not move the right arm at all.
She could move the lower extremities freely, though the
degree of strength could not be tested. The prick of a
pin was felt everywhere.
After my second visit an examination of the field of
vision was made by an oculist. By an oversight this had
not been made sooner. He found concentric contrac-
tion of the field of vision of each eye. I shall give my
reasons further on for believing this observation was not
accurate.
The chief change in the following ten days was a con-
stantly increasing mental apathy, and disinclination to
speak or to move, and that she ate less and less. The
paralyzed arm was somewhat rigid much of the time, so
that there was some resistance to passive movements.
The latter were often painful. The pulse was strong, in
the neighborhood of 80, temperature mostly normal.
February zst — Strong faradic brush applied to right
arm and leg very painful, in leg produced a movement,
a flexing at the same time of hip, knee, and ankle, but
the arm remained motionless. Temperature in left
axilla, 980, in right, 99.80 F. Can scarcely get any re-
sponse from patient except an occasional "Yes" and
" No."
February 3d — Cathartic given, and bed soiled, of
which she is altogether regardless. Eats very little,
hebetude extreme, temperature 98. 5 ° F. in each axilla.
February 4th. — Did not speak a single word. Lies
almost motionless, takes scarcely any food.
102
MEDICAL RECORD.
[July 28, 1894
February 5th. — I found her in the morning in a coma-
tose condition, breathing heavily, face somewhat flushed,
pulse 90, temperature 103.10 F. in each axilla. A very
slight movement of the left arm and leg could be pro-
duced by deep pricking, right extremities motionless
and flaccid. Breathing regular. Some purling of the
lips with each respiration, but lips close in swallowing
(swallowed a little fluid). When eyelids lifted, eyes
were seen to move restlessly to and fro.
During the day the temperature subsided somewhat
and her condition appeared a little better. There had
been a deep burn on right leg a week before through an
accident with a hot brick. Pressure in this to day caused
a movement of right leg with other manifestations of pain.
On subsequent days there were slight fluctuations in
her condition, temperature varied from 99 to 102. 5. ° F.,
usually one to one and one-half degree higher on the
right than on the left side ; pulse remained good, until
the last day or two of life when it became rapid and fee-
ble. She swallowed liquid food without much difficulty.
She was sometimes in apparently sound sleep, and at
times even manifested a certain degree of consciousness,
opening her eyes, moaning " Oh, my ; " and the nurse
thought that she distinguished between food and bad-tast-
ing medicine. The breathing had at times something of
the Cheyne-Stokes character, at other times it was heavy,
labored, attended by paralytic puffing of the lips and
cheek, again there were intermissions of quiet healthy
breathing.
February 7th. — It was first observed on this date that
the tendon reflexes in right arm were heightened, and
they remained so until the end. In the right leg the ten*
don reflexes were at no time excessive. There was no
subsequent movement of left leg, excepting not infre-
quently a kind of tremor or clonic spasm. On some
occasions the left hand was found in a state of contract-
ure. During the last few days of life, the only evidence
that a pin prick was at all felt was that it sometimes was
followed by a movement of the left leg. There was at
no time true facial paralysis.
During the last week of life there was a tendency to
keep the face turned toward the right. If the head were
straightened she manifested pain. She died February
1 2 th.
Only the contents of the cranial cavity were examined
post-mortem. There was a lepto-meningitis of light
grade confined to the pia covering the convexity of the
hemispheres, and most marked over the softened areas.
The beginning of the right middle cerebral artery ap-
peared narrowed and thickened, but the vessel beyond
was patulous, and not collapsed. Otherwise the vessels
at the base were normal.
Three areas of softening were found on the surface of
the hemispheres. The largest and, probably, oldest was
in the left motor area. It destroyed almost the entire
upper two-thirds or three-fourths of the central convolu-
tions, and a small part of the contiguous frontal and
parietal lobes. The softening extended deeply into the
centrum ovale, but did not reach the lateral ventricle.
The paracentral lobule was unaffected.
The second area of softening was in the right occipital
lobe. Almost the entire lobe was affected, the softening
reaching to the posterior and inferior horns of the lateral
ventricle. The third and smallest, and, perhaps, most
recent softening, was in the posterior part of the second
frontal convolution. The lesion just impinged upon the
ascending frontal convolution. The softening extended
about one-fourth of an inch into the white matter.
The other parts of the brain, as far as could be judged
by naked eye appearances, were altogether normal.
Bemarks. — The case illustrates the difficulties and
uncertainty in the diagnosis of hysterical paralysis ; also
that the presence of hysterical conditions — upon which
the diagnosis, hysterical paralysis, must always chiefly
rely — does not preclude the existence of organic disease.
This was regarded as a case of hysterical hemiplegia,
until its gravity revealed the presence of organic disease.
The features of the case which lent it its hysterical as-
pect were the following :
1. A history of repeated hysterical manifestations, and
the recurrence in the last illness of similar manifestations.
Furthermore, the paralysis was preceded by pain in the aim
— pain often excites hysterical paralysis — and by the fixed
idea that she was paralyzed, a. The hemiplegia had pe-
culiar features, ordinarily characteristic of hysterical hem-
iplegia. There was no facial paralysis, which is invariably
true of hysterical hemiplegia. When the diagnosis hys-
teria was made the paralysis was not complete ; and this
is also the rule in hysterical hemiplegia. The paralysis
came on very gradually. This is not uncommon in hys-
teria, whereas it is exceedingly rare as the result of a
brain lesion, excepting in cases of tumor, abscess, scle-
rosis, or chronic softening, all of which could be ex-
cluded in this case.
Finally, the visual symptom, concentric contraction
of the field of vision in each eye, is most frequently
found in hysterical cases. But my impression is that
this was a mistaken observation. The autopsy revealed
a softening of the right occipital lobe, which would cause
the loss of the left half of the field of vision in each eye.
It is true we do not know that this lesion was already
present when this examination was made ; but inasmuch
as at the time of the examination the mental condition
of the patient prevented a careful and perhaps accurate
examination, and the vision was tested for the very pur-
pose of finding out whether the field was contracted or
not, it is not improbable that the loss of one-half of the
field was confounded with a contracted field of vision.
There were some respects in which this case did not
correspond to the most common picture of hysterical
hemiplegia. The paralysis was right-sided, the arm was
more affected than the leg, and there was no anaesthesia;
whereas in hysterical hemiplegia the left side is usually
affected, the leg more than the arm, and there is often
more decided loss of sensation than of power. But
these differences are too common to have much weight
in diagnosis.
This, then, is one of those not uncommon cases
where an hysterical subject, with hysterical symptoms,
has organic disease. The peculiarity of this case was
that, while the patient's history led to the expectation of
new hysterical manifestations, the new symptom in this
instance, the hemiplegia, had in itself so much that is
commonly characteristic of hysteria.
The most striking festure of this case is the gradual
onset of symptoms. From the very beginning there was
a steady progress of the symptoms, from day to day, al-
most to the very end. This was true of the motor
paralysis and the mental impairment. This is not the
mode of onset and course in cases of acute softening.
Wernicke describes a very rare disease, which he terms
chronic softening of the brain, wherein there is a very
slow and gradual increase of motor and sensory paraly-
sis, which may continue for months or even a few years,
a disease which Wernicke believes to be of an inflamma-
tory character. But acute softening, which is due to the
occlusion of blood-vessels, usually produces symptoms
which are more or less sudden in onset When the
cause is embolism the symptoms are always ushered in
abruptly ; and this is, also, largely true in cases of throm-
bosis. Even in cases of senile softening of the brain,
where the slow appearance of symptoms is most likely to
be found, the latter mostly occurs as a series of slight
attacks. In Dr. Diller's case, which belongs to this
order and where the gradual onset was uncommonly well
marked, the phenomena are explained by the unusual
pathological condition found. But my own case was not
one of senile softening, and I do not know of another of
its kind in which occurred such a gradual development
of paralysis.
In part the latter was due to the multiple lesions,
which doubtless occurred one after another. Very likely
the lesion in the left central convolutions appeared first,
then that in the right occipital lobe, and finally the area
July 28, 1894]
MEDICAL RECORD.
io3
of softening in the right frontal lobe. The latter prob-
ably accounts for the attack of coma which came on a
week before death, and for the loss of power in the left
extremities, though the lesion only slightly encroached
upon the motor area. That there was no facial paralysis
is explained by the location of the lesion in the motor
area.
SPLENECTOMY, WITH THE REPORT OF A
SUCCESSFUL CASE.1
By W. J. CONKLIN, A.M., M.D.,
DAYTON, O.
Mrs. A , American, aged twenty-nine, married, II-
para, was admitted into St. Elizabeth Hospital, May 29,
1893. The following history was obtained. Her family
record is without taint, menstruation normal, and general
health but little impaired. Mrs. A.'s early life was passed
in a highly malarious district in Southern Illinois, and up
to her marriage and removal to Ohio she was subject to
frequent attacks of chills and fever, and carried almost
constantly an "ague cake" in her side. For several
years she has been free from malaria and, aside from an
attack of typhoid fever, has had no serious acute illness.
The symptoms of the disorder which now so seriously
interferes with the discharge of her household duties, and
for which she seeks relief, first showed themselves about
two years ago. She then began to have abdominal and
pelvic pains, and some months later discovered a lump
low in the abdomen. Examination disclosed a solid,
freely movable tumor, sensitive to touch, in the left iliac
region, dipping into the pelvis, but not connected with the
uterus, and a small cyst of the right ovary. The uterus
was normal in size, but retroverted.
Dr. Jewett, during whose service she entered the hos-
pital, made a coehotomy, June 10, 1893. The solid
tumor proved to be a displaced spleen about twice the
normal size. It was free from adhesions and easily re-
placed. The right ovary, containing a cyst the size of a
small orange, was removed. Left ovary normal The
abdomen was closed without drainage. Convalescence
was uneventful She was soon discharged with positive
instructions to wear constantly a properly fitting ab-
dominal supporter, with the hope of retaining the spleen
in position.
Mrs. A was readmitted into the hospital during
my service, September 23, 1893. Shortly after her re-
tarn home she again began to sutler from pelvic symptoms,
and for the past two months has had nearly continuous
abdominal soreness and several severe paroxysms of
pain, which drove her to bed Her abdomen has been
steadily enlarging.
Six days ago, while doing the family washing, she was
seized with agonizing pain in the abdomen, which required
for its control the administration of morphia. Vomiting
of large quantities of bile-colored fluid began on the fol-
lowing morning, and still recurs at intervals. In spite of
treatment the bowels have not been opened for more
than a week. Temperature normal.
On examination, the abdomen was found tympanitic,
very sensitive to pressure, and occupied by an immov-
able, solid tumor which completely filled the left side
from the pelvis to the ribs, and extended considerably
beyond the middle line. It could easily be touched per
vagina m.
The former operation greatly simplified the diagnosis,
and left no doubt that the tumor was the enlarged and
inflamed spleen. The acute symptoms were attributed
to intestinal obstruction, due either to pressure from the
spleen or to adhesions at the seat of the ovarian stump.
The symptoms grew steadily worse until forty- eight
hours after admission, when the bowels responded freely
to treatment, after which the vomiting ceased and her
general condition improved. The respite was of short
duration. The local tenderness, paroxysmal pains, and
1 Read before the Ohio State Medical Society, May 17, 1894.
vomiting returned accompanied by fever. The tempera-
ture ranged from 990 to 1010 for ten days, and measured
100 ° on the morning of the operation. Peritonitis had
evidently supervened, and at a consultation of the hos-
pital staff it was decided that the removal of the offend-
ing spleen offered the only chance of recovery.
The operation was made October 7 th, with the assist*
ance of Drs. Jewett and Humphreys, the patient having
been anaesthetized by Dr. Reeve, Jr. The parietal in-
cision, seven and a half inches in length, was made along
the outer border of the left rectus. On exploring the
spleen, contrary to expectations based on the revelations
of the previous operation, it was found adherent to the
abdominal wall, omentum, and intestines. The intestinal
adhesions especially were firm and extensive, involving
the entire under and inner surfaces of the tumor. Their
separation consumed much time, and with the utmost
care the capsule of the spleen was torn in several places.
The peritoneum gave unmistakable evidences of active
inflammation. The pedicle was long, twisted through
three complete turns, and with its engorged and tortuous
vessels resembled a huge umbilical cord. It was trans-
fixed, firmly tied with heavy twisted silk, using the Staf-
fordshire knot, and for greater security encircled with an-
other turn of the ligature. The ligature was cut short
and the pedicle dropped, a glass drainage-tube placed,
and the wound, on account of the patient's condition,
hastil&cjosed.
The hemorrhage was slight and easily controlled. The
shock, however, was profound and wholly out of propor-
tion to the blood lost or the length of the operation.
Hypodermatic injections of brandy and strychnia were
freely used. Apart from the shock which threatened to
prove fatal for hours after removal to bed, and the tem-
perature which for twelve days measured from 99° to
101,0 precisely as it had before the operation, there was
nothing worthy of special comment during convalescence.
No satisfactory explanation of the temperature curve
could be found in the condition of the wound or patient,
and indeed, without the thermometer it would not have
been suspected. At no time was there swelling of the
parotid or lymphatic glands. The spleen drained of its
blood weighed four and a quarter pounds, and measured
ten inches in length by five and a half inches in breadth.
It was firmer in texture and darker in color than the
normal gland. Microscopical examination, by Dr. Schei-
benzuber, showed thickening of the trabecular and inter-
cellular connective tissue and pigment in the vessel walls,
" a chronic hyperplasia probably due to malaria." By an
unfortunate oversight, no microscopical examination of
the patient's blood was made before or soon after the
operation ; at present the proportion of the red and white
corpuscles is normal. Seven months after the extirpa-
tion, the date of the present report, Mrs. A , has
grown very fleshy and reports that she is in excellent
health save in one particular — an overpowering drowsi-
ness. When quiet, it requires constant effort to keep
awake. The habit seems to be increasing and is a con-
tinual source of annoyance and embarrassment.
It is not our intention to enter into a detailed discus-
sion of the surgery of the spleen, but propose simply to
supplement the above report with a few general com-
ments.
Although practically a modern operation, splenectomy
has a history which runs far back into the centuries.
Dionis (1733), quoted by Greig Smith, speaks con-
demningly of a sect of surgeons who achieved notoriety,
about the close of the seventeenth century, from their
operations of " unmilting," as removal of the spleen or
milt was termed. The only successful total extirpations
for disease recorded previous to 1867 were those of Zac-
carelli (1549) and Ferrerius (1711), both of which have
been discredited, probably erroneously, by many authors.
In nearly all of the statistical tables, Dr. G. Volney Dor-
sey, formerly a distinguished member of this society and
an accomplished scholar and surgeon, is credited with a
successful splenectomy made in 1855. Leddeihose
104
MEDICAL RECORD.
[July 28, 1894
refers to this case as the first authenticated success-
ful laparo -splenectomy on record. A reference to the
original publication/ for which I am indebted to Dr. Bil-
lings, United States Army Medical Library, shows that
Dr. Dorsey, in this very creditable pioneer effort in splenic
surgery, did not remove the spleen, nor is there any evi-
dence that he ever entertained such a proposition. The
operation was undertaken for the relief of pain in an en-
larged spleen of malarial origin. On opening the abdo-
men extensive adhesions were found and treated as the
source of trouble. "I then proceeded," says the
operator, " to break up all of the adhesions of the spleen,
and endeavored to place this viscus as nearly as possible
in what I conceived to be its natural position." The in-
troduction of splenectomy into modern surgery dates
from the memorable case of P6an, who in 1867 success-
fully removed from a young woman an enlarged and
cystic spleen. Since then the operation has not only
been accorded a place in legitimate surgery, but has been
extensively practised with fair success, though the mor-
tality-rate is still higher than in laparotomy for any other
cause.
The indications for splenectomy have not been defi-
nitely settled. Taking as a basis the tables of Drs. Fus-
sell," Ledderhose,' and Zuccarelli,* and making the
proper additions and corrections, we have the following
summary, which fairly represents the conditions for which
the operation has been made and the results attqped up
to date.
Num-
ber.
Hypertrophy, simple : malarial 48
Leucaemia | 27
Pseudo-leucaemia a
Traumatism, no serious lesion of spleen. .J 26
Traumatism, rupture of spleen { 6
Floating spleen \ 95
Cysts of spleen, simple : hydatid 1 6
Abscess of spleen 4
Sarcoma of spleen | 3
Syphilis of spleen I 1
Amyloid disease of spleen i 1
Healthy spleen j 1
Total ' xSo
Deaths.
26
Recov-
Percent-
| age of
mortality.
58*
5
68
45*
Like all statistical tables promiscuously gleaned from
current literature, this one must be taken cum grano
salts, since it is always a fair presumption that fatal cases
are less likely than successful ones to find their way into
print.
The celebrated case of Franzolini (1881), which how-
ever has not gone unchallenged, still remains the only
successful splenectomy for leucaemia. With the excep-
tion of Bardenheuer's case, which died from sepsis on the
thirteenth day, none survived the operation longer than a
few hours. Hemorrhage and shock were the cause of
death in all but three cases.
There are a few writers (Fulsell, Adlemann, Asch)
who, in view of the hopelessness of medical treatment,
still look with favor upon surgical procedures, provided
the operation is made when the gland is only moderately
enlarged and before profound alterations have taken
place in the blood. The consensus of opinion is, how-
ever, strongly opposed to this view.
The insidiousness of the onset of leucocythaemia and
the extensive mutilation which splenectomy implies,
taken in connection with the impossibility of eradicating
the constitutional cachexia which is back of the splenic
enlargement, will certainly tend to confine " early oper-
ation " within narrow limits. So far, the ghastly record
leaves unimpeached the dictum of Bryant, " that the
operation is physiologically unsafe and surgically un-
sound.1'
1 Ohio Medical Counsellor, 1855.
* Universal Medical Magazine, September, 1800.
8 Deutsche Chirurgie : lierausgegeben von Professor Billroth und
Luecke, 1890.
* Splenectomies in Italy : American Medico-Surgical Bulletin, May,
X894.
The results in simple or non-leucsemic hypertrophy
are more encouraging, although the mortality-rate is still
high, about 58^ per cent.
Agnew (1889) holds that all cases of hypertrophy,
simple, malarial, or leucaemic, are excluded from the
realm of operative surgery. The latest text-book on
surgery takes the more conservative position that, al-
though hypertrophied spleens have been successfully
removed these cases are for the most part not suitable
for operation.
These statements are hardly sustained by the facts.
It is undoubtedly true that simple hypertrophy will rarely
in itself be a sufficient justification for the performance
of splenectomy ; but in the presence of pressure symp-
toms, twisted pedicle leading to degenerative changes or
disabling pain, all of which may be caused by a moderate
enlargement of the gland, the operation is not only justi-
fiable, but offers a reasonable probability of a favorable
issue.
It is very apparent that the results are better in the
later than in the earlier operations, due, probably, to a
more thorough asepsis and an improved technique, and
lead to the hope of better things yet to come.
The record of the past decade in the operations for
simple — including malarial — hypertrophy, shows twenty
recoveries and eight deaths, a mortality of only 28^ per
cent, against 58^3 per cent, calculated upon the total
operations.
In discussing this phase of the subject it is proper to
take into consideration the brilliant results of extirpation
for floating or displaced spleens.
In over fifty per cent, of these histories it is specifi-
cally stated that the spleen was enlarged, while in very
few it is designated as normal in size. In many of the
cases, as in our own, the hypertrophy was extreme and
gave rise to doubts as to their correct classification.
It is difficult to estimate from the imperfect data at
hand the influence of malaria in causing the enlargement
which led to the adoption of operative measures. It is
only given as a cause of the hypertrophy in nineteen
cases, of which five died and fourteen recovered. The
condition of the blood, however, is a far more important
factor in determining the issue in a given case than the
amount or the nature of the hypertrophy (non-leucse-
mic). In any proposed excision of the spleen the blood
should be subjected to a careful microscopical examina-
tion, and if the relations of the corpuscles are seriously
disturbed, especially if the lymphatic glands are involved,
operative procedures should not be undertaken.
Splenectomy for certain traumatisms of the spleen has
a much better record than for disease. The results as
displayed in the table, which includes both total and par-
tial excisions, are very remarkable, and especially when
the fact is recalled that almost all of the cases which
enter into it antedate the dawn of aseptic surgery.
It is, however, worthy of more than passing mention,
that in the recent literature of the subject there are re-
corded so few removals of the spleen for traumatic
causes, and none for the peculiar traumatism with pro*
trusion which gives the extraordinary results tabulated
above. But unless interpreted in the light of the case
histories, these figures would be manifestly misleading.
The reports, so far as they are accessible, show that the
above results were obtained when there was protrusion
of the spleen through or into a parietal wound without
serious injury to the gland itself or other viscera.
The graver injuries included under the head of trau-
matic rupture have necessarily a high mortality. It is
fair to assume, from the deep-seated and protected loca-
tion of the spleen, that when it, has received an injury
severe enough to suggest splenectomy the concomitant
lesions would be profound and probably fatal.
So far as we are able to ascertain, the case of Riegner l
(1892) is thus far the only successful extirpation for a
subcutaneous trauma of the spleen.
The intense surgical interest of this unique case
1 Berliner klinische Wochenschrift, February, 1893.
July 28, 1894]
MEDICAL RECORD.
105
prompts us to give a brief resume. A lad, aged fourteen,
fell from the third story of a house and struck on his belly.
Twelve hours after the accident, signs of internal hemor-
rhage supervening, the abdomen was opened in the middle
line ; the incision was subsequently enlarged by right and
left cross-cuts. The spleen was found completely torn
across at its middle, and the two sections widely sepa-
rated. The spleen was removed, the abdominal cavity
cleansed of large quantities of clotted blood, and the pa-
tient put to bed much exhausted. Convalescence was
interrupted by gangrene of the foot and leg, which a few
weeks later necessitated amputation through the left
thigh. He recovered from both operations, and seven
months later was in excellent health.
Ledderhose investigated the comparative merits of re-
section, extirpation, and reposition of the protruding
spleen, with the following result : Ten resections with
ten recoveries ; eighteen extirpations with eighteen re-
coveries, and four repositions with one recovery.
The conclusion seems irresistible that in prolapse of the
spleen through an abdominal wound, extirpation, either
partial or total, is a safer procedure than simple replace-
ment However, this deduction is less startling when
we reflect that there is far less danger from sepsis and
hemorrhage in a laparotomy, with its careful toilet of the
peritoneum and better control of bleeding, than in
blindly replacing the protruding organ. These statis-
tics, contrary to the traditions of the textbooks, warrant
the statement that removal of the spleen is not in itself
a highly dangerous operation. An opinion which is for-
tified by the brilliant results in the removal of floating
spleens, already noticed, as well as by the fortunate end-
ing of the case of Trendelenburg, in which he removed a
healthy spleen in dissecting out a retro-peritoneal sar-
coma.
Hemorrhage and shock constitute the great dangers
in splenectomy, about seventy per cent, of the deaths
being attributed to these accidents. Sepsis is largely
eliminated by the promptness with which the fatal issue
follows the operation. According to Mosler, the hemor-
rhagic diathesis so constantly associated with splenic en-
largements, both simple and leucsemic, is often latent
and therefore unsuspected before operative measures are
begun. The pedicle is the most common seat of fatal
hemorrhage ; not infrequently it comes from the torn ad-
hesions, and in a few cases has been attributed to a ca-
pillary oozing from the congested viscera. For greater
security, some operators advise the separate ligation of
the vessels of the pedicle in addition to the ordinary en-
circling ligature, but Treves states that no advantage has
been shown to attend this practice.
The shock is often profound and, as in the case herein
reported, is not easily explained. Traction upon the
pedicle in manipulating the tumor has often brought on
dangerous collapse, due probably to pressure, upon the
splenic nerve-plexus. It is not improbable that many
deaths credited to post-operative collapse are really the
result of a slow intra-abdominal bleeding.
The present position of splenectomy may be briefly
epitomized as follows: It is unjustifiable in leucocy-
thaemia or other conditions in which there is extensive
involvement of the lymphatic glands, or a notable in-
crease in the white blood-corpuscles.
It is indicated - in tumors, simple hypertrophies, and
other splenic enlargements which have proven rebellious
to simpler measures and are attended with danger or
serious disability.
In movable or displaced spleens requiring interference
extirpation is preferable to operative fixation.
Severe traumatisms of the spleen, with or without an
external wound, or simple prolapse of the gland into a
parietal wound, demand, as a rule, immediate extirpation.
In cases of protrusion experience shows thai excision,
partial or total, is a safer procedure than mere replace-
.ment
Removal of the spleen for cystic disease has an ex-
cellent record, but most authors advise a preliminary
trial of incision with drainage. In abscess it is better,
except in rare cases, to incise and drain than to attempt
removal of the organ.
THE ^DANGERS OF GLYCERINE INJECTIONS
INTO THE UTERUS, FOR THE PURPOSE OF
INDUCING PREMATURE LABOR.
By OSCAR EMBDEN, M.D.,
BROOKLYN, N. Y.
T. Pfannenstiel publishes in the Centralblati fur
Gynecologic, No. 4, 1894, -an article concerning the
dangers connected with intra-uterine injections of glyc-
erine for the purpose of inducing premature labor — a
method of late frequently used in this country — and
gives the history of two cases treated by him with the
new method, in the Gynecological Clinic of Breslau.
As I have had the opportunity to observe one case
with a very similar history, showing evidently the dan-
gers of these injections, I take the liberty to give in the
following an extract of the above article together with
my case and some observations of my own. I consider
myself the more justified in so doing, as .Pfannenstiers
first case is not free from objections, leaving only one of
his cases indisputable.
In the beginning of his article the author states that
injections of different liquids into the uterus (for instance
the injection of tar water : Cohen's method) have been
frequently recommended, but generally very soon re-
jected by the profession, on account of the dangers con-
nected with these methods. Most of them, especially
Cohen's mode of procedure, are said to have one great
advantage ; that is prompt and sure action even in cases
where the ordinary methods have failed to act
Following this idea, Pelzer recommended the injection
of glycerine between the uterus and the foetal sac, two
years ago, publishing four cases treated by him success-
fully in this manner. Since that time we have read very
favorable reports of the new method, written by different
distinguished authors, none of whom mentions any dan-
gers connected with this treatment.
Pfannenstiel tries to demonstrate these dangers with
the following two cases :
Case I. — Primipara, twenty-two years of age, enters
the Clinic on September 5, 1892, in the ninth month of
her pregnancy, suffering from a very bad nephritis. Her
legs and face were oedematous, she has no appetite, has
headache and feels very weak. In the past seven days
she suffered from dyspnoea. She is anaemic, badly nour-
ished ; has a hyposcoliosis, but no narrowness of the pel-
vis ; cyanosis in a slight degree. Respiration, 44 ; tem-
perature, 97. 70 F. ; pulse, 130 to 166, small. The urine
contains eight per cent, albumin (Esbach's method),
many casts and epithelial cells, no red blood-corpuscles,
a few white ones ; quantity 200 cc in twenty four
hours.
September 7th, 6 p.m.: — Injection of 80 cc. chemi-
cally pure glycerine between the uterus and the foetal sac
with every possible precaution. The patient stood the
little operation very badly on account of orthopnoea.
She had a slight collapse before the injection and a sec-
ond one immediately after it, so that she required stimu-
lants. Soon after the injection, it was evident that it
had been performed too late. The breathing became
more and more difficult, the pulse became weaker.
Temperature, 95. 90 F. She never had a single pain.
She died September 8th, at 2 a.m.
The postmortem examination showed that she had
died of nephritis. Omitting the full report of this exam-
ination, I only mention that there was one tablespoon-
ful of blood-colored urine in the bladder. The vesical
membrane was of a red dolor. The foetal sac was sepa-
rated from the uterus over an area of about three inches
square. No glycerine was noticeable at this point.
Case II. — This is a III. para with a narrow pelvis ; arti-
ficial labor four weeks before term. Pfannenstie] first
io6
MEDICAL RECORD.
[July 28, 1894
tried, without success, Krause's method for some days :
he pushed in three bougies between the uterus and the
foetal sac
September 26th, 5 p.m. — Injection of 100 c.c. con-
centrated glycerine. The patient had immediately after
the injection very strong and very painful contractions.
These subsided after some time, the uterus remaining ex-
ceedingly sensitive. There was not any effect on the
cervix. One hour after the injection the woman became
drowsy and cyanotic, the temperature rose to 102. 20 F.,
the pulse became slower, 68 per minute. On the previ-
ous days it ranged between 84 and 92. This condition
continued for three hours. Then the temperature be-
came normal, the pulse a little more frequent. After
that the temperature remained normal. The urine,
drawn off with the catheter, one hour after the injection,
quantity 1 oz., was of a blood-red color. The woman
was catheterized every two hours : the urine remaining
as in the beginning until ten hours after the injection,
when the color began to become lighter and twenty-four
hours afterward it was normal. The urine contained
large quantities of albumin until forty-eight hours after
the injection; it contained nearly no morphotic ele-
ments, except some particles of hyaline casts, no red
blood- corpuscles. The spectrum-analysis showed that
there was methaemoglobin and haemoglobin in the urine.
The general feeling of the patient was not disturbed
after the operation, but the appetite was poor for three
days.
Premature labor was successfully brought on by means
of the colpeurynter. The delivery of a living child took
place September 28th, at 4.30 p.m. Puerpernrav with-
out complications.
The case, observed by myself, is as follows : Primi-
para, aged twenty-four, in the ninth month of her preg-
nancy. She has had albumin in the urine for three
weeks, the amount of which is rapidly increasing in the
last few days, in spite of a very strict milk diet (seven
per cent., Esbach's method). The quantity of the urine
is about one quart in twenty-four hours. The sediment
-contains a few white blood-corpuscles, no red ones, a
few renal epithelial cells, and a few hyaline casts. The
patient has a headache, feels sick to her stomach, and
very tired She has slight oedema of the feet and hands.
Under these circumstances it seemed best to induce pre-
mature labor as soon as possible.
March 19, 1893, x P-M- — Injection of 90 c.c. pure
glycerine between the uterus and foetal sac (Dr. Charles
Jewett). This had to be done in chloroform narcosis,
as the patient was very nervous. Soon after she recov-
ered from the narcosis she had slight pains at longer or
shorter intervals until 7 p.m. At that time the uterus
was very sensitive, but there were no real contractions.
At 7.30 p.m. the patient had a very severe eclamptic
convulsion of about three minutes' duration. As it was
very desirable to terminate labor as soon as possible, and
the cervix barely admitting the little finger, manual dila-
tation was very skilfully performed by Dr. Jewett, at 9
p.m., and a living child extracted with his own axio-
traction forceps. The temperature was normal all the
time, but the pulse- rate was very slow, ranging between
50 and 55 per minute ; before the injection it was 78.
The urine was not drawn off before delivery. The first
urine after delivery— drawn with the catheter — was of a
dark red color. It contained no red blood-corpuscles,
but a large quantity of haemoglobin. After twelve hours
the water was only slightly colored, and twenty-four
hours after delivery the color was normal. The albumin
disappeared gradually. The next day after delivery a
severe icterus set in, and the patient fell in a semi-coma-
tose condition, which continued for six days. By this
time the icterus and the coma had disappeared, and the
patient recovered gradually.
In the first place, it is demonstrated by these three
cases that the glycerine-injections do not act as quickly
as we should expect. Pfannenstiel concedes himself
that his first case is of little value in this respect, as it
was too far advanced for any treatment ; but his second
one illustrates clearly that the injections of glycerine
were of no more use than Krause's method (introduction
of bougies). My case shows that there was, about seven
hours after the injection, only a very slight dilatation of
the cervix, although the patient had constant pains from
the beginning.
Pfannenstiel is perfectly right in considering much
more important than this the fact that Pelzer's method
is liable to occasion indisputable symptoms of glycerine
poisoning. This will be— as he says — a death-blow to
the method.
Concerning the first case, he does not, of course, con-
sider the glycerine as the cause of the woman's death, but
the nephritis. He deems it remarkable, nevertheless,
that there was found a small quantity of blood- colored
water in the bladder, the urine being entirely free from
blood in the last days before the injection was performed,
as shown by frequent examinations. Pfannenstiel tries
to find the cause of this in the injected glycerine.
The second case was undoubtedly a case of glycerine
poisoning, and although it did not damage the future
health of the woman it kept her in danger for some
time. The woman was in perfect health up to the time
of the injection ; the urine was normal. One hour after-
ward she had the symptoms above mentioned.
In my case there is a woman with nephritis, but there
was not noticed at any time before the injection any
trace of blood in the urine. After the delivery there was
a good quantity of a dark red urine in the bladder. In
examining the same, I failed to find any red blood cor-
puscles, but there was a large amount of haemoglobin.
Therefore the cause of this could not have been an acute
congestion of the kidneys, as we at first thought — for
there was no hematuria, but a haemoglobinuria — and the
only explanation we could find for this was a decompo-
sition of the blood, brought on by the injected glycerine.
This does not seem so very strange, as we know — ac-
cording to Pfannenstiel — that glycerine is liable to occa-
sion a decomposition of the blood, as Luchsinger,1
Schwan,* Filehne,1 L6b6deff,4 and Wiener* have demon-
strated and Afanassiew9 has shown, experimenting with
dogs and rabbits, that the haemoglobinuria, caused by
glycerine, brings on a glomerulonephritis which is fol-
lowed, after the injection of more glycerine, by intersti-
tial nephritis as well as by interstitial hepatitis.
It is, of course, strange that neither Pelzer nor others
met with a similar accident after injections of glycerine.
Pfannenstiel finds an explanation of this in the fact
that Schwan, L6bedeff, and Filehne have shown that in
rabbits, when the glycerine is brought under the skin,
haemoglobinuria always occurred, but that it did not occur,
or in a slight degree only, when it was injected directly
into the veins. Without giving an explanation of this
remarkable fact, Pfannenstiel deems it possible that, in
Pelzer's cases, the glycerine was very rapidly absorbed
by the circulatory system, while in his cases it acted in
the decidua uteri as if it had been injected by the hypo-
dermic method.
There is another thing about which I would like to say
a few words, that is the icterus which, in my case, fol-
lowed the haemoglobinuria. On this account it seems to
me especially interesting.
It is not very important whether this was, according to
Kuehne's * theory, a real haematogenic icterus, that is,
an icterus directly caused by the pigment of the decom-
posed red blood-corpuscles, or a so-called taemo-hepato-
genic icterus, which is said by Afanassiew, who denies the
existence of a real haematogenic icterus, to be an indirect
result of this decomposition only. This author thinks
1 Pflueger's Archiv, 1875, p. 503
9 Eckhard, Beitrage zur Anatomie of Physiologic 1879, T<>1* ▼»»•• P-
167.
* Virchow's Archiv, vol. cxvii., p, 413.
4 Virchow's Archiv. 1883, voL xci. , p. 303.
* Archiv flier Gynaecologie, 1884, vol. xx'iii.
* Verhandlungen des Kongresses fuer innere Medicin, 1883, p. 2x6,
fF.
T Virchow's Archiv, voL 14.
July 28, 1894]
MEDICAL RECORD.
107
that the pigment of the destroyed red blood corpuscles is
deposited in the liver, where the gall- pigment is normally
formed out of the blood pigment, and the icterus occurs,
in his opinion, on account of an overplus of gall-pig-
ment in the liver, a part of which reflows into the blood.
Leaving this question undecided, one thing seems to
be indisputable, and that is, the icterus was caused, in
my case, either directly or indirectly by the decomposi-
tion of the blood poisoned by glycerine.
I would not dare to say that the semi-comatose condi-
tion of my patient, which disappeared with the icterus,
was brought on by the same cause. It did not look like
a uremic coma, and we were unable to account for its
origin. It might possibly have been one of the indirect
effects of the decomposition of the blood, but it is better
to leave this an open question.
Pfannenstiel also points out another danger of the in-
jection of concentrated glycerine, and that is, according
to the authors above cited, the possibility of a thrombo-
sis, which concentrated glycerine, when brought into the
circulatory system, may produce.
In addition to ail these objections, there has still to be
mentioned another danger connected with the new
method as well as with the injection of any kind of fluid
between the uterus and the foetal sac, namely, the possi-
bility of air entering into the circulatory system. This
cannot be absolutely avoided, even with every possible
precaution.
All this together seems sufficiently to show the great
dangers connected with Pelzer's mode of procedure. It
ought not to be used at all for the purpose of inducing
premature labor, but especially not, in my opinion, in
cases of nephritis, as we have seen that the glycerine is
very liable, on account of its irritating effects on the kid-
neys, to make the existing nephritis worse.
If, in calling the attention of the profession to the
dangers of Pelzer's method, I shall have convinced them
that it is not a method for indiscriminate use, I will have
attained my object.
184 Stats Stkbkt. Brooklyn, N. Y.'
©litxical gepartmetit
AN ECHINOCOCCUS CYST SIMULATING AS-
CITES.
By MARCELL HARTWIG, M.D.,
BUFFALO, N. Y.
D. R , an Italian, appeared in my office February 1,
1894, saying that he had been sick about five months with
loss of strength. Upon examination he presented all the
symptoms of ascites, except that there was a very gradual
change of the percussion dulness in changing position,
and also that there was a remarkable bulging of the epi-
gastrium. On February 5 th I tapped him midway be-
tween the symphysis pubis and umbilicus. Over five
quarts of an intensely green liquid were removed. A
great many brown lumps and flakes came along, some
with a gritty feel. The whole liquid appeared more vis-
cid than ascitic fluid usually does. Microscopic exami-
nation showed rhombic dark brown crystals, which Dr.
Benedict found to be bilirubin, fatty round- cells, and
some large rings with double contour and two or three
central dots which I could but consider eggs of some
worm, but whether of ascaris or taenia I could not de-
termine. The liquid was rich in bile. After the liquid
was removed nothing unusual could be felt in the ab-
domen. The temperature was ioo° F. in the rectum,
pulse 79. Five weeks after the tapping the patient be-
gan to feel uncomfortable again, although he had gained
some in weight. Jaundice had not existed previously, nor
did such appear after the tapping. Fluctuation was dis-
tinct again and I was almost ready to push the trocar
through the old place, when it became evident that the
liquid was above that point, and that, in standing, the
lowermost parts of the abdomen gave a tympanitic sound
up to the middle point between the symphysis pubis and
umbilicus. So, after an exploratory puncture with a hy-
podermic needle a finger's width above the navel, I
pushed a good-sized trocar in and emptied what I now
believed to be a sac. There were about two and one- half
quarts of liquid with the former characters, only that the
search for eggs proved futile. Through the cannula a
N6laton catheter, previously fitted, was introduced to the
depth of a foot, and over it the cannula withdrawn in
order to establish permanent drainage. Liquid of the
same character kept oozing from the end of the catheter.
While I was contemplating how to produce adhesive in-
flammation— thinking, for example, of injecting tincture
of iodine, as in hydrocele, but fearing poisoning — natural
infection came to my aid. The patient became feverish,
the temperature xoften rising to 1030 F. ; the liquid be-
gan to turn into pus containing streptococci only.
After a week's fever I thought the • reaction plenty
strong enough, and began injections of peroxide of
hydrogen, which brought out some crystals for a while.
The size of the cavity began diminishing. April 1 7th
it admitted only 850 c.c. April 25th, 150 c.c. ; May 3d,
100 c.c. — at a pressure of twelve to fourteen inches of
water.
The patient was up and around again. May 17 th
liquid oozes immediately next to the catheter. I shall
shorten the latter daily, as there is no doubt the process
is at an end and the cavity gone. What else than an
echinococcus cyst communicating with the gallbladder
or probably with a bile duct in the liver could this case
represent ? That the gall-bladder did not communicate
with the cyst seems to me probable, from the fact that a
probe introduced into the channel of the catheter, after
the latter's withdrawal, seemed to reach decidedly
too far underneath the lower surface of the liver, and
that the stools were of natural color. This is the first
case of echinococcus I have seen in fifteen years in Buf-
falo, although I have watched for it. The patient, liquid,
and slides were presented in the Buffalo Academy of
Medicine ; and, during the discussion, a gentleman ex
pressed his fear that such a method of drainage might
expose the patient to leakage of fluid into the peritoneal
cavity with resulting peritonitis. But the danger seems
to me absent, even if the cyst should retract off from the
abdominal wall, as long as it is emptied well so that
there is no internal pressure left. In a few days a chan-
nel is formed of inter-intestinal adhesions, forming a per-
fect pipe, cutting off the general peritoneal cavity.
Such a condition I saw years ago, when I placed a thor-
ough drain from an abdominal incision through Douglas's
pouch. Nothing would drain after a few days, until after
about fourteen days an abscess in the neighborhood
emptied itself into the channel, which was purposely
kept patulous by the drain. The first few days the cath-
eter, properly fitting the trocar cannula, will remain
fluid-tight in the cyst as long as there is no internal press-
ure ; afterward the adhesions suffice, if the cyst is ever
so far retracted.
Reynier's l case of peritonitis after puncture of an echi-
nococcus, where he warns, seems to me not good com-
parison, as, at least from the report, it seems that the cyst
was not entirely emptied and the drainage not main-
tained. There is no doubt to my mind that the simplici-
ty of this proceeding is far preferable to incision d deux
temps (Volkmann) or to stitching the cyst to the ab-
dominal wall and incising. The only difficult point is
to determine where the probable root of the cyst is.
This is important, in order to insert the trocar in its
close neighborhood, so that the drain channel should
not be too long. May be that even unilocular ovarian
cysts could be thus cured. Impossible it does not seem
to me even for multilocular cysts, although the present
modus operandi is simpler for the latter. The future un-
doubtedly will show a great extension of this procedure.
Another argument supporting my view of the nature of
> Year-book of Treatment, Lea Brothers & Co., 1894.
io8
MEDICAL RECORD.
[July 28, 1894
this case is Weichselmann's observation that the connec-
tive tissue wall of echinococcus cysts contains bile-ducts
which readily open into the cyst if the wall of the latter
begins exfoliating. Thus it was frequently seen that
echinococcus cysts began oozing bile alter having been
draining for some while. Here this occurrence happened
only before the operation. The amounts of bile oozing
were seen as high as one litre pro die, and it is no wonder
that the whole contents of our cyst seemed to have been
bile.
I have recently shown my patient a specimen of tape-
worm, and asked whether his dog in Italy three yean ago
used to pass similar pieces ; and he said the dog did, while
he wondered about it. Usually there were only two or
three pieces.
A CASE OF TRANSPOSITION OF THE VIS-
CERA.
By HENRY J. HERRICK, A.M., M.D.,
CLEVELAND* O.
It occurs to me that the readers ot the Medical Record
might be interested in hearing of a rather unique case,
at present in Lakeside Hospital, Cleveland, in which the
positions of the internal viscera seem rather mixed.
John S , a German laborer, twenty-five years of
age, entered the hospital about three weeks ago complain-
ing ot loss of appetite, weight, and strength. He had
eight brothers and sisters, all of whom died while young,
and he has always been delicate himself, and unable when
a boy to knock around as his fellows did.
Upon examination, this unusual state of affairs was
found : His heart is normal in size and correct in posi-
tion, except that it is on the right side. The apex beat
is in the fifth intercostal space, and one inch from the
nipple, toward the median line ; his liver is normal and
in perfect position, except that it is on the left side ;
while his stomach seems to have changed places with the
liver, and is on the right side. His spleen could not be
made out.
355 Eub s-
REPORT OF A CASE OF ACUTE SUPRA-GLOT-
TIC (EDEMA WITHOUT APPARENT CAUSE
By JOHN H. PRYOR, M.D.,
BUFFALO, N. T.
Thb term oedema of the glottis is often used improperly,
and the grouping of ail cases of oedema of the larynx
under that head leads to confusion. (Edema of the glot-
tis, or interior of the larynx, is of relatively rare«occur-
rence, and in most of the reported cases the morbid con-
dition is confined to the region above the vocal cords.
This is particularly true of simple oedema, and for many
reasons an anatomical distinction should be made. The
term supra-glottic oedema seems to answer the require-
ments of accuracy and clearness.
J. S- — , a dentist by profession, aged thirty, vigorous
and healthy, consulted me on July 15 th for difficulty in
speaking and breathing. He had retired as usual the
previous evening, and was awakened in the early morning
by a slight sense of fulness and discomfort in the region
of the throat. In the morning, thinking the trouble
trifling, he went to his office and began his usual work.
The local trouble became more urgent, and I saw him
about three o'clock. At that time there were no objec-
tive signs of difficulty in breathing. The face wore an
anxious look, but the feature which immediately attracted
my attention was the peculiarity of. the voice. The
sound was new to me. It was metallic in quality and
seemed to come from a cavern. I can think of no bet-
ter definition than the word sepulchral. Enunciation
was distinct, and there was no difficulty in understanding
each word. The character of the voice differed distinctly
from the muffled quality which is usually heard in second-
ary oedema, and was devoid of hoarseness ; an examina-
tion revealed no evidence of acute pharyngitis or rhinitis,
but marked oedema of the epiglottis and aryepiglottic
folds. The epiglottis showed a line of division in the
centre which gave the appearance of two large puff balls.
It was erect and too firm to be aspirated into the glottis ;
at the base or lingual surface of the right side a large
bleb of about one fourth inch in diameter was plainly
seen. The aryepiglottic folds were greatly distended, and
infringed directly upon the surface of the epiglottis.
Any view into the larynx was impossible, owing to the
extent of the tumefaction. The opening for the admis-
sion of air was almost entirely obliterated. Only the
narrowest chink was visible when the patient uttered a
vowel sound. There was pronounced infiltration of the
connective tissue of the neck in the region of the larynx.
Pressure on the larynx did not produce pain, and there was
no complaint of pain or soreness in the throat or larynx ;
simply a suffocation feeling and no general symptoms
whatever. Breathing eighteen to the minute, and tem-
perature and pulse normal. I hurried the patient home,
and at four o'clock the voice became husky and later
whispering. The breathing grew more rapid and la-
bored, and the face very pale. Applied six leeches in
the region of the larynx. Ordered hot mustard foot-
bath, wrapping in blankets and copious drafts of hot
lemonade and whiskey. The sweating which followed
was most profuse. When the leeches dropped off the
swelling of the neck had disappeared. The neck was
then packed in ice and the patient sent to bed. The
day was unusually warm and the degree of humidity re-
markably high, consequently steam was not employed.
At six o'clock the breathing was much easier and the
voice could again be heard. At eight o'clock the left
vocal cord could be seen and the breathing was natural.
I remained near the patient to scarify, if necessary. The
local improvement was so marked at midnight that I con-
sidered it safe to leave him in the care of a nurse.
Upon inspection the following morning the oedema
was confined almost entirely to one side, and the same
afternoon both cords could be seen. They were pinkish
in hue, but showed no traces of inflammation or oedema.
Whether the otdema was confined to the epiglottis and
aryepiglottic folds cannot be stated, but I believe that
the loss of voice was due to transitory congestion of the
cords.
On Monday, forty-eight hours after the attack, the pa-
tient was well and at work. I have examined him repeat-
edly since and never found any evidence of local disease.
He has never shown any evidences of cardiac or renal
disease, and I have been unable to discover any constitu-
tional condition which might account for the strange at-
tack. The usual causative factors were absent, and after
searching the literature no clew as to the direct cause can
be furnished. No similar case has been reported, to my
knowledge. Some of the authors consider phlegmonous
laryngitis and oedema of the glottis as practically the
same affection. That there is a decided difference in the
two conditions cannot admit of doubt, and this reported
case of simple oedema emphasizes the fact Cases of a
somewhat similar nature have been recorded, which owed
their origin to exposure, cold, untoward drug action, etc
— elements absent in my case. The possibility of it be-
longing to the angio-neurotic variety of oedema described
by Quincke and others, calls for comment. The cases
reported by Quincke, Dinkebarger, Strtiburg, Osier, and
others were essentially different in history and sympto-
matology. They were mostly characterized by recurrent
attacks, skin eruptions, digestive disturbances, and a his-
tory of heredity. Careful inquiry and extended observa-
tion only prove the absence of all the accompanying
features which make the so-called neurotic oedema diag-
nostic. This condition is at present obscure, tfnd we are
not in a position to decide what should or should not be
included under this term.
The evanescent character of the attadk might lead one
to explain the anatomical changes by ascribing the condi-
July 28, 1894]
MEDICAL RECORD.
109
tion to vasomotor disturbance, or temporary stoppage of
the lymph-channels. The former seems most reasonable,
although unaccountable, and the latter theory gains sup-
port by the knowledge of the distribution of the lymphat-
ics which Hajek has supplied.
A more extended consideration of the possible causa*
tion might be interesting, but I prefer to present the case
at this time as rare and most puzzling, and to state briefly
the following points of clinical value : 1. The absence
of any known causative agency and constitutional symp-
toms. 2. The extent of oedema, which may occur with-
out marked dyspnoea. 3. The peculiar character of the
voice. 4. The marked benefit of prompt treatment with-
out scarification. 5. The possibility of the case belong-
ing to a group of obscure clinical manifestations known as
angioneurotic oedema or allied vasomotor curiosities.
A CASE OF PNEUMONIA IN AN INFANT FIVE
MONTHS OLD TREATED WITH INHALA-
TIONS OF OXYGEN.
•By RICHARD P. FRANCIS, M.D.,
SUKGBON TO MOUNTAIXSIOB HOSPITAL, MONTCLAIB, M. J.
The following case seems worthy of record because of
the immediate and very gratifying result that followed
the use of oxygen when the patient was in an apparently
hopeless condition. Oxygen has often been used in
treating pneumonia in adults and children, but it is be-
lieved that its use with infants is not so common, and it
is hoped that this account may be of service to anyone
who may encounter a similar case.
The patient was a bottle-fed baby, five months old,
well developed and nourished, and of healthy parentage ;
she had always been well up to the time of the present
illness. On March 1, 1894, after having had a cough
for two or three days, she was taken with a chill. Physi-
cal examination soon after showed a few fine rales in the
right upper back, but no dulness and no bronchial
breathing. Temperature, 102. 8° F.; pulse, 180; respi-
ration, 45. On March 3d, bronchial breathing devel-
oped and the respirations reached 100 per minute,
while the pulse was 180 and the temperature 1050 F.
Ten drops of brandy were given every half- hour, and a
cough mixture of muriate of ammonia, fluid extract of
licorice, and whiskey every two hours. The next day
the circulation was very bad, the extremities became
cold several times, and the face dusky. At 5 p.m. the
child was put in a hot mustard bath and there were given
twenty drops of brandy in which was dissolved a tablet
triturate containing one minim each of tincture of digi-
talis and tincture of strophanthus, one-eighth of a minim
of tincture of belladonna, and one two-hundredth of a
grain of nitro glycerine. A good reaction soon followed.
From this time on the "heart stimulant" tablets were
given every three hours. Their effect on the heart's
action was most marked ; not so much in diminishing its
rapidity as in increasing its force.
For the next five days the case ran a fairly typical
course — the pulse averaging 160 and the respirations 120.
It is interesting to note that on four occasions the respi-
rations were more rapid than the pulse. On March 4th,
at 12 m., respiration, 140; pulse, 130. March 5th, at
8 a.m., respiration, 120; pulse, 100. March 6th, at 4
p.m., respiration, 144; pulse 140. March 7th, at 4 p.m.,
respiration, 130; pulse, 120. The treatment was taken
well, and two or three ounces of Pasteurized milk were
given daily. Special care taken that the child had
plenty of water, which she took eagerly and with evident
gratification. Frequently brandy was administered in
twenty-drop doses for four or five consecutive hours, to
stimulate the flagging heart On the morning of March
nth the record of the temperature, pulse, and respiration
showed them to be the lowest since the beginning of the
attack, and an examination of the chest gave evidence
of beginning resolution. The next day the temperature
was elevated, as were the pulse and respirations, and on
the 13th bronchial breathing was found in the left upper
back.
The pulse was weak and very rapid (180 to 200) ; the
respirations averaged 140 per minute. During the
morning brandy was given in doses of ten or twenty
drops every half- hour and the " heart stimulant " tablets
every two hours. As it did not seem justifiable to push
these remedies further, and as the infant's strength was
already much reduced by the sickness of two weeks, it
was thought that the safest aid could be obtained from
oxygen. A cylinder was obtained about 5 p.m. and the
administration at once begun by holding the mouth-
piece pressed to the infant's nostril. At this time the
condition was alarming in the extreme, as may be in-
ferred from the fact that the respirations had been 140
all day, and the day before had at one time run up to
160 ; the pulse was varying between 160 and 180 (a little
later it was 200), and the temperature was 103. 5 ° to
10 40 F. The heart's action was weak, the skin dusky,
and the whole condition was so evidently due to lack of
proper oxygenation, that it seemed almost self-evident
what remedy was needed. The only question was
whether the remedy could be satisfactorily applied. But
almost as soon as the stream of gas was allowed to enter
the nostril the favorable effect was observed. The cir-
culation and general condition improved as markedly as
when the gas is given to patients who are able to co-oper-
ate in its administration ; the duskiness of the skin disap-
peared, the respirations grew less shallow and slower, and
the whole appearance changed for the better.
Throughout the day of the 14th, the oxygen was given
every fifteen minutes for five seconds at a time, and dur-
ing the subsequent night it was inhaled almost continu-
ously; the brandy was given in ten- drop doses every
half-hour, and the "heart stimulant " every two hours.
Early the next morning the patient turned on the left
side for the first time since the involvement of the left
lung. The crisis of the disease was apparently reached,
as from now on the symptoms gradually ameliorated ; the
stimulants were diminished by degrees and the food in-
creased. The brandy and oxygen were given in alter-
nate doses every half-hour for a day or two, and not for
three days was the oxygen altogether omitted. The
patient had a most satisfactory and complete convales-
cence, and is now a vigorous baby.
THE TYPHOID SPINE.
By JOSEPH N. STUDY, M.D.,
CAMBRIDGE CITY, IND.
There are certain sequelae of typhoid fever which are
known to physicians, but are rarely referred to in stand-
ard text-books upon the practice of medicine, and only
occasionally spoken of in medical journals.
The title of this subject, so far as I am aware of, was
first referred to by Dr. Gibney, of New York, who, at
the American Orthopedic Association, in 1889, described
a sequela of enteric fever, which he termed the typhoid
spine, an inflammation of the periosteum and the fibrous
structures by which the spinal column is held together.
The only other reference to such a condition that I
know of is in an article published in the American Jour-
nal of the Medical Sciences for January of the current
year, by Dr. William Osier, of Baltimore, who, under
the title of "The Neurosis Following Enteric Fever,
Known as the Typhoid Spine," reports the histories of
four cases, and also three cases of Dr. Gibney. In brief,
this condition is spoken of as following enteric fever,
and has usually occurred after the patient had so far re-
covered as to be up and about. It is characterized by
pain in the back, which, when any movement is made
twisting or flexing the spinal column, is usually of an
agonizing nature, often causing the patient to cry aloud.
In some of the reported cases fever was observed, while
in others it was absent. Usually there was no disturb-
ance of motor or sensory nerves, and further than the
no
MEDICAL RECORD.
[July 28, 1894
painful back there was no indication of disease in any
other part of the body.
I desire to report a condition observed after typhoid
fever, which, for want of a better name, I have called
the typhoid spine. This case presented some features
which are so infrequently seen that to me it was one of
more than ordinary interest.
On August 10, 1893, Mr- w > aged thirty-four,
American, occupation undertaker, father of three chil-
dren, and whose previous health had been excellent, was
taken with typhoid fever. October nth, he was dis-
charged as being convalescent. His sickness was severe,
and he had had hemorrhage from the bowels and diar-
rhoea. His recovery was uneventful until December
13th. At this time he had gained thirty pounds in
weight, and had been doing some work, which consisted
of a twisting or rotary movement of the spine, occasioned
by standing on the rounds of a ladder and using a hand-
saw. Following this appeared a painful affection of the
back, extending from about the fifth dorsal to the third
lumbar vertebra. For over three weeks the pain pro-
duced by any flexion or other movement of the spine was
intense, and at times caused the man to cry aloud. Al-
most the entire time was spent in a reclining chair. In
attempting to place the patient in bed the pain produced
was so great that no persuasion could induce him to
make further efforts. It was only because of the loss of
sleep and the consequent free use of morphia, that the
effort was made at this time.
There was an increase of temperature reaching as high
as 103^° F., which continued for ten days, and was
followed by rather free perspiration. There was] at no
time any hyperesthesia or other indication of either the
motor or sensory nerves being affected. No complaint
was made of pain in any other portion of the body. At
one time a band-like feeling around the waist was com-
plained of for a short time. No tenderness was observed
when pressure was made over the seat of pain. Repeated
examinations of the various organs of the body and of
the urine were made, but were always negative in their
results.
After ten weeks the patient has so for recovered as to
be out, and says he is almost entirely free from pain.
SOME MINOR POINTS TO BE OBSERVED IN
ADMINISTERING CHLOROFORM.
By AARON JEFFERY, M.D.,
RADFORD, VA.
Ever since chloroform and ether have been in general
use, the question of which is the safest and best anaes-
thetic has been debated throughout the country. Re-
cently there appeared in the Medical Record several
articles in support of chloroform, among the number an
article by Dr. Fisher, of California, headed — " Chloro-
form in Organic Disease of the Heart." He lays great
stress on the slow administration of the drug ; and in my
opinion that is one of the most, if not the most, impor-
tant point to be observed in its administration.
By observing this rule, the lungs and heart gradually
become acclimated, so to speak, and the shock to the
nerve-centre is avoided. If a person could be suddenly
removed from a low to a very high altitude, I dare say
the same thing would happen that often happens during
the quick administration of chloroform, namely, cessation
of the respiration, and as a consequence, engorgement
of the heart and death. On the other hand, if the
change be gradually made, the person often can stand
the change well, and, for the same reasons, the slow ad-
ministration of chloroform may be tolerated when the
quick method would cause death. In the German
schools of medicine, I believe they all practise the slow
method, and chloroform is the anaesthetic used mostly
by them.
There are other minor points that should be observed.
The patient's head should be turned so as to allow the
tongue to fall to one side. About ten years ago, on one
occasion, 1 came very near losing a patient on account
of neglecting to observe this rule. The patient's breath-
ing stopped and the pulse became rapid and weak. 1
discovered that this alarming condition was caused by
the relaxed tongue having fallen to the back of the throat,
and thereby shutting off all air from the lungs. The
tongue was pulled out by means of a tenaculum, artificial
respiration performed, and in a short time the man wa
breathing quietly. As a general rule, I think it advisabls
to administer an hypodermatic injection of morphine
about fifteen minutes before commencing the anaesthetice
The nervousness of the patient is thereby lessened, and.
the quantity of chloroform necessary to keep the patient
anaesthetized is also lessened, to say nothing of the stimu-
lating effect of the morphine on the heart's action.
One should always have at hand an hypodermatic
syringe loaded with whiskey or brandy, a phial of aqua
ammoniae, and some nitrite of amyl, to use in case the
heart or respiration should fail.
Nothing original is claimed in this article, but I be-
lieve if these details are observed strictly, namely, the
slow administration of the drug, the previous administra-
tion of morphine hypodermatically, the patient's head
kept on one side, ammonia, whiskey, and nitrite of amyl
at hand, that the deaths from chloroform inhalations will
be greatly diminished.
THE EXCESSIVE CONSUMPTION OF TEA AS
A CAUSE OF MULTIPLE NEURITIS. RE-
PORT OF CASE.1
By WILLIAM PHILIP SPRATLING, M.D.,
NBW YOKK.
The etiology of multiple neuritis is quite extensive and
varied. In different countries the affection is described
under different names. In India, portions of South
America, and the East and West Indies, it is known as
beriberi. In Japan, where it frequently occurs in epi-
demics of great severity, it is called kakkt.
The causes of multiple neuritis differ in these widely
diverse communities. In Japan, the matter of diet has
long been held to be an etiological factor of importance.
The inhabitants of that country, as we know, subsist al-
most wholly on a diet of fish and rice, and drink tea to
the exclusion of all other beverages. Among sailors on
shipboard also, where the disease is frequently found,
restricted diet has been regarded as a potent cause.
The causes of the disease, as we find it in this country,
are most varied. Among those most usually recognized
and active, may be mentioned alcohol, illuminating gas,
lead, arsenic, strychnia, and the infectious agents of cer-
tain diseases, as typhus, diphtheria, small pox, malaria,
and tuberculosis. Exposure to cold and damp, and over-
exertion, are likewise causes.
Go wers is of the opinion that " endemic neuritis, as it
occurs in Japan, is due to some endemic influence." It
is a matter of common knowledge that the Japanese peo-
ple are the greatest tea-drinking race in the world. It is
likewise true that the people of no other country suffer so
frequently and so violently from multiple neuritis as the
Japanese do. Not only is the disease present with them
at all times in an endemic form ; but it frequently sweeps
over the country in the form of severe epidemics.
Is there any connection between excessive tea drink-
ing and multiple neuritis ? I think there is ; and for this
reason. Tea is a recognized stimulant of the nervous
system. Its prolonged and excessive use induces a train
of well-marked nervous symptoms, which vary in indi-
viduals of unlike susceptibilities. A brief reference to
the physiological action of tea, or its alkaloid theine,
will show this to be true.
Richardson 8 says, " This alkaloid exercises a special
influence on the nervous system, which, when carried to
1 Read before the Harlem Medical Association, May a, 1894.
9 Preventive Medicine, 1884, page 364.
July 28, 1894]
MEDICAL RECORD.
111
a considerable extent, is temporarily, if not permanently,
injured." This author observed the most characteristic
effects of tea in " tea tasters/' persons who by profession
are engaged to determine the qualities of tea by the proc-
ess of tasting different specimens of strong teas. He
found in such persons distaste for food, deficient appe-
tite, nausea, nervous depression with muscular tremors
and feebleness, constipation, flatulency, and almost en-
tire inability to sleep.
Wood ^ys : " Chemically, the alkaloid obtained from
tea and known as theine is identical with caffeine ; in-
deed," he adds, " most of the caffeine used in commerce,
according to Dr. Charles Rice, is obtained from the tea
lea£ If, however," he further adds, " the experiments of
Dr. Thomas J. Mays are confirmed, theine is not physio-
logically identical with caffeine. ' ' Dr. Mays asserts, as the
result of his experiments made on frogs, that theine differs
from caffeine as follows: 1. Theine produces spontane-
ous spasms and convulsions, while caffeine does not. 2.
Theine impairs the nasal reflex early in the poisoning
process, while caffeine does not, if at all, until the very
last stage. Dr. Mays also claims that theine is a powerful
local anaesthetic.
Thus we see that all the phenomena observed by Dr.
Mays that were induced by theine, including spasms, con-
vulsions, abolition of nasal reflex, and anaesthesia, were
purely of nervous origin.
The case I have to report is that of W. S. W , male,
thirty years of age. Usually strong and robust, but suf-
fers at long intervals from very mild attacks of subacute
articular rheumatism. Does not use liquor or tobacco in
any form. Is extremely susceptible to the influence of
alcohol, one-half ounce of any light wine quickly caus-
ing flushed face and noticeable exhilaration.
Prior to Novembei, 1892, he had not been a tea-drinker.
At that time the habit was formed of taking one-half
pint of strong tea at noon, and again about four o'clock
in the afternoon. Later the quantity consumed was in-
creased to one and one half pint daily, and the increase
became gradual until from two and one half to three
pints were taken in twenty- four hours. Six weeks after
this indulgence began, a mild tingling sensation appeared
in the right hand, extending half-way up the forearm.
Small blebs, due to trophic disturbances, appeared on the
dorsal surface of the first and second fingers. The skin
of the entire hand was slightly hypenesthetic, and the
temperature sense of the member was impaired. At the
same time it was noted that the heart's action was feeble
and irregular.
An exact diagnosis of the condition at that time was
not made. The use of tea was stopped, small doses of
digitalis given, the patient directed to take long walks
daily, to eat simple, nutritious food, and in six weeks all
traces of the trouble had disappeared.
The second attack occurred in January, 1894, fourteen
months after the first. For three weeks preceding this
attack, strong tea was again used in excessive quantities.
The patient was engaged in literary work and took the
tea as a stimulating and refreshing drink. The first
symptom noted this time was pain in the right wrist,
dull, boring, and burning in character. It was ascribed
to rheumatism, until pain of the same character was felt
in the right shoulder, spreading over the scapula as far
as the spine, and running down through the axilla, along
the course of the median nerve, as far as the elbow. The
brachial plexus was involved, and pressure applied to
any part of the axillary space caused intense pain. The
chafing of the seam of the undershirt in the armpit
caused great discomfort. The median nerve was espe-
cially involved. Pressure over it at any point could
not be borne. Both of the main nerve-trunks below the
elbow suffered. The first disturbance of the temperature
sense of the hand was noted when the hand was put in
water at a temperature of 500 F. Pain was so great that
it had to be withdrawn. The surface of the hand, espe-
cially the dorsal portion, became painful to the touch.
1 Therapeutics, its Principles and Practice, 1892, page 373.
The sensation was described as being similar to that
felt when the skin is blistered and again brought into
contact with heat. A group of three small trophic blebs
appeared over the carpo-metacarpal articulation of the
first finger. A similar group, but more numerous, de-
veloped just below the styloid process of the ulnar. Be-
tween the first and second joints of the phalanges of all
the fingers, small, hard, deep-seated nodules appeared.
Pressure over these caused intense pain. Picking up or
handling hard, firm substances, as a chair or a book, was
accomplished with difficulty. There was delayed trans-
mission of pain and temperature sensation. Remak's
sign was noticeably present. This was well exemplified
by making pressure over the nodules on the fingers above
described, or by pinching or pricking any part of the
hand, when pain would not be felt for two seconds or
more ; and when it did appear, grew in intensity, and
after reaching its height, would slowly subside.
The motor symptoms were not so marked as the sen-
sory ones, due to the fact that the disease did not pro-
gress beyond the inflammatory stage. There was, how*
ever, weakness, and quick sense of lack of power when
the hand and arm were used. Writing was difficult and
could only be done for a limited period of time without
rest.
I regret that I was unable to test the electrical reac-
tions of the case. For diagnostic purposes, however, it
was not needed.
The treatment consisted of the application of the
usual remedies. Good general tonics, and drugs that
build up the economy, are frequently indicated. The
removal of the cause, whenever found, is, of course, su-
perior to all other forms of treatment combined. In
this case, the use of tea was absolutely forbidden ; out-
of-door exercise in abundance prescribed, the use of
light, nutritious food advised, and in six weeks the dis-
ease had entirely disappeared.
70 West Eighty-eighth Street, May i, 1894.
THE TREATMENT OF QUINSY.
By SILAS S. CARTWRIGHT, M.D.,
ROXBURY, M. Y.
Some years since I saw the following prescription in the
Medical Record for quinsy :
9. Norwood's tincture ver. vir gtt. xxx.
Morphia sulphas gr. jss.
Aqua 3vj.
M. — Sig. Dose for an adult one drachm, to be repeated accord-
ing to judgment in one hour, then every two or three hours accord-
ing to the effect of the morphine.
I have used this prescription several times ; in three cases
out of four it has aborted the disease; where suppuration
has supervened the disease has been more under control.
I would give the physician's name and residence but
have forgotten it.
The only other treatment has been mild gargles and a
cathartic of epsom salts. I have tried other methods of
treatment, but this has been the only satisfactory one.
Experiences with lew Anesthetics. — At the meet-
of the Acad6mie de Medicine last week, M. Duplay read
a report on a case of death by bromide of ethyl in the
course of an operation. Hitherto it had been thought
that this agent was innocuous, but some recent accidents
(two deaths) should render surgeons more circumspect
and more prudent in its mode of administration and
cause them to take some of the precautions regarded as
indispensable when chloroform is the anaesthetic. M.
Laborde drew the attention of his colleagues to a new
anaesthetic mixture consisting of nine parts of chloro-
form and one part of ether. It would seem that this
combination acts more promptly and with less danger
than when either of these agents is employed separately.
Further, the active properties of chloroform are atten-
uated.
112
MEDICAL RECORD.
[July 28, 1894
Medical Record:
A Weekly Journal of Medicine and Surgery.
GEORGE F. SHRADY, A.M., M.D., Editor.
Publishers
WM. WOOD & CO., 43, 45, & 47 East Tenth Street
New York, July 28, 1894.
IS THERE A NEED FOR MORE MEDICAL
COLLEGES ?
It is so seldom that we have outspoken views in matters
pertaining to the general welfare of the profession, in
different localities, that it is worth while to make note of
them when they are offered, and give them that weight
which an honest conviction of the principles upon which
they are founded makes manifest. Although such inde-
pendence of thought is oftentimes associated with un-
popularity in affected quarters, it has its wide range of
usefulness in the far-reaching indorsement of the major-
ity beyond. It does not matter, for the sake of the prin-
ciple involved, whether or not a new medical college is
to be started in Alabama, or any other State, but the
question narrows itself to the necessity of any more
medical institutions of the kind anywhere. The dis-
cussion on the true point of issue, in the particular
case before us, centres upon the possibility of quieting
an objector by giving him a place in a faculty.
The failure to do so, however, was emphasized by a
circular letter from him, which treats the question in such
a general and fair way, that we quote extracts for the
benefit of all concerned. The reasons given have an ap-
plication far outside the limits of the particular State.
Dr. Jerome Cochran, of Montgomery, Ala., is the
writer of the letter referred to. He states that the
said letter was originally addressed to the Age Herald,
but " for reasons satisfactory to all concerned, it was not
published in that paper." This will not hinder, how-
ever, other than the readers of that journal from a knowl-
edge of his sensible view of the situation.
" It was only yesterday that I saw in the Age-Herald
of June 10th a list of the professors and lecturers in
the proposed new medical college in Birmingham.
In the list of lecturers I am surprised to find my own
name. What authority you had for publishing me to
the world in that capacity I do not know \ but it was
certainly done without my knowledge and without my
consent. Not only so ; but it places me in a position of
considerable embarrassment; because it must have left
the impression in the minds of those who read the state-
ment that I was in favor of the organization of this new
medical college. But I am not in favor of it. On the
contrary, I regard the establishment of a new medical
college in Alabama as in contravention of the best in-
terests of the profession and the people, and if my name
has any influence, I should regret very much to have it
used for the furtherance of any such enterprise. I do
not desire to be misunderstood. I do not object to the
establishment of a medical college in Birmingham any
more than I would object to the establishment of such
an institution in Montgomery, or in Selma. But we
have already in this country three times, yes, six times
as many medical colleges as we have any need for. In
this opinion I am sure that I will be sustained by nine-
tenths of the doctors in Alabama — in the South — in the
whole of the United States. This being so, the further
multiplication of medical colleges is not a consummation
devoutly to be wished ; and a new medical college, in
Alabama can by no possibility be of any benefit to any-
body except the gentlemen personally connected with it.
It does not fill a long-felt want. It does not respond to
any demand of public utility or convenience.
" Not only have we more medical colleges than we need,
but we also have more doctors than we need. Not one-
half of the doctors in Alabama are now able to make
decent livings by the practice of medicine. Neverthe-
less, the exploitation of a medical college is a business in
which honorable men may honorably engage. Only let
it be well understood that it will not contribute to the
welfare of the people or to the aggrandizement of the
medical profession."
He further says : " In all this I am not taking any new
position. For many years it has been well known in
Alabama that I have regarded the medical colleges as in
a large measure the natural enemies of our people and of
our doctors. In this connection I beg to refer to the
two addresses delivered by me before the Medical Asso-
ciation of the State, one in 1870 and the other in 1871,
and which were printed in the Transactions for the years
mentioned. In one of these I describe the creation of a
medical college in these words : ' The process was sim-
ple enough. It was only necessary to form a company
of seven or eight doctors, build a big brick house, and
apply to a complaisant legislature for a charter, and lo !
the thing was done. Full* fledged professors grew up in
a night like Jonah's gourd ; diplomas in high-sounding
Latin and on excellent sheepskin could be ordered by
the thousand, and the only thing left to do was to get
students. But students they must have or perish.'
" We do not have to seek far to discover the cause of
antagonism between the medical colleges and the medical
profession. It is due to the fact that the great majority
of our medical colleges have been built by private enter-
prise, and have been managed for the private emolu-
ment, in money and in reputation, of the men who built
them. All this is as in the nature of things we should
expect it to be. But let us call things by their right
names."
By way of further vindicating his position he very
forcibly remarks : " The most interesting chapters in
the history of the American medical profession are those
that describe the emancipation of the profession from the
tyranny of the medical colleges — a struggle that has been
going on for the last fifty years, and which is not yet
completely won. In Alabama we have for the protection
of the people and of the profession against the usurpation
of the colleges the medical law of 1877 — a sufficient pro-
tection as long as it is left us. But if we had had as
many medical colleges in Alabama as they have in Ten-
nessee and Georgia, we would have been left, as are the
July 28, 1894]
MEDICAL RECORD.
"3
people of those great States, to the tender mercies of
our enemies, the faculties of the medical colleges."
Well and truthfully said, Dr. Cochran ; you will evi-
dently have the majority with you, not only in Alabama,
but throughout the country.
THE DIGESTION OF MILK.
The importance and value of milk as a diet is acknowl-
edged by all, and needs no exposition here. Milk is not
only a very nearly perfect food, but it is diuretic, and
its lactic acid has been found to have germicidal prop-
erties on the bacillus communis coli (Gilbert and Domi-
nici). But despite all that can be said for milk, there are
many persons who dislike it, and positively assert that it
does not agree with them. The common belief is that it
coats the tongue, produces a bad taste in the mouth, and
leads to fermentation, constipation, and "biliousness."
The physician often has a hard time with these galacto-
phobics. Sometimes he persuades them to try the milk,
and the patient is surprised to find that he is not as much
disturbed as was expected. But more often the patient
returns with the "no better" or "I told you so" ex-
pression on his face, and reiterates the tale of his digestive
limitations. Then, perhaps, the doctor sets to work to
tinker the liquid into more assimilable shape. It is
boiled, sterilized, or pasteurized ; or it is diluted with
water or vichy, or sweetened with malt, or salted a
little to taste, or peptonize*! to non-appetizing bitterness.
Matzoon, koumyss, or buttermilk are then perhaps sub-
stituted. Not infrequently a moderate degree of suc-
cess is achieved, but there is always a percentage of fail-
ures. We welcome, therefore, any substitute for milk or
means of making it more acceptable.
M. Bovet, of Pougues, asserts {Bullet. General de la
Thcrapcutique) that he has succeeded in making milk
digestible by adding to it Ugumine. This substance is
a vegetable ferment, which, he says, acts upon the casein,
turning it into a soluble albuminoid — a sort of lactated
peptone. The legumine is also given independently as a
food in doses of fifty grammes or more a day. He re-
ports a number of cases in which patients were able to
take this combination of milk and legumine when all
other foods were rejected.
THE NEMESIS OF "DOC."
A writer in The National Medical Review says some
words regarding the significance of the title " Doc ' ' which
are apt and eloquent, and which, we venture to surmise,
come from a heart that has been embittered by some sad
personal experiences. "If," says this writer, "it has
been your misfortune to be called ' doc,' and if this rec-
ognition has become at all general among your friends,
you might as well move to some other place. A man
may be called a thief, a liar, and a dead-beat, and yet he
may prosper and live upon the fat of the land. But once
let him be called ' doc,1 and his professional success is
at an end. We would prefer to spend a night in the sta-
tion-house, so far as its effects on our professional success
is concerned, rather than to have our friends notice our
approach by saying, 'There comes doc.' If a man
calls you 'doc/ you need never expect a penny from
him for any professional services you could render. His
answer is sure to be, ' All right, doc, in a few days that
will be all right' 'Doc' means disaster. 'Doc' is
the culmination of all calamity. ' Doc ' is a catastro-
phe given at one stroke. ' Doc ' is the warning that
we have reached the extreme limit, of our usefulness.
' Doc ' is the hand which points us to the next town.
Shun it, my young friend, as you would flee from a Kan-
sas cyclone or a prairie fire. Knock the man down who
first dares speak it to you, and call upon the whole med-
ical profession for vindication of your righteous deed."
There are some people, alas, to whom all doctors are
just " docs." No amount of dignity in appearance, so-
briety in demeanor, superiority in years, wisdom, experi-
ence, wealth, position, or morals makes the slightest dif-
ference. The doctor is clapped on the shoulder and
affably saluted with the damning monosyllable. Hip-
pocrates returned to earth bearing the dignity of supreme
genius and wisdom would be simply welcomed back with
the same " Here comes doc."
But, after all, " doc " is the Nemesis which pursues the
medical profession for clinging to the mediaeval practice
of affixing always the title "doctor " to the physician's
name. Of all men of learning, the doctor alone thrusts
his profession into every phase and association of his
life. He is always Dr. Brown, M.D. No wonder, there-
fore, the title has grown so familiar that it signifies little
to the educated, and fails to protect against the familiar-
ities of the ill-bred*
MANAGING BOARDS AND TRAVELLING
HEALERS.
There is a hospital at Echuca, Victoria, N. S. W. It
is very far away, but hospital managers are just the same
on both sides of the world. This hospital needed funds,
and an entertainment was organized for that purpose.
Among the chief attractions was to be " Professor Ta-
rasco, the marvellous travelling healer," who was to cure
people for various modest sums, all of which would go to
the hospital. The medical board entered a protest
against securing the services of such a person for such a
purpose ; but their protest was almost unanimously un-
heeded, and the medical board was asked to withdraw
its letter. Some of the medical men thereupon resigned.
The affront would certainly justify such action.
The Cutaneous Application of Certain Alkaloids as
Regulators of Thermogenesis. — MM. Guinard and
Geley have found that of eighteen alkaloids applied in
solution or as an ointment to the inside of the thigh of
man or of one of the lower animals, four of them, viz.,
cocaine, solanine, sparteine, and helleborine, have con-
stantly the effect of regulating heat production. This reg-
ulating effect is entirely due to the action of the drug on
the peripheral nerves, and is entirely independent of ab-
sorption through the skin. That this is so is proved by
the absence of any such effect by the introduction of the
same drug into the system. No trace of the alkaloid was,
moreover, discovered in the urine in the above experi-
ments. Again, drugs commonly administered as anti-
pyretics—quinine, antipyrin, phenacetin, sodium salicy-
late, aconitine, etc. — are ineffectual when rubbed into the
skin. The experiments do not show any superiority of
the alkaloids over guaiacol.
ii4
MEDICAL RECORD.
[July 28, 1894
Hears at tfoe WLttk.
The Plague in China. — Surgeon - General Wyman,
of the Marine Hospital Service, has received a report re-
garding the "plague" in China from Dr. Stuart £1-
dridge, a member of the Imperial Board of Health of
Tokio, and Health Officer of the Port of Yokohama.
The report is in the nature of a warning. The plague,
he says, has been known to be present in the Yun-Nan
district of Southern China for at least fifteen years, in
form generally sporadic, at times epidemic in malignant
form. The disease broke out in February, in Canton,
and almost simultaneously was epidemic in Bakhoi, a
port at the head of the Gulf of Tonquin not often visited
by European trade. The epidemic in Canton steadily
increased in March and April, until in the latter month
it had assumed gigantic proportions.
The authorities of Hong-Kong, the centre of trade in
the far East, half a day's journey from Canton, and in
constant communication therewith, utterly ignored the
existence of danger until, in the first ten days of May, the
plague broke out violently and extensively in Hong-Kong.
Since its appearance in Hong-Kong the epidemic,
which is unquestionably a genuine bubonic plague of a
most malignant type, has steadily increased until, by the
latest reliable advices, the mortality is certainly over one
hundred a day ; and this despite the fact that at least one
hundred thousand Chinese and many Europeans have
evacuated the place — the former, in many cases, leaving
on feeling the first symptoms of the disease, in the hope
of dying in their native villages. At least a dozen
Europeans have been attacked, most of them succumb-
ing. Since Dr. Eldridge's report, which was written
about a month ago, there has been no marked progress of
the plague. If it should reach Japan this country would
be in some danger. Still it is a disease that could be
easily controlled.
Cabbage and Ice-cream do not go well together in the
human subject. This physiological fact was tragically
demonstrated by Lena Carey, of Delaware, who on a
wager ate a large quantity of cabbage and followed it
with four plates of ice-cream. Next day she died.
The Eiverside Hospital at Yonkers has received an
additional gift of 150,000 from Mr. and Mrs. M. F.
Cochran.
Mr. George Meredith, the greatest of England's living
novelists, has dedicated his latest work to a physician.
In this he follows the example of one of the greatest of
England's earlier novelists, Mr. Thackeray.
The State Constitution and the Coroner System.— The
obstacle in the way of abolishing the ridiculous and anti-
quated coroner system of this State by legislation, has
thus far been the bare recognition of the office of coroner
in the Constitution. "Coroners" are included among
the officers who must be chosen by the " electors of their
respective counties/ ' and who may be removed by the
governor, and they are mentioned a second time among
the county officers who were to hold office until the ex-
piration of the terms to which they were elected on the
going into effect of the Constitution of 1 846. With these
exceptions, the office is in no way referred to in the pres-
ent Constitution, and it is only necessary to expunge the
name from two sections referring to county offices to en-
able the Legislature to reform the whole system of in-
quiring into the causes of sudden death. There is no
doubt that the gentlemen appointed by the Academy of
Medicine to co-operate with the Constitutional Conven-
tion will see that the proper change is made.
The Columns of The Lancet sprout weekly with aspar-
agus items. We had thought that the matter was settled,
and that asparagus was to be definitely classed as a diu-
retic, and to an extent perfumer of the genito urinary
tract. But Dr. Samuel Wilks comes out in an open letter
and states that the contrary is true. Asparagus is, he
says, in effect anuretic, lessening the urinary flow. When
matters of this kind fail to be settled by the languid and
ineffectual observations of the Old World, it becomes
necessary to call in the aid of the New. Through the
columns of the Medical Record it was established that
the sick do sneeze, and we are sure that our readers can
settle with equal positiveness the important question : Is
asparagus a diuretic ?
The Modern Tendency in Public School management
is to abolish devotional exercises, and substitute gymnas-
tics and sanitation. This tendency has reached its ex-
treme in Vienna, where Dr. Kohn has proposed, in order
to prevent the propagation of diphtheria among school-
children, to have them inhale permanganate of potassium,
in the form of a spray, before leaving the classes.
The Cholera prevails extensively on the continent ot
Europe, cases being reported from Lubeck, Nantes, Ber-
lin, and many places in Russia. In St. Petersburg the
epidemic is rapidly spreading, the new cases averaging
200 daily and the deaths 100. There are over 1,000
patients in the hospitals of the city. The disease has
also broken out in the military camp at Krasnoe Selo,
eighteen miles south of St Petersburg.
Mr. Gladstone's Eye requires another operation, and
he has returned to London to have it performed.
An International Congress for the Protection of In-
fant Lift was held at Bordeaux on July 22, 1895. It
consisted of three sections: 1. A physical section, in
which all questions relating to societies for protecting in-
fant life, maternal charity criches, children's hospitals,
sanatoria, etc., were discussed. 2. A moral section,
for the discussion of questions relating to the protection
of children abandoned by their natural protectors, ap-
prenticing, orphan homes, and agricultural colonies. 3.
An administrative section, in which the Roussel law and
all questions relating to the protection of infant life will
be studied.
Shorthand in Medicine. — In order to promote the use
of shorthand by medical students and practitioners, by
enabling them to increase their knowledge at the same
time of the art and of their profession, a small sheet 01
clinical teaching in lithographed phonetic shorthand has
been issued by a London firm. The paper, which will
be continued if found to fill a need, contains reports of
clinical lectures by Dr. Gowers and other prominent
London clinicians.
Joseph Hyrtl, the distinguished anatomist, died at
Vienna, on July 17th, aged eighty- three. He was Pro-
fessor of Anatomy in the University of Prague from 1837
to 1845, when he was elected to a similar chair in the
July 28, 1894]
University of Vienna. He was the author of a " Manual
of Physiological and Practical Anatomy/ ' and a " Manual
of Topographical Anatomy and its Applications."
A Collective Investigation of Quacks has been pro-
posed by Ernest Hart. He asks medical men to send to
him the following information : the name and address of
the quack, the description of his premises, one of his ad-
vertisements, including a copy of each book and pam-
phlet, and cuttings from the local papers with dates ; a
memorandum must also be made of the date on which
the name, address, and description of the premises is
taken down. The member must do this himself, and
preserve his original notes. The results of the observa-
tions should then be catalogued and arranged by the dif-
ferent branches. It would also be necessary to note the
nature and condition of the neighborhood where the
quack purports to practise, and his hours of attendance.
If this work is carried on all through the United King-
dom, we should then be in a position to call the attention
of Parliament to the prevalence of quackery. I admit
that the task is a heavy one, but unless some such plan is
carried out it will be impossible to expect such drastic re-
form in the Medical Acts as is desirable in the public in-
terest as well as in the interest of the profession. This
class of quacks will scarcely be affected by the hitherto
proposed amendments to the Medical Acts.
The American Journal of Insanity.— In a circular
dated July 12th, the retiring editor, Dr. G. Alder Blumer
announces that the American Journal of Insanity has
been sold to the American Medico-psychological Asso-
ciation, and will be edited by a committee consisting of
Dr. Edward Cowles, of Boston; Dr. Henry M. Hurd, of
Baltimore; and Dr. Richard Dewey (in immediate
editorial charge), of Chicago ; and that until further no-
tice it will be published in Chicago.
The Income Tax and Professional Workers. — It
is gratifying to notice that on several occasions during
the discussion on the Budget proposals influential speak-
ers have directed attention to the injustice of applying
the same rate of taxation to income derived from hard
work, and dependent on the life and health of the payer,
as is applied to income derived from investments. True,
no statesman has yet had the courage or the energy to
devise means for remedying this injustice ; but it is now
' so clearly perceived and expressed that its redress cannot
be much longer delayed. — Lancet.
The Vegro as a Hospital Interne.— In the last exam-
inations for position as interne at the Indianapolis City
Hospital, a negro was appointed as the best fitted among
a considerable number of candidates. The young man
is of Massachusetts birth and is twenty one years old.
He is a graduate in arts of the State University of Mis-
souri, and received the degree of M.D. from the Medical
College of Indiana in this year's class, ranking third in
a class of fifty-four, all the others being white. This
appointment of a negro, though fairly won, has caused
a most bitter outpouring of abuse upon the young man
and all concerned in his appointment. His services
began in the surgical wards, whereupon the pay patients
left and the charity patients made bitter complaint at
what they considered an indignity. The general char-
acter of the vituperation can be judged by the following
extracts from a letter to one of the local medical papers.
MEDICAL RECORD.
"5
After bewailing the fact that during this young man's
service — which the writer will only speak of as " these
circumstances " — no pay- patients will enter the hospital,
and thereby the city will lose some two to five hundred
dollars a month, the letter continues : " The worst feat-
ure of this unfortunate situation is that in four months,
by rotation, this young man will be placed in charge of
the obstetrical department, and white women, whose
only crime is poverty, must submit to the unspeakable
outrage of bringing innocent children into the world
under the touch and manipulation of this son of Ham."
He then asks " the Board of Health, who made this
appointment, the cringing politicians who prevent the
righting of the wrong, and, lastly, all persons who favor
this phase of negro equality : How would you like to look
back to the day of your birth and know that a negro
doctor helped to usher you into the world ? " In con-
clusion he says : " If the Indianapolis city government
does not place this young man where he will only ad-
minister to those of his own race, as is fit and proper,
they will rob the city treasury, degrade and humiliate
many persons, benefit no one, and deserve everlasting
contempt from every citizen, both white and black."
The Indian Medical Congress. — The first Congress of
Indian medical men will be held in Calcutta, on Decem-
ber 24 to 29, 1894. It is proposed that the work of the
Congress should be divided into sections as follows:
Medicine and Pathology ; Surgery, including Ophthal-
mology; Obstetrics, and Diseases of Women and Chil-
dren ; Public Health ; Medico legal Medicine and In-
sanity ; Pharmacology, specially Indigenous Drugs.
Although the Congress is primarily an Indian one, an
invitation to assist at its deliberations is extended by the
Executive Committee to medical men in this and other
countries, some of whom have already accepted. Apart
from the medical work of the Congress, which promises
to be interesting and instructive, there will be the oppor-
tunity of seeing India and visiting its chief cities. The
climate during the winter is perfect, the facilities of
travel excellent, and two or three months, inclusive of
the double voyage, would suffice not only for the work
of the Congress but for a visit to most of the chief cen-
tres of interest. The journey from London to Calcutta
occupies about eighteen days, via Brindisi and Bombay,
about a week longer via Gibraltar and Malta. The P.
and O. S. N. Co. have weekly steamers by both routes,
the British India Company fortnightly via Gibraltar.
The Messageries Maritimes run from Marseilles, the
Rubattino from Genoa, and the Austrian Lloyds from
Trieste. The Calcutta season is at its height during
Christmas week, and the committee expect to be able to
present a varied programme of entertainments, while a
special committee has been formed to attend to the con-
venience and comfort of visitors. Any desired informa-
tion may be obtained from the secretaries, Dr. W. J.
Simpson and D. M. Moir, 5 and 6 Government Place,
Calcutta.
The Medical Golden Rule. — " I feel constrained for
once to give you a golden rule. It is never to speak ill
of any of your fraternity, whatever you may think. You
will do yourself no good, and it will only be thought
that you are jealous." — Dr. Chestet field s Letters to his
Son.
n6
MEDICAL RECORD.
[July 28, 1894
®0txere00 of American Iptgaittetis
75Mr</ Triennial Meeting, held in Washington, D. C,
May 29, jo, ji, and June 1, 1894.
AMERICAN ASSOCIATION OF GENITO-URI-
NARY SURGEONS.
Eighth Annual Meeting, held at Washington, D. C,
May 29, jo, andji, and June 1, 1894.
(Continued from VoL 45, page 76a.)
Second Day, Wednesday, May 30TH.
Aero-urethrosoopy with a lew Instrument. — Dr. W.
K. Otis, of New York, read a paper giving a history of the
subject to the present time and showed his improved in-
strument. Also cystoscope with eye-piece at a right
angle for catheterizing the ureters.
Dr. Belfield showed a tube with catheter curve, with
opening at angle and light in tip of tube, for use in deep
urethra and neck of bladder, and catheterizing the ureters.
A Needle-holder for the Hagedorn Heedle. — Dr.
Brown, of New York, presented an instrument of this
nature. The very secure grasp of this small pointed
holder — equally secure whether a very large or a very
small needle be used — is due to the relief from strain
which the jaws of the instrument derive from a consider-
able degree of spring which the handles have just behind
the principal hinge. The four separate parts which make
up the needle holder are readily detachable. The peri-
neal tube holder serves the purpose of keeping the large
rubber tube securely in every position desired, whether
this be depth of insertion, or upward, downward, or lateral
presentation of the eye of the tube. It facilitates removal
for cleansing or making any little adjustment necessary.
The patient can himself make any such changes. In
case of continuous drainage these apparently minor points
are of considerable moment in rendering an uncomfort-
able condition much more tolerable and manageable.
Dr. Brown also showed a modification of the Clover
crutch, with cross-bar removed from the field of urethral
instruments
Discussion by Drs. Bryson and White.
Stone in the Bladder ; Choice of Operation. — Dr.
William H. Hingston, of Montreal, Canada, read a
paper with this title. In cases where all the cutting
operations are equally practical, he prefers the lateral
method, and offers the following principles :
1. Lithotresis (and by lithotrity I mean that more per-
fect method which was foreshadowed by Mercier, in
France, and brought to its highest perfection in Amer-
ica). In all cases of adults where the stone is neither
too large nor too hard for the lithotrite.
a. Lithotresis, where the urethra is, or can be made,
sufficiently capacious for the crushing instrument
3. Lithotresis in children, however young, where the
urethra can permit the passage of a crushing instrument.
4. In very young children the cutting operation is
preferable, the precise age at which lithotrity is possible
must vary with the calibre of the canal, which in young
children greatly varies in its capaciousness and in its
capacity ; when the urethra in the child is not and cannot
be made fit to receive the lithotrite, the cutting opera-
tion to be chosen is the lateral method.
5. In cases of stone in the aged, where enlarged pros-
tate not only prevents the stone being seized, but its di-
mensions being ascertained, we should act as if the cal-
culus were of large size and incapable of reduction, and
proceed to operate by the suprapubic method.
Dr. Chismore, of San Francisco, said the general
character of the paper commended itself to good sense.
The size and hardness of the stone should not, in his
mind, exclude lithotrity. If when the stone is seized and
considerable pressure is brought to bear and it does not
break, by waiting, the elasticity and spring of the in-
strument in many cases will work its way through stone.
If this fails, should let go and grasp the edge and break
off in this way.
Dr. Post, of Boston, related a case of stone in the
bladder in a child with hip disease, so that he could not
be put into the lithotomy position, and the position of legs
was such that lithotrity could not be performed. He
did a suprapubic operation and found the peritoneum
adherent and extending down to the pubes, and was
obliged to cut through it
Dr. Bangs, of New York, said that in choosing oper-
ation, the removal of the stone is only one thing. There
is a disease causing stone, and we are frequently obliged
to use a cutting operation for drainage to bladder and pel-
ves of kidneys.
Dr. William Judkins, of Cincinnati, showed a speci-
men of calculi formed around a stitch left in the bladder
after operation by the suprapubic method in a case
where it was impossible to get in a crushing instrument.
He thought this case illustrated the stone disease men-
tioned by Dr. Bangs, and he soon expected to have to do
another operation.
Dr. Watson, of Boston, was glad to get the authority
of Dr. Hingston in favor of the operation of lithotrity.
The array of cases presented byDr. Chismore the previ-
ous day was the most remarkable on record. And he
would like to ask Dr. Chismore if he could explain that
fact-
Dr. Chismore, in reply to Dr. Watson, stated that in
his cases of seventy-one operations without a death, the
good result was due partly to the hardiness of the men
and to the fact that the stones were small, and not en-
tirely to the local anaesthetic. He made the operation
short, and if necessary completed it at another time.
Dr. Bryson, of St. Louis, said he was in accord with
the paper, and the choice of operation depended on the
condition of the bladder and urinary organs, and the size
and consistency of the stone. When he chose cutting
operations, it was because of the condition of the blad-
der, kidneys, and prostate.
Dr. Hingston, in closing the discussion, said that he
was not wedded to any method. There is no disease of
bladder and kidneys where lithotrity is not indicated.
The stone causes the condition, and if you remove the
cause the condition will improve. His greatest number of
cases without death was eighteen.
Urine Leakage and Stricture Formation.— Dr. John
P. Bryson, of St. Louis, read a paper of which the fol-
lowing were the conclusions:
1. The close resemblance in the tissue elements, their
arrangement, and effect upon the related normal struct-
ures, point to an identity of the etiological factor, and
give support to the doctrine of urine leakage
2. Observing the prolongation of the urethral epithe-
lium on the fistula wall in an effort to create an adequate
artificial channel for urine, and seeing that the epithelium
lining the stricture also participates in the battle against
urine leakage, we may take fresh hope of radically curing
strictures even of the pendulous urethra, by such means
as tend to restore or rehabilitate the urethral lining.
3. Merely diverting the stream of urine for a time
without such restoration of the lining mucous membrane
would fall into the category of palliative treatment, along
with urethrotomy and the various methods of dilatation.
Dr. Taylor, of New York, regretted that he did not
bring specimens showing the stricture formation from
gonorrhoea to the completion of the process. The patho-
logical appearances do not warrant the theory of urine leak-
age. There is a tendency always for the stricture to be
covered with squamous epithelium, which becomes glazed
over and prevents urine leakage. If it was not covered
with epithelium it was an ulcer, and the appearance of
the cells around an ulcer was not water- logged.
Dr. Bryson, in closing, was glad that Dr. Taylor
raised the point of urine leakage ; ail authors referred to
strictures as if there were but one form, when there were
really two: 1. Inflammatory, a. Cicatricial stricture
July 28, 1894]
MEDICAL RECORD.
117
begins with a multiplication of fixed cells. The differ-
ence between scar-tissue and stricture-tissue was that scar-
tissue is quiescent, while stricture tissue continues to grow.
The Possibility of Overcoming Permanent Stricture
of the Deep Urethra without Kesort to External Ure-
throtomy.— Dr. J. Blake White, of New York, detailed
the histories of two cases relieved without external ure-
throtomy, and concluded that, ordinarily, an external
urethrotomy might have been thought necessary, and
possibly performed ; that the spasmodic element, always
present to a greater or less degree in deep organic struct-
ures, often tends to obscure the judgment of the examin-
ing surgeon as to the possibility of overcoming it through
less grave procedure than external urethrotomy, and that
where a deep organic stricture, not traumatic, is present,
thorough and skilful removal of obstructions in the an-
terior urethra affords the surgeon every opportunity to
relieve it by careful dilatation with graduated sounds ;
since the anatomy of the structure of the deep urethra is
such that it yields more readily to dilatation, and ab-
sorption is more likely to result in this location from
judicious and well directed pressure by the sound. In-
cision at this point is apt to result in cicatricial formations,
which are very apt to necessitate at some future time an-
other operation for the relief of the symptoms which ap-
parently made the first operation a necessity.
Dr. Taylor, of New York, thought the urethral spasm
was due to instruments. That if we would use a soft
rubber catheter in those cases we would have no trouble,
while it resented the approach of the steel instrument.
Dr. Martin, of Philadelphia, was glad to hear of the
cure of stricture with the sound instead of the knife. He
reported a case of stricture of the deep urethra with per-
ineal fistula in a patient who would not consent to opera-
tion. He finally got a guide into bladder and dilated up
to 10th to 1 2th French size.* The man did not return for
six weeks, and the condition was as bad as before. He
then dilated up to 26th French, and it had remained at
that point.
Dr. Lewis, of St. Louis, referred to a case where he
could easily pass a steel sound, but could not pass a soft
catheter.
Dr. Bryson, of St. Louis, said that it is hard to sepa-
rate two processes. When we cut a band of cicatricial
tissue we do not destroy the band, but we make dilata-
tion possible.
Dr. Hingston, of Montreal, thought Dr. F. S. Otis's
rule of gentle dilatation, with cutting in the old cartilag-
inous strictures, the best.
Dr. Brown, of New York, said that there are cases
in which, after internal urethrotomy, sounds can pass
through a previous closed deep urethra. Advises to do
internal urethrotomy first and then try sounds.
Dr. Otis said there was no doubt that strictures can
be dilated. But in a case like Dr. Martin's he should
have done the external urethrotomy. He does not agjee
with Dr. Bryson, that cutting does not remove the strict-
ure ; spasmodic strictures have occurred many times in
his practice, and he does not think them due to instru-
ments.
Exfoliation of the Mucous and Submucous Coats of
the Bladder, Preceded by Renal and Vesical Calculus.
— Dr. Alexander Stein, of New York, referred to the
feet that fifty cases have been reported, forty-five in fe-
males and five in males. After a careful resuml of the
subject, he gave a detailed history of a male case treated
by himself, which he summed up as follows :
In summing up this suggestive history, we find that
the nephritic colic was invariably referred to the left
groin. About six months before he came under observa-
tion, he had retention of urine, in consequence of the
impaction of a calculus in the urethra. Shortly after this
there occurred an intra renal distention from impaction
in either. pelvis of the kidney, or possibly at the vesical
extremity of the ureter. A swelling appeared in the left
lumbar region, which was doubtless a hydro- and a pyo-
nephritic tumor. After stagnation of the urine in the
pelvis of the kidney, alkaline fermentation was ob-
tained, and a pyelitis was excited which, after the dis-
lodgement of the offending calculus, and die emptying of
the pyo nephritic sac per viam naturalem, there was left
a favorable nidus for the subsequent formation of crys-
tals of triple phosphates, which, after descending into the
bladder, continued their destructive work. The stone
was removed by crushing and fragments washed out for a
month ; there was a relief of symptoms, and then a grad-
ual accession of cystitis, which was followed after a time
by the appearance of the exfoliated shreds, which he con-
tinued to pass for two weeks, in such quantities as to
represent the entire lining of the bladder.
Third Day, Thursday, May 31ST.
A Plea for the Excision of the Initial Lesion.— Dr.
Edmund E. King, of Toronto, Canada, sent a paper which
was read by the Secretary. The following were its con-
clusions : 1, The early excision of chancres, that is within
a few hours after their appearance, will abort the disease;
2, the excision of any unhealed chancre will moderate
the subsequent secondary manifestations ; 3, that it is* the
cleanest, least painful, and most scientific method of treat-
ing the lesion.
Epithelioma of the Penis. — Dr. Edward Martin, of
Philadelphia, detailed a case operated on by himself as a
text for his paper, and presented the drawings of a cross
section of the growth, showing typical epithelial forma-
tion.
Ribbon sections were taken of the whole substance of
the penis passing from the centre of the growths back-
ward. The line of demarcation between the healthy and
diseased tissue was, as is usual in epithelioma, rather
sharply marked. In regard to the etiology of the disease,
phimosis is the most common. He quotes various au-
thorities regarding the contagiousness of the disease, and
thinks that it is not unreasonable to believe that the con-
tagious nature of a cancer may some day be clearly rec-
ognized. He also refers to chancre occurring in the ci-
catrix of a syphilitic primary lesion, but the scar he
thinks simply acted as a focus of lessened resistance.
The prognosis of epithelioma of the penis is now
guardedly favorable. Before the epithelioma is fully de-
veloped and only folliculitis and a few watery growths
present, prompt and efficient intervention will be fol-
lowed by a radical cure in the majority of cases.
If the disease progresses to the involvement of the in-
guinal glands, the operations ordinarily resorted to are
insufficient and recurrence in loco takes place.
As to the operation, this, in the precancerous stage,
that is when a case cannot be clearly recognized as can-
cer, may consist in thorough cauterization, or in excision
followed by cauterization. In case the wound does not
heal kindly, amputation of the penis should be performed
at once. If cross-section shows involvement at point of
amputation, extirpation is indicated. In the latter case,
when there are any remains of virility, castration is also
advisable.
In all cases where the amputation of the penis is re-
quired I believe the groin should be opened freely and
the entire chain of lymphatic glands should be removed,
whether they are enlarged or not. The two points to
which the paper was designed to call attention are : 1.
That it is not justifiable positively to deny the possibility
of contagion in epithelioma of the penis. 2. That where
amputation of the penis is required the inguinal glands of
both sides should be dissected out, even though they are
not appreciably enlarged.
Dr. Taylor, of New York, spoke of the coincidence
Of cancer in the syphilitic as it appeared after the syphi-
Atic process had ceased. When occurring in a scar, as in
this case, it was undoubtedly due to irritation. In refer-
ence to contagiousness of cancer, he referred to a case
whese the man, to do penance for past dissipation, had
had frequent intercourse with his wife, who had cancer of
the womb, without any injurious result.
n8
MEDICAL RECORD.
[July 28, 1894
Dr. Lewis, of St. Louis, suggested the advisability of
castration in these cases, as it diminished blood supply
and consequent irritation which would favor recurrence.
Dr. Chismore, of San Francisco, referred to a case
which he operated on by excision of the cancerous mass,
leaving the inguinal glands. Six weeks later there was
no recurrence and inguinal glands smaller.
In concluding the discussion, Dr. Martin, in reply to
Dr. Lewis, advised castration when extirpation of the
entire penis is performed ; when only partially removed
there is a certain amount of sexual satisfaction. The
question of the contagiousness of epithelioma of the penis
is still subjudice, and we may have to regard it as a con-
tagious disease. Should advise a partial amputation and
then examine the periphery of the stump, and if no can-
cerous infiltration, there is little danger of recurrence in
loco. Inguinal glands in all cases should be removed.
Inflammation of the Seminal Vesicles. — Dr. R. W.
Taylor, of New York, said that this condition was not
recognized until the last few years, and it is mainly
through the writings of Mr. Jordan Lloyd that an impe-
tus to its study has been inaugurated. The affection is
almost always secondary to gonorrhoea, occurring in the
third or fourth week, or to hyperemia of the posterior
urethra due to masturbation and venereal excesses, or to
inflammation of this region due to traumatism, catheteri-
zation, endoscopy, and strong injections.
Symptoms are similar to those of posterior urethritis,
and those given as diagnostic of the several forms of
prostatitis.
Course is similar to epididymitis, and at the end of a
week or ten days the symptoms become ameliorated and
resolution sets in.
Chronic Seminal Vesiculitis. — This form occurs when
resolution fails in the acute form. The symptoms are
usually obscure and vague. These disturbances are
mainly of two forms : First, those of lowered power ; and
second, those of erythism of the sexual organs.
Diagnosis can only be made by rectal examination.
The patient should bend body forward, standing with feet
about a foot apart. The examiner can place foot on
chair. Elbow on knee to get pressure and overcome the
perineal muscles. The bladder should be full.
Frequently the amputated vas deferens is mistaken for
the seminal vesicles.
Treatment. — Leeches to the perineum, injection of
cold water in the rectum, and packing rectum with ice if
the procedure is pleasant to the patient ; opium in sup-
positories, diluents and saline cathartics may be adminis-
tered if required. Should an abscess form, it may be
reached by means of a long incision just anterior to the
anus, care being taken not to cut urethra, prostate, or
rectum.
Treatment of the Chronic Forms. — By good hygiene,
tonics, and the treatment of posterior urethritis, if it ex-
ists. He does not agree with a recent paper of Dr. Ful-
ler's, of New York, and shows two anatomical specimens
to prove that the seminal vesicles are so placed that it is
impossible to reach by the finger sufficiently to milk or
-strip successfully.
Dr. Allen, of Boston, said that diagnosis could only
be made by rectal examination, as the urinary symp-
toms were not characteristic. In the treatment of termi-
nal vesiculitis, he had been discouraged by Dr. Taylor's
anatomical demonstration of the normal position of the
-seminal vesicles and the inability to milk them. He
had witnessed in some cases that after squeezing there
had been diminution in size.
Dr. Martin, of Philadelphia, said he had been trying
-for some time to examine the seminal vesicles in all cases
of epididymitis, and in a few cases only had he been en-
abled to make out the seminal vesicles. And in these
cases there was the presence of disease or chronic enlarge-
ment, and that it had been impossible for him to make
out by rectal examination a normal seminal vesicle. He
showed several drawings representing what he had felt in
certain cases. In most cases the symptoms were those of
posterior urethritis, but in three cases pain was referred to
the hip of corresponding side and radiated down only
to surface of thigh. He had found that rectal injections
gave the greatest relief, and for examination the partial
bending of the body was the best In some cases the
lithotomy position was good.
Dr. Brewer, of New York, spoke of pressure in chronic
cases being followed by the ejaculation of a clear fluid
which rapidly coagulated. The specimen shown by Dr.
Taylor proves that we cannot strip the seminal vesicle
completely, but by pressure had diminished the size and
found discharge containing spermatozoa from the urethra,
and in these cases had obtained an improvement.
Dr. Allen, of Boston, would like to put himself on
record as agreeing with Dr. Martin in the difficulty of
feeling the normal seminal vesicles, but regarding the
treatment he agrees with Dr. Brewer.
Dr. Hayden, of New York, had for some time been
examining cases at the Vanderbilt Clinic, and added his
testimony to the difficulty of feeling the normal seminal
vesicle. He was able to feel them only when there was
a prostatitis or epididymitis.
Dr. Bangs, of New York, was glad to hear that others
had had difficulty in feeling the seminal vesicles, as he
could only feel them when enlarged. Yet we can express
a fluid, but he was not willing to admit benefit from strip-
ping.
Dr. Weir, of New York, said that within the urethera,
the last year, his attention had been called to perineal
abscesses from diseased seminal vesicles. They can be
reached and removed, if necessary, by a transverse inci-
sion in front of anus until we reach cellular space, and
through this reach the vesicles, and he had removed those
that were tubercular.
Dr. Belfield, of Chicago, called attention to the im-
portance of the sinus pocularis, which varies much in size,
and when swollen would produce swelling where we
would expect to feel the beginning of the seminal vesicles.
Dr. Bryson, of St. Louis, said the anatomical demon-
stration called to mind conditions seen several times.
He was astonished to find that the vas deferens was so
large, and was probably frequently mistaken for chronic
enlargement, or for tuberculosis. There was a condition
caused by seminal engorgement, and the symptoms were
relieved by emptying a portion of the seminal apparatus.
This occurred in free livers who over-indulged in sexual
intercourse. They would complain of pain in rectum,
which was almost constant, not due to local causes. But
by introduction of the finger into the rectum and empty-
ing the distended pouch there would be complete relief
from the pain.
Dr. Chismore reported a case where he could milk,
from a sac occurring on either side, 3 j- of fluid contain-
ing an abundance of spermatozoa.
Dr. Taylor, in concluding the discussion, stated that
we should be careful in making pressure on distended
sacs felt per rectum. The amputation of the vas defer-
ens was sometimes so marked that it could easily be mis-
taken for the seminal vesicles.
Surgical Interference in Tubercular Kidney. — Dr.
John P. Bryson, of St. Louis, read this paper. In 174
cases of tuberculosis of the genitourinary tract observed
by the author, only 18 gave unmistakable evidence of in-
volvement of the kidney. He gave in detail the histories
of several cases treated by surgical methods, and gave the
rules usually followed, given as a guide for surgical inter-
ference. The conclusion he had arrived at was, to oper-
ate only in cases of emergency. The probability of
trouble in the other kidney, its absence or the presence
of chronic nephritis, made the operation a very serious
one. Also the fact that there was probably tuberculosis
of other parts of the genitourinary tract, or even of the
lungs, even to drain a tubercular cavity in any part of
the body was of doubtful efficacy. To remove a stone or
to open an abscess which is not sufficiently drained by
ureter, or to remove a suppurating kidney which is affect-
ing the whole system, when we can assure ourselves of
July 28, 1894]
MEDICAL RECORD
119
the soundness of the opposite organ, are the only surgical
interferences he considered justifiable.
Dr. Bangs said that in closer study of genito-urinary
tuberculosis for the past two years he had become more
conservative. Good hygiene was the only cure for tuber-
culosis, and that combination of gases known as " fresh
air." Vesical tuberculosis is made worse by instrumen-
tation. He had performed all kinds of operations, but
the result was not good. He sends those cases away,
Southern California is a favorite place, the warm climate
is less stimulating to kidneys, and is therefore prefera-
ble to cold. The effect of operation or other traumatism
is to make the condition more acute. He applied same
rules to tubercular testicles. In the cystoscopic examina-
tion of the bladder he frequently found a pulpy condi-
tion, rarely only can he find ulcers. He had begun to
look upon that condition as tubercular.
Dr. Keyes, of New York, had not made a special
study of genito- urinary tuberculosis, but thought the
surgeon should stand aside and operate only in emer-
gency ; there was too much surgeon and not enough med-
icine in these cases. He has tried surgery, and it failed
to help him. Transplantation of the patient was the
last means of cure. He did not consider the pulpy con-
dition spoken of by Dr. Bangs always due to tuberculosis.
He had never seen it above, always at the base of blad-
der; bleeds on contact with instrument. He had seen it
in strictures and pyelitis where the base of the bladder is
bathed in pus, also in tuberculosis.
Dr. Belfield, of Chicago, added his testimony to non-
interference in tuberculosis of genito-urinary tract. He
had operated eight times, and there was only one case
that gave him any satisfaction. That was one in which
the drainage was kept up eighteen months. Later died of
general tuberculosis. Reported a case of peri nephritic
abscess which was aspirated, and sent to a suitable climate
with improvement.
Dr. Bryson, in concluding the discussion, said he did
not think there was characteristic appearance of the base
of the bladder in tuberculosis. The question of involve-
ment of the other kidney is very important. He hoped
that the new instrument shown yesterday by Dr. Belfield
might help us ; also the presence of albumin and casts were
important in making a correct diagnosis.
Cystitis and Pyelonephritis, Due to the Colon Bacillus,
Requiring Nephrectomy. — Dr. F. Tilden Brown, of
New York City, related a case which presented in the sur-
gical service of Dr. McCosh at the Presbyterian Hospital,
and reported by Dr. Brown to bring out an expression of
opinion regarding the importance or non-importance of
the colon bacillus as a pathological agent. An interest-
ing feature of the operation was rupture of the renal artery,
attended with very serious hemorrhage, which was suc-
cessfully controlled by long clamps left in place for fifty-
eight hours.
S. W. D , male, aged forty; widower; United
States; masseur. No rheumatism, tuberculosis, gonorrhoea,
or syphilis. History; In 1886 sustained an injury to
the left side by a fall, which probably injured somewhat
the left kidney, as slight functional impairment of urina-
tion and sexual powers followed. He then began treat-
ment by the passage of sounds. At the end of the fourth
month of this treatment he was conscious of being hurt
by a larger sound than had been passed before. Ten
minutes later he noticed hematuria. Cystitis promptly
supervened, and he entered a hospital where, at the end
of ten days, he was cured. Returning to his former
doctor he submitted to the introduction of a sound, and
the next day returned to the hospital with a relapsing
cystitis, which soon extended to a left-side pyelitis. He
was confined to bed for three weeks. He had a great
deal of pain and occasional hematuria. After a while he
noticed that the urine would at times be rather scanty and
comparatively clear. Again the urine would suddenly
increase in quantity and contain a good deal of pus.
This state continued for two years, when in 1890 he
first noticed an enlargement in the region of the left kid-
ney. This abdominal tumor was not permanent, but
regularly subsided after a brief period of polyuria at-
tended with pyuria. In September, 1893, tne patient
substituted for boric acid solution, as a vesical lavage,
peroxide of hydrogen, twenty per cent, solution. Im-
mediately after its first employment he was seized with a
chill ; high fever and sweating ensued. At irregular inter-
vals every few days he now had a repetition of these chills.
He noted extreme distention of the abdominal tumor,
followed by its disappearance, and increased quantity of
urine. Four such attacks were noted between September,
1893, and January 23, 1894, when he entered the Presbyte-
rian Hospital. At this time his temperature was 980 F. ;
pulse, 84 ; respiration, 20.
Physical examination was negative, except that on the
left side and well upward border of the ribs, on deep pal-
pation, some pain and resistance could be detected. As
the tumefaction he had himself been able to notice did
not now exist, he was kept under observation until Feb-
ruary 20th. During this time his urine, drawn by steril-
ized catheter, gave a pure culture of colon bacilli grown
on agar, and tested by reaction on milk. The specific
gravity of urine was 1.020, acid, albuminous; contained
pus, and occasionally blood.
During the week previous to February 20th, pain in
left side has been quite constant. Abdominal distention
has increased, and a tumefaction in the left kidney region
has been quite marked.
Nephrectomy by Dr. McCosh: Ether. During the
operation many firm adhesions are met with after the
ureter has been ligated and divided, and while detaching
the upper segment of the large pyonephritic mass the
renal artery is ruptured. During a critical hemorrhage
the vessels are caught in long clamps, which are left in
place forty-eight hours. A slow but uneventful convales-
cence ensued. The colon bacillus is again cultivated
from the removed kidney, and again from the urine on
April 2d, and again on May 23d. The patient has
gained twenty pounds. The urine is free from albumin.
Point for consideration : Was the left kidney damaged
by a previous traumatism, and thus rendered susceptible
to ascending infection at the time of acquiring cystitis?
And was the cystitis due to a trauma inflicted upon the
posterior urether by a sound, and to a simultaneous im-
plantation of septic matter in the form of the bacillus
colli communis ?
Is the continued presence of the colon bacillus in the
urine, despite bladder irrigation with antiseptics, to be
ascribed to the blind canal made of the ligated ureter ? Is
entire removal of the ureter to be advocated in nephrec-
tomy for septic matter ? Does the presence of the colon
bacillus* at present render the patient more liable to a
pyonephrosis of the remaining kidney in case it becomes
impaired by traumatism or disease ?
Fourth Day, Friday, June ist.
Tumor of the Testicle.— Dr. R. W. Taylor, of New
York, showed drawings of tumor of testicle removed by
him. The history was as follows: N. D , aged
twenty-seven ; United States ; brakeman. Had had gonor-
rhoea twice. A year ago patient said he had a chancre,
and about the same time he noticed a small hard lump
at upper part of right testicle, increasing steadily in size.
About six months ago he was struck in the testicle by a
peach, since which time he thinks the tumor has grown
moreTapidly.
On admission to hospital the testicle was enlarged to
about the size of two fists. It was hard and painless, the
inguinal glands very large and hard. The testicle was
removed by Dr. Taylor, and was adherent to the scrotum,
the inguinal gland was not removed, as the patient ob-
jected. He was discharged cured in a month. The
tumor was examined by Dr. Van Giesen, of the College of
Physicians and Surgeons. Section showed : 1 , portions
of the tumor a perfect type of adenoma ; 2, a less
120
MEDICAL RECORD.
[July 28, 1894
perfect form of adenoma on the border line of carcinoma;
3, sarcomatous tissue ; 4, hyaline cartilage.
This disease begins slowly and insidiously, forms a
large, indolent, smooth, oval, dense, and sometimes elastic,
not painful or tender, surface, usually smooth, and even
later may become bassy and fungating ; sometimes there
is hydrocele, rapidity of growth ; when large produces a
dull, dragging sensation ; usually begins in early life.
Conche, in a study of thirty cases, in twenty-four of
which the observer notes the affection developed between
the ages of twenty and forty. Uttial Johnson described
a case in a child, two years and nine months of age, in
which the trouble began at the third month of life.
Dr. Bangs asked if Dr. Taylor made the diagnosis at
first Dr. Taylor replied that he gave internal remedies
for syphilis, but the tumor got worse and produced a
fungating mass.
Dr. Bangs then detailed a case in which there was no
venereal history, the patient was in general good health.
There was an ulcer on anterior surface of scrotum appear-
ing like a malignant growth, had an indurated base
and bled easily; necrosis of the central portion took
place, a portion was removed, and the pathologist sent
report of epithelioma. The man refused operation, but
the case healed up entirely.
Dr. Bryson, of St. Louis, said that in malignant and
tubercular growths the exhibition of potassium iodide
made tendency to bleed greater. He had never seen a
case of simple growth — always more than one element.
The surgeon had this before him. Make diagnosis be-
tween syphilis and these growths by antiseptic treatment ;
if not syphilitic or tubercular should be removed. Com-
mends non-removal of inguinal glands, although it does
not agree with modern surgical principles. He would
like to ask Dr. Bangs his rules.
Dr. Bangs replied that he removed all enlarged neigh
boring glands in all cases.
Dr. Keyes, of New York, wanted to ask if in the case
reported there was involvement of the scrotum. For if
the tumor is confined to testicle and cord, it returns in
peritoneal glands. But if the scrotum and surrounding
tissue are involved, inguinal glands should be removed.
Dr. Bell, of Montreal, detailed a case of multiple
tumors of the brain, and the question of syphilis was
considered. Later there developed fibrous growths of
the epididymitis, the right side grew slowly and became
as large as the tumor described by Dr. Taylor, and
showed multiple growths. Growth on the other side did
not increase, but later in cord began a large enchon-
droma which has now begun to fungate.
Dr. Taylor, in concluding, said that he had given the
patient antiseptic remedies for a while. His duties as a
brakeman caused frequent contusion and irritation of the
testicle. The tumor was fungatory and the inguinal
glands were enlarged. They had grown smaller since
removal, as they frequently do in epithelioma of the penis.
Perhaps the enlargement is purely inflammatory. He be-
lieves in thorough removal of inguinal glands in such cases.
During How Long a Period is Syphilis Communica-
ble?— Dr. James Bell, of Montreal, reported a case
which was thoroughly treated, and married two years and
eight months after development of secondary symptoms.
During this time he took treatment regularly and showed
no evidence of the disease. His wife contracted genital
chancre, and developed constitutional syphilis. The
author gave history in order to show : 1, That the hus-
band was properly treated, and was, as far as could be
seen, free from the disease when he married; and 2,
that there can be no doubt as to the diagnosis in the
case of the wife. For the rest I believe the husband to
have been perfectly honest in the matter, and the wife to
have been in every respect above suspicion. In my
opinion this must have been a case of blood inoculation.
The second case, in which a man contracted syphilis a
few years before he was married, and before the sore ap-
peared the wife beeame pregnant She never showed
any symptoms of the disease, although she was given
protoiodide of mercury pills up to time of delivery. She
remained in good health and was delivered in full term
of a fine healthy child, which she nursed for six months,
when her milk failed and she was obliged to wean it
The child (now nine months old) has never shown a
sign of syphilis, and is a typically healthy, well-nourished
baby.
Dr. Taylor was very much interested in the two cases,
especially the first. In these cases we must eliminate ex-
tra-genital infection. It was either a case of great pertinac-
ity of the lengthjof the infecting period, or there was a lover
somewhere, and he was inclined to the latter view.
Dr. Bangs thought that as the time was only two
years and eight months, it was not unusual for infection
to occur.
Dr. Keyes wished to put himself on record as thinking
that infection, at least up to the end of the third year, was
quite possible.
Dr. Judkins, of Cincinnati, related a case where a
man had chancre and wife aborted, although impregnated
before the development of the primary sore.
Dr. Bell, in concluding, stated that he was as scepti-
cal as Dr. Taylor, but if there was ever a case where you
could trust your evidence, this was surely one.
Dr. CHisMOREmade a few remarks, resigning the chair
to Dr. Bangs, the newly elected President. The Associa-
tion then adjourned until the following year.
AMERICAN CLIMATOLOGICAL ASSOCIATION.
Eleventh Annual Meeting, held in Washington, D.C.,
May 2p, 30, 31, and June 1, 1894.
(Continued from Vol. 45, page 763.)
Second Day, Wednesday, May 30TH.
Climatic Treatment of Phthisis.— Dr. H. B. Moore,
of Colorado Springs, had sent a paper entitled " A Plea
for the Earlier Recognition of Pulmonary Tuberculosis,
and the Adoption of Proper Climatic Treatment." Ow-
ing to the absence of Dr. Moore his paper was read by
title.
Three Tears* Experience in the Sanitarium Treat-
ment of Pulmonary Disease near Boston. — The second
paper was read by Dr. Vincent V. Bowditch, of Bos
ton, with the above title. He presented the results oi
the treatment of pulmonary disease for three years at the
Sharon Sanitarium, near Boston. He referred to the well-
known Frankenstein Sanitarium, near Frankfort-on -Main,
Germany. It is built on an elevation of fifteen hundred
feet above sea-level. It was a famous resort for the
wealthy classes. The Sharon Sanitarium was on a hill
four hundred feet above sea-level. It was for die work-
ing classes, largely shop-girls. He referred to the City
Sanitarium established in New York by Dr. A. L.
Loomis, and Dr. Charles Quimby, of that city.
It goes almost without saying that the climate of New
England is deemed unfavorable for consumptives What
can we do for the poorer classes ? It has been cod liver
oil, cough sirup, and advice about air and food. Left to
old-time methods they slowly faiL The ordinary Ameri-
can country boarding-house is not suited to such cases,
they are badly ventilated and the food is badly cooked.
The building at Sharon is a beginning, it can accom-
modate nine patients, all females. It was purposely con-
structed for an abundance of sunlight and pure air.
Every room is freely ventilated. One patient in a room.
Building has broad piazzas, where patients are kept out
in the pure air. No carpets or mats within to hold dust.
No sweeping allowed. Damp cloths are used. Sputa are
destroyed. Cups used for that purpose are burned.
The Sharon Sanitarium opened February 9, 1891. Of
48 patients 8 were bronchitics, the remaining 40 had
various forms of phthisis — 10 had been discharged with
the disease arrested. In no case did he use the term cure.
The majority had been away from eighteen to twenty-
four months. All reports from them were favorable. In
July 28, 1894]
MEDICAL RECORD.
121
several cases both lungs were involved. Some of these
left improved. In the 8 arrested cases bacilli were pres-
ent in but 3. He often found that the bacilli were not
present in cases presenting all the evidences of phthisis,
i.e., cough, hemorrhage, sputa, malaise, and night-sweats
— in fact, all of the usual symptoms, but in certain cases
no bacilli. One case had been in two years, and had
gained twenty- eight pounds ; another got fat and well ;
another had had cough and hemorrhage, had gained
fourteen pounds and a half in four months. Now she is
in California, with an excellent prospect for recovery.
In some twenty-five per cent, the disease seemed to be
arrested, and there was general improvement in thirty-
three per cent.
Bacilli had been found in cases classed as improved.
In six cases of this nature the results had been very satis-
factory.
He advocated the sanitarium form of treatment. Pre-
vious to opening the Sharon, he feared that having such
patients in a community would be unfavorable to them.
Experience had shown his error. What was the effect of
the proximity of patients one to another ? At first, it
caused depression, but it soon wore off. They are kept
under control, hence the direct benefits of such a system
as the sanitarium treatment, under skilled management.
All can be carefully watched. It was his rule to receive
cases where the early symptoms were present. If they
failed to improve in a few weeks, he advised them to re-
tarn to their homes.
Referring to methods of treatment, daily visits of the
physician — a sanitarium should have a resident physician.
Their chief aims were fresh air and good food. He
deems them absolutely necessary for recovery. Exercise
within fatigue, rest in the open air, even in the coldest
days in winter, patients being carefully wrapped.
As a rule he avoided drugs. Cabinet treatment and
pulmonary gymnastics were most valuable. He had no
faith in the germicidal action of drugs or vapors. He
was not wholly convinced of the value of tuberculin.
In making a brief report on three years' work, he en-
deavored to leave out the personal equation. Our sole
aim should be to do our best for our patients, and in
reports to deal with the truth and nothing but the
truth.
Dr. Von Ruck, of Asheville, S. C.; deemed Dr. Bow-
ditch's experience and observations valuable. Climate
is not so important ; it is not so much where it is done,
as how it is done. While practising in Ohio, he had had
about the same results as those given by Dr. Bowditch in
fifty-eight observed cases. In twenty-five per cent, there
was arrest, and improvement in a third of all under ob-
servation. Benefit may be had at home if patients will
do as they are instructed.
He did not concur in Dr. Bowditch's views regarding
the value of tuberculin. He uses it still, and to day has
greater faith in it than ever. Early cases of phthisis want
to wait. They invariably think others worse than them-
selves. Tuberculin applied in the earlier cases, as recom-
mended by Dr. Koch, in his hands gave excellent results.
It has a stimulating effect on the tissues. It can be
pushed to produce congestion, some using as much as
100,000 milligr. in a month. Such treatment simply
does harm, and was not indicated by Dr. Koch. It was
overdone. Using tuberculin in the smallest doses gives
an effect in from five to ten hours. Where fever is pro-
duced the limit of the dose has been used. He firmly
believed that the results will be as good as Dr. Koch led
us to hope for, and which the speaker firmly believed we
would attain.
Dr. J. H. Musser, of Denver, Col., said that we had
reached a time when, if tuberculosis is properly managed
within certain limitations, it might be deemed a self-lim-
ited disease, and the tendency is to cure.
Plans and sanitaria such as those advocated by Dr.
Bowditch, deserved the warmest encouragement. Sani-
taria within the limits of cities for the poorer classes.
If a sanitarium is not properly conducted it will fail.
Careless methods will kill it. Reference was made to
the infectiousness of the disease.
Dr. Quimby, of New York City, gave an account of
the founding of the New York Sanitarium, and what they
hoped to accomplish. A lady well known in New York,
noted for her charities, had enabled them to give the
scheme form and substance. He was of opinion that
hitherto too much had been said relative to phthisis, and
too little as to the treatment of phthisics. The object of
the New York Sanitarium was to relieve the working
classes, and aid and advise those having a fortnight's hol-
iday in the year. The consulting staff of the sanitarium
would be requested to see all cases on entrance and make
* a forecast as to their probable expectation of life. This
he wanted for the purpose of comparison. He outlined
what they hoped to accomplish.
Dr. Curtain, of Philadelphia, spoke of some results
at the Philadelphia Hospital, in the phthisis ward. Dur-
ing 1888 and 1889, the patients therein had tubercular
sputum. In 1890 influenza appeared, when half of the
old cases died. In 1891, or after the influenza epidemic,
out of 28 cases 15 had no tubercle bacilli. He con-
ducted a number of post-mortems. Ulceration of the
lungs was found, but the closest examination of the tis-
sues failed to detect bacilli. Recently a German bacteri-
ologist had found a new bacillus, different from the tuber-
cle bacillus ', this, he thought, might explain these cases.
Creosote, Guaiacol, and Benzoyl of Ouaiacol in
Phthisis. — Dr. Roland G. Curtain, of Philadelphia,
read the paper. He gave a resumi of his hospital ex-
perience at the Philadelphia Hospital, stating that one
object was to elicit a discussion on the treatment of tu-
berculosis by creosote and guaiacol. Dr. Glasgow, in
1 89 1, read a paper on the action of guaiacol. In 189 a
Dr. Jacobi, of New York City, dealt with the treatment.
Twelve years ago he, the reader, had used Declats's
syrup of phenic acid. Guaiacol and phenic acid gave
much the same results. Subcutaneous injections of phe-
nic acid were very painful. One patient frankly said that
ht preferred death. In his experience, as the result of
the use of phenic acid, there was an improvement in the
appetite and an increase in flesh, less dyspnoea. Speak-
ing of beechwood creosote, he said that it and guaiacol
chemically have much in common. Dr. J. J. Whittaker
had published results in 1893. When creosote is pure it
is harmless and easily borne by the stomach. It has no
effect on the bacilli. Some patients take small and others
large doses. Creosote may produce hematuria. In
those who bear it best as far as the stomach is concerned,
increase in weight follows. In acute phthisis with high
temperature, no benefit results from guaiacol. The class
most benefited is that where there is slight fever and
poor digestion. Dyspepsia is cured by phenic acid ; also
greatly benefited by guaiacol. He uses the latter in the
form of pills. It acts well in chronic ulceration of the
lungs. He does not believe that it has any specific effect
on the lungs.
Benzoyl of guaiacol was introduced by a German phys-
ician. He has not found it any better than guaiacol, and
it is expensive. He does not deem it as reliable as
guaiacol. Guaiacol is not so liable to produce irritation
of the kidneys ; when pure you know what you are ad-
ministering.
Dr. A. L. Loomis, of New York City, did not believe
that any of the agents named exert any special action or
effect in the disease. In many cases the patients seemed
to do just as well without such remedies. When intro-
duced into the stomach there is no evidence that they
have any other effect than to improve the digestive
powers in a certain class of patients. Some patients were
saturated with creosote.
Dr. Robert H. Babcock, of Chicago, had used both
creosote and guaiacol. Some patients stood them well,
others did not. He recalled a case where one hundred
and fifty drops had been given in twenty-four hours,
with benefit. Previously there had been hemorrhage.
She was a young woman. There was a cessation of the
122
MEDICAL RECORD.
[July 28, 1894
symptoms, and the physical signs all improved. Many
patients cannot tolerate it. It allays fermentative proc-
esses in the digestive tract. Guaiacol is used after meals.
He kept it up until the urine became of a dark-green
olor, then, reduced the dose to one half, then gradu-
ally began decreasing it. Some patients cannot take
either.
Dr. Von Ruck, of Asheville, S. C, used creosote four
years ago, hypodermically. In four cases, who persisted
in spite of suffering, he continued the remedy for two
months, they received four grammes a day. He watched
the urine, tubercle bacilli were present in all the cases.
It had no effect on the bacilli. He was satisfied that
they got good results from creosote. It was particularly*
beneficial in bronchial cases, also of marked benefit in
gastro intestinal cases.
Dr. W. M. Gibson, of Utica, N. Y., found that creo-
sote had a direct effect on the blood. Following a
moderate dose of creosote after a meal, there is an in-
crease in the leucocytes, producing, he said, better phyga-
cytosis ; a count of the corpuscles would prove it.
Dr. Elksner, said that in hospital and private prac-
tice he had got very good results with creosote. He
said that it was most difficult to make an early diagnosis.
In many cases no bacilli were present, unless there had
been infiltration in the lungs; there must be breaking
down to get the bacilli.
Dr. J. B. Walker, of Philadelphia, deemed the odor
of creosote in the breath of such patients very objection-
able ; said that whether the skin will take it in or not,
the skin will give it out ; that such people in street cars
and elsewhere were unpleasant. If not anti bacillary,
why give such large doses? He believed it to be anti.
catarrhal, and that it has a modifying effect on the
tissues. It does not kill the tubercle bacillus.
Dr. A. L. Looms had found tubercle bacilli without
destruction of tissue. They may be present in a patient
without any destructive changes in the lungs, or air-pas-
sages. He had got bacilli in a case where the lungs were
unaffected ; he mentioned the case while examining the
chest of a young man ; he had quite a profuse hemor-
rhage, some blood was secured, it contained a little mu-
cus. In it were found a large number of bacilli ; again
he examined the chest carefully and got no evidence of
pulmonary disease. The patient had hemorrhages for
three or four days, the blood gave bacilli ; there was no
expectoration, yet bacilli were found ; that was two and
a half years ago. Man now seems well. Bacilli may
lodge in the bronchi. This may occur without their en-
tering the lung tissue. Tubercle bacilli may get into the
lungs through the lymphatics and the blood vessels. In
the bronchi they cause local inflammation. It may be a
long time in any case before there are real destructive
changes, and when such do occur we get the ordinary
symptoms.
Dr. Elksner respectfully begged to differ with Dr.
Loomis, he thought that previous tubercular infiltration
was possible, and then necrosis of the vessel. The
majority of cases do not give us the presence of tubercle
bacilli. Even in miliary cases you have great difficulty
in making a diagnosis between phthisis and typhoid
fever.
Dr. Loomis, in reply, said that if a patient has symp-
toms of bronchitis, no bacilli will be got. He would
hesitate to pronounce a case one of tuberculosis unless
the sputum gave bacilli. He was not criticising the
views of others ; merely relating an experience in his prac-
tice.
Dr. Glasgow deemed creosote very valuable. He had
not noticed any kidney effect. He gave from two
to seventy minims a day, depending on the patient ;
one minim seemed to poison some. The creosote he
placed in a little whiskey, and that was mixed with milk
and cream. He got striking results in cases of bronchial
phthisis and in alveolar phthisis. Creosote does not
have any effect on the bacilli, but he thought that it has
an effect on the poisons they generate. He also believed
in the good result of inhaling the vapor of creosote at
night.
Dr. Curtain closed the discussion, and expressed his
satisfaction with the many views elicited.
State Prevention of Phthisis. — Dr. Frederick I.
Knight, of Boston, read a paper entitled " Shall Any-
thing be Done by Legal Authority to Prevent the Spread
of Tuberculosis?1' Twelve years since the real nat-
ure of tuberculosis was made public, but little seems to
have been done to cope with the disease to prevent its
spread. He reviewed the methods recommended by
various boards of health, referring to the action of the
Pan-American Medical Congress of 1893, the Ameri-
can Public Health Association of 1893, and their action.
The method adopted by the New York Board of Health
of February, 1894, was deemed an advance. Its manifesto
he read in extenso. In his State, Massachusetts, he
deemed the time right for its practice. The Board of
Health in Massachusetts had issued a bulletin and a leaflet
covering the ground. The dangers now so well known he
reviewed. Danger of sputa-infected cattle and milk.
Dr. Bowditch, of Boston, fully concurred in the views
held by Dr. Knight. He said that we want boards of
health to take the happy medium between two extremes.
The poorer classes should be under the observation of
such boards, the better classes have their physicians.
Dr. Von Ruck referred to the results at the Loomis
Laboratory, New York City. Also to Tissini's work.
Out of fifty six autopsies made by him in ten or twelve
death was due to accident. In them tubercle bacilli were
found in the bronchi. He referred to the disease-resist-
ing power of men who ward off phthisis and other dis-
eases when well — as in the cases mentioned, had warded
off phthisis; but where the vis medicatrix nature* is
lowered by typhoid fever or influenza, in such phthisis
finds a foothold. He fully concurred in the views ex-
pressed by Dr. Loomis as to bacilli being present where
there weie no evidences of pulmonary disease.
Dr. John Winters Brannan, of New York, referred
to several years' work in New York City on this theme.
The timely action of the State Board of Health of Michi-
gan pleased him. Its literature used the proper terms.
He said that tuberculosis was not contagious in the old
sense of the word. The Michigan Board of Health had
been very happy and wise in stating that it was " a com-
municable disease." The New York Board was prepared
to use the word " contagious disease," but, adopting the
wise course of Michigan, used the word " communica-
ble/' instead. Tuberculosis is a communicable dis-
ease.
He referred to the excellent work done by the Board
of Health of New York in dealing with diphtheria. The
Board assisted New York physicians, and by its judicious
action had the warm sympathy and countenance of New
York practitioners.
Dr. Wolcott, of Boston, endorsed Dr. Knight's
views, and deemed the New York method good, an ad-
vance in the right direction.
Dr. Andrew H. Smith fully endorsed Dr. Knight's
statements and views. He was in favor of securing the
end sought — protection — with as little friction as possible.
Dr. Knight closed the discussion. He was very
much pleased that so large and influential a meeting en-
dorsed his views. He offered the following resolution, to
be submitted to the Congress the following day :
" Whereas •, The American Climatological Association
was founded, among other objects, to promote the study
of the nature and treatment of diseases of the respiratory
organs; and
" Whereas y Tuberculosis is the most fatal cause of
such diseases ; and
" Whereas ', Modern research has placed this disease
among the infectious, and hence, to some extent at
least, among the preventable diseases ;
" Resolved, That this Association do strongly recom-
mend all boards of health of this country to adopt
means tending to the restriction of the disease."^
July 28, 1894]
MEDICAL RECORD.
123
Third Day, Thursday, May 31ST.
Dr. Isaac Hall Platt, President, in the Chair.
The Condition of the Heart in Diabetes, and its Rela-
tion to Diabetic Coma. — Dr. Leonard Weber, of New
York, read a paper with this title, which was based upon
a study of sixty cases in his practice. The majority of
the patients were over forty five, and most of them were
women. He reported two cases in children — one case
in a child aged twelve, due to scarlatina, death occurred
three months later. Another case in a child following a
large use of potassium bromide. In cases after middle
life there were no recoveries. The duration of the dis-
ease was from three to twenty years.
A complication of renal disease renders the cases more
difficult. The condition of the heart must then be
watched. There are cases where the heart is weary,
overworked. Such cases are often associated with ar-
terial sclerosis. The acetone odor can be noticed in the
breath, marked in many cases. First syncope, followed
by speedy cardiac failure. Heart disease is not so rare
in these cases. The speaker cited a case of a lady aged
seventy-three, recently dead. She had had the disease
thirteen years. Three years ago it showed itself in weak-
ness of the pulse — beats twenty-four to thirty, perfect
bradycardia. Death was easy and painless. Her husband,
a broker, aged seventy-two, developed diabetes. Lived
two years.
Diabetes may be a cause of neurc-muscular disease,
fatty degeneration of the heart, etc. Doubtless, the
poisonous action of ptomaines has an important influ-
ence. Gastro-intestinal symptoms and marked dyspepsia
are well known in connection with diabetes and chronic
interstitial nephritis. To repeat, the heart must be
watched in all cases of diabetes. The diet in such cases
requires careful study.
Diabetes is more often a disease of the whole system
than any special organ. Brain and heart disease, and
locomotor ataxia may be found as complications.
Ds. Steven Mackenzie, of London, reported eighty
cases ; forty- five died suddenly. In the profession there
is an increasing opposition to an exclusive meat diet.
Adapt the therapeutic requirements to individual cases.
Study all cases on their individual indications ; obtain
from the patient a minute history of the case. Get also
fall life history. There are no fixed rules for treatment.
No absolute meat diet ; rest and massage ; try to get rid
of the sugar; try the usual alkaline treatment; if soda
solutions do not agree he gives opium in some cases ;
watches its effect on heart and stomach. Schlott's method
is valuable.
In cases of diabetic coma he deemed it most impor-
tant to evacuate the bowels. Then fill the lower colon
with alkaline water. So far he has seen no case recover.
Chronio Heart Disease Treated by the Schott Method
of Baths and Gymnastics. — Dr. Robert H. Babcock,
of Chicago, read a paper with this title. The baths owe
their efficacy to saline and alkaline constituents, and
also to their warm temperature. Warm baths, in such
cases, as a rule, are debilitating. Temperature should be
92°.to 930 F., gradually reduced to 870 F. They feel
warm at 920 F; often chilly at 870 F. The duration of
the bath is limited, one bath a day. They are omitted
every fourth day. They are given during six months.
After each bath the patients rest an hour, to rest the heart.
Pulse is lower during the bath. Under the baths there
is improvement in the rate and quality of the pulse.
Sphygmographic tracings show the marked improvement
in the cardiac currents. Baths lessen the rapidity and
decrease the force of the heart's action.
The baths act by causing contraction of the cutane-
ous vessels. A cold bath is followed by a slower and
stronger pulse, and by dilatation of the internal vessels.
The modus operandi of the baths may be described as
follows : First, patient may experience a sensation of
chilliness, followed by warmth, due to the gentle stim-
ulation of the cutaneous nerves caused by the salines in
the bath. The bath is an aid to the heart Baths
slow and strengthen cardiac contractions. Light exer-
cises, gymnastic movements of flexion and extension of
the trunk — a skilled attendant directs them. All exer-
cise within fatigue. No exercise is peimitted that em-
barrasses respiration. Call a halt when theie is any evi-
dence of dyspnoea. The exercise acts on the heart and
circulation in much the same way as the baths. Gym-
nastics slow the rate and increase the volume of the pulse*
A sensation of comfort follows the bathing. Exercise
improves the arterial circulation. Cases so treated re-
ceive permanent amelioration.
Dr. Babcock reported 19 cases treated by him. Nine
males, 10 females. He deems the treatment very risky
in cases of aneurism and arterial sclerosis. Schott does
not deem chronic interstitial nephritis as contraindicating
the treatment.
Dr. Roland G. Curtin, of Philadelphia, referred to
cases in the Philadelphia Hospital where there was tem-
porary diabetes or saccharine urine. It was not a serious
symptom and disappeared. They appeared last fall.
Dr. Glentworth R. Butler, of Brooklyn, said that
the disease known as diabetes was but a s)mptom of
some underlying condition. It may be caused by some
'lesion of the liver or pancreas, or the result of one
of the numerous processes of metabolism. Glyco-
suria is the symptom. There are weak hearts in such
cases. General muscular weakness in that disease, and
the heart participates ; degeneration of the muscular fi-
bres of the heart. Cited a case in his practice. Man
aged fifty -five. Urine showed a small percentage of sug-
ar— one tenth of one per cent. Coma came on without
any warning. Two months ago had an attack of syn-
cope, an examination revealed dilatation of the heart.
Under treatment the heart improved. Man did well, ex-
cept an attack of syncope of very brief duration, brought
on by over-exeition. Regarding diet in diabetes, he ac-
cepts no fixed rules. The general condition of such pa-
tients is impaired. He does not believe in cutting off
all the carbohydrates and saccharine substances at once.
He mentioned a case of a pregnant woman. Found lac-
tose in the urine. It was due to irritation of the nervous
system. She improved under treatment and the symp-
toms disappeared.
Dr. Charles E. Quimby, of New York, referred to
the defect in all our to day methods in treating cardiac
disease. Arterial extension must be present if we are to
have good circulation. In aortic regurgitant disease
there is a slowing in the circulation. He thought that
the indications, in the treatment of valvular lesions, was
to hasten circulation and keep up the nutrition of the
body.
A lew and Distinguishing Sign of Latent Aneu-
rism of the Aorta. — Dr. Glasgow, of St. Louis, Mo.,
said that in most cases of aneurism, early in their history
there was an utter absence of dulness on percussion.
That at a later period only were physical signs manifest.
Then pressure symptoms, etc., gave a suspicion of the
disease. He said that his new sign in thoracic aneurism
is the presence of a systolic sound in the brachials— due
to vibration of their walls; that it was synchronous
with the systole of the heart. It is practised by having
the patient extend the arm at a right angle from the body,
and by placing the ear over the brachial. The vibrating
sound got by the ear he designates as his new sign of
aortic aneurism. He finds no mention of such a sound
in the older English, French, or German classics on
heart-disease and aneurism. He gave reports on five
cases in his practice.
Dr. Murray, of Washington, presented a patient
whom he regarded as a ''suspect." The man was a
negro, aged twenty-six. Pulse, irregular; pain in the
left side ; pain in shoulder to wrist left side ; right side,
a small area of dulness ; no cardiac murmur ; heart ap-
parently normal. He suspected aneurism. Dr. Glas-
gow had called on him ; he practised Dr. Glasgow's path-
ognomonic sign, and found the brachial systolic sound.
124
MEDICAL RECORD.
[July 28, 1894.
Dr. Curtin, of Philadelphia, had been working in
much the same direction — an earlier means for discover-
ing aneurism. He thinks that digitalis increases the
force of the heart and increases the aneurism. Had
been experimenting on the effects of pressure on the
chest-walls, with a view to an easier location of aneu-
rism. Had reduced chest circumference an inch and a
half; described a method of bending forward to facilitate
feeling an aneurism through the suprasternal fossa.
Ozone in Phthisis. — Dr. Charles E. Quimby, of New
York City, read a paper entitled, " Ozone in Phthisis,
with special reference to the Pneumatic Cabinet."
Reviewing the medical history of phthisis, tubercle
bacilli, and medical agents, he said that the use of creo-
sote may be due to the lingering belief that it acts as a
germicide. Since he had made a systematic study of
the disease, he wished to attack it through the systemic
forces. He referred to recurrent tubercular and septic
influences. For a year past his agents in treatment had
been three, alcohol, creosote, and oil of cloves.
Mention was made of an apparatus devised by him
fulfilling all requirements. His plans were available to
anyone interested in the matter. Next he dwelt at
length on the powerful oxydizing properties of ozone.
It was described as stimulant. Reviewing the pathology
of phthisis he said that a large number of cases were
adynamic in character — a fact duly recognized by Koch.
In the disease there was a degeneration and necrotic
activity.
The use of the pneumatic cabinet and ozone was de-
scribed. The treatment was applicable in any stage of
the disease. He reported a number of cases benefited by
the treatment. He makes no claim that they are cured ;
changes noted are due to local stimulation. Ozone
is a powerful stimulant to the mucous membranes. It is
a pulmonary antiseptic, an agent of known value. He
does not know of any remedy that will destroy tubercle
bacilli in the tissues. Effects of ozone on tubercle ba-
cilli in sputa are nil.
The ozone treatment gives a prompt reduction in tem-
perature. It gives a result quite equivalent of climatic
influences. The value of an ozonized atmosphere in
phthisis is marked. Some patients cannot take iron
without headache. Several of this kind after the treat-
ment have been able to assimilate iron. In some cases
under cabinet treatment the area of respiration is re*
stored. Believes that ozone meets the demands of the
system, called it a respiratory food. It can be generated
in houses.
9 : Tuberculosis in Domestic Pets. — Professor Frohner,
of the Berlin Veterinary School, has recently made some
investigations as to the prevalence of tuberculosis among
small domestic animals, the results of which are as im-
portant as they are interesting. In the clinic for small
animals during the last seven years, out of a total number
of 70,000, only 281, or 0.4 per cent, have been found to
be suffering from tuberculosis. The proportion of tuber-
culous dogs was as low as 0.04 per cent. ; cats seem to
be considerably more subject to the disease, the propor-
tion of tuberculosis among them being one per cent. The
animals most severely affected are parrots, the ratio of tuber-
culosis among them being twenty five per cent., no doubt
owing to imperfect acclimatization. Living as these
birds mostly do in rooms constantly used by members of
the family, their liability to tuberculosis makes them
somewhat dangerous pets. — British Medical Journal.
Ascites and Resignation. — Dr. Kelley, writing in the
Cleveland Medical Gazette, says that he recently saw a
tombstone in the Bunhill Fields burying-ground, Lon-
don, upon one side of which was the usual inscription of
nam;, age, and date of death, while upon the other side
was carved a clinical history reading as follows :
In 67 months she was tap'd 66 times
Had taken away 240 gallons of water
Without ever repining at her case
Or ever fearing the operation.
OUR LONDON LETTER.
(From our Special Correspondent.)
ROYAL MEDICAL AND CHIRURGICAL SOCIETY CARDIAC SE-
QUEUE OF INFLUENZA — PAIN IN REGION OF HEART-
ACCELERATION OF BEATS — A CASE OF ACANTHOSIS NI-
GRICANS— SIR GEORGE HUMPHREY, F.R.S. — HEALTHY
LONDON — PREVALENCE OF SMALL POX — EXTENSION IN
THE PROVINCES — THE LEICESTER CRAZE — THE LOCAL
PRESS — DEATHS OF PROFESSOR JOHN CLAY, W. L. UN-
DERHILL, DAVID TAYLOR, PROCTOR S. HUTCHINSON
London, June 20, 1894.
The concluding meeting of the Royal Medical and Chi-
rurgical Society was held on the 12th inst, when Dr. San-
som read a paper on tachycardia and cardiac pain after
influenza. He had met with 100 cases in which cardiac
disturbances had followed influenza at more or less
distant intervals. Of these there were 23 of pain, and
37 of tachycardia ; 25 irregularity (arhythmia) ; 5 of
bradycardia, and 10 of organic disease. The present
communication dealt with the first two sections of cases.
The pain experienced in the region of the heart was in
some cases paroxysmal and in some resembled angina ;
in others it was more or less protracted. It might be
intense and sudden, so that some patients fell completely
unconscious. In some unconsciousness occurred paroxys-
mally in the absence of severe pain. There were not
the associated signs of true angina pectoris. Hysteria
was excluded, for several patients were men, and some
typical athletes, who had been in perfect health until their
attack of influenza. In the cases manifesting more con-
stant pain the beating of the heart was often accompanied
by subjective discomfort ; there were sometimes tender
spots in the intercostal spaces close to the sternum, with
more deeply seated pain in defined situations, and in sev-
eral instances symptoms of concomitant neuritis involving
some of the nerves proceeding from the brachial plexus.
He attributed the symptoms to a neuritis affecting some
of the ganglia of the cardiac plexuses, or to a disturbance
of the sensorium analogous to that in epileptiform neu-
ralgia or in visceral neuralgia. Quinine in five grain
doses, with antispasmodics, morphia sparingly and cau-
tiously administered subcutaneously, and a course of the
bromides and iodides with arsenic were recommended.
Good results might follow the use of a weak continuous
galvanic current from the nape of the neck to the region
of the vagus. Next, as to the cases of tachycardia fol-
lowing influenza. It might occur immediately after the
attack or after several months, and continue for long
periods — at least eighteen months. In many cases the
heart was very irritable, quickened action being pro-
voked by very slight causes or occurring at intervals
without assignable cause. It might be accompanied by
many, or even by all, the signs of Graves's disease — a
circumstance which was of interest in the question of
pathology of the latter affection. The most probable
initial cause was a disturbance of the vagus at its origin
or in some parts of its course, whereby its controlling
power over the cardiac contractions became impaired ;
possibly irritative lesions of the accelerator nerves of the
heart, in the cdrd, in the course of the sympathetic fila-
ments, or in the ganglia, might be concurring causes, and
in some cases hypersecretion by the thyroid might be a
subsidiary cause. In the treatment of post-influenzal
tachycardia drugs seemed to be inefficacious except as
modifying the associated symptoms, but the systematic
use of weak continuous galvanic currents from the nape
of the neck to the region of the vagus might be followed
by good results.
Dr. Althaus remarked that hysteria was met with in a
considerable number of men. In addition to the treat-
ment which had been adopted, he had employed salicy-
late of soda with much benefit in the early stages, while
later a combination of phenacetin and caffein gave ad-
July 28, 1894]
MEDICAL RECORD.
"5
curable results. The continuous galvanic current was
useful, a good effect being obtained by one miliiamp&re.
As to the cause of the tachycardia, though there might
be in some a peripheral neuritis of the vagus, he thought
that the cardiac and vasomotor centres in the bulb
were more at fault. He had never seen vomiting in
these cases, though it ought to be common in peripheral
neuritis of the vagus He had seen polyuria, glycosuria,
and albuminuria all follow influenza, and this latter sug-
gested the medulla oblongata as the seat of the lesion.
As to the pathology of Graves's disease, some French ob-
servers had considered it to be a neurosis which left no
anatomical evidence in the nervous system, while German
physicians had attributed it to perverted nutrition of the
thyroid body. He himself had regarded it as an organic
disease of the medulla oblongata, and he rested his con-
clusions on both clinical and experimental grounds. It
had been shown in animals that if the restiform bodies
were injured the symptoms of Graves's disease would be
produced, and the results of necropsies on the human
subject had revealed degenerations in different parts of
the medulla. He had never seen an instance of com-
plete recovery from Graves's disease, the mortality from
which was very considerable, even as high as fifty per
cent., and in some who died very suddenly the cause
appeared to be a failure of the cardiac centre in the
medulla. Mr. Spencer Watson asked Dr. Sansom what
were the signs by which it was possible to distinguish
tachycardia and heart pains due to influenza from those
due to other causes ; and whether any group of cardiac
symptoms consecutive to epidemics of influenza had not
before been seen in association with other diseases. In
reply to this and questions by other speakers, Dr. San-
som said, the chain of evidence between influenza and
the sequelae seemed to be complete in his cases, and he
had never observed a similar grouping of symptoms
without a previous attack of influenza. He agreed that
salicylate of soda was good in the early stages and in the
pyrexial period, but he had been chary of pushing it on
account of the liability of its producing toxic effects.
Phenacetin and caffein he had found very valuable. As
to the question of absolute recovery from Graves's disease,
he had seen some very bad cases get absolutely well, ex-
cept for an occasional outburst of emotional disturbance
to which so many women were liable. As regarded the
urine, he had noticed exceptionally large quantities of
nitrogenous products excreted, and sometimes albu-
minuria. He had never seen glycosuria in post influ-
enzal tachycardia, though he had met with it in Graves's
disease. Although he had never seen a typical case of
spasmodic asthma due to influenza, yet he had seen
several cases of marked dyspnoea of a peculiar character
often spoken of as " tachypneea." There seemed to be
a general consensus of opinion that the symptoms noted
were due to changes in the central nervous system, and
these changes might, he suggested, be minute hemor-
rhages. If these hemorrhages occurred in a region which
Impaired the function of the vagus, then tachycardia
would result ; but if they occurrwi lower down, brady-
cardia and cardiac irregularity would be produced.
At this meeting Mr. Morris showed a single woman,
aged thirty-five, suffering from widely disseminated dis-
coloration of the skin, with diffuse warty growths in vari-
ous parts, which he submitted as an example of the dis-
ease called by Unna " Acanthosis nigricans." Only two
similar cases had been recorded (Politzer, Janovsky).
Nothing was known as to its pathology. Dr. Eddowes
produced some sections taken from Politzer's case. A
great deal of discoloration appeared to be due to dirt, as
was the case in ichthyosis. He suggested that there was
a close connection between this condition and seborrhoeic
eczema.
London. June 30, 1894.
Sir George Humphrey has been so ill as to give con-
siderable anxiety to his numerous friends. At his best
he is not very strong, and has suffered several attacks of
illness. This time a severe abdominal attack has laid
him aside, and phlebitis, from which he had previously
suffered, reappeared. I am glad to be able to report
that during the week convalescence seems to have set
in steadily. Everyone is wishing him complete re-
covery.
Although we make such frequent complaints of insani-
tary conditions and preventable diseases, it is not to be
supposed that Londoners are exposed to greater dan-
gers than other citizens. In fact, not a few of us have
long been satisfied that we live in the healthiest city in
the world, and our boast to this effect is just now sup-
ported by official mortality records. For a month past
London mortality has been at the rate of only 16.3 per
1,000, while in Paris it has been 20.5, in Berlin 18.2, and
Vienna 22.5. Even you in New York have been consid-
erably above us, although below Paris and Vienna.
We are, however, by no means free from zymotic dis-
eases, and the continued prevalence of small-pox is most
unsatisfactory. There were fewer admissions last week
to the hospitals. Still there remained 170 cases under
treatment. This is 21 less than the previous week, and
with fewer fresh cases reported we may anticipate a de-
cline. But a more serious circumstance is the diffusion
of this disease in the provinces. A great number of
towns have now contributed their quota to the records,
and although in most of them the outbreaks have been
localized, the necessity of looking to our armor has been
made manifest to all but the most perverse faddists. Of
these Leicester has for some time been the head-quarters.
In that town the local authorities have boasted of a
" system " of their own and rejected vaccination. They
have not, however, escaped an epidemic, and the last re-
port of the medical officer of health for the town is a
most instructive document. Its influence is, unfortu-
nately, likely to be lessened by the determined opposition
of the anti-vaccination faction, led by Mr. Biggs, a town-
councillor, and a member of the sanitary committee, who
seems to fancy this office qualifies him to pass judgment
on medical questions ; for he has not hesitated to enter
into controversy with the medical officer of health and
to criticise his actions with no little acerbity. Moreover,
this same oracle has ventured to call in question the
treatment of cases in the hospital. Such inflated self-
assurance should open the eyes of his fellow-townsmen
to the absurdity of being led by one whose vanity is his
chief qualification for setting up his private prejudice
against the views of a profession of which he has not ac-
quired the most elementary lessons.
But a sadder spectacle than that of the self opinionated
town councillor is the attitude of the local press, which
has lent its influence to what I suppose it imagines to be
the popular view, for it is difficult to believe that the staff
of a daily paper should be completely blinded by the fad-
dists. Statistics are thrown about in a manner that would
make the real statistician aghast, and which tend to en-
courage the notion that " anything may be proved by fig-
ures." I have friends at Leicester who are intelligent,
but the faddists at present are in the majority. There
may be a rude awakening for them yet. Of course for the
time the town enjoys the protection afforded by the vac-
cination of the adult population before the present craze
existed. When mothers learn how their infants have
been sacrificed to this craze there maybe a wailing which
the most infatuated faddists may regret to have had any
share in producing.
Death, ever busy in our ranks cutting down both young
and old, often gives occasion to sad notices from my pen.
John Clay, of Birmingham, has passed away after a short
illness, aged seventy-three. Your readers will remember
how some years ago he thought he had found a remedy
for some forms of cancer in chian turpentine. But he
had done good work as obstetric surgeon to the hospital
and professor at the Queen's College. He enjoyed, too,
a large practice. On the 23d inst. Mr. W. L. Underhill,
of Tipton, was buried in the local cemetery. He had
passed a long and active life in the town, reaching the
age of eighty. David Taylor, another veteran whose
126
MEDICAL RECORD.
[July 28, 1894
sons are among us, died on the 16th inst, in his eighty-
sixth year.
In contrast with these comes the demise of Proctor, the
second son of Mr. Jonathan Hutchinson, who died this
week, aged only thirty-one. His health had not been ro-
bust, and he had travelled in the colonies and the States
before settling down to practice. After doing so he again
broke down and gave up his London prospects and went
again to Canada. For a time he improved, but eventually
returned to spend his last days at home, as many another
promising young practitioner has done. Sic transit.
THE MEDICAL OPPORTUNITIES OF PARIS.
To the Editor of the Medical Record.
Sir : A medical student, earnestly desiring to do best
work in the best place, I was surprised always and often
annoyed by the question universally put to me by my fel-
lo w- Americans on learning that I was pursuing my medical
studies at Paris : " But why do you not do all of that in
America."
It was no mere chance which decided me to prepare
myself there, but a well-grounded determination after
careful inquiry in regard to the advantages of the best
medical schools of the United States, Great Britain, Ger-
many, Austria, and France.
The faults of others will not form the subject of this
paper, though, after detailing the preparation of a doctor
of medicine here, it might subsequently be interesting to
draw comparisons between this, other European, and
American requirements for a medical degree. The ob-
ject of this paper is merely to answer the question of my
American friends by outlining the work that is required
here, and also enumerating the special opportunities of-
fered at Paris for advanced and efficient work in special
branches of medical science.
The paper may have a public interest in that public
attention should be drawn to the preparation that is given
to medical men, the doctors to whom each family in-
trusts the lives of its members in times of critical illness,
and to whose wisdom and efficiency implicit confidence
must be given. For this the public is interested that its
medical service be adequately prepared and trained.
Do we give proper attention, in the requirements of our
medical schools, to insure an attendance and care that
vital necessity and a public conscious of its dependence
should demand ?
Examine the preparatory work of the continental
medical student. Study the American school in com-
parison. Offset the vital and casualty statistics of the
two worlds, with due allowance for difference of race and
climate. Then come to a conclusion founded upon
positive knowledge, and not hearsay evidence or impres-
sion.
How is a doctor trained in France ? What is the re-
quirement and the signification of the degree " Docteur
en Medecine " of the University of Paris ?
To commence the courses of the medical school a can-
didate must be already provided with the degrees of
"Bachelier es Lettres" and " Bachelier es Sciences."
In short, a graduate of the high standard colleges of the
United States finds himself admissible to commence his
medical studies here.
The courses commence in the early part of October,
and continue, with but two weeks' interruption, until the
middle of August, ten months. The student follows a
full and carefully compiled programme of study for four
years, before becoming admissible for his final and severe
examinations, three in number, but each divided into
several parts. The examinations are grouped as follows.
At the end of the first year's work, examinations " in
course" of the first year's studies must be passed, viz
chemistry, the general science, organic and inorganic,
with applications to medicine; physics in like manner;
zoology, in general, with parasitology, bacteriology, and
comparative anatomy ; botany, in general, and materia
tnedica; histology, general and technical. Twenty
months later, or half way through his third year, the stu-
dent presents himself for examination in general and de-
scriptive anatomy, with practical exercise with the
cadaver and subsequent demonstration of his preparation.
This is perhaps the most exacting of all examinations, on
account of the minutiae of detail and technique demanded,
and covering two years' work in the dissecting rooms.
At the beginning of the fourth year the examination in
physiology must be passed, and after the completion of
the fourth year come the strictly medical examinations,
and here lies the test of four years' work. The student
presents himself the fifth October after the commence-
ment of his medical course, for the final and conclusive
series of examinations for his degree.
The first of these comprises the subjects of operative
surgery, external pathology and obstetrics, with practical
demonstrations, before a jury, of surgical operations.
After this examination (which is called the first part of
the third, lasting several weeks, with delays more or less
prolonged according to the need of special preparation)
the student undergoes the last part of the examination,
this time on the subjects of internal pathology, or pare
and general medicine.
Some time later, according to the wish of the student
and his readiness in preparation, comes the fourth exam-
ination. The subjects are hygiene, legal medicine,
materia medica, therapeutics, and pharmacology.
Last of all the fifth examination, and in this one all
the force of the student must be called into play. The
examination consists of three clinics, one in medicine,
another in surgery, and the other in obstetrics, made by
the student before an examining jury, selected for each
specialty, each member of which designates a patient
chosen at the time of examination, giving the candidate
ten minutes to examine his case, but no means of book
preparation or assistance other than his own knowledge
and personal interrogation of the case in question. This
examination is an affair of several weeks, and its success-
ful termination lifts a burden from the student's mind.
Between him and his medical degree there is now but one
step — the thesis.
The thesis must be on a medical subject chosen by the
student, and approved by an examining committee. To
this subject are brought all results of personal observa-
tion and investigation possible for the candidate to
gather and digest. Much original work and many valu-
able counsels of his masters are there expressed in a well-
developed solution, the results of medical query and theo-
retical problems not before determined to scientific
satisfaction. The thesis is a matter of at least six months'
devoted labor, and it is not rare to find a thesis the re-
sult of several years of most exhaustive and thorough
study. With the presentation, publishing, and public
sustentation of his thesis, our medical man reaches his
goal ; and, with a hard-earned degree, finishes his student
career to commence the public duty for which he is so
well qualified.
At Paris one does not study medicine for the " fun of
it ; " nor to be called, in after life, by the high sound-
ing name of " Doctor." The study costs too dearly for
that, and by the bedside, through all those years of ser-
vice for the sick and poor, one leaves the personal
vanity that demands a sounding title. Nothing but
earnest determination and fondness for scientific work
for a chosen profession gives the courage to continue to
the well-merited, but poorly recompensed end of the
student's efforts.
In preparation for the examinations the student has re*
course to three sources, his books, the instruction given
by the medical faculty and the hospital.
For the books little need be said ; the masters of all
branches of the sciences are at hand, modern, complete,
plentiful, varied, and not too expensive.
The medical faculty of Paris belongs to the largest
university in the world, and naturally has more students
by several hundred, by official statistics of last year,
July 28, 1894]
MEDICAL RECORD.
127
than any other medical faculty. Consequently the force
of instructors is very large. The faculty counts thirty-
five professorial chairs which give instruction throughout
the entire year. Besides countless laboratory assistants,
demonstrators, professor's aids and clinical aids, the force
of professors in activity the present year numbers seventy
or more.
Practical laboratory work is required for the following
subjects : physics, chemistry, zoology, botany, histology,
physiology, anatomy, pathological anatomy, operative
surgery, with short courses in bacteriology, pharmacology,
experimental pathology, general pathology, therapeutics,
obstetrics, legal medicine, and hygiene.
During the year there are delivered by the professors
of the faculty, at least twelve hundred lectures and
seven hundred clinics, so divided as to give three
lectures a week upon each of the subjects of instruction ;
but for internal and external pathology, legal medicine
and obstetrics, twice that amount, one lecture every
day on each subject throughout the school year, is given.
The clinical professors each give two clinics per week.
They are numbered and assorted as follows: Medical
clinics, four professors ; surgical, four ; obstetrical, two ;
mental pathology, children's diseases, skin and syphilitic
diseases, diseases of the nervous system, ophthalmic and
diseases of the urinary organs, each one professorial
clinic.
After the books and the faculty, but not the least im-
portant, comes the hospital work of the student. For
the last two years of his course he is obliged to serve in
the hospital two hundred and eighty-four days of each
year. Without this regular service he cannot be allowed
to continue his medical course. Most of the students
do much more than this and follow regularly the hos-
pital work for four years or more.
The students at the hospitals are under the control of
the physician in charge of the service, the direct super-
vision of the chief of the resident service, and subject to
the direction of the house physician of the service in
which the student is accepted as an aid. In this way a
systematized grade of bedside instruction and clinical ob-
servation is maintained in all of the hospitals, while, at the
same time, the student serving as an aid must do all the
practical work himself as fast as he becomes well grounded
in its principles.
There are in all twenty six hospitals to which the stu-
dents have free access and in which they are invited to
serve according to their choice. In these hospitals are
fifteen thousand beds, always full. The acting surgeons
and physicians of this immense organization of hospi-
tals are the best practitioners in France, chosen by
competitive examination, in a struggle where success
means the only way to establish a living practice at Paris.
All of these surgeons and physicians devote to the hospi-
tals the morning of every day in the year, year after year
until retired by death or age.
In the hospitals, many clinics and lessons are given in
addition to those under the auspices of the faculty and
already mentioned.
At present there are given no less than thirty such les-
sons and clinics each week. Each specialty has its
masters and its own hospital service; thus enabling the
student, already strong in his general medical education,
to choose and pursue to best advantage his chosen spe-
cialty.
In addition to all of these advantages is another that is
often appreciated. Every student of the faculty of med-
icine is admitted without charge to all of the courses and
laboratories of La Sorbonne — i e. Faculty of Sciences,
College de France and of the Museum d'Histoire Natu-
relle. These three institutions give the most advanced
courses of science, language, and philosophy.
At the College de France during my course were the
famous Professors Berthelot and Schiitzenberger in
chemistry ; Brown-Slquard in medicine ; Balbiani, com-
parative embryogeny; Ranvier, histology; Ribot, ex-
perimental psychology ; Renan, the philosopher ; Gaston
de Paris, the philologist and so through a list of famous
names that this paper has not space to enumerate.
At the Museum d' Histoire Naturelle were given the
courses of Fremy, Van Tieghem, £mile Blanchard, A.
Milne Edwards, DeQuatrefages and others.
The faculty of sciences at the Sorbonne includes the
instruction of Poincarre, Javal, Troost, Pellat, Lippman,
Friedel, and Wolf, with many others, but less interesting
to the student of medical science.
There remains another source of instruction at Paris,
the importance of which to the medical student demands
something more than a mere mention ; the " Institut
Pasteur."
The "Institut Pasteur" is a name well known in
America. The man whose name it bears, and his mar-
vellous work need no heralding there. But what is not
generally known is the fine opportunity offered by the
institute for special students in microbiology. The es-
tablishment of the Pasteur Institute is wholly in accord
with the educational policy of France— the best regardless
of cost, but instruction free. In consequence, in this
institute, besides the equipment and accommodation for
the special end for which it is constituted — the treatment
of hydrophobia — there are found six special services for
instruction in microbiology.
The first is the hydrophobia treatment, under the
charge of Professor Grancher ; the second, general mi-
crobiology, Professor Duclaux; the third, technique of
microbiology, Roux; the fourth, microbiology applied
to hygiene, Chamberland ; the fifth, morphological mi-
crobiology, Metchnikoff; and sixth, comparative micro-
biology, directed by Gamelela. These six services, each
equipped with its special laboratories and apparatus, com-
prise about fifty workers.
The first service, treatment of hydrophobia, comprises
the work of vaccination of the bitten, by Drs. Charrin and
Chantemesse, and all studies relative to the subject of
hydrophobia.
In the services of general and morphological micro-
biology, the chief, if not the only, aim, is to study the
form and functional properties of the microbe, in order
to know if these functions are constant or little variable
and can consequently serve to characterize distinct spe-
cies; or if, on the contrary, these properties exist in
condition of perpetual change, vacillating in limits too
large to permit their service for other means than to form
their classification in groups.
The variations of form help to determine the classifi-
cation question, but are not alone sufficient to decide it,
even should they be more distinctly defined than is the
case. The variation of physiological properties must
also be determined. This is done by the difficult study
in detail of pure cultures and by means of attentively ap-
plied chemical experience to test the physiological action.
The chemical side of the question belongs to the service
of general microbiology. In this laboratory are em-
ployed and taught all the methods of chemical analysis
capable of serving in the study of microbes, their needs
of nourishment, methods of culture, and their products of
secretion and excretion.
The laboratory of microbiology applied to hygiene,
similar to that of general microbiology, includes in its
work all that concerns the hygienic study of air, soil, and
water, and also the study and preparation of all vaccines.
Mark, in passing, that had the lymph of Koch passed
through this laboratory, it would, in all probability, not
have been amenable to the charge of killing numerous
invalids, which is now so forcibly pressed against it.
The two laboratories of comparative and technical mi-
crobiology are devoted to the study of diseases of microbic
origin, the first as a laboratory of special research, the sec-
ond for special instruction and training. Into this latter
laboratory Dr. Roux receives the entering students in se-
ries commencing every six weeks. To them are given the
notions and all technical details to render the student
competent in questions of microbiology. This practical
laboratory technique and study renders the student capa-
128
MEDICAL RECORD.
[July 28, 1894
ble of entering upon the advanced work and researches
of his subject. At the end of his six weeks' training he
passes into the other laboratory, chosen for his intended
line of work, and where his stay is limited only by his
needs and his capacity.
There is a fee of admission, payable once for all, and
a monthly tax, according to the expenses of the labor-
atory, both at a minimum. The animals necessary for
experiment are furnished at one-half the market price.
The instruction is free ; and, more than that,- the admin-
istrative council exercises the right of remitting all ex-
penses, even for personal experiment, to such workers as
may be judged worthy of this remission and thus be en-
abled to continue their studies without expense.
As will be seen, this institute, aside from its special aim,
furnishes instruction of great importance to a medical
student interested in this line of work.
With the " Institut Pasteur " closes the list of medical
opportunities offered in Paris. For these opportunities
my fellow-students from the United States and myself
were self-exiled from home, families, and friends for a
period of five or six years. For these advantages, we
worked with severe determination, resolved to overcome
the strangeness of a foreign tongue and endure the isola-
tion of student life in a great and foreign city. Were
we mistaken in believing Paris to possess superior advan-
tages, or were our questioners badly informed ?
William S. Magill, A.M., M.D.
4656 State Street, Chicago, III.
gdjcjflical Stems.
Contagions Diseases— Weekly Statement— Report of
cases and deaths from contagious diseases reported to the
Sanitary Bureau, Health Department, for the week end-
ing July 21, 1894.
Tuberculosis
Typhoid fever
Scarlet fever
Cerebrospinal meningitis
Measles .
Diphtheria.!.!!."!!..*."."."!!
Small-pox
Oholera
Varicella
Pertussis
Erysipelas
Leprosy
Cases.
Deaths.
52
128
14
9
45
4
0
8
4i
5
193
4i
4
a
0
0
0
0
0
0
0
0
0
0
The Use of Bromide of Ethyl as an Anesthetic in
France. — At a recent meeting of the Soctete de Chirurgie
M. Segond spoke on the different methods of applying
anaesthetics and their composition. He said that for the
last year all his operations were done under bromide of
ethyl alone or inhalations of ethyl followed by that of
chloroform. When the operation was of short duration
the former anaesthetic sufficed alone, but it was not so
when the operation was lengthy, grave, and tedious, such
as hysterectomies, laparotomies, etc. No accident had
ever been witnessed out of the four hundred and forty-
three cases. He always administered the anaesthetic to
the patient in the dorsal decubitus, and where the bro-
mide of ethyl alone was used he poured at first a few
drops on a compress and presented it to the patient, in
order to accustom him as it were to the odor of the
liquid, after which a large dose was thrown on the fold,
which was pressed firmly over the mouth so as to prevent
all communication with the free air. In twenty seconds
resolution was complete and the period of excitement
was frequently wanting. Where the effect of an anaes
thetic had to be kept up for some considerable time a
few drops of chloroform were applied from time to time.
M. Bazy said that he had tried bromide of ethyl in a
certain number of cases and found it satisfactory. M.
Monod gave similar testimony to the merits of bromide
of ethyl, but said that at the first moments of the inha-
lation the patient was seized with such a terrible sensa-
tion of anguish and suffocation that the speaker preferred
without hesitation using chloroform. M. Berger. and
several other members expressed themselves in the same
sense. — Medical Press.
Otic Gymnastics as a Cure for Deafness. — Professor
Urbantschitsch, of Vienna, has again brought his re-
puted new method of treatment before the Vienna Medical
Society in the form of a lecture {Medical Press). This
consists of selecting different sounds which are regularly
produced at the ear of the deaf until he becomes familiar
with them. The sounds should be continued five to ten
minutes daily, or at least three times a week. This treat-
ment is reputed to act like magic on the young, but is
slower in operation in the aged. Much depends upon
the voice, however, in awakening the perceptive power,
as the high and deep tones are not equal in effect. The
intervals must be filled in gradually with inter-tones. If
a correct record be kept during the treatment, the right
ear will probably differ from the left during the period.
After the perception of speech, musical tones should be
practised. Urbantschitsch has constructed a harmonica
with five and a half octaves, which answers this training
admirably. As to the time this treatment must be con-
tinued, no limit is fixed, different cases requiring differ-
ent durations before reaction sets in. Total deafness be-
ing rare, it is considered that this treatment must affect a
large number of the two hundred thousand alleged, by
statistics, to be helplessly deaf in Europe. Another dif-
ficulty he pointed out in educating these unhappy pa-
tients was the mental condition. In many of these
cases the mind is weak, intelligence low, and education
difficult to impart even in healthy ears, hence we find
children making rapid progress under treatment. The
practical worth of this treatment is often questioned if it
be worth the trouble, but from a mere social point
there is only one answer. Since commencing his treat-
ment in "The Landesanstalt " sixty cases have been
regularly under treatment. At the beginning of the
course not [one could hear a sentence, six of them could
hear a word, twenty- two could perceive vocal sounds,
while thirty-two had a trace of hearing. To day twelve
could follow sentences, sixteen words, twenty-one vocal
sounds, and eleven a trace of hearing. Professor Gruber
agreed with Urbantschitsch in the training of the young,
but considered the time far too limited to pass a definite
opinion. He recollected visiting the Israelitish deaf
institution thirty years ago, where the director practised
this treatment with vocal sounds, and could recall many
cases of children rapidly improving. Toynbee and Hin-
ton, in their " Handbook of Aural Disease," record many
favorable results by these otitic gymnastics. He also re-
lated the case of several families who have quite recov-
ered by this slow treatment. Professor Politzer agreed
with much that had been said by Urbantschitsch, but
was not so sanguine of the future results. The treatment
was not new, and therefore had a longer trial both in
Germany and France.
Physician to the Household of the Ameer. — Dr.
Lilias Hamilton has recently gone to Kabul to serve as
physician to the harem of Abdurrahman, the Ameer of
Afghanistan. She is to have a personal guard of six sol-
diers, three of whom will accompany her whenever she
ventures out upon the streets of the city. The Indian
Government has sought to dissuade the young lady from
what it considers her venturesome undertaking, and has
warned her that she goes at her own risk, and that it dis-
claims all responsibility for whatever of an unpleasant
nature may befall her.
Purification of Water. — Alum has been regarded as
one of the best means of purifying water, but Teich has
found that it has no effect upon typhoid bacilli, and that
cholera germs are destroyed only after the water has been
treated with alum for at least twenty-four hours.
Medical Record
A Weekly yournal of Medicine and Surgery
Vol. 46, No. 5.
Whole No. 1239.
New York, August 4, 1894.
$12.00 Per Annum.
Single Copies, toc.
THE ETIOLOGY OF THE DEFORMITIES OC-
CURRING IN KNEE JOINT DISEASE.
By A. M. PHELPS, M.D.,
NSW YORK.
FtOFESSOB OF ORTHOPEDIC SURGERY IN THE UNIVERSITY OF NEW YORK AND
THE NEW YORK POST-GRADUATE MEDICAL SCHOOL AND HOSPITAL; PRO-
PSSSOR OP SURGERY IN THE UNIVERSITY OF VERMONT ; PRESIDENT OF THE
AMERICAN ORTHOPEDIC ASSOCIATION ; SURGEON TO THE CITY HOSPITAL.
Propositions. — i . In diseases of the condyles of the femur
or the head of the tibia the leg always assumes a flexed
position to a greater or less extent. 2. After the limb
flexes the foot rotates outward, and rotation increases
with flexion. 3. In diseases confined to the patella the
limb never flexes. 4. In disease of the synovial sac, or
fibrous capsule, anteriorly, unattended with diseases of the
condyles, cartilage, lateral, or crucial ligaments, the limb
remains straight.
In diseases of the entire joint, including the cartilages,
the leg always flexes, whether there is fluid present or
not.
I must qualify these propositions by saying that certain
pathological changes which may have taken place, may
modify these deformities. But such exceptional deform-
ities are always easily accounted for, as, for instance,
that seen in Charcot's disease, or in cases attended by
complete destruction of either condyle or either side of
the tibia. My observations have been made in a large
number of cases upon which I have operated in the Post
Graduate and City Hospitals, New York City, and the
Mary Fletcher Hospital, Burlington, Vt., and I found
that the foregoing propositions were correct, with an oc-
casional exception, as already noted.
Many German and English experimenters have tried
to account for flexion upon the fluid hypothesis. It is
true that when the knee joint is forcibly injected it will
flex slightly, to give the greatest possible capacity to the
capsule, but this is insufficient to explain the deformities.
Barwell does not attempt to explain them, but says
(Barwell, p. 106, Wood's Library, 1881), "It is true
that the flexors are probably in all limbs stronger than
extensors, but in fact a mere examination will show that
on the flexor side muscles are rigid, and on the opposite
side flaccid. Our knowledge is as yet insufficient to ac-
count for this phenomenon."
The fluid hypothesis is wrong, why ?
1. Because by far the largest per cent, of knee-joint
diseases are unattended by fluid effusions. Still the same
picture of deformity is seen as in those cases attended by
large effusions.
2. Cases of disease, extra-capsular, located in the epiph-
ysis of the femur, or in the head of the tibia, in which
the joint was not found involved at the time of aspira-
tion, presented the same picture of deformity.
3. Large serous effusions, from synovitis or other
causes, are frequently unattended with flexion.
4. After the joint is evacuated in large effusions, the
limb should again assume the straight position, but it
does not.
These are the chief and valid reasons why the fluid
hypothesis is incorrect.
The statement of Barwell just quoted, is incorrect. I
have carefully weighed the muscles acting upon the leg,
and find that the flexors weigh eight pounds and the ex-
tensors fourteen pounds in the subject examined. The
quality of fibre of these muscles being equal, and other
things taken into consideration, the extensors would be
stronger than the flexors, in the proportion of fourteen to
eight, while the limb is in the straight position, as neither
group would have the advantage of leverage.
Experiments to Demonstrate the Relative Strength
of Each Group. — Experiment I. — A man was strapped
to a table, the popliteal space at the end of the table and
leg extending over. He could sustain 136 pounds sus-
pended from his foot. Turned on his face, the patella
at the edge of the table and limb extended, he could now
only sustain 36 pounds suspended from the heel.
These results correspond very closely to similar ones
attained by Haughton, of Dublin. (See Haughton's
" Animal Mechanics.")
Experiment II. — Subject standing, right leg flexed to
right angle, he could hold suspended from heel 90
pounds. In other words, the flexor group were 55 pounds
stronger when the leg was flexed than when straight.
Experiment III.— Subjects standing against bar, which
crossed the legs at right angles behind at the popliteal
spaces, the left toe of foot against a spike in the floor to
prevent slipping. A strap around ankle of left leg ad-
justed to spring scales, which were pulled upon from be-
hind, showed a resistance of the extensor group of mus-
cles of 240 pounds.
Same subject was strapped on his back, leg hanging at
right angles over the edge of the table. The same scales
were now pulled upon under the table, and it was found
that a pull of 80 pounds would flex the leg still further,
a difference of 150 pounds of resistance in the quadriceps
group of muscles between the leg flexed and extended.
Then we have this formula for extensor and flexor group :
1. Flexors, first experiment, 35 pounds. Extensors,
same experiment, 136 pounds. Difference of power of
each operating with equal advantage, equal 90 pounds.
2. Flexors, same experiment, leg flexed, greatest ad-
vantage of flexors, 90 pounds. Extensors, leg straight,
greatest possible advantage for extensors, equal 240
pounds. Experiment III. Difference, equal 150 pounds.
Difference in favor of flexor, limb straight or flexed,
55 pounds.
Difference in power of extensors, limb flexed or straight,
150 pounds. This proves that the extensors are stronger
than the flexors, the proportion being 240 to 90, the
limb being straight to give extensors the greatest advan-
tage, and flexed to give the flexors a similar advantage.
The limb when flexed, so modifies the strength of these
groups as to make the proportion in favor of the flexors
as 90 is to 80.
The extensors lose in power as the limb flexes, while
the flexors increase in power in about the same propor-
tion. We all remember the futile effort of one boy to
bend the other's leg by putting his knee in the popliteal
space, and grasping the foot, the other boy on his face.
And again, sitting on a fence while hunting, the toes
under or behind a rail, one can easily lower himself back-
ward until the head is on the ground, and can quite
easily again resume the upright position. The power
exerted by the quadriceps group of muscles in such a case,
acting as a pulley over the end of the femur, raising a
weight of 150 pounds on the end of a lever (the femora)
of nearly two feet, must be enormous, amounting to hun-
dreds of pounds.
We will now examine a knee-joint. It is a hinge
*3°
MEDICAL RECORD.
[August 4, 1894
which, when in the straight position, is firmly fixed, ow-
ing to the tension of the lateral and crucial ligaments.
This forces the articular surfaces firmly together and pre-
vents lateral motion. The leg flexed, there is lateral
Fig. 1.
Fig. a.
motion of the joint, which increases as the leg flexes, and
not only lateral but rotary motion. This is due to the
relaxation of the crucial and lateral ligaments by flexion.
Another fact : the patella, and a portion of the capsular,
" ' 1 . ii
\
Fig. 3>
anteriorly receives its nerve-supply from the obturator,
and possibly from the anterior crural. The other portion
of the joint is supplied from the great sciatic The great
sciatic supplies the flexor group, while
the obturator and anterior crural sup-
ply the extensor group. A clinical
fact is, that when the entire joint is at-
tacked with acute inflammation, all the
muscles surrounding it are affected by
spasm. Still flexion rapidly takes place,
whereas disease of the condyles always
produces great spasm and rapid atrophy
of the flexors, while the extensors re-
main quiescent. Diseases limited to
the patella produce spasm and atrophy
of the quadriceps extensor femoris, and
the limb remains straight.
Understanding that the extensors are
stronger than the flexors ; that the mus-
cles about the joint are equally affected
by spasm when the entire joint is dis-
eased, why does not the leg remain
straight ? Before attempting to answer
the question, I desire to call your atten-
tion to these diagrams. Fig. 1, a lever
with a joint at a. Both hands pulling
ten pounds, the bar would not flex.
But the bar being flexed at right an-
gle puts one string on the lever and the
other around the pulley (Fig. 2). This
gives to the string acting on the lever a
tremendous advantage, quite easily cal-
culated. This is exactly what takes place when the leg
flexes, and explains the difference in power as illustrated
Fig. 4.
by my experiments. The same mechanics applies to the
anatomy of the leg, roughly represented by a rude pen-
cilling (Fig. 3). A photograph of one of my dissections
(Fig. 4) shows the biceps acting on the head of the fibula,
the limb straight, and also the extensors and patella.
When this leg is flexed the biceps is seen to act on a lever,
and the extensors over a pulley (head of the femur). The
muscles being dried, do not give an accurate idea of
their position while contracted, as they fall in curves
on flexion. Fig. 5. The same leg straight, showing in-
side flexors acting on the tibia. Fig. 6. The same leg
flexed. It will be seen that these flexors increase in
power as the leg flexes, by being placed on a lever,
and the extensors decrease by being wound around the
head of the femur.
Q. Why does the leg flex when the entire joint is dis-
eased, and all muscles are equally affected by spasm ?
A. When the leg is straight the tension upon the
lateral and crucial ligaments produces great pressure be-
tween the articular cartilage. This
produces great pain, and the patient
to relieve this flexes the leg to relax
these ligaments. This at once re-
lieves intra- articular pressure. But
the flexion of the leg has put the
flexors on a lever and the extensors
on a pulley. The flexion now hav-
ing the advantage, will continue to
flex the leg.
Q. Why does the leg rotate out-
ward?
A. Flexion, by relaxing the late-
ral and crucial ligaments, permits
free lateral and rotary motions at the
knee joint. The biceps inserted into
the head of the fibula, and being the
stronger of all the flexor group, and
having the advantages of direction
and leverage, rotates the leg out-
ward.
Q. Why does the leg never flex
in diseases of the patella alone ?
A. Because the reflexes from the
area of disease are transmitted
through the obturator and anterior
crural nerves, which supply only the
quadriceps. A voluntary effort to
relieve pain is also present. FlG- *
Q. Why are the extensors relaxed in disease confined
to the head of the tibia and condyles of the femur pos-
teriorly ?
A. The reflexes from the area of disease are trans-
Fig. 6.
mitted through the great sciatic, which nerve supplies the
flexors. Exceptional deformities are produced from
pathological destruction of bone or soft parts.
August 4, 1894]
MEDICAL RECORD.
131
Conclusion!. — Typical deformities are produced by
change of leverage and action of muscles due to :
1. A voluntary effort to relieve pressure and pain.
2. Involuntary spasm and contraction of muscles,
which increases the deformity by advantage of leverage
due to flexion.
3. Nervous irritation of groups of muscles due to local-
ized lesion in or about the joint.
4. Exceptional deformities are produced by patho-
logical destruction of bone or soft parts.
5. Outward rotation of the leg is produced by spas-
modic contraction of the biceps after flexion has taken
place. Flexion allows lateral and rotary motion at the
joint.
GENIUS AND DEGENERATION.
By JAMES WEIR, Jr., M.D.,
OWEKSBORO, KY.
That the psychical function or intellectuality is fre-
quently developed at the expense of the physical organ-
ism is well known, and that genius is seldom or never
unaccompanied by physical and mental degeneration is
a fact that can no longer be denied. I use the word
degeneration in its broadest sense, and intend it to in-
clude all kinds of abnormalities. The facts noted above
are by no means recent knowledge, but were vaguely
recognized and commented on centuries and decades of
centuries ago by the Hebrews and kindred races of peo-
ple. The Hebrew word nabi means either madman or
prophet, and it is now admitted that most of the proph-
ets gave evidences of insanity as well as genius. The
Greeks and the Romans recognized this kinship, and we
read in the Bible of a certain Festus who, when con-
fronted by a man of genius and being unable to answer
his arguments, said to him, " Paul, much learning hath
made tl*e mad!" Lauvergne, when speaking of the
oxycephalic (sugar loaf ) skull, an unquestionable exam-
ple of degeneration, wrote many years ago, "This head
announces the monstrous alliance of the most eminent
faculty of man, genius, with the most pronounced im-
pulses to rape, murder, and theft."
The purpose of this paper is to show that wherever
genius is observed, we find it accompanied by degenera-
tion, which is evinced by physical abnormalities or men-
tal eccentricities. It is a strange fact, however, and one
not noticed by Lombroso or any other writer, as far as
I know, that mechanical geniuses, or those who, for the
most part, deal with material facts, do not, as a rule,
show any signs of degeneration. I have only to instance
Darwin, Galileo, Edison, Watts, Rumsey, Howe, and
Morse to prove the truth of this assertion. It is only
the genius of aestheticism, the genius of the emotions,
that is generally accompanied by unmistakable signs of
degeneration. I hope to amplify this conclusion in some
future paper, but lack of space forbids it at the present
time.
Saul, the first king of Israel, was a man of genius and,
at times, a mad man. We read that, before his corona-
tion, he was seized with an attack of madness and joined
a company of kindred eccentrics. His friends and ac-
quaintances were, naturally, surprised and exclaimed :
" Is Saul among the prophets," i.e., " Has Saul become
insane." Again we are told that he was suddenly seized
with an attack of homicidal impulse, and tried to kill
David. Before this time he had had repeated attacks of
madness, which only the harp of David could control
and subdue. David himself was a man whose mental
equilibrium was not well established, as his history clearly
indicates. He forsook his God, indulged in licentious
practices, and was, withal, a very immoral man at times.
At his time, the Hebrews had reached a high degree of
civilization. Abstract ethics had become very much de-
veloped, and any example of great immorality occurring
during this epoch is proof positive of atavism or degen-
eration. As I have intimated before, many of the ancient
Hebrew prophets, who were unquestionably men of
genius, gave evidences of insanity ; notably, Jeremiah,
who made a long journey to the river Euphrates, where
he hid a linen girdle. He returned home, and in a
few days made the same journey and found the girdle
rotten and good-for-nothing; Ezekiel, who dug a hole
in the wall of his house, through which he removed his
household goods instead of through the door; Hosea
who married a prostitute because God, so he declared,
had told him so to do ; and Isaiah, who stripped himself
naked, and paraded up and down in sight of all the peo-
ple. King Solomon, a man of pre-eminent genius, was
mentally unbalanced. The " Song of Solomon " shows
very clearly that he was a victim of some physical dis-
order, sexual in its character and origin. The poems of
Anacreon are lascivious, lustful, and essentially carnal,
and history informs us that he was a sexual pervert.
Swinburne's poems show clearly the mental bias of
their author, who is described as being peculiar and ec-
entric. Many of the men of genius who have assisted in
making the history of the world have been the victims of
epilepsy. Julius Caesar, military leader, statesman, poli-
tician, and author was an epileptic. Twice, on the field
of battle, he was stricken down by this disorder. On one
occasion, while seated at the tribune, he was unable to
rise when the senators, consuls, and praetors paid him a
visit of ceremony and honor. They were offended at his
seeming lack of respect, and retired showing signs of an-
ger. Caesar returned home, stripped off his clothes, and
offered his throat to be cut by anyone. He then ex-
plained his conduct to the senate, saying that he was the
victim of a malady which, at times, rendered him incap-
able of standing. During the attacks of this disorder
" he felt shocks in his limbs, became giddy, and at last
lost consciousness." Moliere was the victim of epilepsy ;
so also was Petrarch, Flaubert, Charles V., Handel, St.
Paul, Peter the Great, and Dostoicffsky ; Paganini, Mo-
zart, Schiller, Alfieri, Pascal, Richelieu, Newton, and
Swift were the victims of diseases epileptoid in character.
Many men of genius have suffered from spasmodic and
choreic movements, notably Lenau, Montesquieu, Buffon,
Dr. Johnson, Santeuil, Cr6billon, Lombardini, Thomas
Campbell, Carducci, Napoleon, and Socrates. Suicide,
essentially a symptom of mental disorder, has hurried
many a man of genius out into the unknown. The list
begins with such eminent men as Zeno, Cleanthes,
Dionysus, Lucan, and Stilpo, and contains the names of
such immortals as Chatterton, Blount, Haydon, Clive,
and David. Alcoholism and morphinism, or an uncon-
trollable desire for alcohol or opium in some form or
other, are now recognized as evidences of degeneration.
Men of genius, both in the Old World and in the new,
have shown this form of degeneration. Says Lombroso :
"Alexander died after having emptied ten times the
goblet of Hercules, and it was, without doubt, in an alco-
holic attack, while pursuing naked the infamous Thais,
that he killed his dearest friend. Caesar was often carried
home on the shoulders of his soldiers. Neither Socrates,
nor Seneca, nor Alcibiades, nor Cato, nor Peter the
Great (nor his wife Catherine, nor his daughter Eliza-
beth), were remarkable for their abstinence. One recalls
Horace's line ' Narrator et prisei Cantonis seepe mero
caluisse virtus' Tiberius Nero was called by the Ro-
mans Biberius Mero. Septimius Severus and Mahomet
II. succumbed to drunkenness or delirium tremens"
Among the men and women of genius of the Old
World, who abused the use of alcohol and opium, were
Coleridge, James Thomson, Carew, Sheridan, Steele,
Addison, Hoffman, Charles Lamb, Madame de StaeH,
Burns, Savage, Alfred de Musset, Kleist, Caracci, Jan
Steen, Morland Turner (the painter), Gerard de Nerval,
Hartley Coleridge, Dussek, Handel, Gliick, Praga, Ro-
vani, and the poet Somerville. This list is by no means
complete, as the well-informed reader may see at a glance,
yet it serves to show, however, how very often this form
of degeneration makes its appearance in men of genius.
In men of genius the moral sense is sometimes obtunded,
13*
MEDICAL RECORD.
[August 4, 1894
if not altogether absent. Sallust, Seneca, and Bacon were
suspected felons. Rousseau, Byron, Foscolo, and Caresa
were grossly immoral, while Casanova, the gifted mathe-
matician, was a common swindler. Murat, Rousseau,
Wagner, Clement, Diderot, and Praga were sexual per-
verts. Genius, like insanity, lives in a world of its own,
hence we find few, if any, evidences of human affection
in men of genius. Says Lombroso: "I have been able
to observe men of genius when they had scarcely reached
the age of puberty ; they did not manifest the deep aver-
sions of moral insanity, but I have noted among all a
strange apathy for everything which does not concern
them ; as though, plunged in the hypnotic condition, they
did not perceive the troubles of others, or even the most
pressing needs of those who were dearest to them; if
they observed them, they grew tender and at once hast-
ened to attend them ; but it was a fire of straw, soon ex-
tinguished, and it gave place to indifference and weari-
ness."
This emotional anaesthesia is indicative of psychical
atavism, and is an unmistakable evidence of degenera-
tion. Lombroso gives a long list of the men of genius
who were celibates. I will mention a few of those with
whom the English-speaking world is most familiar:
Kant, Newton, Pitt, Fox, Beethoven, Galileo, Descartes,
Locke, Spinoza, Leibnitz, Gray, Dalton, Hume, Gib-
bon, Macaulay, Lamb, Bentham, Leonardo da Vinci,
Copernicus, Reynolds, Handel, Mendelssohn, Meyer-
beer, Schopenhauer, Camoens, and Voltaire. La Bruygre
says of the men of genius : " These men have neither
ancestors nor descendants; they themselves form their
entire posterity.' '
There is a form of mental obliquity which the French
term folic du doute. It is characterized by an incerti-
tude in thought co ordination, and often leads its vic-
tims into the perpetration of nonsensical and useless acts.
Men of genius are very frequently afflicted with this form
of mental disorder. Dr. Johnson, who was a sufferer
{torn folic du daute, had to touch every post he passed.
If he missed one, he had to retrace his steps and touch
it. Again, if he started out of a door on the wrong foot,
he would return and make another attempt, starting out
on the foot which he considered the correct one to use.
Napoleon counted and added up the rows of windows in
every street through which he passed. A celebrated
statesman, who is a personal friend of the writer, can
never bear to place his feet on a crack in the pavement
or floor. When walking, he will carefully step over and
beyond all cracks or crevices. This idiosyncrasy annoys
him greatly, but the impulse is imperative, and he can-
not resist it. Those who have been intimately associ-
ated with men of genius have noticed that they are very
frequently amnesic or " absent-minded/' Newton once
tried to stuff his niece's finger into the bowl of his pipe,
and Rovelle would lecture on some subject for hours at
a time, and then conclude by saying : " But this is one
of my arcana which I tell to no one." One of his stu-
dents would then whisper what he had just said into his
ear, and Rovelle would believe that his pupil " had dis-
covered the arcanum by his own sagacity, and would
beg him not to divulge what he himself had just told to
two hundred persons."
Lombroso has combed history, as it were, with a fine-
tooth comb, and very few geniuses have escaped his
notice. This paper, so far, is hardly more than a review
of his extraordinary, comprehensive work ; therefore, I
will conclude this portion of it with a list of men of gen-
ius, their professions, and their evidences of degenera-
tion, as gathered from his book :
Carlo Dolce, painter, religious monomania.
Bacon, philosopher, megalomania, moral ancesthest u
Balzac, writer, marked epilepsy, megalomania.
Caesar, soldier, writer, epilepsy.
Beethoven, musician, amnesia, melancholia.
Cowper, writer, melancholia.
Chateaubriand, writer, chorea.
Alexander the Great, soldier, alcoholism.
Molifere, dramatist, epilepsy.
Charles Lamb, writer, alcoJiolism, acute mania, melan-
cholia.
Mozart, musician, epilepsy, hallucinations.
Heine, writer, melancholia, spinal disease.
Dr. Johnson, writer, chorea.
Malibran, epilepsy.
Newton, philosopher, amnesia.
Cavour, statesman, philosopher, suicidal impulse.
Ampere, mathematician, amnesia.
Thomas Campbell, writer, chorea.
Blake, painter, hallucinations.
Chopin, musician, melancholia.
Coleridge, writer, alcoholism, morphinism.
Donizetti, musician, moral anesthesia.
Lenau, writer, melancholia.
Mahomet, theologian, epilepsy.
Manzoni, statesman, /<?//> du doute.
Haller, writer, hallucinations.
Dupuytren, surgeon, suicidal impulse.
Paganini, musician, epilepsy.
Handel, musician, epilepsy.
Schiller, writer, epilepsy.
Richelieu, statesman, et>tlepsy.
Praga, writer, alcoholism.
Tasso, writer, alcoholism, melancholia.
Savonarola, theologian, hallucinations.
Luther, theologian, hallucinations.
Schopenhauer, philosopher, melancholia, omniphobia.
Gogol, writer, melancholia, tabes dorsalis.
Lazaretti, theologian, hallucinations*
Mallarml, writer, suicidal impulse.
Dostoieffsky, writer, epilepsy.
Napoleon, soldier, statesman, folic du doute, tseudo-epi-
lepsy.
Comte, philosopher, hallucinations.
Pascal, philosopher, epilepsy.
Poushkin, writer, megalomania. ^
Renan, philosopher,/*//* du doute.
Swift, writer, paresis.
Socrates, philosopher, chorea.
Schumann, musician, paresis.
Shelley, writer, hallucinations.
Bunyan, writer, hallucinations.
Swedenborg, theologian, hallucinations.
Loyola, theologian, hallucinations.
J. S. Mill, writer, suicidal impulse.
Linnaeus, botanist, paresis.
The reader will observe that I have made use of the
comprehensive word, writer, to designate all kinds of
literary work except theology and philosophy. The
above list is by no means complete, and only contains
the names of those geniuses with whom the world is well
acquainted. When we come to the geniuses of the New
World, we find that they are few in number, and that
they likewise show erraticism and degeneration. Poe
was undoubtedly a man of great genius, and his degen-
eration was indicated by his alcoholism. Aaron Bun-
was the victim of moral anaesthesia, and Jefferson was
pseudo epileptic and neurasthenic Randolph was a man
of marked eccentricity, and Benedict Arnold was, mor-
ally, anaesthetic. Henry Clay was addicted to an over-
indulgence in alcohol ; likewise Thomas Marshall and
the elder Booth. Booth also had attacks of acute mania.
His son Edwin had paresis, so also had John McCulloch,
John T. Raymond, and Bartley Campbell. A distin-
guished statesman and politician, and a man who stands
high in the councils of the nation, has, for a number of
years, given evidence of mental obliquity, by his uncon-
trollable desire for alcohol. No power, outside of bod-
ily restraint, can control him and keep him from indulg-
ing his appetite for alcohol when this desire seizes him.
One of the most noted poets of to-day, whose verses stir
the heart with their pathos and bring smiles to the gravest
countenances with their humor, was, for a number of
years, an inordinate user of alcohol. Robert Ingersoll is
undoubtedly a man of genius and of considerable origi-
August 4, 1894]
MEDICAL RECORD.
133
nality, and a close study of his writings shows conclu-
sively his mental eccentricity. Judging wholly from his
printed utterances, Mr. Ingersoll is only a superficial sci-
entist and mediocre scholar. His power lies in his won-
derful word imagery, and his intricately constructed verbal
arabesques. He is a verbal symbolist. Symbolism, when-
ever found, and in whatever art, if carried to any extent,
must necessarily be an evidence of atavism, consequently
of degeneration.
Thomas Paine gave evidences of a lack of mental equi-
poise. We fincl-scattered throughout his works the most
brilliant, irrefutable, and logical truths side by side with
the most inane, illogical, and stolid crudities. Among
other men of genius who showed signs of degeneration
we may include Alexander Stevens, Joel Hart, Adams,
Train, Breckenridge, Webster, Blaine, Van Buren, Hous-
ton, Grant, Hawthorne, Bartholow, Walt Whitman.
We must not confound genius and talent — the two are
widely different. Genius is essentially original and spon-
taneous, while talent is to some extent acquired. Gen-
ius is an abnormality, but one for which the world should
be devoutly grateful. Psychos, in the case of genius, is
not uniformly developed, one part, being more favored
than the others, absorbs and uses more than its share of
that element, whatsoever it be, which goes to make up
intellectuality, hence the less favored or less acquisitive
parts show degeneration. Why genius should exist is
one of the unexplained phenomena of nature, but that
it is the result of natural causes I have not the slightest
doubt.
Movable Liver. — Dr. Leube remarks on the rarity of
this condition. . The ligaments attaching the fiver to the
diaphragm must become loosened. (The British Medi-
cal Journal.} Pendulous belly due to repeated preg-
nancies, chronic ascites, etc., predispose. He records a
case in a lad, aged seventeen, with heart disease and gen-
eral dropsy. The abdomen had to be tapped, a fine tro-
car being used, and ten, sixteen, and ten litres were
drawn off at different times. On admission the umbili-
cus bulged, a fluctuation thrill could be easily felt, and
the abdomen was dull all over, except in the region of
the stomach. The liver reached 10 ctm. below the ribs
in the mammary line; the surface was smooth, the con-
sistency hard, and the organs pulsating. Behind, pul-
monary resonance extended on both sides down to the
eleventh vertebra. After tapping, a depression was
noted in the upper part of the right abdomen, and
lower down a projection. This tumor measured ten to
eleven ctm. in the middle line, and 15 ctm. in the
right mammary line, and over it the percussion note was
dull. The lower border could be followed from left to
right, and the convex upper surface of the liver felt. Be-
tween the liver and the diaphragm fluctuation could be
made out, and the surface of the liver could be dipped
upon. The liver could be readily pushed up, the pulmo-
nary resonance behind being then raised 1 ctm. The
fluid seemed to remain between the liver and the dia-
phragm, whether the patient was lying down or sitting
up. This was also proved at the necropsy, the lad dying
some months later. The liver was very movable, en-
larged, and of the nutmeg variety, with consequent in-
duration. The suspensory ligament was 7^ ctm. long.
The pulmonary resonance behind was raised when the
liver was pushed up, owing to the displacement of the fluid
backward. An additional cause of the mobility of the
liver may lie in the loosening of its posterior attachment,
for usually the vena cava is firmly bound with the liver
and vertebral column. This case, as well as another seen
by the author, occurred in men ; hitherto movable liver
has been exclusively seen in women. ^
Tubercle Bacilli.— Dr. Kronig succeeded recently in
finding tubercle bacilli in the blood, taken from the heart
post mortem of a case of* acute miliary tuberculosis, by
means of centrifugal motion. He thinks the method
would also succeed with blood taken during life.
PASTEURIZED MILK AS SUPPLIED TO THE
POOR BY THE STRAUS MILK DEPOT OF
NEW YORK.1
By ROWLAND GODFREY FREEMAN, M.D.,
PATHOLOGIST TO THE FC UN DUNG HOSPITAL; PATHOLOGIST TO ST. MA&Y'S
FRKK HOSPITAL. FOR CHILDREN ; ASSISTANT PHYSICIAN TO ROOSEVELT HOS*
FITAL, OUT-PATIENT DEPARTMENT.
It is the purpose of the writer to describe some of the
details of a most worthy charity, the expenses of which
have been met by one man, since perhaps other equally
charitable persons here or in other parts may be disposed
to carry out the same sort of work, and may thus be able
to benefit by the methods here described.
Since there can be no doubt that the milk supply may
be a source of danger on account of the large number,
and possible pathogenic character, of the micro- organisms
contained in it, it becomes of the greatest importance to
investigate the manner of this contamination and the
methods of avoiding its dangers. The most important
source of contamination is undoubtedly the dairy, where
dirty and ignorant methods are almost universally em-
ployed, not only during the milking but in the subse-
quent care of the milk. Delay in transportation affords
time for the multiplication of the germs which have en-
tered the milk.
It is evident that this danger may be met in one of
two ways : best by a reformation in dairy methods and
the manner of transportation, but failing in this, by sterili-
zation. It is the object of this paper to show how this
latter has been accomplished on a large scale in New
York, for the purpose of supplying milk to the poor.
As such an undertaking is original and certainly worthy
of emulation, and at the same time of great service to
those members of the profession who practise among the
poor, it may be of interest to know how the work was
done and what the results were.
This enterprise is due to the philanthropy of Mr. Na-
than Straus, who, in the spring of 1893, established and
has since maintained a depot for supplying the poor with
a good quality of raw and sterilized milk. His first aim
was to obtain as pure a milk supply as possible, and for
this purpose the dairy was inspected by Mr. S. K. John-
son, veterinarian of the New York1 Board of Health, and
was approved by him. The depot in New York has been
admirably planned and superintended by Mr. A. L. Kin-
kead. Three sorts of milk were provided : pasteurized
ordinary milk, pasteurized modified milk, and raw milk.
Pasteurization at about 750 C. (1670 F.) was used in-
stead of sterilization at ioo° C. (2120 F.), under the as-
sumption that it furnishes a more nutritious and more
digestible milk than that sterilized at a higher tempera-
ture, and at the same time one which is freed from dele-
terious germs. Pasteurized ordinary milk was sold in
eight- ounce bottles at one and a half cent each.
The pasteurized modified milk is simply a one-half
dilution of ordinary milk with the addition of sufficient
sugar of milk to bring up the amount in the dilution to
five per cent., and enough lime-water to neutralize any
slight acidity the milk might have, and then the mixture
is pasteurized.
In this way a milk approximating somewhat mothers1
milk is furnished. The formula used is :
Sugar of milk 12 oz.
Lime-water 8 oz.
Milk 1 gal.
Water 1 gal.
It is evident that the deficiency in this dilution is in
fat. It was intended, however, for very young or sick
infants, and for these answered very well. On the other
hand, to have increased the fats would have introduced
some difficulties. This pasteurized modified milk is dis-
pensed in six- ounce bottles, a charge of 1% cent being
made for each bottle. With each six- or eight-ounce bot-
tle of milk a sterile nipple is supplied. A deposit is re-
1 Read before the Section of Pediatrics of the New York Academy
of Medicine on May 10, 1894.
134
MEDICAL RECORD.
[August 4, 1894
quired of 2j£ cents for each six-ounce bottle and nipple,
and 3 cents for each eight-ounce bottle and nipple.
It was thus intended to furnish for infants and sick
children a sterile milk of good quality in a sterile nursing-
battle, with a sterile nipple through which it could be
fed.
This milk depot was located on a pier at the foot of
East Third Street, that situation being accessible to a
very large tenement-house population. Awnings and
seats were put up on the pier so that the babies and their
mDthers could remain there and inhale the fresh air from
the river.
The building which was erected was, owing to the
character of the site, of necessity long and narrow ; it
was placed several feet from the edge of the pier, so that
an outside passageway connecting the rooms was re-
served. The building was divided into four rooms. The
first room is U3ed for sterilizing the bottles, stoppers, and
nipples, and preparing and pasteurizing the milk. The
second room is occupied by large water-baths of iced
water for keeping the pasteurized milk until it is deliv-
ered. The third room contains ice-boxes for the cans of
raw milk The fourth room, which is nearest the end of
th; pier, is devoted to the business of selling the milk.
The first of these rooms contains all the apparatus : the
ovens for sterilizing the bottles at a dry heat of 1500 C.
(3020 F.), the mixer used for the preparation of the
modified milk, the pasteurizers, and the trough of run-
ning water for rapid cooling after pasteurization. This
room has a slanting cement floor which can be flushed
with a hose for purposes of cleanliness. The ovens for
sterilizing the bottles are made of sheet iron and heated
by gas. The bottles, after being thoroughly cleansed,
are placed in this oven, which is then closed and the gas
beneath is lighted. The bottles are kept here at a tem-
perature of 1500 C. (30 20 F.) for one hour. The bot-
tles used were especially designed and made for the pur-
pose. They have sloping necks so as to be easy to clean,
and spheroidal bottoms so that they will not stand up.
This latter peculiarity was introduced so that they might
not be opened and left standing uncorked, thus allow-
ing a further contamination of the milk by bacteria.
The method of pasteurization used is the same as that
applied by me to the small apparatus which I described
two years ago.1 The principle is as follows: If into a
definite amount of boiling water, the source of heat hav- ,
ing bsen removed, a properly proportioned amount of
cold milk be introduced in bottles under such conditions
that they will not break, the temperature of the milk
will be raised to the desired point, i.e., 75 ° C. (1670 F.).
The amount of boiling water used in this apparatus is
such that, in raising the temperature of the milk through
abDut 6d° C. (1080 F.) it itself loses an equivalent
amount of heat, so that when the milk reaches its maxi-
mum temperature the water is of the same temperature.
The apparatus used at the Straus depot consists of
large copper boilers for the water, and copper receptacles
for the bottles of milk. The boilers are twenty- four
inches long and have a groove encircling them, to indi-
cate the point to which they are to be filled with water.
The receptacles consist of groups of copper cylinders,
each one just large enough to contain one bottle. These
receptacles are made of different sizes for six-ounce,
eight-ounce, or pint bottles. The apparatus is thus
essentially the same as the small apparatus referred to
above, except that it is of larger size, allowing a greater
number of bottles to be pasteurized at a time.
The method of pasteurizing the milk is as follows :
The boilers are first filled with water to the groove and
thj gas stoves beneath them are lighted. The sterilized
bottles, having been cooled, are now filled with milk and
loosely stoppered with rubber corks which have previ-
ously been sterilized in boiling water. The stoppered
bottles are then placed in the hollow copper cylinders of
the receptacles, and the space surrounding the body of
1 On the Sterilization of Milk at Low Temperature, etc. Medical
Record, July 2, 1892.
the bottle in each cylinder is filled with cold water. As
they are prepared, they are left on a shelf until the water
in the boilers generates steam vigorously, indicating a
temperature of ioo° C. (212° F.). The gas under the
boilers is then turned off, and the receptacles containing
the filled bottles are set in the boiling water; the boilers
are then covered and not disturbed for half an hour.
The milk here reaches a temperature of about 750 C.
(1670 F.) in ten minutes, and remains at that tempera-
ture for the remaining twenty minutes. The receptacles
containing the bottles are then removed and placed in
the tank of running water for twenty minutes, at the end
of which period the milk in the bottles has reached
nearly the temperature of the surrounding water, that is,
2o°-25° C. (68°-77° F.). They are then carried into
the next room, where the bottles are removed and placed
in racks in iced water at a temperature of about io° C.
(500 F.). They are kept here until dispensed. Suffi-
cient milk for one day's use is pasteurized, and it is never
carried over.
As soon as one lot of receptacles is taken from a boiler,
the gas beneath is lighted, and the temperature of the
contained water, now about 750 C. (1670 F.), is brought
to boiling for a new lot of receptacles, which, with their
bottles, are at once introduced.
A large number of experiments with milk subjected to
this treatment, show that by it the practical purposes of
sterilization are accomplished. With each bottle of milk
a rubber nipple is supplied which has been sterilized in
boiling water.
Of this pasteurized milk twenty-five hundred bottles
were dispensed in a single week, and thirty-four thousand
bottles wore supplied during the season. Five persons
were employed in this depot during the summer of 1893,
including a cashier, a porter, and a scrubwoman. The
actual technical work of pasteurizing was accomplished,
for the most part, by one man. Many remarkable cases
were observed of infants and children with bad surround-
ing, and suffering from severe gastrointestinal disorders,
who rapidly improved and attained good health on sim-
ply a good sterile food and the fresh air of the pier. It
is interesting to note that, although this milk was often
kept in hot tenement-houses where ice could not be
afforded, only one case of the pasteurized milk turning
sour was reported. This case was investigated, and it
was found that the milk had been kept under the kitchen
stove.
The scope and technical facilities of this charity will
be enlarged this year. Six depots in various parts of the
city will be established. The milk will be brought from
Delaware County, N. Y., the herd supplying it being
first carefully inspected by a veterinarian of the Board of
Health. Both raw and sterilized milk will be supplied.
The same formula will be used for the modified milk,
which will be dispensed in six ounce bottles. Pasteur-
ized milk will be sold in eight- ounce and six teen-ounce
bottles.
In addition to pasteurized ordinary milk and pasteur-
ized modified milk, as supplied last year, a pasteurized
milk diluted with barley water and sweetened with cane
sugar, and containing also table salt, has been introduced
at the suggestion of Dr. Jacobi. The formula used is :
Table salt . i oz.
White cane sugar 10 oz.
Milk I gal.
Water 1 gal
This barley milk will be dispensed in six-ounce bottles.
This depot will be prepared to supply hospitals and
dispensaries.
203 West Fifty-seventh Street.
He Swallowed Two Hundred Hails. — Gastrotomy
was recently performed on an inmate of the Lancaster
County (England) Lunatic Asylum, and nearly two hun-
dred nails from one and a half to three inches in length
were removed from the sorely overweighted stomach.
August 4, 1894]
MEDICAL RECORD.
135
SOME ABNORMAL CONDITIONS OF THE GEN-
ERATIVE ORGANS, ASSOCIATED WITH MEL-
ANCHOLIA OR MANIA1
By W. GILL WYLIE, M.D.,
1
NEW YORK. ■
It is a generally recognized fact that abnormal condi-
tions of the generative organs in women cause reflex dis-
turbances to the nervous system, such as severe headaches,
hysteria, etc. ; but the fact that a chronic subinvoluted, or
an enlarged and congested condition of the uterus, may
induce a typical case of melancholia in some women, has
not yet been fully accepted by the profession. Tnere
may be an abnormal condition of the nervous system
present, and the uterine disease merely makes it active,
for in many of my cases other members of the family
have been mentally unbalanced, and several times I have
had tiro sisters with the same symptoms. Even though
there may be a strong predisposing cause in many cases,
caring the local condition relieves all the symptoms.
Most of my cases have been in women who have borne
children, but in several instances I have cured well
marked cases of what such men as Spitzka, Eroy, and
Sachs have diagnosed as cases of melancholia, by ampu-
tating a diseased cervix uteri where diseased glands and
follicles had kept up an enlarged and congested condition
of the uterus in virgins. Some of these cases complained
of no local pain, and a profuse leucorrhsea was the only
indication of uterine disease, although most of such cases
have dysmenorrhoea, backache, etc., due to the local dis-
ease, and as a rule the nervous symptoms would be
classed as hysterical rather than melancholic. In three
of th* cases brought' to me having marked delusions or
acute outbreaks of mania, treatment of the uterus failed
to relieve them. In one I could plainly define acute
salpingitis and ovaritis, and removal of the appendages
cured the mania. In the second case I could not define,
even under ether, any disease of the appendages, but Dr.
Spitzka said in his opinion the mental trouble was reflex,
and I made an exploratory incision and found both Fal-
lopian tubes occluded and the distal ends filled and en-
larged with pus. The patient made a complete recovery,
although for many weeks a trained attendant was with
her night and day to prevent suicide before the last oper-
ation. The third case had well-pronounced melancholia,
and I found a diseased cervix and subinvolution ; this was
treated in the usual way and for several months she
seemed well, but then all symptoms returned. I pro-
nounced the condition of uterus normal and proposed an
exploratory incision, as she had some local pain on the
sides, but on account of cost for operation, etc., she re-
turned home, and later Dr. Van de Walker, of Syracuse,
N. Y., operated and found salpingitis. The patient was
reported cured.
The three cases reported to-night are those that have
b^en recently under my care, and were all examined by
well-known alienists. One well marked case of melan-
cholia, with decided outbreaks of mania, was sent to me.
Although she had a lacerated cervix uteri and some en-
largement, it was not enough to account for the melan-
cholia ; so I turned her over to Dr. L C. Gray, and he
treated her as he liked for a year or more ; but she was
not cured, and then I operated under ether for the lacera-
tton, etc. ; the effect on the mental condition was negative,
but certainly did not make her worse, and I turned her
over again to Dr. Gray. Without a single exception, all
my cases were in every instance seen in consultation and
examined by at least one alienist of good standing, and
I am sure that some of the many cases of melancholia
treated by opium, rest, etc., could be relieved, if not per-
manently and radically cured, if a gynecologist was called
in consultation. I know that most doctors think they can
examine and diagnose any serious disease of the uterus and
appendages ; but unfortunately many of them are merely
unconscious of their ignorance, for all learned doctors
1 Read before the Northwestern Medical and Surgical Society
March ,1894.
are not artists, their brains may be great but their hands
are not so well trained.
Case I. — Mrs. S , aged thirty-five, came to con-
sult me, November 20, 1893. §ne s^d she had had six
children ; the last four years ago. After the third child
was born she had some unusual nervous symptoms, but
they passed off after a month or more. Since the birth of
the last child she had not been well, had become very
nervous, and had been treated for more than two years
for nervous prostration. She imagined her husband did
not like her, or that she did not love him, and everything
was wrong ; and at times she was so depressed that she
was afraid she would kill herself. She had recently been
treated by Dr. Baruch with baths, etc., and was improved
in her general health. She looked in fair general health,
her color was good. She had no actual pain anywhere,
and had never had a local examination since the birth of
her last child. After hearing her story I suggested that
all her nervous symptoms might be due to subinvolution
of the uterus, and she consented to an examination. I
found a large and soft uterus held back in the pelvis by
a very hard tumor about the size and the shape of a
large kidney ; it seemed to lay between the bladder or
pubic bone and the uterus, but did not seem firmly at-
tached. She gave a history of excessive menstruation,
but no other direct symptoms of local disease.
I advised consultation with Dr. Sachs, he pronounced
it a well-marked case of melancholia, and wished to give
her treatment and keep her under observation for a week
or two. Although I was told afterward that several of
her family had had mental disease, I advised removal of
the tumor and treatment for the subinvoluted uterus.
She was admitted to my sanitarium December 1st, and
Dr. Sachs began the orthodox opium treatment for mel
ancholia ; under this she was less nervous, but not re-
lieved of her depressing thoughts.
December nth, I operated and removed this most un-
usual tumor, which appeared to be a fibroid, detached en-
tirely from the uterus and appendages, rolled up in the
lower end of the omentum, and coated over with a calca-
reous shell. The tumor has no blood-vessels running
into it and seems to have been treated by the surround-
ing tissues as a foreign body. It is shaped something
like an abnormally large kidney; it was removed without
difficulty and the patient made a good recovery. In less
than two weeks patient was practically well. The uterus
and subinvoluted pelvic tissues were further treated by the
applications of boro-glyceride cotton pledgets put in the
vagina twice a week ; in six weeks patient was dismissed
cured ; no medicine except laxatives used after operation.
Case II. — Mrs. K , aged thirty, was brought to
my sanitarium by her father and brother, who were both
physicians. In the fall of 1892 Dr. W., the brother,
wrote me that his sister had been insane for four years,
and for the past seven months she had been under the
care of Dr. Stern, of Hartford, Conn., and seemed to be
practically incurable, and wanted to know if I would
take out her ovaries, as he believed that their disease
caused the insanity. I wrote him that I would be glad
to see the case, but I would not agree to remove the ova-
ries unless I could make out by local examination posi-
tive indications of actual disease of the ovaries.
December 28, 1892, I examined her. She had had
four children. Four hours previous to birth of last child
she had been well. Except for a time after birth of sec-
ond child, she was very nervous and mentally much dis-
turbed. The last labor was not difficult nor unusual in
any way, but several weeks after labor she grew more
nervous, and marked symptoms of melancholia came
on, which in spite of treatment, rest, etc., gradually
grew worse. Dr. Spitzka saw her and pronounced it a
case of melancholia. For the past seven months she had
been confined to Dr. Stern's sanitarium and was consid-
ered insane. She had a dislike for and was suspicious of
her husband and family, and would get excited and rattle
off a mixture of German and English that no one could
understand for hours at a time. She was pale and thin,
136
MEDICAL RECORD.
[August 4, 1894
but not in very bad general health. She needed constant
care and watching by a nurse. She had been examined
locally by Dr. Stern, but local treatment was not deemed
necessary. On local examination I found a large,
soft uterus, with marked relaxation and subinvolution of
the vagina and pelvic blood-vessels. The uterus was
fully as large as at two months' pregnancy, and the cervix
was greatly enlarged and everted by diseased glands and
follicles, and was lacerated to some extent. There was
a history of excessive menstrual flow.
It was, in my opinion, a typical case of subinvolution,
due to disease of the glands and follicles of the cervix,
with some laceration of the cervix at labor.
Dr. Spitzka saw her and advised me to try the local
treatment and operation to cure the subinvolution, etc. , af-
ter regulating her bowels and feeding her carefully, and
applying cotton pledgets to the vagina, soaked in sol.
boro glyceride, twice a week.
On January 9, 1893, she was etherized and I dilated
the uterus, curetted it, and amputated the diseased tissue
of the cervix and sewed up the laceration, lining the
cervical canal with flaps of healthy mucous membrane
drawn in from the vaginal part of the cervix. I also di-
lated the anus and tied off some haemorrhoids. For sev-
eral days after the operation she was in an excited state,
gabbling her jargon most of the time as she had done at
intervals before, but on the tenth day she seemed to be
perfectly rational and remained so without interruption.
Gradually her general condition improved, and after the
tenth day I made the boro glyceride applications to the
vagina twice a week to hasten involution.
On January 31st she was discharged as cured, and went
to her home in Brooklyn. For several weeks she came
for the simple local treatment twice a week. Her menses
became normal in amount and were regular till last fall,
when she went over two weeks and then menstruated
quite freely. Some of her old mental confusion returned ,
but after four or five boro glyceride applications to the
vagina she felt well. She has gained flesh and strength,
and attends to all her duties at home without trouble.
Case III. — Mrs. B , aged thirty- two, admitted
November 16th, said she had been married eight years,
was always nervous, and several of her family had had
serious mental symptoms. As a rule, she had enjoyed
good health. She had had two children, and after the
first child had severe pains in her head and was de-
pressed, etc. ; this gradually passed off. Eighteen
months ago she had a miscarriage, since then she had
some dragging sensation about the pelvis, and had
gradually become very nervous and suffered, especially
about the time of her menses, with severe occipital head-
aches, and could not help looking at this in a depressed
and abnormal way. She was seen by Dr. Spitzka, who
said it was melancholia, probably caused by reflex disturb-
ance due to disease of the generative organs. Local ex-
amination revealed a large and soft uterus which bled to
the touch of the sound on the endometrium. There was
follicular disease of the cervix with a slight tear, and
there was subinvolution of the vagina, and a laceration
of the inner part of the perinaeum which caused the lower
end of the rectum to crowd forward the posterior wall
of the vagina and form a rectocele.
November 20, 1893. — The uterus was dilated, curetted,
and the diseased tissue of the cervix removed, and lacera-
tion sewed up. The perineum was also repaired and the
anus dilated and treated.
The patient made a good even recovery, and after the
use of the boro-glyceride cotton pledgets twice a week
she was dismissed cured. Once since then some of her
nervous symptoms returned, but they promptly disap-
peared after three applications had been made of the
boro-glyceride. I do not mean that the enlarged condi-
tion of the uterus which we call subinvolution, or the
other diseased local conditions, will cause melancholia in
all, or even in many women, but will do sa in some
cases, and that the melancholia seems incurable as long
as the local disease remains uccured.
Clinical g^partment
A CASE OF FACE PRESENTATION, WITH RO
TATION INTO THE SACRAL CAVITY.
By JAMES B. BULLITT, M.D.,
GLCBK, A. T.
Mrs. N , aged twenty- one, had previously given
birth to two healthy, living children, first becoming a
mother when seventeen years of age. During the third
month of this third pregnancy she was threatened with
an abortion ; in addition to the pains, a considerable
amount of bloody mucus was discharged, and the mouth
of the womb was sufficiently patulous to admit the tip of
the index ringer. With the recumbent position and opi-
ates the disaster was averted and she carried the child
successfully until the end of the eighth month. At this
time I was again called to see her ; I found her in con-
siderable pain, of intermitting type, referred to the lower
portion of the abdomen chiefly, and complaining of great
aching pains in the small of the back. Palpation dis-
closed the child's body in the first position, head present-
ing. The mouth of the womb was sufficiently patulous
to admit the finger, which could feel the presenting head.
There was a slight discharge of bloody mucus. I sup-
posed this to be the beginning of labor, and left instruc-
tions to be sent for as soon as true pains began. The
next morning, however, the condition was much the same;
no true pains had commenced, and the discharge of
bloody mucus had ceased. Five days later, on Friday,
I was again called to see the case ; true labor pains had
begun the evening before, and the amniotic fluid had
been discharged on Friday at two o'clock, it being six
o'clock when I arrived. Pains were recurring at intervals
of five minutes, and were strong, but no advancement
seamed to be made. The mouth of the uterus was not
more open than at the examination, five days before, ju^t
admitting the tip of the index finger. Gentle manipula-
tion permitted the introduction of two fingers, upon
which a diagnosis of face presentation with rotation pos-
teriorly was made. The fingers received the sensation of
the pelvis being bridged across, instead of being filled in
with the round occiput as in ordinary occipital presenta-
tions. Under chloroform, and with the assistance oi
Drs. Collins and Fox, the uterine mouth was manually
dilated ; and then, with the hand in the vagina, two fin-
gers on the supra-maxillary bones, and thumb on the brow,
I made pressure upward, the other hand on the abdomen,
pulling the head in the same direction. The head was
readily dislodged; the external hand then pushed the
occiput downward, the hand in the vagina pushing the
chin still farther upward.1 Conversion into an occip-
ital presentation was readily effected ; forceps were then
applied, and a living child brought to the light in a short
space of time. The whole procedure consumed an hour
and ten minutes' time. The patient took chloroform
very badly, rendering the manipulation more difficult and
more lengthy than there was necessity for. The mother
made an absolutely uneventful recovery ; the temperature
was never higher than 990 F., and in three weeks' time
she was able to attend to her household duties. The child
was a well developed girl, weighing seven and one- half
pounds. There was a marked facial paralysis ; this has
gradually disappeared, leaving the child as sound as the
fondest mother could desire.
The child's head was of an average size, not very small,
while the mother's pelvis was also of average dimensions,
not very roomy. In case of failure to carry the head up-
ward and then convert the position into an occipital one,
I should have attempted rotation of the face forward.
Had this failed I was prepared to do a symphyseotomy, be-
lieving thereby it would have been an easy matter to slip
the occiput beneath the pubic arch, from which point de-
livery would be plain sailing. Has the operation of sym-
1 Manipulation described by Parry. American Journal of Obstet-
rics, May, 1875.
August 4, 1894]
MEDICAL RECORD.
137
physeotomy been so employed ? So far as I know there
has been no report of such a case, but it would be un-
questionably feasible. With the forceps and without
symphyseotomy, the chin has been dragged down over
the sacrum and perinaeum, when the occiput and calvarium
glided underneath the pubes.1 Such procedure is cer-
tainly of very violent nature, and fraught with danger to
both mother and child.
A CASE OF LOOSE CARTILAGE IN THE
KNEE-JOINT.
By CHARLES G. R. JENNINGS, M.D.,
SLMtVA, N. Y.
Mr. A. B. G , civil engineer, gave a history of trouble
with his knee, dating back several years to an injury re-
ceived in foot- ball at college. From that time he had
repeated attacks of synovitis. During one of these,
while examining his knee I discovered a floating carti-
lage on the inner side of the joint, which immediately
escaped from beneath my finger and could not be found
again. For nearly a year after that he was comparatively
free from trouble with the knee. The cartilage reap-
peared unexpectedly one day while he was descending a
flight of stairs, and as a result of its becoming pinched
between the bones he almost fell headlong. As soon as
he recovered from the shock of pain and surprise, he
clapped his hand upon the knee and felt the foreign
body. From that time on it made its appearance repeat-
edly at short intervals. It seemed to enjoy the freedom
of the whole synovial sac. Wherever the sac extended,
this wandering body was liable to go, sometimes being felt
behind the knee in the popliteal region, sometimes above
the knee beneath the quadriceps extensor, at other times
below the patella, but most frequently on either side of
the joint. The patient finally came to me for operation.
I doubted whether it would be possible to fix the car-
tilage in an accessible part of the capsule and keep it
there long enough to administer an anaesthetic and pre-
pare for a formal operation, so I resorted to the following
plan of procedure : First I had the knee shaved and
thoroughly scrubbed with green soap and washed with
ether and sublimate ; then a full antiseptic dressing was
put on. The patient was allowed to go where he pleased,
but was advised, whenever the cartilage made its appear-
ance, to keep it in sight if possible until I could be noti-
fied and remove it. In a few days it got pinched again,
slipped to the inner side of the joint, and there he held it
until I was ready for the operation.
With my left thumb I crowded it as far down over the
head of the tibia as possible and on the inner aspect of
the joint The sac seemed very loose and large, so that
the body felt as if it were at the top of a well, with a
strong tendency to fall back into the cavity. Cocaine
was injected beneath the skin in the line of incision. Then,
while pressing my thumb between the cartilage and the
general synovial cavity, thus completely shutting off the
joint from the pocket in which I had the cartilage isolated,
I cut down upon it until the sac appeared. Stopping all
hemorrhage, I then incised the sac, when the shining pearly
button of cartilage presented, and was seized with mouse-
tooth forceps and removed through the slit very much as
one slips a button through a button- hole. The cartilage
had no attachment, was a perfectly round flattened disk,
three quarter inch in diameter, and upon one edge there
was a short fringe by which it had originally been at-
tached to the synovial membrane. No synovial fluid
escaped, nor did air enter the joint, as I held my thumb
down upon the bone, shutting the opened portion of cap-
sule off from the rest. Catgut sutures were used for cap-
sule and skin. No drainage was used, as I felt confident
it would not be needed. An ordinary dry aseptic dress-
ing was applied, the leg put on a posterior splint, and the
patient was kept in bed for four or five days. There was
no rise of temperature whatever nor any local disturb-
1 SmeUie, Hicks, and Braua. Science and Art of Midwifery : Lusk.
ance. He very soon left off the splint, and resumed
walking with perfect use of the leg. The knee was capa-
ble of the fullest flexion and as good as new. It is now
eight months since the operation, and he has had no
trouble with his knee at any time since the cartilage was
removed.
In cases where the cartilage is so freely movable and hard
to retain in sight, I believe the above operation is better
than to open the joint in the usual manner under anaes-
thesia and fish for a loose cartilage which may require
very considerable manipulation within the synovial sac
before it can be grasped and removed.
27a Baldwin Strbht.
CYST OF PHARYNGEAL TONSIL.
By ANNETTE E. LAMPHEAR, M.D.,
NBW YORK.
On February 2, 1894, G. M — -, male, aged twenty-four,
Swede, cook by occupation, came to Dr. Jonathan
Wrights clinic at Roosevelt Dispensary for treatment of
"catarrh."
The patient's family history was good. The personal
history was somewhat vague. About ten months ago he
had a sore throat, which was probably a peritonsillitis.
Has had no aural trouble, no nasal obstruction, but for
an indefinite time a great deal of post-nasal dropping, and
expectorates very much mucus.
Examination of nasal fossae and oropharynx showed
nothing particularly abnormal, but on introducing a
post-nasal mirror the vault of the pharynx seemed low.
This appearance was seen to be due to the projection
downward from the middle of the vault of a slightly ob-
long body about the size of a bean. The membrane
covering this projection was smooth, and differed none
in appearance from the remainder of the naso-pharynx.
The diagnosis of cyst was made and verified by a digital
examination.
After cocainization the mass was removed with post-
nasal forceps, its detachment requiring considerable trac-
tion. The cyst cavity was filled with plugs of inspissated
mucus.
The microscopical examination of its wall showed both
the outer and inner surface to be covered with stratified
pavement epithelium. The inner surface was smooth,
excepting near its attachment to the pharynx, where there
were a few crypts. The mucous membrane was rich in
lymph corpuscles, but there were very few lymph fol-
licles.
It would seem that this cyst resulted from adhesions
between the lateral folds of a hypertrophied pharyngeal
tonsil, its wall being formed by the complete closing in
of the median fissure. The form of epithelium, stratified
pavement, I think, is somewhat unusual, most authorities
giving the ciliated columnar as the type of the naso-
pharynx. This is the only case of retention cyst in over
five thousand patients treated in the Throat Department
of Roosevelt during the last six years, and I have been
able to find only one other case reported in our American
journals, that of Dr. Wright's, in the Philadelphia Med-
ical News, of 1889.
Extract of Leeches in the Prevention of Thrombosis. —
Dr. Sahli reported to the International Medical Congress
that an infusion of leeches given by intravenous injection
would prevent thrombosis. From experiments made on
rabbits it was found that an infusion of the head of one
leech to every two ounces of blood in the body was the
required dose. For a man weighing one hundred and
thirty pounds, between eighty and ninety leeches would
be needed. As the effect of the remedy is not perma-
nent, it being found necessary to repeat the injection at
short intervals, it is improbable that this new medicine
will find a very wide application.
i3»
MEDICAL RECORD.
[August 4t 1894
The Etiology and Treatment of Hydronephrosis. —
The surgical treatment of various pathological conditions
of the kidney has of late years come very prominently to
the front, thanks in great part to the improvements that
have been introduced into the technique of the operative
procedures, improvements which have had for effect to
make nephrectomy about as safe as an ordinary ovari-
otomy, and that is saying a good deal. The affections of
the kidney in which the surgeon has shown himself able
to intervene with a fair amount of success are hydrone-
phrosis and pyonephrosis. Pyonephrosis comprises two
varieties, which require to be distinguished both on patho-
logical and on therapeutical grounds. There is one form
associated with calculus. In this form it is pyonephrosis
from the commencement, and should be dealt with pref-
erably by nephrotomy and drainage, especially if by the
removal of the obstructing calculus the patency of the
ureter can be restored. The other form occurs as the re-
sult of suppuration in a hydronephrosis. In this form
the disorganization of the secreting portion of the organ
is usually so complete that nothing remains but to remove
the cyst which has become a source of danger to its pos-
sessor. In a paper which Mr. Bland Sutton recently read
before the Medical Society of London, he pointed out
that to cause hydronephrosis the obstruction to the flow
of urine must be incomplete, or, if complete, intermittent,
because sudden complete and permanent obstruction tends
to cause atrophy rather than dilatation of the kidney.
This tendency to intermission is one of the most remark-
able phenomena associated with hydronephrosis, which
thus simulates the "phantom tumors " dear to gyne-
cologists. When bi- lateral, the intermission may be
alternate, and the diagnosis then presents less difficulty.
The most curious feature about these cases of hydrone-
phrosis is that though an obstruction to the flow of the
urine must presumably at some time or another have ex-
isted, no trace of the original obstruction is sometimes
discoverable during operation or post mortem. This fact
is perhaps, after all, not so surprising as it looks at first
sight. It is quite conceivable that the original condition
which gave rise to the obstruction may have become oblit-
erated by the grave changes, both in the kidney and in
the neighboring structures, involved by the formation of
an extensive hydronephrosis. Thus a movable kidney
which originally rejoiced in sufficient mobility to kink or
otherwise obstruct the ureter, may subsequently, when
developed into a cyst of considerable dimensions, have
contracted adhesions, thus disguising the primary cause
of the obstruction. It is assumed, moreover, that ob-
struction of the ureter low down is invariably associated
with dilatation of the ureter right up to, and including,
the pelvis of the kidney. Mr. Henry Morris pointed out
that this conception tended to mislead, because in some
cases the ureter may bulge in a particular spot as the re-
sult of internal pressure acting on walls of unequal resist-
ance, and that spot may be near the pelvis of the kidney,
in which event the dilatation would probably be con-
founded with that of the kidney pelvis ; or the bulge, if
lower down, may compress the ureter above it as an
aneurism sometimes does in respect of the artery on which
it is situated. It follows that non-dilatation of the ureter
throughout the whole or the greater part thereof does not
preclude the possibility of the hydronephrosis being due
to some obstruction low down. Hydronephrosis is a
curiously silent affection ; indeed, the only symptom for
a long time may be an increase in micturition. This is
particularly the case in respect of unilateral nephrosis,
which may form without any indication of renal disease,
and may remain unnoticed and undiagnosed until by its
size it gives rise to symptoms incidental to the presence
of such a growth. In the double affection the same silent
course may be pursued, until the kidney substance has be-
come so much degenerated that enough does not remain
to provide for contingencies, and then the slightest strain
on the excretory organs may determine grave symptoms
of renal inadequacy. It is now generally conceded that
in presence of a hydronephrosis, a fortiori, if suppurating,
and provided the other organ is in good working order,
the best course is to remove it by nephrectomy. Inas-
much as it is essential to ascertain for certain the condi-
tion of the other organ, the surgeon is advised to proceed
by a median incision through the front of the abdomen,
through which he can without difficulty examine the con-
dition of both kidneys. Should he deem it expedient to
remove the diseased organ, he then closes the anterior
wound, and turning the patient over, removes the kidney
through a lumbar incision — that is to say, without enter-
ing the peritoneal cavity. This is a point worth bearing
in mind by gynecologists, who not infrequently stumble
on a renal tumor which has been cut down upon under
the impression that it was ovarian or uterine. In the
flurry of the discovery the gynecologist is tempted to go
ahead and to remove the organ through the peritoneum,
instead of closing the original wound and attacking it
from behind, thereby adding considerably and needlessly
to the risk of the intervention. Altogether the question
is a very interesting one, for it is full of promise in a de-
partment where formerly little or no hope could be en-
tertained of affording relief. — Medical Press.
Sloughing of Cervix after Labor; Bee 0 very.— Dr.
Magnaux has observed this complication in a woman,
aged thirty-eight, who had been twenty times pregnant —
twelve labors at term, one in the middle of the sixth
month, and six miscarriages, while the twentieth preg-
nancy began at the end of November, 1892. She was
seen at the Hopital Tenon in April, when no morbid
history could be traced. On August 26, 1893, labor
set in at 10 p.m. She was delivered at 9 a.m. the next
morning, having been admitted into the same hospital.
The cervix, it was noticed, was never entirely effaced,
and during the efforts at expulsion the anterior lip pro-
jected at the vulva, and appeared (Edematous and deep
violet in color. The child was very big, and there was
some trouble in delivering the shoulders ; the head had
presented in the first position. The left arm was dam-
aged, but the child was saved. The cervix uteri of the
mother was found next day lacerated on both sides. A
part of the posterior lip was found partly detached. The
anterior lip, over three inches long, projected at the vulva ;
it was sloughy. The vagina was syringed daily with
lysol, and the cervix painted with iodine and iodoform
gauze passed into the cervical and vaginal canals. With-
in a week the sloughy tissues had separated. By Sep-
tember 1 2th, no trace of any anterior lip remained, the
posterior lip was very thin, and about half an inch long.
The child's left arm remains partially paralyzed. — Ar-
chives de Tocoiogie.
The Antiseptic Power of Ichthyol. — As the result of
recent experimental studies Dr. Abel states that : 1. The
ichthyol preparations in weak solutions, and in a short
time, destroy the pyogenic and erysipelas streptococci.
The action of various commercial preparations is prac-
tically identical. Ichthyol is used with success in the
suppuration from these cocci. 2. The staphylococcus
aureus and albus, the bacillus pyocyaneus, the bacillus of
typhoid, ozasna, and anthrax, the spirillum of Asiatic
cholera, show more or less resistance to ichthyol, in that
when pure it must act upon them by the hour in order to
destroy these organisms in cultures. 3. The diphtheria
bacillus in fresh colonies is easily destroyed by weak
ichthyol solutions, while mature ones are acted upon
with difficulty. Therefore it is useful in diphtheria only
in prophylaxis. 4. Ichthyol has rendered good service
in the treatment of typhus and ozsena, although it can
only with difficulty make harmless these infections. 5.
It is recommended that it should be preserved only in sub-
stance or in a fifty per cent, solution ; weaker solutions
may be culture mediums for micro-organisms. Weak so-
lutions should be sterilized by heat, which has no influence
upon its properties. — Ccntralblatt fur Baktcrio logic.
August 4, 1894]
MEDICAL RECORD.
139
Medical Record:
A Weekly Journal of Medicine and Surgery.
GEORGE F. SHRADY, A.M., M.D., Editor.
Publishers
WM. WOOD & CO., 43, 45, & 47 East Tenth Street
New York, August 4, 1894.
THE VALUE OF LIFE IN CASES OF ACCIDENT.
The recent action of the Committee on Preamble of the
Constitutional Convention of the State of New York, in
favor of retaining the limit of damages by railroad acci-
dent resulting in loss of life to five thousand dollars, has
naturally given rise to some adverse criticism by the
daily press. The objection taken is founded upon the
absurdity of allowing any limit for damages short of kill-
ing, and stopping by legal enactment at the sum of five
thousand when the victim is entirely sacrificed. The
question resolves itself into the ridiculous solution that a
part is of more value than the whole. In other words, it
appears to be cheaper to kill a man outright than to
strain his back, put out an eye, crush his foot, or maim
his hand. In the former case he is done for at once, his
earning capacity is at an end, and the Tailroad compa-
nies give the price for the carcass ; while in the other the
probabilities of his still being able to earn something of
a living are offset against any sum of damages within the
range of the sympathies of the jury.
The real question bears upon the earning capacity of
the victim. It is well known that a wide latitude, in case
of maiming, is given in determining the relative earning
capacity of different individuals, and damages are
awarded accordingly. Why the relative value of lives
should not in such a score be equally considered does
not appear. The life insurance companies, in questions
of life expectation at given ages, with different surround-
ings and with stated hereditary proclivities, have reduced
the charges to mathematical calculations and govern
their premiums accordingly. But by the present rule all
lives are equal before the law, no matter how young or
old the victim may be, what his earning capacity has
been proved to be, what his future might reasonably
guarantee, and what the degree of loss may be to his
dependent family. In this respect the ordinary day
laborer, with an earning capacity of two or three dollars
daily, is on an equal footing with the professional man,
the expert artisan, or the progressive tradesman whose
possibilities are almost without limit.
If we rest the claim for damages upon the basis of rea-
sonable expectation of earnings, which, in fact, is the
only way of • proper adjustment, we are forced to admit
that the highest award should be rendered in case of
death ; while in mere maiming the parties accountable
for the same should pay in proportion to the degree and
extent of the incapacity occasioned by the particular
injury. If the jury is competent to decide the extent of
damages in one case, why not in the other ? To the
medical man, who is accustomed to weigh all the circum-
stances in the cases of injury, this is the only way to do
justice to all.
The railroad companies are, of course, in favor of the
statute as it now is, the reasons for which are too obvious
for mention.
LAWYERS ON THE FEES OF DOCTORS.
For some reason, lawyers have developed a special ten-
dency to lessen the monetary value of physicians' services.
It is the common experience that a doctor's bill which
has to be visid by a lawyer will surely be cut down.
Laboring men, business men, corporations, and most
classes of society, even including clergymen, are usually
willing to pay for medical services ; but the lawyer seems
always to think them appraised too high. This at least
is the complaint which is often made to us. And quite
in harmony with this is an editorial expression on the
subject by the New York Law Journal. The editor
says:
" In dealing with rich patients and clients, physicians
and surgeons, and lawyers acting in cases not involving
specific property, should make out their bills not com-
mensurately with the wealth of their employer, but
simply on the basis that he is rich enough to pay what-
ever is right The charges should be fixed according to
the practitioner's standing and experience and the amount
of labor involved, the customary rates of practitioners of
equal standing in the same community for similar ser-
vices being kept in view as a guide and a possible cor-
rective. This general rule would not preclude the accept-
ance of smaller fees from poor people, but it would debar
a practitioner from charging a man worth $ 1,000,000
more than one worth J 100,000 for the same service. We
believe it is essentially communistic and subversive of
professional conscience and dignity to charge a rich man
all that can be screwed out of him, in order to make up
for what one thinks he ought to have received on account
of professional acts of charity or mercy."
The wording of the above is ingenious, and the plea
made has an air of justice. Certainly no one will dis-
agree with the statement that "a rich man should not be
charged all that can be screwed out of him." But it
would be inferred that no less should be charged for a
capital operation on a person of very moderate means
than for one done on a multiple millionaire, or a person
upon whose life depends the safe and productive manage-
ment of some great industrial, social, or political work.
The fact is, we believe, that most surgeons have a certain
scale of maximum and minimum fees. The maximum
is a fixed one and is applied to the wealthy. All would
apply it to millionaires, while few would apply it to a
person worth one-tenth that sum, since this does not by
any means make him wealthy if he lives in this town.
Bellevue Hospital. — Plans are being made for the re-
construction of certain portions of Bellevue Hospital,
New York, that part which is used as reception office,
examination and admission rooms, besides store-room of
the hospital.
T40
MEDICAL RECORD.
[August 4, 1894
DOCTORS AND DEFINITIONS.
A certain weekly paper in this town has adopted the
practice of publishing some scurrility about the medical
profession in each issue. This is not a matter of very
much importance ; still it possesses some academic in-
terest to physicians, who, as a rule, take both eulogy and
satire in a very equable manner.
What one might object to as regards this particular
departure in journalism is the fact that the man who does
the medical items in the aforesaid weekly gets them out
of ancient jest books, which is, we think, a wrong practice
and dishonest to his readers. For example, the latest
medical joke is a " Definition of a Doctor,1' this definition
being: "A person who, when you are ill, comes and
guesses what is the matter with you." Now, this is very
good and amusing, but it is not as good as the definition
given by Voltaire (a.d. 1740), to the effect that "a
doctor is a person who pours drugs of which he knows
little into a body of which he knows less." Yet it is evi-
dently the same idea. Swift's satire was equally brilliant.
"Apollo was the god of physic and the sender of dis-
eases. Both were originally of the same trade and con-
tinue so." And something in the same line was the epi-
gram of Martial :
" Diaulus, the doctor, was a sexton made,
Though he is changed, he changeth not his trade."
The material for similar definitions of doctors exists in
literature from ancient to modern times. It is resur-
rected at regular intervals and is always the same. The
point is, that doctors are ignorant, useless, avaricious,
pretentious, dishonest, slayers of men, or else that they
are promoters of suffering, heartless, and brutal vivi-
sectors. The jokes always show that doctors do not
know, they only guess ; they do not cure, they only pre-
tend ; they do not tell the truth ; they carve up living
animals who all the time suffer conscious and excruciating
agony ; they enjoy the misery of others, and they work
to prolong it ; their bills are high, their labor light, their
responsibilities trivial, and their rewards in money and
appreciation enormous.
This is the sum and substance of the medical jokes of
the past two thousand years. They are all in print, or
at least samples of them, and form a part of accessible
literature. We could refer the amiable malefactor who
writes his weekly medical jokes in this New York paper
to the volumes in which all the above facetiae are com-
piled, but he shows that he possesses it.
Why not, however, give the world some new jest on
the evils of medicine, or else give proper credit to our
sympathetic critics of the past ?
And why not sometimes be pleasant also and show the
other side? Even Voltaire, who was a bigger man after
all than the average New York jest-maker, said :
" Nothing is more estimable than a physician who,
having studied nature from his youth, knows the prop-
erties of the human body, the diseases which assail it, the
remedies which will benefit it, exercises his art with
caution, and pays equal attention to the rich and the
poor."
Mr. Lawton Tait was going to move to London, ac-
cording to some of the English papers, a year or so ago.
Now the American papers state that he is going to Chi-
cago.
Hexus of Vht W&cek.
Rewards for Fecundity. — The Province of Quebec
has a law bestowing 100 acres of government land upon
every father of a family who has twelve living children,
issue of a lawful marriage. Up to the present 174,200
acres of rich agricultural land have been given away in
bounties to 1,742 fathers of twelve or more children, who
have complied with the conditions of the act. Not all
of these proud fathers, however, are satisfied with the
amount of the bounty, for instances of families of twenty
or more children are not rare, and the fathers of these
want a proportionately higher reward for their patriotic
efforts. One old gentleman, Mr. Paul Belanger, of
River du Loup, wants 300 hundred acres, and bases his
claim upon the fact that he has thirty-six living children.
Another claimant for an increased allowance is Mr.
Theoret, of St. Genevieve. His wife, who is but thirty
years of age, has presented him with seventeen children.
She has just givpn birth to triplets for the second time in
five years, and has had twins three times. Mr. Theoret
hopes to acquire a large portion of the Province if his
wife will continue to do her share.
Medical Education in China. — Western medicine is
slowly making its way in the Celestial Empire, under the
fostering care of the progressive Viceroy Li Hung Chang.
The medical school established by him in Tien Tsing is
in a flourishing condition, and it has been decreed that
the medical officers of the army and navy shall in future
be taken from its graduates. The medical stores for use
in both services must first be approved by the faculty ot
this school.
Professor Max von Pettenkofcr has resigned from the
University of Munich. The cable reports that this has
aroused a great deal of public indignation, as it is un-
derstood that the resignation was enforced by pressure
from Berlin in consequence of Dr. Pettenkofer objecting
to some of the anti-cholera measures recommended by
Professor Koch.
The American Association of Obstetricians and Gy-
necologists will hold its seventh annual meeting at
Toronto, Ont., Wednesday, Thursday, and Friday, Sep-
tember, 19, 20, and 21, 1894, to which a cordial invita-
tion is extended to the medical profession.
The German Association of Scientists and Phy-
sicians will hold its sixty -sixth annual meeting in
Vienna during the week ending September 30th. The
Austrian Government has made an appropriation of
$5,000 to defray the expenses of the meeting.
A Russian Leper Colony. The St. Petersburg cor-
respondent of the London Daily Chronicle states that the
general governor of the Amoor province is arranging
in the vicinity of Nicolaivsk for a colony of lepers, which
will be surrounded by a stockade, to prevent the patients
leaving the place. Land is being set apart within the
enclosure for gardens and the necessary buildings.
The Kentucky School of Medicine. — At the meeting
of the Association of American Medical Colleges, held
in San Francisco on June 7, 1894, the Kentucky School
of Medicine, of Louisville, Ky., was dropped from mem-
bership in the Association.
August 4, 1894]
MEDICAL RECORD.
141
The University of Halle has been celebrating the
second centenary of its foundation on Thursday, Friday,
and Saturday of this week.
Dr. Jules Comby, of Paris, editor of the Revue Men-
suelle des Maladies de VEnfance, has been created
Chevalier of the Order of the Crown of Italy.
Dr. Paul Berger has been appointed to the chair of
Clinical Surgery in Paris, vacant through the death of
Dr. L6on Lefort.
The Mortality in Rio de Janeiro, for the second half
of the month of March, was at the rate of 65.31 per 1,000
inhabitants.
The Plague Bacillus.— Dr. Kitasato, the Japanese
bacteriologist, has been investigating the plague in Hong
Kong, and believes he has found the cause of the disease
in a bacillus resembling somewhat that of anthrax. It
consists of short, slender, straight rods. Animals inocu-
lated with cultures of this micro organism died with
symptoms of the plague.
Tractions on the Tongue for Asphyxia. — M. Laborde
has recently published a small work on this method of
treating the apparently dead, in which he describes the
procedure as follows : Seize the anterior third of the
body of the tongue firmly between the thumb and index-
finger, using a towel or handkerchief to prevent slipping.
Then make strong, repeated, rhythmical tractions on the
organ, from fifteen to twenty times a minute, imitating
the rhythmical respiratory movements. The operator
must be sure that the root of the tongue is drawn up with
each movement of traction, a very easy thing to do when
asphyxia is profound. The first sign of returning con-
sciousness is a resistance to this drawing up of the root of
the tongue. One or two movements of deglutition are
then usually made, followed soon by a noisy inspira-
tion, which Laborde calls the "inspiratory hiccup."
The operator is cautioned to persevere in this procedure
in spite of apparent insuccess, the author having seen the
first indications of returning life appear after tractions
had been practised for over an hour. M. Laborde's ex-
planation of the mode of action of this procedure is that
two extremely sensitive nerves supply the tongue, namely,
the glosso-pharyngeal and the lingual, while the superior
laryngeal sends several filaments to it. These nerves,
taking their origin directly or indirectly fron the respira-
tory centre, stimulate it when stretched, and the bulb
stimulates, in its turn, the phrenic nerve which supplies
the diaphragm.
A Medical Press Association is to be established in
Germany after the model of a similar organization al-
ready existent in France.
Professor Czerny, of Heidelberg, who recently declined
the chair of surgery in Vienna, is said to have been led to
take this step through a misunderstanding of the condi-
tions. The call has now been accepted by Gussenbauer,
of Prague. Dr. Mikulicz, of Breslau, was the third can-
didate nominated by the professorial college to fill Bill-
roth's place.
Kumyss Poisoning. — A number of persons in one of
the health resorts of* the Caucasus were poisoned last
summer by ptomaines in the kumyss which they drank.
An investigation showed that the maker had neglected to
scald out his barrels, and he was thereupon sentenced to
six weeks' imprisonment and to pay the costs of the in-
vestigation.
A Lapsus Calami. — In the issue of June 30th, we
noted a fortuitous combination of items, in which the
notice of a meeting of a medical society was immediately
followed by a prescription for sexual debility, and erro-
neously attributed the same to the Journal of the Ameri-
can Medical Association. Our esteemed contemporary
very properly confines advertisements of proprietary
medicines to the outside pages where they belong, and
we regret having, through pure accident, done it this in-
justice.
The Hospital for Consumption at Ventnor has re-
ceived a gift of $ 1 0,000 from an anonymous donor in
memory of two daughters who died from phthisis.
Professor Madelung, of Rostock, has been appointed
Professor of Surgery in the University of Strasburg in
succession to the late Professor Luecke.
Anomalous Foetal Nutrition in Twin Gestation. — In
the article with this title by Dr. John C. Hupp, published
in the issue of July 21st, the words, " the cord of the
smaller foetus," were omitted in the ninth line. It
should have read : " There was only one placenta, which
was attached to the ordinary sized cord of the larger foe-
tus. The cord of the smaller foetus, which was not larger
than a thread, encircled its neck," etc.
Professor Joseph Hyrtl, who died recently in his
home near Vienna, at the age of eighty-four, was best
known, perhaps, as an anatomist, but he was besides a re-
markable linguist, an original investigator, and an elo-
quent lecturer. He was one, and the last survivor, of
the brilliant coterie of scientists who made the Medical
School of Vienna so celebrated throughout the world.
A writer in the London Telegraph says that, "as a
teacher, Professor Hyrtl was almost unsurpassed. He
was so gifted with eloquence that his lecture-room could
only with difficulty accommodate the crowds of students,
of all nationalities that flocked to hear him. As an orig-
inal investigator and scientist, Professor Hyrtl attracted
the warm admiration of his contemporaries. He was the
first German writer who published an independent trea-
tise on topographical anatomy. His celebrated hand-
book on that subject appeared in 1847. With the publi-
cation of his ' Lehrbuch der Anatomie des Menschen,' of
which the twentieth edition has appeared this year, a
new era was opened in anatomical text-books. His
books have been translated into all European tongues.
Professor Hyrtl's celebrity as a linguist is well known.
He had so completely mastered the tongue of Cicero
that it became in his mouth a living language, and he
was always prepared to give the fullest explanations in
elegant Latin to all inquirers. His knowledge of the
Greek classics also was amazing, and in 1861 he deliv-
ered before the Paris Academy a much-admired extem-
poraneous lecture in the French language. In his sev-
entieth year he took up the study of Hebrew and Arabic
with such success that three years later he was able to
produce his remarkable work upon the anatomical ideas
of the Jewish and Moorish physicians. Hyrtl was dis-
tinguished for his benevolence, and, considering the
modest amount of his income, his benefactions were as-
142
MEDICAL RECORD.
[August 4, 1894
tonishing. He supported poor students and benevolent
institutions in a generous fashion. He caused two or-
phan institutions to be erected in Modling, near Vienna,
to accommodate two hundred orphans, and thus be-
stowed on Lower Austria a gift that cost him ^30,000."
The Cholera. — In St. Petersburg the epidemic appears
to be abating somewhat, the number of new cases daily
reported being reduced to about eighty, and of deaths to
between forty and fifty. The disease is spreading, how-
ever, in Austrian Galicia near the Russian frontier, and
prevails to an alarming extent in the district of Cracow.
In Marseilles also many cases of cholera have been re-
ported during the past week, and the Spanish consul in
that city has informed his government that the epidemic
is spreading with great rapidity, although the local au-
thorities deny its presence. The disease is present in
many towns in Belgium along the river Meuse, and thir-
teen cases with six deaths are reported in Maastricht,
Holland, situated lower down on the same river — another
fact, if any more were needed, in support of the theory
of the water-borne nature of cholera, so strenuously in-
sisted upon, among others, by Ernest Hart. In Radom,
in Russian Poland, a serious riot was occasioned by the
attempt of the authorities to bury the bodies of a number
of persons, who had died of cholera, in the cemetery of
the town. A mob resisted this attempt and compelled
the bodies to be taken elsewhere. They then made an
attack upon the hospital and carried a number of sick
persons out into the surrounding grounds. The police
had hitherto been powerless, but they were reinforced by
a detachment of gendarmes, who fired into the crowd,
wounding many persons.
Dr. Francois OUment Maillot died in Paris on Sun-
day, July 29th, at the age of ninety years. He was
made a member of the Legion of Honor in 1839, and
held many high offices in the civil and military services
between 1825 and i860, and was a retired medical in-
spector of the French army at the time of his death.
Deaths from Sunstroke. — Statistics of the Health De-
partment show that the number of deaths from sunstroke
in this city in the past four years was : The deaths in
1890 were 62 ; in 1891, 95 ; in 1893, 43, and until
July 26th of the present year, 40. In 1892, when there
were 320 deaths, 29 occurred in June, 252 in July, and
39 in August. In each year two-thirds of the deaths
occurred among males.
The Cancer Germ.— Dr. van Nissen, of Wiesbaden,
has found a micro organism in cancerous tissue, which
he is led to regard as the cause of the disease. In cult-
ures the cell-groups bore a very close resemblance to the
so called epithelial cell nests of carcinoma. He calls this
new micro-organism claspodium cancerogenes, or, for the
sake of brevity, canceromyces. The organism is de-
scribed briefly in the Centralblatt fur die medicinischcn
Wissenschaften, No. 21, 1894, but the author promises
to present a more complete account of his experiments
shortly.
Professor Hothnagel has become unpopular with the
Vienna students by reason of his attempts to combat the
anti Semitic agitation. The students recently made such
an uproarious demonstration that the rector has ordered
all the courses in medicine to be suspended.
La Revista de Tisiologia is the title of a new quar-
terly journal devoted to the study of tuberculosis. The
editor is Dr. Valenzuela, of Madrid.
Chloroform Mortality in Melbourne. — An Australian
paper points out that the mortality from the administra-
tion of chloroform in Melbourne is about three per an-
num in a population of 450,000.
The Use of the Decimal System of Weights and
Measures is to be obligatory on physicians and pharma-
cists in Russia after the end of the present year.
Women are now allowed, through a recent decree of
the sultan, to practise medicine in the Turkish domin-
ions.
The King of Italy has given a prize of $4,000 to
Drs. Tizzoni and Luciani for their experimental work on
the functions of the cerebellum. And still the functions
are somewhat in doubt, though these gentlemen have
advanced our knowledge greatly.
Sewing-up Wounds by an electrical machine is one
of the latest advances in surgical technique.
Physicians as Dispensers of their own Medioines. —
According to a bill now before the French Senate, after
passing the Chamber of Deputies, physicians are not to
be allowed to dispense any medicine at all.
The Hew Tork Lying-in Asylum. — The managers of
the New York Lying-in Asylum, which has for many
years maintained an admirable out-door as well as in-
door maternity service for the benefit of the poor, have
secured, as the future home of their institution, the fine
old mansion of the late Hamilton Fish, standing at the
corner of Second Avenue and Seventeenth Street, and
fronting on Stuyvesant Square.
Rochester (IT. T.) Hospital.— The Board of Managers
of the Rochester State Hospital held its quarterly meet-
ing July 17th, at which meeting the plans and specifica-
tions for a new building and repairs made necessary by
the recent fire were forwarded to Albany for approval.
The appropriation for the new building is $65,000.
A Protestant Hospital — Articles have been filed for
the establishment of a new hospital in the city of Seattle,
Wash. The objects are to found and maintain a hospital
under the management of Protestants, for the medical
and surgical treatment of sick and infirm persons, with
the object of furnishing such treatment, as far as possible,
gratuitously to the poor.
The Memphis Board of Health has sent a communi-
cation to the Tennessee State Board of Health, calling
for such action as will lead to legislation prohibiting in-
fant and child life insurance within the State, on the
ground that the practice leads to criminal negligence of
the proper care of children, and is to that extent preju-
dicial to public health.
A Hew Fluke has beeq discovered in America by Pro-
fessor Ward, of Nebraska. It is called the Distama
Ringeri,
Venereal Diseases in the British Army. — Accord-
ing to some statistics presented to the House of Com-
mons by the war secretary, out of a total of 196,534 men
in the British army there were in one year 52,155 ad-
mitted to hospitals to be treated for venereal diseases, or
more than one-quarter of the effective force.
August 4, 1894]
MEDICAL RECORD.
H3
<2p0tt0ttes£ of American gbigsiciatiB
and Surgeons.
7)b></ Triennial Meeting, held in Washington, D. C,
May 2Q, 30, 31, and June 1, 1894.
AMERICAN ORTHOPEDIC ASSOCIATION.
Eighth Annual Meeting, held at Washington, D. C,
May 2Q, 30, 31, and June 1, 18Q4.
(Continued from Vol. 45, page 766.)
First Day, Tuesday, May 29TH.
The Etiology of Deformities in Knee-joint Disease. —
Dr. A. E. Hoadley read a paper with the above title, in
which he claimed, after experimenting with eighty differ-
ent subjects, that the flexor muscles are under all condi-
tions, except when paralyzed, stronger than the extensors.
Also, that the flexor muscles may at certain times become
extensors, and that in all ordinary deformities of the knee
it is not the result of the flexors dominating over the
extensor. The cause of flexion in case of disease was
rather due to the pain, and consequent attempt, on the
part of the patient, to change the position of the joint
Dr. Wirt made a demonstration of the mathematics
involved in the mechanics of the knee-joint.
Dr. Whitman asked if the gastrocnemius did not play
an important part in the deformities at the knee.
Dr. Phelps said that the experiments of Dr. Hoadley
differed from those of Haughton, of Dublin, who had done
a great deal to make the subject plain ; also from his own,
which were published in the Transactions of the Associa-
tion last year. He said that the extensor muscles lose
force as flexion takes place, while the flexors increase in
force as the limit of flexion is reached. Rotation is pro-
duced by the biceps muscle, which is absorbed into the
head of the fibula.
Dr. Ridlon said as muscles reach their limit they lose
strength*
Dr. Hoadley, in closing, said that Dr. Phelps's experi-
ments had been limited to one case, while his own series
rightly should have more weight. In reply to Dr.
Whitman, he agreed that the gastrocnemius muscle was
a powerful flexor.
Hoffa's Operation for Congenital Dislocation of the
Hip-joint. — Dr. E. H. Bradford, of Boston, presented
a pathological specimen from a child on whom he had
operated for a congenital dislocation, the patient dying
subsequently from diphtheria. The acetabulum in this
case, while somewhat misplaced, was well formed. Ow-
ing to the abnormal position, he failed to find the ace-
tabulum at the time of the operation, but had made a
socket for the head of the femur at another place in the
ileum. The speaker said that the specimen illustrated
that there was danger from curetting too freely into the
acetabulum of the cases, as the bone might be perforated.
He also stated that Hoffa was wrong in the assertion that
the acetabulum was the thickest part of the pelvis. A
specimen of rachitic deformity of the hip joint was pre-
sented by the same speaker. The condition was similar
to that described by Dr. Whitman.
Dr. Whitman emphasized the point that patients
afflicted with congenital dislocation of the hip not only
suffered great disability, but oftentimes had pain.
Dr. Ryan said he had not met with cases complaining
of pain.
Dr. Weigel agreed as to the disability, and thought
the specimen presented by Dr. Bradford showed that
more might be obtained by treatment by traction.
Dr. DeForrest Willard thought that if all cases of
congenital dislocation were like the specimen presented,
the operation would be called for, as the acetabulum was
deformed, and he believed it would be found even more
so in the majority of the cases.
Dr. Bartow spoke of a case of congenital dislocation
he had treated by traction, and the head of the bone re-
mained in the acetabulum.
Dr. Wirt had seen cases who complained of pain when
walking.
Dr. Phelps said dislocation might take place in any
direction. He considered the operation justifiable, as not
a single case had been cured otherwise. Hoffa had said
to him that he did not operate after the patient was four
years of age.
Dr. Bradford, in closing, confirmed what had been
said about pain and disability. He considered it impor-
tant to obtain union by first intention in Hoffa's opera-
tion. Dr. Phelps's remarks he considered theoretically
correct, but he had seen adults without much disability.
Second Day, Wednesday, May 30TH.
Flat-foot. — Dr. Royal Whitman, of New York, opened
the discussion on this subject. He did not believe that
flat-foot is caused by shortening of the tendo Achilles,
but rather that it is due to a disproportion of the weight
thrown on the arch of the foot when in a faulty position.
Flat-foot he considered a dislocation of the bones of the
arch, which must be reduced and kept so by some form
of apparatus which will not restrict the tendinous or
muscular structures which assist in maintaining the arch.
It is usually advisable to forcibly correct the deformities
under ether, even over-correcting the deformity so as to
produce a club-foot, and apply a plaster- of- Paris splint so
as to temporarily hold the foot in this position. He
does not advocate the cutting operation, but considers
the prognosis good when his line of treatment is followed
out.
Dr. Shaffer, of New York, in calling attention to
the mechanism said that studies must be made from the
normal foot. Flat-foot, he believed, was due to shorten-
ing of the gastrocnemius muscle, while paralysis of the
same muscle resulted in talipes calcaneus. The reason he
gave for not having flat-foot in cases of talipes equinus
was that the relation of the axis of the leg to the medio-
tarsal joint was changed. In no case of flat-foot was the
gastrocnemius ever elongated.
Dr. Wirt thought that Dr. Shaffer was in error as to
the mechanical principles involved. By his model he
has shown a difference in the force exerted on the astrag-
alo scaphoid joint and the breaking down of the arch
when the tendo Achilles is shortened by representing
that the heel rises in this condition, while in the normal
foot he represents flexion of the tibia forward at the
ankle joint without any rise of the heel. Now, in truth,
do we walk in this manner ? In the act of walking the
muscles of the calf are contracted. The tendo Achilles
is pulled upon and the heel rises from the ground, the
weight being borne upon the ball during fully one- half of
the step. The difference in length between the normal
tendo Achilles and one slightly shortened would be made
up by a greater and earlier contraction than in the case
of the normal, which would put the foot upon the ball in
about the same length of time.
Dr. McCurdy said that Marks had shown that mo-
tion at the ankle joint was not necessary for comfort in
walking.
Dr. Ketch asked Dr. Shaffer if it was first necessary
that we should have equinus before flat-foot occurred.
Dr. Bartow thought the gastrocnemius muscle is short-
ened in flat-foot, but that this usually takes place after
the change in the arch of the foot.
Dr. Weigel suggested the taking of a series of instan-
taneous photographs of a man in the act of walking, so
as to test the position of the ankle joint.
Dr. Shaffer, in closing, said it was necessary that the
motion of the ankle-joint be stopped at a certain point
which throws the weight upon the medio tarsal joint and
thus produces flat-foot. He had employed an instrument
for stretching the gastrocnemius muscle in cases of flat-
foot.
Rachitis.— Dr. A. Jacobi, of New York, in opening
the discussion, said that rachitic deformities represented
144
MEDICAL RECORD.
[August 4, 1894
a comparatively new disease in this country. He re-
membered when it was difficult to find a sufficient num-
ber of cases for his clinics. Some of the appearances and
general physiognomy of rachitic children are as follows :
Less hair on the head ; the veins are more dilated ; the
head has a quadrangular appearance and may be hydro-
cephalic ; the forehead is more prominent, the bones in
this region may be two or three times the normal thick-
ness, this may all disappear, but often some deformity re-
mains ; the teeth are irregular and decay early ; the sec-
ond crop are usually hard and of a yellow appearance ;
we may have the Hutchinson teeth in rachitic children ;
the trunk is short in these cases, clavicle is thickened ;
chest prominent anteriorly, lower ribs stand out, and the
rosary may appear as early as the second month. May
have kyphosis or scoliosis of the spine ; pelvis is rarely
deformed, but adults who have been the subjects of rachitis
may have undeveloped pelves ; the sacrum is usually more
steep in the rachitic child ; the extremities suffer greatly
in this condition ; the epiphyses are painful, the diaphyses
are usually bent ; fractures are rare because of the peri-
osteal thickening ; the ligaments are flabby and soft ; the
periosteum suffers from rachitic deposits ; there may be
hemorrhages during the course of this disease which are
not due to scurvy ; deformities are due to changes in the
epiphyses, and when calcification takes place growth
stops. The general system and the muscles, both the
voluntary and involuntary, suffer as much as the bones ;
this is not paralysis but simply a weakness ; the heart is
large and the arteries are small, the cause and effect of
which it is difficult to decide ; the stomach is dilated ; con-
stipation is usually one of the first symptoms. Other in-
ternal organs may be displaced.
Dr. Benjamin Lee, of Philadelphia, said that rachitis
in its earlier stages was most marked in the structures
where the lime salts and phosphorus should be most
prominent. The child may appropriate the fats and yet
fail to assimilate the salts. Constipation is usually pres
ent, or the patient may have diarrhoea. It sleeps poorly,
and this restlessness may be the only symptom for the
first few months. Convulsions are not uncommon , twitch-
ing of the muscles of the eyes, spasm of the muscles of the
larynx, and vaso motor disturbances are common ; bron-
chitis is very frequent. Nerve starvation, he says, ex-
plains many of these phenctmena. The deformities the
result of rachitis are numerous.
Diagnosis. — Acute rheumatism, he said, was rare in
young children ; the absence of snuffles and sore throat
ruled out syphilis. In considering the prognosis, the au-
thor thought that death was often due to rachitis which
had not been diagnosed. The most important point in
the treatment was diet. Exercise, both passive and active,
he said, would often prevent deformities. One question
which he brought out, regarding the sterilization of milk
which had become so prevalent during the past few years,
was to the effect that the lactic- acid ferment, which is de-
stroyed by this process, might be necessary to take up the
salts. This he thought was the reason why the wealthy
as well as the poor suffered from this disease.
Dr. Samuel Ketch, of New York, said that the ortho-
pedist did not have the opportunity of seeing cases of
rachitis in their incipiency. He does not think sufficient
attention is paid to prophylactic measures. Many of the
deformities are due to faulty positions assumed while ra-
chitis is present, and he suggested the use of portable
frames so as to enable these cases to get fresh air. Braces,
he thought, should not be used on the very young, but
massage and manual force would usually suffice to over-
come these deformities. All apparatus applied to cases of
bow-leg and knock-knee should be frequently observed by
the surgeon, so that its shape might be changed to meet
the exigencies of the case. Massage should be done in
all these cases, even though they be under mechanical
treatment. Frequent tracings of the deformities should
be made. Operation should not be resorted to in rachi-
tic deformities until eburnation of the bones has taken
place.
Third Day, Thursday, May 31ST.
Correction of Eachitic Deformities. — Dr. DeForrest
Willard, of Philadelphia, said that the deformities might
be corrected by apparatus before solidification of the
bones had taken place, but it was often difficult to have
the treatment properly carried out at home, and he was
of the opinion that the correction of the deformity by a
greenstick fracture, produced by manual force, was
preferable. When it was necessary to use the osteoclast,
he said the epiphyseal line should be avoided. Osteot-
omy he considered frequently necessary in extreme cases,
especially in large children and adults. The anterior
curves of the tibia, he said, were extremely difficult to
correct by apparatus, and for this, osteoclasis by manual
force, or osteotomy, should be performed. He had
abandoned the cuneiform osteotomy, as a simple divis-
ion of the bone had proven quite as satisfactory. The
author thought that osteotomy was indicated nine times
out of ten. Osteoclasis, he said, pulpifies the soft parts
overlying the bone. In performing an osteotomy he
does not use the Esmarch bandage, as the hemorrhage
which takes place prevents infection from without
Dr. Weigel asked Dr. Willard if he now advised the
use of drainage, after operating upon the anterior tibial
curvatures, as he once did. Dr. Weigel had not found
the drain necessary. He thought more of osteotomy than
of osteoclasis.
Dr. Ryan, also, agreed that osteotomy was more exact
than osteoclasis. He said that cuneiform osteotomy was
practically abandoned, except for anterior tibial curva-
tures. He asked Dr. Weigel if he sewed up the wounds.
Dr. Ryan did not think any case should be operated
upon, before four and a half years of age, as the deform-
ity was likely to relapse. Deformities often improve
without any treatment, as was shown by a family of
children, residing near his office, who had received no
medical attention whatever.
Dr. Gillett had never performed osteoclasis. He
preferred osteotomy. He spoke of an accident following
osteotomy, in which he failed to get perfect correction
of the deformity, the patient became dissatisfied, and he
was unable to follow up the case.
Dr. Cook, while he preferred osteotomy to osteoclasis,
said the results were not always good.
Dr. Bartow did not think the fear of injuring the
soft parts was well grounded. In exceptional cases,
where the bone was hard, osteotomy should be performed.
He thought it possible to correct some of these deformi-
ties, without even breaking the bone, by means of the
osteoclast.
Dr. Townsend said that one of the advantages claimed
for osteoclasis was that the bone was broken without
being converted into a compound fracture.
When Mr. Grattan visited America, he had seen him
use his osteoclast on two different cases, and in both
considerable laceration of the soft parts was produced.
While neither of these patients had any trouble following
the laceration of the soft parts, he thought there was con-
siderable danger of getting such a wound infected from
the instrument, which was not aseptic, or from the pa-
tient himself, because the limb is rarely prepared for this
operation, as it would be for osteotomy.
Dr. Coolridge said he thought a great deal depended
upon the instrument employed. With the Lorenz osteo-
clast he had never seen the skin broken.
Dr. Bartow said that he always protected the skin,
over the region to be operated upon, with moleskin plas-
ter.
Dr. Ketch did not agree with Dr. Ryan, that cases
got well without treatment. He believed, in all in-
stances, massage had been employed at home.
Dr. Lee thought that with osteoclasis a simple con-
densation, without displacement of the soft parts, would
result.
Dr. Willard, in closing, said he rarely performed the
cuneiform osteotomy at present, as he had gotten excel-
August 4, 1894]
MEDICAL RECORD.
145
lent results from the simple linear division of the bone,
which was just as strong afterward, and the recovery was
much quicker. When he does perform cuneiform oste-
otomy now, the wound is left open without drainage, as
he does not think much of union by blood- clot. On the
contrary, he thought large blood-clots sometimes pre-
vented the callus from being thrown out. After all
osteotomies he emphasized the importance of over- cor-
recting the deformity. The details of after-treatment, of
applying the plaster of Paris, should be done by the
surgeon, and not by his assistant.
Bubber Heels for Patients with Pott's Disease Dr.
John Schapps, of Brooklyn, N. Y., presented a shoe
with the rubber heels attached, which he said was em-
ployed for the purpose of overcoming concussion of the
spine while walking. This simple procedure had given
considerable relief to the patients.
Elastic Traction in the Immediate Treatment of Club-
foot.— Dr. Bernard Bartow, of Buffalo, read a paper
with the above title, in which he advised division of the
contracted tendons and the correction of the deformity
in club-foot as early as at three weeks of age. When
once the foot is gotten into the normal position, he ad-
vises the use of elastic traction, because the foot is not
restricted, as when immobilized with plaster of Paris and
other braces, and thus atrophy of the muscles does not
occur. The elastic traction is made by rubber bands,
extending (1) from the knee to the foot, for overcoming
the equinus, and (2) others on the outside of the foot,
for overcoming a varus. These rubber bands are fastened
to attachments, which are held in position by adhesive
plaster. When the two sets of bands are applied, one,
for the purpose of abducting and rotating the foot out-
ward, the other, for overcoming the equinus, the force
to be exerted can be regulated by the number of bands.
It was advisable to instruct the mother, after the adjust-
ment of the above-described apparatus, to manipulate the
foot at regular intervals, so as to over correct the deform-
ity, by which means the atrophy of the muscles, which
would occur if an immobilization apparatus were ap-
plied, is prevented.
Dr. Shaffer was of the opinion that continuous and
intermittent traction had their places. As to nutrition,
he had seen muscles develop very perceptibly in a few
weeks after intermittent, forcible traction.
Phelps's Method for the Cure of Club-foot in Adults.
— Dr. William E. Wirt, of Cleveland, in concluding
his remarks on the above subject, said that adults and
* older children would not endure the amount of traction
necessary to correct these extreme deformities, and that
even tenotomies, combined with tarso-clasis, were not
sufficient to cure the cases, although the deformity might
be temporarily corrected. Not infrequently it is neces-
sary to divide the plantar structures openly, after the
method of Phelps, and divide the tendo Achilles, to-
gether with the application of tarso clasis, to be able to
overcome the deformity. In the worst cases, in addition
to the above, it will sometimes be necessary to remove
the wedge-shaped piece of bone from the tarsus.
Discussion. — Dr. WsiGELsaid the term " cure " should
not be applied to these cases of club foot, as he consid-
ered only improvement was obtained. He reported a
case of double congenital club-foot, and double club-
hand, and presented a photograph of the same before
operation. On the right foot he had performed Phelps's
operation, and later, cuneiform section of the bones of
the leg, just above the joint. The operation performed
upon die left foot consisted in the removal of the head
of the astragalus. The Phelps operation, he says, does
not answer in the extreme cases, but must be supple-
mented by the removal of bone. He does not agree
with Dr. Wirt in his idea of dividing the tendo Achilles
by an open incision, but thinks the subcutaneous method
just as good.
Dr. Townsend said that with all due deference to the
Phelps operation, it was not always successful ; and he
believed the force applied by the long lever, after the in.
cision had been made, was very essential. The Phelps
operation, he considered, had a limited field.
Dr. Ketch said that Dr. Weigel's case suggested a
spastic condition, nor did he think the Phelps operation
had a broad field.
Dr. Houston, of Montreal, said he did not think the
surgeon should be wedded to any operation. The indi-
vidual case, he said, should always be considered.
Dr. Coolridge spoke for Dr. Myers, who had to re-
turn home, and described an operation for club- foot, in
which he made a small incision over the most prominent
bony deformity ; through this he inserted a scoop for the
purpose of removing the bone. Then the foot is forced
into position.
Tarso-clasis. — Mr. Nicholas Grattan, F.R.C.S., of
Cork, Ireland, in a paper on the above subject, said he
had, during the past two years, paid considerable atten-
tion to the treatment of resisting cases of club-foot. He
had used the Thomas wrench without effect, but now, af-
ter having made some alterations in the osteoclast which
he presented to this Association in 1892, he was able to
exert sufficient force to produce fracture of the tarsus,
which, he believes, is often necessary, and should be re-
peated at intervals, until resistance ceases, and the foot
has assumed its normal shape and position. If the equi-
nus persists, tenotomy of the tendo Achilles should be
performed, and it is possible by this means, combined
with osteo clasis of the tibia and fibula close to the ankle-
joint, to permit the rotation of the foot upward, and to
enable the patient to walk, on whom astragalectomy had
failed to cure. Flat foot can be easily corrected by for-
cible instrumental rectification.
Mr. Edmund Owen, F.R.C.S., of London, said he
had compared the old fashioned or orthodox treatment
of club-foot with the radical operation of Phelps, and he
preferred the latter method. While he had met with re-
lapses from the older methods, such had not been the
case since the employment of the free and open division
of all constricting bands in the plantar region ; and for
the perfect correction of these deformities it was often
necessary to open up the astragalo-scaphoid joint. The
foot is forced into an over-corrected position, that of
calcaneo-vulgus. The wound is treated openly, and a
fixed plaster-of Paris dressing applied.
Dr. H. P. Kaptyn, of Abcande, Holland, was pleased
with the results obtained from the open operation of
Phelps ; he had previously reported forty-two operations
on thirty-two cases, to the International Congress at
Berlin, of the cases in Holland treated after this method.
t In the newly born, he employed the fixed gypsum appa-
ratus. The cases treated by the Phelps method ranged
from nine months to fifteen years of age. Most of the
cases were double. In no case, did he have to remove
any of the tarsal bones, nor even open up the tarsal joint,
as reposition of the foot was always possible after the con-
tracted tissues were freely cut.
Excision of the Knee for the Eelief of Crippling from
Infantile Paralysis. — Dr. Ap Morgan Vance, of Louis-
ville, Ky., said he had reported his first operation for the
production of synostosis in 1885, it having been per-
formed one year previously, to relieve the crippling
from infantile paralysis. Since then he had performed
the operation six times, making, in all seven operations
upon five patients. The two eldest patients, respectively
five and seven years of age, died of some inflammatory
complication of the heart, possibly endocarditis. The
younger cases may be subjected to this treatment, with
every possibility of success, but he does not advise the
operation as late as eight or ten years of age.
Dr. A. M. Phklps, of New York, presented some mod-
ifications of his own splints, and of those of other sur-
geons, for knee and ankle joint diseases. The same
author presented a new, improved celluloid corset. He
said the apparatus combined neatness, elegance, durabil-
ity, and lightness.
An Improved Machine for Treating Scoliosis. — Dr.
Max Schede, of Hamburg, Germany, in a paper giving a
146
MEDICAL RECORD.
[August 4, 1894
description of an apparatus, in which the patient was par-
tially suspended, the shoulders and pelvis being fixed,
advised that direct pressure be made over the ribs, over
the most prominent part He advised the placing of the
patient in the apparatus, twice a day, for half an hour
each time, and the application of as much pressure as
could be borne with comfort A good spinal support was
worn during the interim ; periodical measurements of the
deformity should be made, so as to reckon the changes.
Development of the muscles was also to be encouraged.
In three months, the author claimed, appreciable im
provement was often noted, in the most obstinate cases.
Infantile Apoplexy and Infantile Paralysis — Mr.
William J. Little, of London, suggested that copious,
fatal apoplexy in the brain may occur during existence
in utero, and that a lighter amount of apoplexy in a nerve-
centre, at an earlier stage of uterine life, may be the
cause of some of the anomalous conditions or congenital
distortions, in which the growth and development of a
limb had been interfered with. The author is of the opin-
ion that the imbibing of alcohol in excess is the cause
of the death of infants in utero, and says he recalls many
instances of congenital distortions among the well-to do,
which have been produced by mental shock and mental
trouble happening to the pregnant woman.
Treatment of Deformity Following Infantile and
Spastic Paralysis. — Dr. De Forrest Willard, of Phila-
delphia, laid great stress upon the prevention of deform-
ity, in the above class of cases, by means of apparatus.
When contractures have occurred, it is necessary to resort
to surgical measures before the apparatus is applied.
Myotomy and tenotomy are perfectly safe operations, and
the muscles are placed in better condition for action
than they were before the operation . Forcible straighten-
ing, following division, is usually necessary. In spastic
paralysis, lengthening of the tendons assists better locomo-
tion. Locomotion is the best form of gymnastics.
An Original Operation for Wry neck.— Dr. A. M.
Phelps, of New York, had devised an operation so as to
prevent scarring, by beginning the incision at the lobe of
the ear, which was carried upward, along and behind the
ear, following the creases to its superior angle. The in-
cision was carried directly across, into the hair, and ex-
tended obliquely downward, keeping within the hair
line, to the side of the neck. This flap was retracted,
and the offending sterno-cleido mastoid cut. Sometimes
it was necessary to divide that muscle at its sternal end.
The after-treatment was by a brace made of straps, at-
tached to a plaster-of- Paris corset, together with gymnas-
tic exercises.
Fixation in the Treatment of Fractures into Joints.
— Dr. Ansel G. Cook, of Hartford, Conn., claimed that
it has been conclusively proven, by experiments on men
and animals, that fixation, per se, no matter how long
continued, does not produce ankylosis ; that ankylosis
is the result of injury and consequent inflammation, and
that early passive motion only irritates the injured
structures and increases the production of callus, thus
bringing about ankylosis. He thinks that immobiliza-
tion is only useful when inflammation is present, or until
the broken bones and ruptured ligaments have been
mended. From three to eight weeks of immobilization
is the time usually required. Lastly, passive motion,
massage, and use, until the tissues become normal. Oc-
casionally complete rupture of all adhesions, under an
anaesthetic, is required.
Dr. Ryan said that passive motion should be employed
as early as the sixteenth day.
Dr. Brackett asked Dr. Ryan if he had not been
careful to regard the matter of pain produced by passive
motion.
Dr. R. F. Weir, of New York did not believe in early
passive motion in the case of fractures into joints.
Disease of the Shoulder joint. — Dr. W. R. Town-
send, of New York, read a paper with the above title,
in which he said out of 3,000 cases of joint diseases
only 21 were diseases of the shoulder joint. The disease
comes on more slowly in childhood than in adult life.
Atrophy of the deltoid muscle may be so marked, in
these cases, as to simulate paralysis. The sternal end oi
the clavicle is at times dislocated, while the shoulder-
joint may be partially or completely ankylosed. Loss
of function is one of the most prominent symptoms. The
duration of the disease he considers to be from two to
three years. The prognosis should be considered from
the general condition of the patient and the local con-
dition of the joint. The treatment may be by simple
rest in a sling, or by fixation with plaster of Paris. The
operative treatment may be partial or complete excision
of the joint. Rarely is it advisable to excise the joint
before the eighteenth year, up to which time partial
arthrectomy is preferable, so that the growth of the bone
will not be interfered with. The author did not think
the statistics gathered before aseptic and antiseptic sur-
gery were understood should be a criterion for our work
of to-day.
Dr. Ketch said that Dr. Judson once read a paper
on this subject, in which he explained its infrequency
by the comparative freedom from injury and the blood-
supply of the shoulder-joint. Dr. Ketch had not found
ankylosis of such frequency as did Dr. Townsend.
Dr. Shaffer said he had an apparatus by which
traction was made with an axillary crutch, and he does
not think excision advisable, as his cases had usually
gotten well without abscess. It is sometimes advisable
to break up the adhesions under an anaesthetic.
Dr. John Ridlon said he had not seen any case
which required excision, nor did any of them go on to
ankylosis which would submit to mechanical treatment.
He had used the traction splint of Shaffer in a consid-
erable number of cases, but did not find that they did so
well as when simple immobilization, without traction,
was employed, while, on the contrary, in one or two
cases, the pain had been increased by this traction splint.
The treatment which he employed was to bind the
elbow to the side; supporting the hand by sling or
" halter," and covering the shoulder, top and side, back
and front, with two or three layers of stiff adhesive
plaster.
Dr. Townsend, in closing, said that he felt all sur-
geons had to experience a period of radicalism in the
treatment of joints, which resulted in more conservative
views being taken. He wished to emphasize, however,
the difference between the shoulder- and hip-joints. In
the former, he considered it all important to have free
movement, while in the latter a weak or frail joint is
worse than one which is ankylosed.
Infantile Scorbutus in its Relation to Orthopaedic
Surgery. — Dr. Henry Ling Taylor, of New York, in
a paper with the above title, said that infantile scorbutus,
due to imperfect feeding, had lately attracted consider-
able attention, over seventy cases having been reported
at a recent discussion of the New York Academy of Medi-
cine. The disease, he said, is insidious in its onset and,
unless recognized, may be fatal. The symptoms, some
of which may be absent in any particular case, are: 1,
a dusky pallor ; 2, emaciation ; 3, peevishness and gen-
eral sensitiveness, which is often excessive; 4, exqui-
sitely tender swellings, without local heat, near the joints
of the lower extremities, due to subperiosteal hemor-
rhage ; 5, inability to move the lower extremities and
the trunk (pseudo-paralysis) ; 6, spongy or bleeding
gums near the erupted teeth ; and, most significant of
ail, 7, rapid improvement and cure on diet of fresh milk
and orange- juice. The peri- articular swellings have been
frequently mistaken for rheumatism, which may the more
happen as fever may be present. A baby, a year old,
was sent to the writer last summer, from the South, for
treatment for a supposed spinal or hip affection. This
baby had been fed on condensed milk, and presented a
spinal projection at the upper lumbar region, with rigid-
ity, in addition to the usual symptoms. The cachexia,
spongy and bleeding gums, powerlessness of the legs,
exquisite sensitiveness, and a swelling above the right
August 4. 1894]
MEDICAL RECORD.
H7
ankle made the diagnosis clear. All the symptoms dis-
appeared, inside of three weeks, on a diet of Pasteurized
milk and orange- juice. As other cases have been mis-
taken for hip-disease — osteitis of the knee, sarcoma of the
knee, and infantile paralysis — it is particularly needful
for orthopedists to bear in mind the possibility of scurvy,
when differentiating infantile joint and paralytic affec-
tions. Discussion.
Dr. Ketch said that Dr. Jacobi, in discussing this
subject, did not consider these so-called cases of pseudo-
paralysis anything more than weakness.
Dr. Gillett reported a case, and said that he had
found it difficult to distinguish it from rheumatism.
His patient, however, was somewhat older than those
being discussed.
Dr. Shaffer said that the differential diagnosis in
scurvy at this age was from rachitis, Pott's disease, and
rheumatism.
Dr. Ryan remarked that the late Dr. Knight, of the
Hospital for Ruptured and Crippled of New York, had
spoken of the scorbutic diathesis.
Dr. Taylor, in closing, said that he considered ra-
chitis and scurvy to be different diseases.
The Association went into executive session, and the
papers for the fourth day were read by title.
Election of Officers.— The officers elected for the en-
suing year were as follows : President, Dr. John Ridlon,
of Chicago ; First Vice President, Dr. Bernard Bartow,
of Buffalo, N. Y.; Second Vice-President, Dr. L. A.
Weigel, of Rochester, N. Y. ; Secretary, Dr. Royal
Whitman, of New York ; Treasurer, Dr. E. G. Brackett,
of Boston.
Paralysis in a Telephone Employee.— Dr. Ewald re-
ported at a recent meeting of the Berlin Medical Society
the case of a young telephone operative who was just put-
ting two subscribers in communication with each other,
when she felt a violent shock and lost consciousness.
When she came to herself she was found to have right
hemiplegia, with contraction of the muscles on the right
side of the face. The latter disappeared in a few days,
and the paralysis of the arm gave place to tremor with
ataxia; the paralysis of the lower extremity persisted
longer, but was finally replaced by tremor. In the course
of some months other nervous symptoms appeared, such
as headache, vertigo, lumbar pains, trembling of the
tongue, asthenia, etc. All measures looking to relief of
these symptoms were ineffectual. The question arose
whether the affection was hysterical in character, but
none of the stigmata of hysteria could be found after a
most careful examination. Inspection of the switch-
board in the central telephone office showed that the
operator, at the time of making the communication, may
have become part of the circuit, receiving the full strength
of forty volts.
The Value of Combining Heart-tonics.— Convallaria
majalis is a simple cardiac tonic and a safe remedy. Its
action is similar to that of digitalis, but not so marked.
It causes slowing, and increases the force of the heart-
beats. But it will frequently be found, in lessening com-
pensation, that each of the foregoing drugs individually
fails, and disappoints us after a time. Then a combina-
tion of all three often produces an effect little short of
marvellous. Once or twice in recent years I have been
called in consultation over cases of advanced mitral dis-
ease, in which central failure has shown itself by exten-
sive dropsy of the limbs, oedema of the lungs and liver,
and a general water-logged condition of the system. On
inquiry of my colleagues in attendance as to the exhibi-
tion of digitalis, the reply has been, " He has had it."
A similar response has been given in the cases of stro-
phanthus and convallaria. But they had not been given
collectively — and when this was done, benefit speedily
accrued to the patient, and credit to his medical ad-
visers.—Dr. Taylor, in The Clinical Journal.
^merijcatx ptedicaft Association.
Forty-fifth Annual Meeting, held in San Francisco, Cal.t
June s,6, 7, and 8, 1894.
(Continued from VoL 45, page 799.)
SECTION ON OBSTETRICS AND DISEASES OF
WOMEN.
First Day, Tuesday June 5TH.
Suprapubic Hysterectomy. — Joseph Eastman, of In-
dianapolis, President of the Section, read the annual ad-
dress, taking for his subject the operation of suprapubic
hysterectomy. This operation, the speaker said, was
original with him, and the method of procedure was illus-
trated by means of diagrams and instruments.
The method consists in tying the uterine arteries in
the broad ligament close to the cornua of the uterus, and
then peeling the peritoneum from the uterus, leaving the
uterine arteries in the pelvis. The advantages claimed
are the slight hemorrhage and the greatly diminished
liability to septic infection by having no ligatures in the
abdominal cavity. In closing the abdominal wound he
said that the surgeon should expend greater efforts upon
the proper suturing of the peritoneum than upon the ex-
ternal appearance, so that the wound will drain outward
and not into the peritoneal cavity. He prophesied that
in the near future the death-rate from the removal of
fibroids will be reduced to an equality with that of the
removal of ovarian cysts.
Operative Treatment of Fibroid Tumors of the
Uterus — Dr. Franklin H. Martin, of Chicago, then
read a paper on this subject, in which he made a summary
report of six previously published cases, and a first report
of two recent cases, of his new operation for fibroids.
Following are the conclusions of the paper :
1. In hysterectomy we have an operation which is
bearing the test of time well ; in selected cases in the
hands of well-trained men it is the only absolute cure
yet demonstrated for a certain class of fibroids.
2. The objections to hysterectomy as a cure for
fibroids are the long training necessary to safely equip
an abdominal surgeon for this most formidable of pelvic
operations, the great death-rate of this operation in the
hands of the tyro, the long prostration, accompanied
frequently with nervous symptoms, following otherwise
successful hysterectomies, its inapplicableness to ex-
tremely exsanguinated and otherwise reduced patients,
and finally its inevitable death-rate of at least five per
cent, in the hands of expert surgeons.
3. Removal of the appendages as an operation for
fibroids is usually unsatisfactory, and should not be re*
sorted to ordinarily, except as a last resort in a compli-
cated case where the abdomen has been opened for the
purpose of removing the uterus, and the latter operation
for some reason has proved impracticable.
4. If the appendages are removed for the purpose ot
establishing an artificial menopause, and for the purpose
of reducing small fibroids by modifying their nutrition,
make sure to include in the ligature the main channel of
the ovarian artery.
5. Vaginal ligation of the base of the broad ligament
for fibroid of the uterus is an operation still on trial. As
far as we have history of cases to back the theories of the
operation it has stood the test.
6. Vaginal ligation of the broad ligament is a minor
operation from the stand- point of mortality, and it is a
minor operation from the stand-point of immediate and
remote shock to the patient. It can be performed on
any patient without risk, in almost any condition of
physical prostration or weakness, so long as she is capa-
ble of taking an anaesthetic.
7. The operation is prompt in saving blood. It suc-
ceeds in cutting off one-third more blood to the uterus
than does the Battey-Tait operation. Theoretically and
practically it immediately checks uterine hemorrhages,
148
MEDICAL RECORD.
[August 4, 1894
and at once begins the diminishing of the myoma by de-
priving it of its nourishment.
8. The operation of ligation of the broad ligament
does not leave an abdominal scar, does not unsex the
woman, as do both hysterectomy and the Battey-Tait
operation.
9. There are no good reasons why ligation of the
broad ligament should not be an early procedure in all
conditions of uncomplicated fibroids of the uterus in
which the operation is practicable, even though in a few
cases, subsequently, a more radical operation might be
necessary.
10. The operation of vaginal ligation of the broad
ligament is practicable in all interstitial or moderately
subperitoneal fibroids in which it is possible by careful
dissection to expose the base of the broad ligament high
enough to include in a ligature the uterine artery and its
branches.
Dr. R. £. Horton, of Illinois, opened the discussion
on the papers of the afternoon, saying that we must be
guided in the selection of the method by the condition
of the case. He commended Dr. Martin's operation for
controlling hemorrhage and starving small fibroids.
Dr. McCall, of Michigan, spoke of the President's
method as an ideal one, but thought that in many cases
it could not be done. He recommended the conservative
method of Dr. Martin, whenever applicable and spoke of
the excellent results he had had with this operation. He
thought that the failures in the operation of the removal
of the appendages were largely due to the fact that the
ligatures were not placed deep enough and close enough
to the uterus. It is well even to include the cornu of
the uterus itself.
Dr. Lapthorne Smith, of Montreal, followed with a
plea for the trial of electricity before more radical meas
ures are resorted to. He believed in using the positive
galvanic current and constitutional treatment for two or
three months, and if the case showed no improvement
then, operate. Of the operations, he preferred Dr. Mar
tin's, in which there was no death-rate, to that which in
the best of hands gave a mortality of five per cent. Only
in extreme cases should the graver operations be resorted
to.
Dr. McMonagle, of San Francisco, summarized the
dangers of fibroids of the uterus under the heads of hem-
orrhage, pressure, and malignant degeneration. With re-
gard to Dr. Martin's operation, he inquired, "Will the de-
generation be simple or malignant ? " The operation, he
felt, was still sub judice. He had had the misfortune to
see electricity continued so long as to change a fibroid
into a sarcoma. He also asked Dr. Martin, "What
if the woman should become pregnant ? " also if a starv-
ing of the uterus might not result in degeneration of mu-
cous membrane and septic infection. He suggested that
as a preliminary to the operation the uterus be curetted
and stuffed.
Dr. H. O. Marcy, of Boston, said that he had never
used electricity that the patient did not feel benefited by
it. He has discarded its use for fibroids. If patient is
young and tumor small it is best treated by ligation of
the vessels and removal of the appendages. If the
growth is larger, removal of the appendages may fail.
He spoke of the extra- abdominal treatment of the stump
as not being ideal surgery. It was still resorted to sim-
ply because the experience of older men taught it to be
safe. If surgery is aseptic, nothing is gained by this
method. We simply confess that we are afraid of hemor-
rhage and infection.
Dr. E. E. Montgomery, of Philadelphia, thought that
the removal of so large a quantity of blood as in Dr.
Martin's operation might cause degeneration, sloughing,
and danger of sepsis. He feared that the use of elec-
tricity might produce malignant degeneration.
In reply to a question put to Dr. Marcy, he said he
had never seen malignant degeneration follow the use of
electricity.
Dr. Smith said, in response to inquiry, that he never
employed gal vano puncture, as it contained an element
of danger, and the use of electricity should be free from
danger. He thought that the cases in which electricity
was charged with causing malignancy were errors of
diagnosis. He instanced a case in which a supposed
fibroid, not improving by electricity, was operated upon,
when it proved to be a sarcoma of the ovary in which
the uterus was embedded.
Dr. Martin, in closing the discussion, said he wished
to eradicate an impression left on the minds of some not
acquainted with him. He did not believe that his opera-
tion was applicable to all cases. When the case de-
manded it he was as ready to open the abdomen as any-
one. He said he never knew a case of malignant degen-
eration to follow the use of electricity, but, on the con-
trary, a case of bleeding sarcoma, pronounced such by one
of the most eminent pathologists in the United States,
had been cured by him by this method. He called the
attention of the Section to Dr. Byford's operation of
hysterectomy as one of the best.
With regard to the results feared from cutting off the
blood-supply in his operation, he said that in his first
operation he was moved by the same fears, and it was the
least successful of his cases because it was not sufficiently
thorough. While perhaps two thirds of the blood-sup-
ply is cut off, there is still more than the normal amount
going to the uterus. He thinks that pregnancy can take
place, and come to a successful termination, and hopes
to demonstrate this in the near future. He stated that
as a preliminary to his operation he always curetted the
uterus, so as to make a clear field for his vaginal wounds.
Dr. Eastman showed that gangrenous masses existed
in some of the specimens of fibroids that he exhibited.
He asked Dr. Martin how he could tell that these did
not exist before tying the broad ligament. All methods
are not applicable to all cases. If any one method is
applicable to all, it is that of enucleation. He thought
that if it was necessary to drain through the vagina at all,
cut widely upon a staff and pack the cervical canal, or
insert a tube surrounded with gauze. He protested
against a drainage that did not thoroughly drain. He
thought the strongest point in favor of the abdominal
fixation method of the stump was that there was one
wound instead of two.
Second Day, Wednesday, June 6th.
Placenta Previa. — Dr. Llewellyn Eliot, of Wash-
ington, D. C, sent a paper with this title, in which he
designated placenta previa, next to puerperal convul-
sions, the most serious complication that can occur in the
lying-in chamber. The physician is usually not called
until hemorrhage has appeared. No woman should be
allowed to suffer from these hemorrhages if the child is
viable, for it is as easy to resuscitate a child at seven
months as it is a child at nine that has been subjected
to the weakening effects of repeated hemorrhages. He
considered the proper procedure to be to forcibly dilate,
turn, and deliver, the child acting as a tampon in con-
trolling the hemorrhage. He would hesitate to resort to
Caesarean section.
Dr. Eschlemann, of Fresno, said that placentae previse
were much more common occurrences than generally
supposed, a large number of abortions being of this char-
acter, it being nature's method of getting rid of them.
He objected to the forcible dilatation and introduction of
the hand for the performance of version. All that is
necessary is to dilate the cervix sufficiently to introduce
a small forceps, seize the head, and, using it as a tampon,
bring it down and deliver the child. The os is usually
very dilatable, particularly if the hemorrhage has been
severe.
Dr. McChesney, of Philadelphia, said that in a case
of placenta previa there is no time for nice distinctions.
One must use what means he can to dilate the cervix,
turn, and deliver. In reply to a question from Dr. Whit-
ney, of Oregon, as to the procedure in placenta previa
August 4, 1894]
MEDICAL RECORD*
149
centralis, he said the finger of the hand should be passed
rapidly through the placental mass and then proceed as in
a case of lateralis. Hemorrhage after delivery is checked
by copious injections of hot water, massage, and ergot, or
ergot and strychnine hypodermically or by the mouth.
Dr. Martin, of Chicago, said that it had been noticed
formerly that fever had invariably followed the delivery
of women in cases in which it had been necessary to in-
troduce the hand into the uterus. We know now the
cause of this. As much care should be taken in prepar-
ing the hands preliminary to introduction into the cervi-
cal canal and uterus as for a case of laparotomy. He
recommended for this purpose saturated solution of per-
manganate of potash and oxalic acid, as used at Johns
Hopkins.
Dr. Montgomery, of Philadelphia, believed that
placenta previa was the one condition in which the life
of the child should not be considered. In central pla-
centa previa hemorrhage usually begins about the fifth
month. The patient may have a fatal hemorrhage at
any moment. As soon as the diagnosis is established,
the uterine contents should be evacuated. When there
is lateral implantation and the hemorrhage slight and
later, we may temporize ; but even in these cases it is
well to bring on premature labor. The speaker did not
think Cesarean section necessary or advisable.
Dr. Newman, of Chicago, thought that dilatation,
version, and delivery was the best and safest method.
The case should be treated strictly on surgical principles.
With regard to the use of an anaesthetic, he would hesi-
tate to use chloroform after an extreme hemorrhage. He
thought better work was done with the use of an anaes-
thetic, and ether was safe.
Dr. E. M. Westley, of California, has adopted differ-
ent methods. If the patient is exsanguineous when the
physician arrives, the life of the child cannot be consid-
ered. At once detach the placenta and bring it down ;
bring down the head of the child and deliver. If hem-
orrhage is slight and child alive, he preferred version be-
fore delivery.
Dr. Eshlemann, of California, emphasized the fact that
in turning it was necessary to dilate the cervix to the
size of the physician's hand, and run all the risk of sep-
tic infection. In introducing the forceps according to
his method a dilatation of an inch was sufficient.
Dr. Carpenter, of Pennsylvania, reported that he had
had three cases lately. In two he applied the forceps
high up after getting head into position by external
manipulation. He then brought the head down so as to
compress the placenta, which had previously been pushed
to one side. In one case he held the forceps in place
one half hour before dilatation was accomplished. The
patients were sustained by hypodermic injections of
whiskey and strychnine. In the third case, one of cen-
tral implantation, he found the patient moribund when
he arrived. He tore through the placenta and found a
foot, which he seized, and delivered the child as soon as
possible. The patient died. With the hemorrhage con-
trolled, the physician can afford to wait, and he believed
that had he been less hurried in his procedure, and had
improved the delay by the administration of proper
stimulants he might have saved his patient.
Tetanus Puerperium. — Dr. Allison Maxwell, of In-
dianapolis, sent a paper with this title, in which he gave
the clinical history of a case of this rare disease that had
occurred recently in his practice. He reviewed the
etiology of the disease and recommended in its treatment,
besides prophylactic measures, the use of antispasmodics
and antitoxines.
Dr. McChbsney, of Philadelphia, in discussing this
paper, said that the offending cause was some kind of
dirt. The disease presupposed some kind of infection,
and should have directed against it local treatment aimed
toward its removal. He had had a case in which the
initial symptoms of tetanus had appeared He used an
intra-uterine douche of a two-quart 1 to 3,000 bichloride
solution, every eight hours, following this by water
which had been recently boiled. He used at the same
time hypodermic injections of peptonized milk.
Private Hospitals.— The President replied to some
remarks made in the Surgical Section reflecting upon
private hospitals and their owners. He said that the at-
tack upon private hospitals struck at the very life of ab-
dominal surgery. It was in a private hospital that it
was born, nourished, and grew to full developed man-
hood. He resented the imputation that surgeons would
be dishonest and use the private hospitals as a means of
gain by retaining patients after the need of such retention
had ceased.
Third Day, Thursday, June 7TH.
Obstetrical Forceps. — Dr. Briggs, of Sacramento, read
a paper on the " Function and Form of Obstetrical For-
ceps," using in demonstration instruments invented by
himself.
Mrs. £. S. Meade, M.D., of San Jos6, in discussing
these forceps, said that they presented an anatomical de-
fect, the pelvic curve was wanting. She thought the in-
strument too complicated. Great force was not neces-
sary in delivering a child with instruments. She applied
the forceps, used traction during pain, and readjusted the
instruments as it might be necessary during the intervals
of pain. Sometimes as long as half an hour would be
necessary to accomplish the delivery. Too often phy-
sicians thought only of quick work without considering
whether the mother and child were wounded. She con-
sidered that it was impatience and lack of anatomical
knowledge that destroyed so many uteri and peri-
naeums.
Dr. Oscar Mayer, of San Francisco, thought the com-
plicated nature of the instruments was opposed to the
principles of obstetrical asepsis.
Dr. Winterberg, of San Francisco, thought it a very
easy matter to find an obstetrical case in which this and
all oiher necessary instruments can be placed, and the
whole thoroughly sterilized by subjecting to the necessary
heat.
Dr. Brown, of Mendocino, Cal., objected to the for-
ceps because they lacked the proper curve.
Dr. Briggs, in closing the discussion, said that the
curve was greater than it seemed, being equal to three
inches. It appeared less than this because the handle
was parallel to the axes of the blade, while in the ordi-
nary forceps it formed an angle.
Massage in Gynecology. — Dr. Oscar J. Mayer, ot
San Francisco, read a paper upon " Massage in Gyne-
cology." He said the object of uterine massage is to
bring about a healthier state of the circulation and to im-
part tone to the various structures of the genital tract.
It is indicated in all disorders of chronic inflammation,
as well as in such diseases as cause uterine displacements,
produced by relaxation of the ligaments or by pelvic
exudation, with or without adhesion. It is very im-
portant to form a correct diagnosis of the disease and to
exclude all pyogenic disorders. The speaker then went
into a description of the various methods employed and
the indication for the employment of particular methods.
The indications for massage in gynecology are the same
as those for massage in surgery. He said, By massage
treatment we wish to produce: 1. Acceleration of the
absorption and retrogression of inflammatory and trau
matic exudation and deposits. 2. Stretching, loosening,
disintegrating, cicatricial, or hypertrophied connective
tissues, caused by inflammatory processes. 3. Stimulation
of the circulation and restoration of the normal elasticity
and tone in (a) contracted, hardened, and hypertrophic
tissues, or (£) relaxed tissues.
The sphere of usefulness may be tabulated as follows :
1. Pelvic exudations and hemorrhagic infiltrations. 2.
Chronic parametritis and perimetritis. 3. Retroversio
uteri. 4. Chronic metritis. 5. Prolapsus of the uterus
and vagina.
Massage is contra-indicated in all diseases of the genital
*5°
MEDICAL RECORD.
[August 4, 1894
tract requiring perfect rest of the whole body or of the
genital tract alone.
The best and quickest cures from massage are observed
in chronic diseases following the puerperal state. A
longer time is required in diseases following acute inflam-
matory processes, also when coincident with anomalies of
position of the pelvic organs, especially in retro derivations
of the uterus. Even if we do not succeed in some cases
in restoring the uterus to its exact normal position we can
obtain a symptomatic cure without recourse to surgical
procedure. The combination of massage with electricity
is to be recommended in the relaxations of the supports
of the uterus, provided the structures are intact.
By exercising proper circumspection we can often
achieve more by alternating massage treatment with other
treatments than by long-continued massage.
In conclusion, Dr. Mayer said that massage does not
set up for itself the claim that it constitutes an independent
and sufficient form of treatment. It is only a mechanical
therapeutic agent, intended to be used in combination
with other tried and accepted remedies in effecting a
permanent cure, or in considerably lessening the time
formerly required therefor. American gynecologists have
been somewhat slow in accepting massage as a new re-
medial agent to be employed in diseases of women, and
have been suspicious of the beneficial results that have
been claimed for it. But the encouraging reports of
European authorities, many of them erstwhile bitter op-
ponents of massage, are favorable beyond the expectations
of the most sanguine, and must work a change in this
American sentiment.
Dr. J. H. Barbat, of San Francisco, bore testimony
to the great good he had seen accomplished by massage,
combined with electricity and glycerine tampons, even in
cases when the removal of the ovaries had been recom-
mended by competent physicians. He looked upon mas-
sage as one of the greatest remedial agents of the day.
Dr. Shuey, of Oakland, Cal., said that she had used
massage in the painful menstruation of young women with
the result of perfect relief from pain. They were cases of
long standing, where none but medicinal treatment had
been tried She used the massage every day for three or
four weeks, and during the menstrual period for three or
four months afterward.
MEDICAL SOCIETY OF NEW JERSEY.
One Hundred and Tkuenty-eigJith Annual Meeting, held
at Lake Hopatcong, June 26 and 27, 1894.
John G. Ryerson, M.D., President, in the Chair.
Reports. — Dr. Stephen Pierson, Chairman of the Com-
mittee of Arrangements, read an interesting programme.
The report of the Treasurer, Dr. Baldwin, showed a bal-
ance of over four thousand dollars. Dr. D. C. English
said the Committee on Ethics had had nothing to do.
The Committee on Honorary Membership made the fol-
lowing report :
The only name presented at the last meeting was that
of our Recording Secretary, Dr. William Pierson, and in
recommending him to the Society for election as honor-
ary member, your committee take pleasure in referring to
his twenty seven years' consecutive service, during which
he has so faithfully and honorably discharged the arduous
duties of that office ; and although he was unanimously
tendered the position of Third Vice-President by the Nom-
inating Committee at the last session of this Society, he
declined the honor, preferring to remain at his post and
continue in the office over which he and his honored
father have for over half a century presided.
A standing vote was taken, none voting in the nega-
tive.
the Health of New Jersey.— Dr. D. C. English read
the report of the Standing Committee, which included an
abstract of reports from physicians in the different parts
Qf the State as to contagious and other diseases. It ap-
peared the year had been a healthy one, there having
been less of malaria, of diphtheria, scarlet fever, and
other infectious diseases. In one or two places where
diphtheria and typhoid had occurred, they had been
traced to the milk-supply. Variola had been promptly
suppressed, cholera had been kept out, the local health
boards had shown more than usual activity. The organ-
ization in Essex County for a pure milk-supply had been
successful, and promised to be of marked service in pre-
venting the spread of tuberculosis, diphtheria, etc
Prevention of Blindness.— Dr. W# B. Johnson read
the report of the Committee on the Prevention of Blind-
ness through Legislative Enactment. The movement to
prevent blindness by legislative enactment had origin-
ated in New York State, and laws had been enacted in
that State, and perhaps half a dozen others. They were
based on the fact that blindness was due chiefly to con-
tagious ophthalmia, and looked to the cure of this and
prevention of its spread to others through use of towels,
etc. The ophthalmia of the newly- born caused about
ten per cent, of all cases of blindness, and made it im-
perative that the midwife should report cases at once in
order that they might receive timely treatment, espe-
cially that known as Crede's by way of prophylaxis —
washing the eyes immediately after delivery and dropping
into them from the pipette two per cent, solution of ni-
trate of silver. On motion, the committee was continued
and legislation urged.
Dr. William Perry Watson thought the license of
midwives should be taken from them when they failed to
report cases of ophthalmia neonatorum.
Report of Committee on Bovine Tuberculosis. — Dr.
J. W. Stickler, Chairman of the Committee, made the
report. He said the committee had supposed, when it
went before the Legislature, that everybody was aware
that tuberculosis existed in animals, and was likely to be
transferred to man through milk and flesh. But they
were mistaken, and were surprised to encounter not a lit-
tle antagonism to legislation in the matter, and particu-
larly against the bill which the committee had prepared
as an efficient one ; so that instead of adopting this bill
another became law, which on account of its laxity
would probably prove quite useless in the suppression ot
tuberculosis among cattle.
Dr. A. E. Conrow said it was necessary to have the
co-operation of the farmers and the dairymen as far as
possible, and therefore the bill which had been passed
met with his approval until a more radical law could be
enacted.
On motion the committee was continued, Dr. Con-
row's name being added.
The Permanent Fund. — Since 1868 the Society had
been accumulating a permanent fund, the interest on
which, as the Treasurer, Dr. Baldwin, stated, was to be
used for the publication of the yearly "Transactions."
The sum had now risen to over four thousand dollars.
Motions had been made from time to time to divert this
fund to some other purpose, especially to the Society for
the Widows and Orphans of Medical Men, which had no
direct relations with the Medical Society. Dr. Ill had
proposed a change in the by law, turning the amount of
the permanent fund over to the society referred to, and
making the members of the State Medical Society also
members of the other. Drs. Skinner. Lielbach, and
others spoke eloquently in favor, while Dr. Baldwin took
the lead in opposition. The change was rejected.
President's Address. — Dr. J. G. Ryerson, of Boon-
ton, chose for the subject of his address, " Chronic Ne-
phritis and Lactose." The following were some of W e
facts mentioned in relation to chronic nephritis, as lead-
ing up to the question of a special fonn of treatment,
which in his experience had given remarkable results.
The profession generally, he said, did not realize fully
the frequency of interstitial or cirrhotic kidney disease,
nor its distinct pathology, its well-marked symptoms, its
better prognosis under judicious treatment. In a fair
amount of general practice Dr. Ryerson had, within a
August 4, 1894]
MEDICAL RECORD.
151
little more than two years, met with thirty three cases of
chronic nephritis, twenty-nine of which he had diagnosed
as cirrhotic. The diagnosis was frequently not made,
because the symptoms were mistakenly attributed to
disease of other organs, which, if affected at all, were
affected only secondarily. Among the complications
were heart disease, pulmonary disease, pleurisy, pneu-
monia, emphysema, bronchitis. The agents through
which the different organs became affected was probably
excess of one or more of the normal excretions of the
kidney present in the blood. Increased action was
demanded of the kidneys for its elimination, which called
for increased force in circulation, the coats of the ar-
teries in the kidneys became affected first, then elsewhere
in the body. Incidentally, the President expressed dis-
belief in the view that men were more often affected than
women, and that alcoholic drink was a common cause.
His statistics pointed in the opposite direction.
Without considering the large number of symptoms he
wound say that an increase in the quantity of urine with
low specific gravity, pain in the head, loss of flesh and
strength without apparent cause, were symptoms which
should direct attention to the kidneys. If there should
be frequent headache, palpitation and dyspnoea, general
dulness, and disturbance of vision the diagnosis should
be clear.
Dr. Ryerson had first used lactose in milk, and after
learning that the beneficial effects were due to the lactose,
he had during the past three years given this alone, and
bad found it much more efficient than in natural combi-
nation. This was a point on which stress was laid. He
had now used lactose in 33 cases of chronic kidney dis-
ease in which he felt confident of his diagnosis, 30 hav-
ing been cases of the cirrhotic kidney. Fourteen had
previously been treated by other physicians, and inn
the diagnosis had also been made previously. Emacia-
tion was noticed in 27, insomnia in 28, dyspnoea in 24,
pain in the head in 27, emphysema in n, heart compli-
cations in 13, the urine was examined in 22, and albumin
was found in 8, the average age was 53, males 13, females
20. Six patients had since died, and symptoms had re-
turned after treatment in 7. He had also been furnished
with notes of 13 cases treated by lactose by other physi-
cians. In 36 cases of the total number lactose was the
only treatment, in the others it was the only treatment
of importance. Lactose was given in doses of from twenty
to fifty grains. The average duration of the disease had
been fifteen months. The points of interest in the treat-
ment of chronic Bright's disease by lactose might be
summed up as follows: Uniform certainty of effect;
promptness of action; permanency of improvement;
value in diagnosis; smallness of dose required; benefit
not due to diuretic action ; difference in effect of lactose
taken in natural combination and taken as he recom-
mended, in the free state. Forty three of the 46 cases
were markedly benefited, all but 7 within three days.
In 4 of the 7 in which the symptoms returned, relief was
again obtained by lactose. In the 43 there was no re-
turn of the symptoms — so far as could be learned — within
six months. In no cases was as much as three drachms
of lactose prescribed in one day. The action of the
remedy, he thought, lay beyond the kidneys, probably
in the blood.
Erysipelas as a Complication in Abdominal Surgery.
—Dr. George H. Ballerav, of Paterson, described in
this paper three cases of erysipelas, involving the abdom-
inal wound, in patients operated upon by him some years
ago, in the old building of the Paterson Hospital, the
origin of the infection not being known, although two of
the patients gave what might be called a history of pre-
disposition to the disease. All recovered. Incidentally
the author expressed preference for strict cleanliness in
contradistinction to antisepsis during operations, and
was apparently justified in his preference by the results of
Mr. Bantock, compared with Mr. Thornton's, who worked
in the same hospital.
Medico-legal Aspect of Abortion. — A committee was
appointed upon this subject, consisting of Drs. Stickler,
Baldwin, and C. A. Adams.
Observations on Cases of Movable Kidney. — Dr. H.
G. Wetherill, in this paper, expressed preference for the
incision parallel to the last rib, impressed the advantage
of operating with the patient lying prone, cylindrical air-
cushion under the abdomen to push up the kidney, gave
preference to Dr. Edebohl's method of anchoring the
kidney, and cautioned against the use of silk, lest abscess
develop and lead to final destruction of the organ, if not
to fatal sepsis.
The paper was discussed by Drs. Rogers, Chandler,
and Ballerav.
Angina Pectoris. — The subject for discussion pre-
sented at the last annual meeting related to angina pec-
toris, its true pathology, and an explanation of its sudden
termination in death. The gentlemen who were to open
the discussion were not present, but Dr. Baldwin related
an interesting recent case of death in the first attack.
The man had been in good health, ran violently some
hundred feet, felt nauseated and faint, was assisted to his
room, complained of pain and weight in both arms, and
a feeling of depression, but there was no evidence of
spasm. This was. in the morning; he was relieved, but in
the evening, while sitting up, he fell back dead. Post-
mortem was not obtained. Dr. Baldwin thought ob-
struction of the coronary arteries had much to do with
angina pectoris ; also affection of the cardiac nerve sup-
ply, especially in sudden death.
Dr. Rogers and Dr. Cooper also made some remarks.
To Confer with the Pharmacists.— Delegates to cor-
responding societies presented their reports. Dr. Coit,
who had attended the meeting of the New Jersey Pharma-
ceutical Society, offered a resolution, asking for the ap-
pointment of a committee of three to meet a like com-
mittee from the Pharmaceutical Society, to formulate some
plan which might lead to more rational therapeutics and
pharmacy.
Dr. Reynolds, of the Pharmaceutical Society, read a
paper which went to show the necessity for closer rela-
tions between the pharmacist and physician, and between
the two State Societies. The committee was appointed,
and consisted of Drs. Coit, Silver, and Lewis.
Catarrh of the Upper Air-passages. — The Third Vice-
president, Dr. T. J. Smith, read a somewhat exhaustive
paper upon this subject. It was briefly discussed by Dr.
W. B. Johnson.
The Code of Ethics.— Dr. George T. Welch, Chair-
man of the Committee appointed to consider the proposed
revision of the Code of Ethics of the American Medical
Association, said the committee had sent a circular to
the district societies, and of eight which had replied be-
fore the recent meeting of the American Medical Asso-
ciation, six were in favor of the old Code, two thought it
required modification. Since the American Medical
Association had already taken action, sustaining the old
Code, Dr. Welch hoped the report would be received
without discussion and the committee discharged. His
wish was granted by vote, but Dr. Barker asked, and
finally obtained, consent to offer some resolutions re-affirm-
ing the Society's allegiance to the Code, and read a paper
in argument therefor. The resolutions were almost
unanimously adopted.
Action on the amendments to the by-laws, proposed at
the last annual meeting, was deferred another year.
According to the report of the Committee on Prize
Essays (prize of one hundred dollars), this Society, like
many others, has to do much urging in order to bring
out papers in competition. None had been offered in
years.
Officers.— President, O. H. Sproul ; First Vice-Presi-
dent, William Elmer ; Second Vice-President, T. J. Smith ;
Third Vice President, D. C. English ; Recording Secre-
tary, William Pierson ; Corresponding Secretary, E. L.
A. Godfrey; Treasurer, Archibald Mercer; Standing
Committee, H. W. Elmer, William H. Iszard, Henry
Mitchell ; Committee of Arrangements, G. E. Reading,
152
MEDICAL RECORD.
[August 4, 1894
James Mercer, V. M. D. Marcy, L. M. Halsey, B. S.
Lewis; Business Committee, H. R. Baldwin, W. B.
Johnson, G. Van Wagenen, E. L. B. Godfrey, Updyke
Selover.
Place of meeting, Cape May ; time, June 25 and 26,
i895-
SECTION IN SURGERY.
First Day, Tuesday, June 5TH.
Chairman's Address. — Dr. John B. Roberts, of Phila-
delphia, said that operative madness is rife in our day.
This madness is endemic among those whose preliminary
training has been deficient. Preliminary education is a
corrective, and a reaction is fast taking place. A true
surgeon, possessed of a thorough pathological knowledge,
must be a man of broad culture and have had an adequate
preliminary education. Surgeons should be careful to
make accurate statements and to refrain from criticising
others. A great surgical sin is the overlooking of the
influence of the nervous system upon disease. The
speaker condemned the evil of physicians controlling
private hospitals. Such an institution is a hotel for pa-
tients, and of course chose interested are tempted to strive
to keep it filled with long-staying guests. The sin of
charging large fees was also condemned. A man who
refuses his counsel to a brother practitioner because the
patient is poor, commits another sin, as also does the one
who charges for services rendered to a physician or his
family. The use of secret nostrums was denounced as
unscientific.
Malignant Neoplasms from a Micro-technical Stand-
point.— Dr. A. P. Ohlmacher, of Chicago, said that
many things are described as cancer parasites because this
subject has been handled unscientifically. A great num-
ber of reagents have been used, hence the diversity of re-
sults, since artificial products are formed by the reagents.
It has been found that sporozoa treated by different fixing
solutions act differently. Some agents distorted the
spores and interfered with the subsequent staining. All
the present methods of investigation are faulty, and no
results are to be looked for until new methods are devised.
Early Surgical Interference in Malignant Tumors. —
Dr. R. A. McLean, of San Francisco, Cal., said that
malignancy once established, removal must be immediate.
Recurrence is frequent because the laity delay until the
case is hopeless.
The causes of failure in operation are : The size of the
growth, infiltration, metastases, ulceration, exhaustion,
and septicemia. The great mistake is in not insisting
on a radical operation. A temporizing policy is fatal.
In suspected cases, carcinosis, tuberculosis, and syphilis
are to be differentiated. Early in the case a small opera-
tion only is, as a rule, necessary. In operating take out
as much as possible with safety, go well around the prob-
able limits of infiltration. In carcinoma of the tongue
or lip, take out the bone if eroded. In the extremities,
amputate on the proximal side of the next articulation
above the growth. Excision should be practised in all
cases where general health is good.
The Value of Caustics in Malignant Growths. — Dr.
John Parmenter, of Buffalo, said that many claims are
made for caustics, to wit : That after their use recurrence
is less frequent, that the various agents of this kind have
a selective action, and that we may obtain a reduction in
size of the enlarged lymphatics. These claims are not
well grounded. The value of caustic lies in the selection
of a proper agent and the selection of proper cases. A
proper caustic is one which entirely destroys the diseased
tissue, and it should be rapid in its action. Caustics must
be used in conjunction with common-sense. Burn all the
diseased tissue. Don't spread over too extensive a sur-
face. Mitigate as much as possible the pain. Suitable
cases are those located in a favorable anatomical situa-
tion, and those in which there is no involvement of the
ymphatic glands.
Dr. L. Duncan Bulkley, of New York, said that caus-
tics are used by quacks, still they have their use. They
are indicated in (1) the early stages, and are useless after
metastases, extensive ulceration, or glandular involvement
have taken place. (2) In the formative period. (3) In
epitheliomata in accessible regions.
The best form of caustic is a mixture of wheat flour,
arsenic, cinnabar, ammonia muriate, mercury bichloride,
and zinc chloride. Mild caustics are useless, and silver
nitrate is of no value whatever.
Pyrogallic acid is serviceable after curetting.
The Radical Cure of Malignant Tumors by Operation.
— Dr. J. H. Wythe, of Oakland, said that cancer is
often removed as a palliative measure. Cure by removal
can follow only when the growth is of local origin. Per-
sistent removal after recurrence is often followed by per-
manent cure. Two principles are to be observed, namely,
operate early, and remove a quantity of the neighboring
tissue with the growth.
Dr. Morrison said that general practitioners should
be able to recognize and also treat malignant growths.
Caustics are useless, and we should always use the knife.
Dr. Shiels, referring to Dr. McLean's paper as re-
gards differentiating between syphilis and malignancy by
treatment, said it was not always possible, because some
forms of gummata yield neither to iodides nor mercury.
Dr. Griswold, of Pennsylvania, recited a case where
he operated simply to prolong life. Caustics should be
used only when the patient positively refuses surgical
measures.
Dr. Plane, of Michigan, thought that there was no
means of making a prognosis in a large class of tumors.
Dr. J. W. Cottenhauer, of Iowa, made the claim that
malignant tumors are never cured.
Dr. Bulkley, of New York, said caustics as commonly
used are dangerous. He believed that a simple growth
might be made malignant by the irritation of caustics.
Dr. Bishop, of Pennsylvania, appealed to the Section
to take a decided stand in regard to caustics. We should
never allow the patient to select the method of treatment.
Second Day, Wednesday, June 6th.
Discussion on Tubercular Joint Disease. — Dr. Emmet
Rixford gave briefly the symptoms which are to be de-
pended upon in the early recognition of this disease.
Dr. R. H. Sayre, of New York, laid much stress on
the manner of applying the plaster cast in the treatment
of joint disease. Interest was added to the paper by
photographs displayed to illustrate the various methods.
Dr. S. Stillman, of San Francisco, followed with a
paper on the "Treatment of Tubercular Joints by the
Injection of Iodoform." He dwelt on the technique of
the operation aud on the location of the tubercular foci.
Concussion of the Brain — Dr. L. C. Lane, of San
Francisco, read a paper on this subject. After reviewing
the history of the subject and giving a general resume' of
the various theories brought forward in regard to the sub-
ject since 1840, he went on to explain why in most cases
the diagnosis was easy, whereas in other cases most diffi-
cult, especially where there was no history of a blow or
a fall upon the head.
He divided the cases into three general classes or
grades: 1, The mild ; 2, severe ; and 3, the fatal cases.
As symptoms of the trouble he enumerated vertigo,
faintness, weakness, drowsiness, and coma. The prog-
nosis was dependent on the extent of the injury. As
after-effects in some cases, he mentioned melancholia and
mania.
Treatment of Fractures of the Lower End of the
Humerus. — Dr. Allis sent a paper with this title.
The main point brought out was the advantages to be
derived from treating such injuries with the arm in ex-
tension and the patient in the recumbent posture. This
facilitates the circulation of the blood, the examination
of the part, and the renewal of the applied dressing.
August 4, 1894]
MEDICAL RECORD.
153
Passive motion he said was only to be used in the latter
half of the treatment. A lengthy discussion then fol-
lowed, which was represented on the one side by Dr.
Lane, who favored the method employed by Allis, and
on the other side by Dr. Sayre, who favored the rectan-
gular position.
Discussion on Hernia. — Dr. J. Ransohoff, of Cin-
cinnati, O., emphasized the great importance of imme-
diate operative interference in the case of the strangu-
lated hernia, and the great danger to be apprehended
from prolonged taxis which has a tendency to decrease
the vitality of the gut, as well as to make the subsequent
operative procedure less favorable in its results.
Dr. A. E. Rockey, of Portland, Ore., then followed
with a paper entitled " Observations on the Radical Cure
of Inguinal Hernia." He advocated the idea of opera-
tive interference also in many cases of long standing and
in cases where the hernia is very large.
Dr. H. O. Marcy, of Boston, advocated the use of
kangaroo tendon in suturing, in preference to catgut. A
lively discussion followed, which showed that there are still
many adherents to the conservative method of treatment.
A Plea for the Better leaching of Anatomy. — Dr.
Schikl read a paper with this title, in which he said
that among all medical studies, anatomy probably ranked
first in importance. The lack of interest shown by
students in the study of anatomy was, he thought, largely
due to the methods of teaching. He also laid great
stress on the evil results consequent upon a deficient
education in this branch of medical science. These, he
said, were not only meted out to the physician, but also
to the patient, who falling into the hands of a practi-
tioner with only a superficial knowledge of anatomy was
like a lamb being led to the slaughter, unconscious of the
danger which awaits him.
Third Day, Thursday, June 7TH.
Symptoms and Treatment of Tumors of the Bladder.
— Dr. C. F. Buckley, of San Francisco, read a paper
which was mainly a detailed account of three cases of
tumors of the bladder, produced in these patients un-
doubtedly by traumatisms of the perinaeum. He indi-
cated that in his opinion not enough attention was paid
to injuries of this sort. Dr. Buckley also exhibited a
slate pencil removed from the bladder of a male subject
by the median operation ; and a collection of gall-stones
removed from the gall-bladder of a patient during life.
Pathology and Symptomology of Hemorrhoids, Anal
Fistulas, and Anal Fissure. — Dr. David Powell, of
Marysville, Cal., read a paper with this title. Clinically
he divided piles into external and internal, although
their pathology is the same. The veins involved are the
inferior and superior hemorrhoidal plexus. In their in-
itial stage they are nothing more than dilated rectal
veins. Later, characteristic changes take place and the
tumor enlarges. As causes he enumerated fecal accumu-
lations, the gravid uterus, or some obstruction to the
hepatic circulation* The internal he classified into: 1,
venous; 2, arterio- venous ; and 3, the capillary. The
speaker next took up the subject of anal fistula. This
usually originates in an ulcer. It may also be caused by
a thrombosis or tubercular foci which induces suppura-
tion. This trouble he said was often not accompanied
by any urgent symptoms.
The subject of anal fissure was next discussed. This,
the speaker said, was a most important subject practically,
not because of its pathology but rather because of the
pain and annoyance which invariably accompany it.
Among the characteristic symptoms he mentioned : Dull
aching pain, aggravated by evacuation of the bowel.
Morning diarrhoea, loss of blood, continual irritation of
the genitourinary organs, and tender prostate. The
constitutional disturbances are often marked. If trouble
is unrelieved, patient becomes pale, anxious, and looks
careworn.
Dr. G. B. Somers, of San Francisco, said the treat-
ment of anal fistula was by no means always a simple
one on account of two complications : 1, cicatricial tissue
was frequently found in the canal ; and 2, collateral
sinuses often existed, hindering the surgeon in his work.
In most cases the fistula is preceded by an abscess, which
may be either pyogenic or tubercular in origin, which im-
parts to the fistula its characteristic aspect.
Methods of treatment are mainly four: 1, by injec-
tion ; 2, by ligation ; 3, by Mathew's fistulatome ; and
4, the radical operation by the knife. Dilatation of the
sphincter, he said, should always precede the operation.
Dr. Thomas W. Huntington, of Sacramento, stated
that anal fissure, though more common between the ages
of twenty and thirty- five, occurs at times during infantile
life and in old age. It occurs as often in men as it does
in women, a view not generally held up to this time.
The symptoms are morning diarrhoea, tenesmus, in-
tense paroxysmal paralyzing pain quite out of proportion
to the size of the ulcer.
There are two general methods of cure : 1, by dila-
tation of the sphincter ; and 2, by incision. Incision
always to be done under anaesthesia. The speaker fav-
ored the combined plan of incision and dilatation.
Treatment of Stricture of the Urethra.— Dr. Rosen-
stein gave briefly his experience with the employment
of gradual dilatation and internal urethrotomy. In sum-
ming up he stated that he decidedly favored gradual dil-
atation, and that in his opinion internal urethrotomy will
eventually be abandoned because of the dangers asso-
ciated with the operation, and because, in his opinion,
the cure after urethrotomy was not any more permanent
than after gradual dilatation.
A lively and very interesting discussion now ensued.
Dr. Thomas, of Pennsylvania, said that in certain
cases he decidedly favored internal urethrotomy, in
others divulsion.
Dr. Huntington, of California, remarked that he
rather favored internal urethrotomy, as gradual dilatation
did not always cure the discharge.
Dr. Dodge, of Michigan, said he had seen worse re-
action from the use of the sound than from internal
urethrotomy.
A number of other physicians gave their opinions, by
which it seemed to be the consensus of most present that
internal urethrotomy was well adapted in many cases,
and that it will always occupy a place in surgery.
It also was thought by many that the cure of stricture
is not a permanent one, and that sounds have to be used
at shorter or longer intervals to keep the stricture from
again contracting.
Fourth Day, Friday, June 8th. *
Hew Plastic Operation for Varicocele. — Dr. O. J.
Mayer, of San Francisco, read the paper. The feature
of the operation is the transverse suturing of the longi-
tudinal wound, which method considerably shortens the
scrotum. A case which had been operated on was pre-
sented.
Dr. Mayer then read a paper on a " Bloodless Vaginal
Myectomy.' ' The essential step in the operation being
the temporary ligation of the uterine arteries.
Acetanilid in Medicine and Surgery. — Dr. G. W.
Woods, of the United States Navy, Mare Island, Cali-
fornia, read a paper in which he gave a brief account of
the preparation and composition of acetanilid. Anti-
febrin, he said, was simply another name for acetanilid.
It is a good antipyretic and not poisonous if given in small
doses at the commencement, even to children. It acts
slowly and is both a diaphoretic and diuretic. It may be
given in any and all fevers and inflammations. It is a good
substitute for iodoform in venereal sores. The only thirg
experienced on its application to a granulating surface is a
burning sensation, which, however, persists only a short
time. It is useful in the dressing of all forms of burns, ul-
cers, moist eczema, gunshot wounds, abscesses, etc. When
applied to extensive granulating surfaces it sometimes pro-
154
MEDICAL RECORD.
[August 4, 1894
duces cyanosis, which is not due to a disturbance of cir-
culation, but to a deficient oxygenation of the blood.
To sum up, the speaker said, acetanilid is exceedingly
useful because it is cleanly, odorless, antiseptic, desiccat-
ing, practically non-toxic, does not crust, is easily re-
moved, insignificant cost, not altered by moisture.
Contagious Period of Syphilis. — Dr. Thomas, of
Pennsylvania, emphasized the fact that he was perfectly
convinced that syphilis is only contagious in the primary
and secondary stages, that is only for three to four years
after the primary lesion.
Dr. Schiels reported a case of multiple, symmetrical,
bilateral lipomata. The lipomata were not limited to
any particular part of the body, but occupied positions
from the neck down to the groin.
The Surgical Engine — Dr. Bonnwbll, of Philadel-
phia, Penn., then read a paper on this engine, which was,
he said, very similar to the ordinary dental engine. It
caused the trephine or burr to revolve from a hundred to
twenty thousand times a minute. It is said to be adapted
to the performance of all sorts of surgical operations, on
both the soft parts and bony tissue.
NEW YORK PATHOLOGICAL SOCIETY.
Stated Meeting, February 14, 1894.
George C. Freeborn, M.D., President, in the Chair.
Rupture of the Liver. — Dr. E. Hooenpyl presented the
specimen. There was extensive laceration of the organ
due to an injury, yet death did not occur for three weeks,
and was then due to peritonitis and septic infection. The
patient was said to have had a kick from a horse, yet he
received practically no attention until about three weeks
later, when he reached the hospital after a ride in a street-
car and a short walk. He was much exhausted at the
time of admission, and died two hours later. At the
autopsy the body was found to be emaciated. There was
no external sign of injury, and no fracture of the ribs or
vertebrae. There was an intense peritonitis with con-
nective tissue bands uniting the coils of intestine. Be*
hind the intestine, on either side of the vertebral column,
were two large collections of stinking blood — at least
two quarts on either side. The whole of the right lateral
border of the liver was torn away, and the right lobe was
exceedingly friable, so that a dull probe could be inserted
into the liver tissue for at least six inches. The fact that
the man survived the injury so long was very remarkable,
for most cases of rupture of the liver prove fatal within a
few hours, from hemorrhage.
Sub-phrenic Abscess. — Dr. Hodenpyl also presented a
specimen of sub phrenic abscess. It had apparently re-
sulted from a perforation of the gall-bladder. The sub
j set was a man twenty-three years of age, who had been
excessively intemperate. In the winter of 1892 he had
severe colicky pains in the region of the umbilicus, lasting
for three weeks. The present illness began on December
10th, with a nearly constant pain referred to the umbili-
cus and upper abdominal region. Two days later he no-
ticed the abdomen beginning to swell, and ever since
then it had steadily increased in size. On admission he
was well nourished, and very slightly jaundiced. There
was some swelling of the feet and limbs ; the abdomen
was considerably distended, but there was no fluctuation ;
the temperature was ioo° F. ; pulse, 112; respirations,
24 ; urine normal. Physical examination showed flatness
over the lower part of the right lung, beginning at the
third space, and some dulness posteriorly over the left
lung. The heart was normal; splenic dulness not in-
creased. On December 2 2d paracentesis abdominis was
performed, and 166 ounces of slightly turbid reddish brown
fluid were withdrawn. This gave marked though tem-
porary relief. On December 25 th a needle was inserted
into the right chest posteriorly and some bloody serum
drawn off, and on the following day paracentesis was again
performed. Some reddish-brown fluid wa3 evacuated,
and this gave a distinct bile reaction. On December 2 7th
a four inch vertical incision in the right lumbar region
was made, about the level of the umbilicus, and on cutting
through the abdominal muscles and peritoneum about two
and a half litres of clear brownish fluid escaped. The
incision was enlarged and disclosed a cavity of consider-
able size. There was a well marked line binding to
gether the intestines and separating them from the peri,
toneal cavity. In the upper part of the incision was a
rounded cicatrix half an inch in diameter. The wound
was packed. After two days the patient developed diar-
rhoea with some blood in the stools, and on January 16th
he died. No complete autopsy was permitted, but the
liver was removed through the abdominal wound. Over
the whole right lobe, posteriorly, was a large collection
of fibrin and pus immediately beneath the diaphragm.
Over the whole lower lobe of the right lung was a rather
thick coating of fibrin and pus. There was an intense
peritonitis with organized adhesions. The gall-bladder
showed a circular opening about the size of the little finger
with rounded edges. This might have been ante-mortem
or due to the necessarily forcible extraction of the liver.
The speaker said that in most of the cases of sub phrenic
abscess that had been reported, the condition was due to
the extension of a pleuritis, but in this he thought it was
rather due to rupture of the gall-bladder.
Carcinoma of the Stomach. — Dr. Hodenpyl next pre
sented a specimen of the above. It was removed from ?
man, fifty years of age, who had suffered for a number
of years with phthisis. For the last year of his life there
were marked gastric symptoms, particularly vomiting of
" coffee-ground " material. He was so much emaciated
that the tumor could be easily felt on palpation of the
abdomen. There was not much stricture of the pylorus,
but just above this point was an ulcer one and one-half
inch in diameter and one inch deep. There were sev-
eral large capillaries in the base of this ulcer, from which
the hemorrhage probably occurred.
Dr. George P. Biggs said that last spring he had pre-
sented to the Society a specimen not unlike the one of
sub phrenic abscess just exhibited. In his specimen
there was a large calculus having the shape of the inte-
rior of the gall-bladder, and lodged in the common and
hepatic ducts. There was one quite large ulcer and
several small ones in the fundus of the gall bladder, and
several collections of pus around the gall-bladder with
perforation into the pleural cavity.
Sarcoma of the Tongue. — Dr. £. K. Dunham pre-
sented this. It had been removed by operation, by Dr.
Joseph D. Bryant, from a man sixty-one years of age,
whose family history was negative, except that several of
the members of the family had died of tuberculosis. The
man was somewhat alcoholic in his habits, and was accus
tomed to smoke ten pipes of tobacco a day, using a
briar wood pipe. About eight months ago he bit his
tongue on the right side, one inch from the tip, causing
a blister, which by contact with a rough tooth became
irritated. A tumor slowly grew on this spot, and when
first seen was three-fourths of an inch in diameter. On
microscopical examination the structure of the tumor
appeared to be that of a large round-cell sarcoma. The
speaker said that the literature of the subject was very
meagre* Max Schreier, in the KUnische Wochenschrift
for June, 1892, reported several cases. He also recorded
two cases in which there was an anatomical diagnosis of
sarcoma of the tongue, but in which no clinical history
was obtainable. In the cases which he cited the majority
were at the back of the tongue, and most of them were
either small round cell, spindle-cell, mixed-cell, or
lympho-sarcomata. The only large round cell sarcoma
reported was one by Mercier in 1890, situated near the
tip of the tongue on its dorsal surface. It was a fungous
growth attached to the tongue by a thick pedicle, and
was made up of large round cells, some of which were
multi nucleated, with a small amount of intercellular
stroma which could be more or less distinctly traced from
the connective tissue surrounding the tumor. In that
August 4, 1894]
MEDICAL RECORD.
155
case, as in the one just presented, there was no ulceration
around the tumor ; the epithelium was intact, and showed
no tendency to involve the underlying tissues.
Dr. T. M. Prudden said that the specimen seemed to
be undoubtedly one of sarcoma, perhaps of the kind
sometimes called angio-sarcoma. He had seen three or
four small sarcomata of the tongue, all of the spindle-cell
or small round- cell variety. The specimen exhibited
under the microscope was so beautiful, he would like to
ask how it had been hardened.
Dr. Dunham replied that the whole tumor was first
hardened in a saturated solution of bichloride for five
hours ; then in seventy per cent, alcohol containing some
iodide of potassium, and then successively in eighty per
cent., ninety-five per cent., and absolute alcohol. The
section was cut in paraffin.
Typhoid Fever with Extensive Ulceration.— Dr.
George P. Biggs presented a supplementary report on
the case of typhoid fever with extensive ulceration of the
caecum which he had presented some time ago to the
Society. Cultures from the spleen showed bacilli pos-
sessing all the morphological and biological characters
of typhoid bacilli, including the growth on potato.
Cultures from the peritoneal exudate showed the strepto-
coccus pyogenes very abundant, with bacilli which had
apparently the characteristics of the colon bacillus, in-
cluding the development of bubbles of gas in cane sugar
•bouillon.
Pulmonary Thrombosis and Infarctions. — Dr. George
P. Biggs also presented a supplementary report on this
recent case. It was one of dilated heart with multiple
pulmonary thrombi and infarctions. The areas in the
lang showed the ordinary structure of hemorrhagic in-
farctions, and branches of many of the pulmonary arte-
ries showed distinct endarteritis. The lesion most fre-
quently seen in the sections was a fibrous thickening of
the intima with slight narrowing of the lumen ; distinct
obliterating endarteritis was occasionally seen. The
media and adventitia of some of the vessels contained a
few small round cells. The vessels of the liver and kid-
neys appeared to be normal. It was rather interesting
to note the absence of any gross evidence of arterial dis-
ease, and the evidence microscopically of slight, but dis-
tinct, changes apparently limited to the pulmonary arte-
ries. The arterial disease, with the marked enfeeblement
of the circulation present in the case, fully accounted for
t le thrombi, and apparently for their presence only in
tie lung.
In connection with that case the speaker reported one
presenting very similar lesions. A woman, forty years
of age, had had for several years more or less palpita-
tion, dyspnoea, and oedema of the legs. She had never
had rheumatism. Five months before death she had se-
vere headache, cough, vomiting, dyspnoea, and dimness
of vision, soon followed by oedema of the feet. The
urine became scanty and high-colored. On admission,
the temperature was 10 1° F., respirations, 40, and the
pulse, 108 ; there were many subcrepitant rales over the
lung posteriorly. The apex beat was in the fifth space,
$*4 inches to the left of the median line. A faint sys-
tolic murmur was heard at the apex ; the heart action
was regular and of fair force, and the pulse had a high
tension; The liver extended from the fifth space to the
level of the umbilicus. A moderate quantity of fluid
was detected in the peritoneal cavity, and there was
marked oedema of the lower extremities. Examination
of the urine showed it to have a specific gravity of 1.014,
and to contain from ten to twenty per cent, of albumin,
with many casts. Twenty to twenty-five ounces of urine
were voided daily. She was under observation in the
New York Hospital for two months, during which time
the dyspnoea, vomiting, headache, and scanty urine were
ths prominent symptoms. During the last ten days of
her sickness there was cough with moderate bloody expec-
toration. At the autopsy it was noted that she was an ex-
tremely obese subject, the fat in the abdominal walls be-
ing 7 ctm. in thickness. Many old pleuritic adhesions
were found, and also a moderate increase in the peri-
cardial fluid. The heart was considerably hypertrophied,
but predominantly dilated. All the cavities were dis-
tended with post-mortem clots; all the valves were
normal; the muscular substance was pale, but fairly
firm. The coronary arteries and the aorta were slightly
atheromatous. There was a thin thrombus, 1 ctm. in
diameter, at the junction of the transverse and descend-
ing portions of the arch of the aorta. There were no
ante-mortem thrombi in the heart itself. In the left
lung ante-mortem thrombi were found in many of the
larger branches of the pulmonary artery in both lobes.
Many of these thrombi nearly occluded the vessels, but
there were no infarctions except two small ones in the an-
terior border of the base, ij4 ctm. in diameter. In the
right lung there were large thrombi in the main subdivi-
sions of the pulmonary artery, and multiple small infarc-
tions scattered through the upper and lower lobes. The
largest, which was in the posterior part of the lower
lobe, measured 4 ctm. in diameter. The lungs were
generally congested and oedematous. In the common
iliac and femoral veins were large thrombi apparently
completely occluding the vessels. The kidneys showed
advanced chronic diffuse nephritis. It was quite possi-
ble that some of the infarctions came from emboli in the
femoral vessels.
Typhus or Typhoid Fever t— Dr. George P. Biggs then
presented specimens from a case seen first at the Recep-
tion Hospital, and then at the Riverside Hospital. The
patient was an Austrian, twenty one. years of age, who
when admitted to the Reception Hospital had a temper-
ature of 1050 F., with a moderately profuse eruption
which was regarded as that of typhus fever. He said he
had been sick for three days. The patient was under ob-
servation for eighteen days, and the history was furnished
by Dr. S. D. Hubbard, of the Riverside Hospital. The
temperature for the first three days was between 1050
and 1060 F., and, during the following eleven days, it
ranged between 1060 and 1030, the average being 105°
F. During the last four days it fell gradually from 1030
to ioo°, the average being 1020 F. His pulse for the
corresponding periods was 120 to 124, then 100, then
80, and during the last few days 124. The respirations
varied between 26 and 36 during the entire time. Low,
muttering delirium was noted on the sixth day of the
disease, and was frequently present throughout the course
of the disease, especially at night. The eruption was at
first macular, but by the ninth day it became petechial.
The countenance was dull and dusky, and the eyes were
congested. The spleen was enlarged throughout the
course of the disease. There were signs of obstruction
of the dorsalis pedis artery two days before death. At
the autopsy it was noted that he was extremely emaci-
ated, and that rigor mortis was well marked. The toes
of the left foot were of a pinkish-red color, owing to the
obstruction of the artery. The serous membranes were
all normal. The heart was distended with post-mortem
clots. Attached to the inner surface of the lower half
of the anterior wall of the left ventricle were many firm
grayish ante-mortem clots, forming a mass about the size
of a hen's egg. The ventricular wall corresponding to
the attachment of these thrombi was only 1 ctm. in thick-
ness, while at the base it was 2 ctm. thick. There seemed
to be no explanation for these variations in thickness of
the wall. The muscular substance was pale and moder-
ately soft. The valves were all normal. No ante-mortem
clots were found in the heart, except in the left ventricle.
The coronary arteries and aorta were very slightly ather-
omatous. The lungs showed marked bronchitis, but no
thrombi or infarctions. The spleen was about four times
its normal size, was of a dark-red color, and contained an
infarction in the posterior portion, 4 ctm. in diameter,
and two others in the anterior portion, somewhat smaller.
The mesenteric glands were distinctly enlarged, measur-
ing itoi^ ctm. in diameter. The kidneys were exces-
sively anaemic, and their parenchyma degenerated. In
the left one was an infarction, 4 ctm. in diameter. The
156
MEDICAL RECORD.
[August 4, 1894
liver was soft and pale. The mucous membrane of the
whole ileum was moderately congested ; Peyer's patches
were unusually distinct, with a finely granular surface ;
some of them were slightly elevated and presented a few
points of superficial ulceration, two to three mm. in
diameter. The colon appeared to be normal. The
brain showed marked atrophy of the convolutions, with
corresponding increase of the fluid in the pia.
The cause of death in this case appeared to be a car-
diac thrombus with resulting multiple embolism occur-
ring as a complication of some acute infectious disease.
It was diagnosticated clinically as typhus fever. The
speaker said he thought the lesions pointed rather to ty-
phoid than to typhus. The points in favor of typhoid
fever were, first, the distinct enlargement of the mesen-
teric glands, which were not usually enlarged in typhus
fever ; and secondly, the distinct but slight lesion of Pey-
er's patches. There was no characteristic lesion of these
patches, unless possibly the " shaven beard " appearance.
Regarding the case as one of typhoid fever, it would be
in the fourth week at least. The most reliable statistics
placed the average duration of typhoid fever at twenty-
four to twenty eight days. In the fourth week, therefore,
if the disease had progressed favorably, one would expect
to find varying degrees of healing of the ulcerated Pey-
er's patches, and this seemed to be the condition in the
specimens presented.
In this connection the speaker presented specimens
from a recognized case of typhoid fever on the twenty-
third day of the attack. The patient was a male,
thirty- five years of age, in whom the disease ran a per-
fectly characteristic course for four weeks. The tempera-
ture remained nearly at the normal for about three days ;
then it rose again and continued high for twenty-three
days, when he died of multiple pulmonary thrombi with
infarctions. The autopsy in this case showed the heart
considerably dilated and flabby, without thrombi. There
was an infarction in the anterior border of the right base,
about one inch in diameter, and four smaller ones in the
left lower lobe. In addition there were many thrombi of
the size of a split pea in both lungs, at the bifurcation of
the pulmonary arteries. They encroached only moder-
ately on the lumen of the vessels. The spleen was twice
the normal size, of a deep red color, and moderately
soft. The mesenteric glands were moderately enlarged.
The kidneys showed parenchymatous degeneration. The
liver was soft and pale. The intestines were heavily
coated with mucus, but appeared otherwise normal, ex-
cept in the lower portion of the ileum, where the Peyer's
patches were slightly pigmented and presented a finely
granular surface. The colon showed a few pigmented
points, probably healed ulcerations, and a few superficial
ulcerations not yet healed.
The pathological conditions in these two cases were
very similar, yet the clinical history of the first case re-
sembled that of typhus, while that of the second case cor-
responded with that of typhoid fever. In the first case
death occurred about the beginning of the fourth week,
or possibly later; in the second case death occurred
at the beginning of the fourth week of the relapse. In
both the intestines have evidence of lesions of Peyer's
patches undergoing repair, and also of a slight enlarge-
ment of the mesenteric glands, and decided enlargement
of the spleen. The cultures from the spleen in the first
case developed nothing which could be regarded as at all
characteristic of typhoid ; in the second case cultures
were not made.
Sarcoma of the Faoe. — Dr. J. E. Weeks presented
this. Tumor was removed from the face of a man aged
sixty five. About thirty years ago he had noticed a small
tumor on the side of the nose, which, after some years,
presented a small ulceration. This tumor was removed
in 1870. About twelve years later, the cicatrix became
congested and the tumor recurred. The patient then
came under the care of Dr. Derby, who found the growth
on the left side of the bridge of the nose, near the inner
canthus, adherent to the subjacent tissue, and separated
from the canthus by a half- inch strip of healthy skin. It
was nodular, irregular, and elevated, and on removal ex-
posed a bleeding surface. There was no enlargement of
the pre* auricular gland on that side. The tumor was re-
ferred to the speaker for examination. The posterior sur-
face of the tumor was covered with degenerated epithe-
lium, and consisted chiefly of irregularly cylindrical and
club-shaped hyaline, homogeneous masses, which took
eosin stain like connective tissue. There were small col-
lections of epithelial cells between the hyaline cylinders,
which penetrated to a considerable depth. Pymphoid
cells were quite numerous, and in some places were seen
in the centre of the hyaline masses. There was a scanty
connective-tissue framework in nearly all parts of the
growth. The blood-vessels were not found in the centres
of the hyaline masses, but were quite plentiful on the
periphery. The walls of the arteries in the centre of the
hyaline masses were thickened and degenerated, and
there were extensive extravasations of red corpuscles and
blood pigment throughout the growth, indicating pro-
found vascular changes. This form of tumor, the speaker
said, had been classified as sarcoma. Billroth described
a similar tumor in 1866, which he termed a "cylin-
droma. ' ' This variety of new- growth was most frequently
met with on the face, although it had been found at the
margin of the anus. Out of twenty-four tumors collected,
fourteen were from the mesoblastic elements, and ten
from epiblastic elements. The hyaline masses probably*
resulted from the degeneration of mesoblastic tissue.
The term cylindroma should only be employed as an ad-
jective.
An Astragalus. — Dr. R. H. Sayre presented an as-
tragalus from a case of club foot. The specimen had
been removed by operation from a patient, aged twenty-
six, with very exaggerared talipes varo-equinus. After
extensive incision of the soft parts on the inner side of
the foot, he was unable, after reducing the varus, to get
rid of the equinus ; hence, the astragalus was enucleated.
This bone presented a very different appearance from the
normal astragalus. Its superior articular surface was not
more than one third the usual size ; the body of the bone
was almost completely absent ; the neck was much twisted
inward and the surface which should articulate with the
scaphoid was much altered. The astragalus was bent
downward on itself at a very sharp angle. The larger
part of it was entirely free from articulation with the
bones of the leg. After removing it, it was found that
the os calcis was bent inward at an angle of about 45 °, so
that it was necessary to remove a V-shaped section from
the outside of the os calcis in order to efface this curve.
In these old club-feet it was usual to find more or less
distortion of the bones. This was about the first astraga-
lus that he had felt compelled to remove in an adult in
order to reduce the deformity, but the great alteration in
the bone seemed to fully justify this procedure. No
more convincing proof could be given of the importance
of overcoming the deformity in club-foot while the bones
were still flexible.
Abscess of the Liver. — Dr. J. S. Thacher presented
specimens from a case of abscess of the liver. The man
was operated upon six years ago, in Egypt, for abscess of
the liver following an attack of diarrhoea. After wearing
a drainage-tube for ten months, he recovered completely,
and according to his statement, remained well for five
years. He entered the hospital last fall complaining of
diarrhoea and some abdominal pain. There were a few
streaks of blood in the faeces, and he had also the symp-
toms and urinary signs of nephritis. The liver showed a
distinct enlargement and increased hardness. He left
the hospital after a few weeks, and did not return until
ten days ago. When readmitted, the left lobe of the
liver was found extremely prominent — a large, inegular
mass projecting in the epigastrium. The right lobe of
the liver was less prominent and softer, but was not
easily palpated on account of ascites. He had been
twice tapped for ascites. He was tapped again in the
hospital, and the fluid on examination showed a few
August 4, 1894]
MEDICAL RECORD.
157
" budding cells." At the autopsy it was found that the
part of the liver which had formed the tumor was not
that which was most diseased; it was waxy, degenerated,
and hypertrophied. The right lobe of the liver was
deeply excavated by an enormous abscess. The spleen
and kidneys alio showed waxy degeneration. The fact
that he had been operated upon before for abscess of the
liver, and that there had been no elevation of tempera-
ture in spite of the large abscess, were the most interest-
ing features.
Cerebro-spinal Meningitis. — Dr. F. Ferguson pre-
sented the brain from a case of cerebro-spinal meningitis.
It was removed from a man, thirty- four years of age, who
was admitted to the New York Hospital on February 5,
1894. He was found unconscious in the street, and was
brought to the hospital in an ambulance. On admission
he was so extremely drowsy that it was impossible to get
from him a satisfactory history. He stated that for two
past weeks he had suffered from headache and general
pains, and that the illness began with chills, vomiting,
fever, and cough. He also seemed to have some pain in
his chest. The expectoration was blood stained, and ac-
cording to his statement had been so for two days. The
slightest touch appeared to cause him the greatest pain.
The temperature was 102. 40 F. \ respirations, 36; and
pulse, 92. Physical examination disclosed a soft systolic
murmur over the heart apex, but otherwise the thoracic ex-
• animation was negative. His pulse was slow, regular, and
of good tension, with corresponding heart action. Exami-
nation of liver, spleen, and abdomen was negative. He
was anaemic, but well nourished. His urine had a specific
gravity of 1.022 ; it contained no albumin or sugar, and
microscopical examination was negative. The pupils
were contracted. On the day of admission he had a
convulsion at 4 p.m., and at this time eighteen ounces of
urine were drawn by catheter. He was restless and noisy
all night. The following day he complained of head-
ache. The head was shaved and an ice-cap applied con-
tinuously. The attending physician, Dr. G. L. Peabody,
made a diagnosis of meningitis. He was treated with
large doses of sodium iodide. The temperature remained
at 1020 F., while the pulse varied from 92 to 102, and the
respirations from 28 to 40. On February 7 th his temper-
ature fell one degree in the morning, but rose in the even-
ing to 1040 F., the pulse being 100, and the respirations
32 per minute. He was so noisy and restless that night
that morphine was given, and on the following day he
was still restless and was tearing the clothing, although
unconscious. At 5 p.m. his temperature was 103. 8° F. ;
pulse, 106 ; respirations, 28, and shortly after eight o'clock
he died. At the autopsy both the right and left ventri-
cles were found slightly dilated, and the cardiac muscle
was anaemic. The lungs were congested and contained
numerous punctate hemorrhages in the most dependent
parts. With the exception of the spleen, which was
rather large and soft, the thoracic and abdominal organs
presented pothing of special interest. On removing the
calvarium the dura mater was found congested and firmly
adherent to the skull over the left cribriform plate.
While the meningitis in this location appeared older, ex-
tension upward through the cribriform bone and dura
could not be recognized. The pia mater everywhere
contained pus and lymph, which, however, were more
abundant over the vertex of both hemispheres, and over
the posterior surface of the cord in the lumbar region.
The fourth ventricle also contained pus. On microscopi-
cal examination of the brain the pia mater everywhere
was found to be the seat of intense inflammation, with
great hyperemia and numerous punctate hemorrhages.
On following the vessels through the cortex they were
found to be the seat of innumerable small round cells,
some of them apparently in the walls of the vessels, and
some in the perivascular spaces. Adjacent to the dura
the cortex of the brain in places was infiltrated with an
unusual number of small round cells, especially at the
base of the left frontal lobe, where, over an area of nearly
two centimetres in diameter, the entire cortex of the
brain was infiltrated with pus. Over this area the dura
mater was also extensively involved. Collections of
small round cells were also found in limited areas along
its external surface. Examination of the cribriform plate
and the ethmoidal sinuses failed to show any lesion be-
yond intense hyperaemia. Bacteriological examination
of sections revealed numerous diplococci, identical with
the micrococcus pneumonia crouposce. The speaker ex
hibited culture- tubes showing the characteristic develop-
ment of these organisms, anti also microscopical slides.
He stated that pure cultures of these organisms had been
taken from several parts of the brain and spinal cord.
In the vast majority of cases of cerebro-spinal meningitis
examined by him during tne past three years this micro-
organism had been found.
Acetabular Form of Hip disease. — Dr. V. P. Gib-
ney presented a specimen illustration. It was taken
from a boy who was eight years of age at the time he
was first admitted to the hospital, on January 9, 1889.
He had already been treated for hip-disease three years,
and had worn a protection splint for one year. On ad-
mission there was an immense abscess on the outer aspect
of the thigh. The inguinal glands were much enlarged.
There was a range of motion over 35 ° or 400. Two
days later the abscess was incised under ether, and on
January 26th another sac was incised. In June, of 1890,
the sinuses, three in number, were still discharging.
They were curetted under cocaine, and this was repeated
on January 6, 1891. He was discharged from the hos-
pital shortly afterward. At this time the sinuses were
discharging very slightly, the limb was in good position,
and he was still wearing a brace. On January 29th of the
same year he was readmitted with the sinuses discharging
very freely. Shortly after this an abscess was opened,
and from this time until October the sinuses were cu-
retted several times. During the month of October he
was etherized, and the sinuses on the inner and upper
third of the thigh were found to communicate with a si-
nus in the inguinal region above Poupart's ligament.
Tents were drawn through and through. There was no
question then about the acetabulum being perforated.
Up to April, 1893, these sinuses had variable discharges,
and were occasionally curetted. The boy spent that
summer in the country, and on his return in the fall the
discharge from the sinuses was very slight. Early in De-
cember, 1893, one ^nus remaining above Poupart's lig-
ament was curetted, and the ilium found necrotic. A
large drainage tube was inserted. The sinus was scraped
thoroughly and a shell of bone removed. The operation
was followed by high fever and much pain, and a few
days later an abscess formed at the back of the ilium.
The boy died of tubercular pneumonia, and the autopsy
was made by Dr. H. S. Stearns, on January 24, 1894.
The base of the left lung was found to be full of tuber-
cular nodules the size of a pea. The apex was oedema -
tons, the remaining portion consolidated. The whole
lower half showed a fairly intense pleurisy with a fibrin-
ous deposit and two ounces of pus. The left lung
showed a few recent adhesions behind a large tubercular
cavity in the lower part of the lung, with trabecular run-
ning through and through, and also three or four tuber-
cular deposits at the apex just undergoing softening.
The kidneys were slightly enlarged, nodular on the sur-
face, with non-adherent capsules, and markings distinct.
The stomach and intestine were normal. The spleen
was decidedly enlarged, and contained nodular tuber-
cles. The liver was very much enlarged, weighing four
and three quarter pounds, and was lardaceous. The peri-
toneal cavity contained three or four ounces of pus. The
specimen itself showed no disease in the head, neck, or
shaft. At the time of section the trochanter itself pre-
sented a normal appearance, but the acetabulum was
broken down throughout the upper portion, and there was
a large hole into the pelvis.
Dengue. — An epidemic of dengue is raging in Jeddah
among the pilgrims recently returned from Mecca.
158
MEDICAL RECORD.
[August 4, 1894
OUR LONDON LETTER.
(From our Special Correspondent.)
<X)LLEGE POLITICS — COMING ELECTION AT COLLEGE OF SUR-
GEONS— RIGHTS AND ASPIRATIONS OF FELLOWS — WANT
OF RIGHTS OF MEMBERS — PROPOSED NEW CHARTER — DE-
FENCE OF MR. ANDERSONJs CASE — LAWRIE, OF HYDERA-
BAD IN ENGLAND — SPECIAL MEETING TO HEAR HIM —
QUAIN'S DICTIONARY — SPREAD OF SMALL-POX.
London, June 93, 1894.
" College politics/1 as affairs connected with the Royal
College of Surgeons are commonly called, are just now to
the fore. By the way, I do not know why one particular
college should thus be spoken of, unless that the members
are so numerous that the fellows may fancy that the con-
cerns of their smaller number interest the latter. They
do, indeed, but in a different sense. The fellows have the
election of the council and desire further rights. An
election is just at hand for three seats on the council, and
there are five candidates. This is the reason college mat-
ters are the subject of the week. The members have no
voice in this or any other college affair, and" therefore
are only interested in candidates on personal grounds.
Although many questions arise, and there is some expec-
tation of a new charter being applied for, it must be con-
fessed that the interest evinced in the election is rather
languid. One candidate, supported by the association of
fellows, actually neglected to send in his papers in due
time and is therefore ineligible. Another claims sup-
port because he lives in a provincial city. Another as
the senior fellow. Another is supported by the new
society of fellows, which has no programme and appar-
ently no raison d'Strt. When the few hundred fellows
admit the members to their rights, every college matter
will interest the whole profession. Then a new charter
may be of some value. Anent the present position, the
association of fellows has passed a resolution that "such
changes as the body of fellows may desire should be em-
bodied in a new charter." Not a word about what mem-
bers may desire.
Before leaving the college I may mention that the
council at the last meeting appointed two of their number
to represent the college on a committee that has been
formed to carry the case of Mr. Anderson before the
Judicial Committee of the Privy Council. Important
civil rights are involved, and Mr. Anderson has been
fighting the cause of the profession as well as defending
himself
Surgeon Lieutenant Colonel Lawrie has come from
Hyderabad to still further demonstrate the results of the
Chloroform Commission, which is due to his labors.
He has already appeared at one or two of our hospitals
and been received with the cordiality his work deserves.
Further, it has been arranged to hold an extra meeting of
the Royal Medical and Chirurgical Society on July 3d
for the express purpose of hearing Dr. Lawrie, who will
endeavor to show that chloroform has no effect upon the
heart, and that it is useless to watch the pulse during the
administration of the anaesthetic. Lawrie's views are,
of course, well known, but it will be very interesting to
hear them from a man of such striking personality, be-
sides which we may expect an adequate discussion when
our premier society holds an extra meeting after the con-
clusion of the session for the purpose of hearing Sur-
geon Lieutenant- Colonel Lawrie.
A second edition of "Quain's Dictionary of Medi-
cine " was issued on Monday. This valuable work of
reference — which is so well known — first appeared nearly
twelve years ago and speedily achieved success. Many
changes have taken place in these twelve years. The
death of some of the contributors has necessitated their
share of the work being entrusted to others. A number
of new articles are also inserted, among which I may in-
stance Greenfield, on Microbes; Sidney Martin, on Im-
munity and Phagocytosis; and P. Manson, on Negro
Lethargy. The last named has also revised his article
on Filaria Sanguinis Hominis. The rapid progress ot
knowledge and the changing way of regarding some
facts has in fact rendered revision necessary on the part
of most of the writers of the first edition, and their
authority is perhaps a sufficient guarantee that they have
done this work carefully. I note, however, that the
venerable editor declares himself still " personally respon-
sible for the work, of which no portion has been issued
without being carefully revised by him.11 Really, there-
fore, Sir R. Quain may claim to be a very industrious
editor, for many of the articles are by the foremost
authorities, and can receive no additional importance
from any reviser, and the reading of the two volumes, in
which the work now appears, comprising 2,500 pages, is a
task which few aged physicians would care to undertake.
The spread of small-pox continues to create anxiety
on the part of sanitary authorities. A number of pro-
vincial towns have suffered, and in not a few cases the
disease has been brought by tramps, and where vaccina-
tion has been neglected the consequences have been such
as were anticipated by medical men.
RELIABILITY OF STATISTICS.
To the Editor or the Medical Record.
Sir : Dr. Carl Beck, in his letter in the Medical Record
of July 2 1 st, has very cleverly ignored everything charged
against him, except the date of the recovery of the child
reported as Case IX. In this matter he convicts himself
of inaccuracy, for the dates he gives do not not agree
with each other, or with the time mentioned in his pub-
lished history of the case. The history I gave for Dr.
Beck's information was obtained from the mother, who
nursed her child through a serious illness, and must be
presumed to know the time of recovery with more cer-
tainty than the father. Indeed, even the medical at.
tendants seem to have obtained their revised history from
her. In proof of this, and to show how little the father
remembered of the particulars, I may quote from a clip-
ping of a letter from Dr. Voegtle, dated June 28 and 30,
1894, which Dr. Beck sent me in explanation of his ina-
bility to give me a few facts about this case. Dr. Voegtle
writes, evidently in answer to a request of Dr. Beck to
obtain these facts : " Will attend to it in the next few
days ; was there, the wife is in the country, and the hus-
band himself knows nothing definitely about it."
As to the relative merits of exsection and incision, of
what value is Case IX. when I have proved it to be one
of resection following an exsection ?
Again, what value can be ascribed to Dr. Beck's sta-
tistics on exsection when they are based on cases, among
which, as I have shown, are some in which no exsection
was performed ? Therefore I repeat : Statistics in order
to be valuable should be, as to their material facts, cor-
rect. Arnot Spence, M.D.
July 37, 1894.
TRANSPORTATION OF THE INSANE TO HOS-
PITALS.
To the Editor of the Medical Record.
Sir: In the Medical Record of July 21st, page 76, in
regard to the " Transportation of the Insane to Hospi-
tals," you say, " those in charge of our public hospitals
have absolutely nothing to do with the manner in which
patients are brought to them." You are mistaken so far
as New York State is concerned. It is the practice for
the Superintendent of the Poor of the County to notify
the asylum authorities, and they send attendants to take
the lunatic to the asylum. It is very exceptional in this
county for private persons to take lunatics to the hospi-
tal. I think the rules of the Lunacy Commissioners re-
quire the insane to be taken by their own attendants on
notice to the hospital authorities.
A. D. Kennedy.
Morris ville, N. Y., July 23, 1894.
August 4, 1894]
MEDICAL RECORD.
159
fjfredical %tems.
Contagions Diseases — Weekly Statement.— Report of
cases and deaths from contagious diseases reported to the
Sanitary Bureau, Health Department, for the week end-
ing July 28, 1894.
Tuberculosis
Typhoid fever
Scarlet fever
Oerebro-spinal meningitis
Measles
Diphtheria
Small-pox
Cases,
9*
21
38
I
4a
163
3
Deaths.
1x2
12
4
3
5
A Varied Diet — An inquest was held in London, not
long ago, on the body of a man who had died suddenly.
The man used to make his living by going about to the
different " pubs " in the evening, and eating anything
that was offered him, for a small monetary consideration.
He died after an operation for intestinal obstruction,
and at the autopsy the following articles were found
lodged in various portions of the digestive tube : A bul-
let, twenty or thirty pieces of cork, twenty pieces of tin-
foil, a piece of string eighteen inches long, with coiks
attached, and a piece of leather nine inches long, with
a hook at each end.
In Memoriam. — Dr. Samuel T. Hubbard, the last sur-
vivor of the original members of the New York Society
for the Relief of Widows and Orphans of Medical Men.
At a meeting of the Board of Managers of the New
York Society for the Relief of Widows and Orphans of
Medical Men, the following remarks were read by Dr.
Andrew F. Currier. On motion of Dr. Charles A. Leale
they were ordered entered on the minutes of the Board.
It was also ordered that a sufficient number of copies be
printed and sent to Dr. Hubbard's family, to the medi-
cal journals of the city for publication, and to the mem-
bers of the Society. It was also ordered that they be
incorporated in the annual report of the Society:
"Died, June 1, 1894, Dr. Samuel T. Hubbard, at the
age of eighty six. This is the last link which bound us
to the founders of this Society. Of the original mem-
bers whose names appear on the list for 1842, all are gone
now ; the last leaf has fallen from the tree. The fathers
are no longer with us, they are but a memory, a remi-
niscence. ' The king is dead, long live the king ! ' Dr.
Hubbard was our Nestor, and I do not see how one
could have been very long in his presence without being
strongly attracted by his most lovable personality. It
was not the attraction of a weak old age, it was not the
attraction of an overpowering intellectuality. No, his
was the vigor of the rugged oak which is in its prime
when other trees around it are decaying, or of the stanch
old ship with timbers sound and spars unbending after
many a storm, being made of honest material through
and through. He made you think of Moses, with his
more than fourscore years, looking over into the prom-
ised land, his eye undimmed and his natural force un-
abated, and from the heights of his serene old age I
doubt if one ever saw him looking back to the remote
days of the past, and making comparisons unfavorable
to the present. It would not have been like him to do
so, for his life, so far as I have known it or could ascer-
tain, was one of charity and beauty. There is some-
thing about the physicians and surgeons of New York of
half a century ago, a subtle quality, which it seems to
me is not developed to the same degree with us. I do
not mean genius, though Mott and Parker and Kearney
Rodgers and others of our early confreres possessed that.
It may be that it was strong common sense, or some-
thing allied to it, a power of handling men and women
to advantage, a savoir-faire, and, perhaps, in our more
assiduous cultivation of science we have somewhat over-
looked that important qualification. Such a quality our
dear friend possessed to a considerable degree. In the
meetings of our Society how we shall miss him. He was
always present, always prompt in his attendance, genial
and wise in discussion, leaning toward the broadest
charity in the objects for which our Society is conducted.
Peace to his ashes ! His memory will long be fragrant
among us.
" 'His life was gentle, and the elements so mixed in
him, that nature might stand up and say to all the world,
This was a man ! '
A Centenarian. — A woman is now living in a Home
for the Aged in Sables d'Olonne, France, who was born
in 1 790, being, therefore, one hundred and four years of
age. She is in full possession of all her faculties and
receives daily a number of visitors, who are attracted by
the reports of her extreme age, entertaining them with
her lively conversation and witty repartee.
The Bieyele for Women. — The bicycle has become
the fashion even for women, and the following wise ad-
vice should prove of interest to physicians. Dr. Laura
Liebhardt, in discussing before the Colorado State Medi-
cal Society the question of bicycle exercise for women,
declared that "the majority ride with the saddle too
low," and that this is responsible for cramping of the
chest, straining the back, and impeding full action of
the muscles of the leg. There results a constant tension
of the muscles above the knee, which gives a short, awk-
ward stroke, as the reach is too short. The seat should
be amply high for the entire leg to be extended and give
to these muscles a second of relaxation on the downward
stroke of the pedaL The knee must have perfect free-
dom, and in this respect a woman finds herself particu-
larly handicapped, as she is unable to make the entire
stroke with the action of the knee limited by a dress
skirt. In Paris they do not stop with the unsightly
bloomers, but have almost universally adopted the prac-
tical, yet far too radical, knickerbockers. This striking
costume attracts but a passing notice, for the rationale of
it all appeals to the French mind ; but as we have fortu-
nately not yet reached the Parisian standard, it is to be
hoped that knickerbockers will confine themselves to
spins in the mountain?. Wheelwomen also subject them-
selves to needless jars by jumping instead of gliding from
the wheel. They should be taught to mount and dis-
mount from either side as men are wont to do. Corsets
on the wheel, as elsewhere, should be denounced in the
strongest terms, although nearly one half of all wheel-
women tie up their muscles in this barbaric fashion.
Many condemn cycling on the ground that the move-
ments are identical with those called forth in running a
sewing-machine. Machine- running stimulates more the
faulty way of wheeling, and the position is almost iden-
tical with that assumed when the handle-bars and saddle
are placed too low. In wheeling there are a greater va-
riety of movements and less tension. Two- thirds of all
women who ride wheels foolishly incur great risks by
riding during certain periods, even to the extent of hill
climbing, when they should never mount a wheel, ex-
cept for short distances, during the first two days. Dur-
ing the discussion the general opinion seemed to be that
the saddles in use were hardly proper. The long, wide
saddle suspended between springs was considered very
much superior to the rigid or hard models. A saddle
much wider throughout was considered desirable, and
cases were quoted to substantiate this claim.
Signs of Death. — A correspondent of The Lancet
writes that he was called to see an old lady who was be-
lieved to be dead, but whose appearance was so lifelike
that the family dared not bury her until they were abso-
lutely certain that death had actually occurred. To
quiet their apprehensions the physician applied a series
of tests with more or less confusing results. The follow-
ing were the tests in the order in which they were ap-
plied : 1, Heart-sounds and pulse — absent ; 2, respiration
i6o
MEDICAL RECORD.
[August 4, 1894
— absent ; 3, temperature of the body 60 ° F., the same
as that of the atmosphere of the room ; 4, a needle left
for some time in the substance of biceps muscle showed
no signs of oxidation ; 5, electricity — no response to elec-
trical stimulation of the muscles ; 6, a ligature tied about
the arm caused no swelling of the veins below ; 7, upon
opening a vein the blood was found to be fluid ; 8, the
subcutaneous injection of ammonia gave rise to a dirty-
brown stain, said to be indicative of commencing decom-
position of the tissues ; 9, cautious movements of the
joints revealed a slight stiffness of rigor mortis; 10,
upon holding the hand up against a powerful light, the
red line of light between the fingers was as distinct as in
the case of a living person; 11, the temperature of the
room was raised, and when evident decomposition had
set in the woman was pronounced dead.
Hyperpyrexia. — Dr. Richet reports a case of intermit-
tent fever in a woman in which the temperature rose one
day from 1020 in the morning to 1130 F. in the evening.
On two other occasions the fever rose to 1150. Under
the influence of quinine the temperature fell to 970, but
rose again to 1150 F., when the remedy was discontinued.
The patient finally recovered.
Explosive Compounds. — A Parisian lecturer in speak-
ing of the dangers of polypharmacy enumerated explosion
as one of them. He had collected several formulae of
this anarchistic quality, among them being a liniment of
tincture of iodine and turpentine, another a mixture of
chromic acid and glycerine, and a third a tooth-powder
composed of pulverized charcoal, cinchona bark, and
chlorate of potassium.
Diseases of the Eeotum Our esteemed friend, Dr.
Baudoin, of the Progres M&dical, takes an interest, and a
very intelligent one, in medical matters in this country.
He is doing a good work in correcting some errors and
misapprehensions concerning America which our French
confreres entertain, and deserves our gratitude therefor.
Some of our customs, however, strike him, not unrea- '
sonably, as peculiar, if not amusing. Among^ these is
the multiplication of specialties, in which he thinks we
have gone ahead even of our English cousins. The spe-
cialty of rectal diseases is one that recently engaged his
attention, and he has very kindly attempted to provide
its professors with a name. He thinks they might be
called rectists, after the analogy of oculist and aurist, or
better perhaps, because longer and more sonorous, proc-
tologists. The Quarfsrly Journal of Proctology would
be an excellent nam6 for our esteemed contemporary by
the Falls of the Ohio.
The Hew French Medical Law.— The new law regulat-
ing the practice of medicine in France came into force on
December 1st. As inquiries are frequently made as to
the conditions under which foreign doctors may practise
their profession in France, the following explanation of
their position under the new law may be of interest.
We give it on the authority, and almost in the words, of
the Journal des Connaissances Mtdicales, the editor of
which is Professor Cornil, a member of the French Sen-
ate, who was president of the committee which drafted
the law, and who, in fact, may almost be described as its
author. The new law has taken away the power formerly
possessed by the Government of authorizing medical men
having foreign diplomas to practise in France. Under
the new law no one is allowed to practise unless he pos-
sesses a French diploma of doctor of medicine. Certain
facilities may, however, be granted, according to the cir-
cumstances of the case, to foreign doctors wishing to ob
tain a French diploma. What these are maybe gathered
from a circular letter which the Minister of Public In-
struction has lately addressed to the rectors of the medi-
cal faculties throughout France. The periodical registra-
tions required of French medical students may be partly
or totally dispensed with, but exemption from examina-
tion can never be more than partial. In no case shall
candidates be exempt from examination in more than
three subjects. Such exemption as may be allowed will
be granted by the minister on the advice of the faculty
of medicine before which the candidate wishes to pre-
sent himself, and of the Consultative Committee of Pub-
lic Education* In considering applications the faculties
must concern themselves solely with the value of the di-
plomas and scientific works submitted to them by candi-
dates. The provisions apply to French citizens who
have obtained a medical qualification in some other coun-
try as well as to foreigners, and, indeed, the Minister in-
structs the medical faculties to exercise special care in
weighing the claims of Frenchmen who, on the strength
of a foreign diploma, ask for exemption from part of the
tests which are compulsory in the case of their country-
men who go through the ordinary course at home. The
course to be pursued by an English medical man who
wishes to practise his profession in France is, therefore,
to select one of the recognized faculties — Paris, Montpe-
lier, Nancy, Lyons, Bordeaux, Lille, or Toulouse — and
submit to it his papers with whatever records of scientific
work or other claims to professional recognition he may
possess. He will then be informed in due course what
examinations he must pass before he is pronounced dig-
nus entrare in nostro dodo corpore. — The British Medical
Journal
A Swiss Paper relates that of the seven thousand physi-
cians who attended the Medical Congress in Rome, only
five hundred were invited to the garden party in the
grounds of the Quirinal, while there were present about
two thousand other persons, many of whom had found a
way to buy tickets at $10 each.
Phosphorus Butter.— Comby {Prat, des MaL des Enf,
1893) recommends the following prescription, a modifi-
cation of Trousseau's, for the preparation of iodo phos-
phorated butter, which may be used as a substitute for
cod liver oil in hot weather :
3 . Fresh butter 1 lb. \\ oz.
Iodide of potassium * gr. iv.
Bromide of potassium gr. xv.
Chloride of sodium 3ij.
Phosphorus gr. \.
About one-third of an ounce daily, spread on bread.
Greek Typewriting. — A lady in Cambridge announces
in the London medical journals that she is prepared to
typewrite Greek manuscripts. She will have plenty to
do when this is adopted as the official language of inter-
national congresses.
Insanity from Tea drinking. — In a report upon in-
sanity in Ireland, recently issued, attention is called to
the immoderate use of tea as a cause of mental disease
among the poorer classes. " While the moderate use of
properly prepared tea," the report states, "is regarded
as innocuous, or even beneficial, in its action on the ner-
vous system, its ill effects, when decocted or over-infused,
on persons who make it their staple article of dietary,
are dwelt on by almost all the resident medical super-
intendents in their several reports. Undoubtedly, the
method of preparation adopted, and the excessive use of
this article of diet, now so general among our poorer
population, tends to the production of dyspepsia, which
in its turn leads to states of mental depression highly
favorable to the production of various forms of neurotic
disturbance." The tea used is generally of an inferior
quality, and the method of preparation is to put a quan-
tity in the teapot early in the morning, and to allow it
to stew during the day, water being added as required.
The excessive use of tobacco, also, especially among the
young, is thought to contribute in a minor degree to
swell the statistics of mental failure.
A Hew Lip. — Dr. Berger has presented to the Paris
Academy of Medicine a young woman whose under lip
was restored by a graft taken from the arm. The new
lip presented a very natural appearance, the vermilion
border being almost perfect.
Medical Record
A IVeekly yournal of Medicine and Surgery
Vol. 46, No. 6.
Whole No. 1240.
New York, August ii, 1894.
$12.00 Per Annum.
Single Copies, 10c.
ftrtgitral Articles.
CASES IN GENITO-URINARY SURGERY.1
I. Excision of the Bladder for Epithelioma. II.
Excision of Tubercular Seminal Vesicles, Testes,
and Spermatic Cords. III. Implantation of an
Artificial Testis after Castration. IV. Vesical
Papilloma of Unusual Duration.
By ROBERT F. WEIR, M.D.,
nonssOR op sukgbxv, Columbia college ; surgeon to tub new vork
HOSFITAI, ETC.
Before presenting to you the cases of excision of the
bladder, a few prefatory words on the subject may, I
trust, be allowed.
Tumors of the bladder of a malignant character are
encountered in about eighty per cent, of neoplasms of
this organ. Tumors of any kind are very rarely situated
at the summit or on the anterior face of the bladder or in
the trigone ; but the region between the summit and the
mouths of the ureter, and especially on the posterior wall,
is the usual site of such growths. One-half of the cases
of carcinoma, however, invade one or both of the ureteral
orifices. Secondary growths occur quite late in the dis-
ease, though adjacent gland infection is not uncommon ;
but the latter are usually situated within surgical reach.
The mortality involving the removal of a carcinomatous
growth of the bladder reaches, according to Alberran, to
nearly fifty per cent. The usual method for removing
vesical tumors has been, until quite recently, that of expos-
ing the growth by suprapubic section of the bladder,
with its subsequent removal by the knife or scissors, the
surgical interference seldom going beyond the mucous or
muscular layers at the base of the growth. Recurrence
after this method of operation amounts to fifty-seven per
cent The method of a more heroic operation was in-
augurated first by Sonnenberg, in 1884, who then extir-
pated nearly the entire bladder, except the neck, trigone,
and ureteral orifices. The patient survived five weeks.
At the autopsy a new but comparatively small bladder,
formed of the remnant of that organ, and a modified
cicatricial tissue was found. A further step in advance,
however, was made in 1885, by Antal, who evolved a
procedure which has proved since of great importance in
connection with the surgery of this region of the body.
It consisted in the demonstration that the peritoneum
could be peeled off from the summit and posterior wall
of the bladder without very much difficulty. Since that
time a number of cases, nearly twenty in number, of re-
section of more or less considerable portions of the blad-
der walls outside of the limits of malignant growths have
been undertaken. The benefit that accrues from this
wider removal of a malignant growth is seen at once in
the diminished chances of recurrence after such operations.
From fifty-seven per cent., as already quoted as the
proportion of recurrences after the ordinary removal, it
has been diminished by this latter procedure to twenty-
eight per cent. With the encouragement afforded by
this improvement in the technique of the operation, sur-
geons have been led to undertake the removal of larger
and larger portions of the bladder, and even total abla-
tion of this organ has been successfully undertaken.
Bardenheur, in 1887, removed the whole bladder in a man,
1 Read at a meeting of the Practitioners* Society, held 1894.
aged fifty seven, for cancer of the base that involved the
ureters. This was easily accomplished, the peritoneum
peeled off readily, though considerable hemorrhage was
encountered as the neek of the bladder was divided.
This was readily checked by tamponing the parts.
Death, however, resulted on the fourteenth day from
uraemia. Two other extensive resections, though not
total ones, have since been reported by the same surgeon,
one of which has remained completely cured up to the
date of the last report, and one died five months later
from a recurrence of the disease.
The difficulty connected with such extreme operations,
aside from the immediate results of shock, etc., was
centred in the disposition of the severed ureters. Bar-
denheur, in his experiments on animals, endeavored to
solve the difficulties by implanting them into the rectum,
but in all the animals experimented upon death resulted
either from dilatation of the ureters, due to the contrac-
tion at the place of implantation, or a fatal issue ensued
in consequence of infectious pyonephrosis of rectal origin.
Tuffier, the French experimenter, also had the same re-
sult. Similar fatal results have occurred in the human
subject in nearly every instance where this implantation
into the rectum has been resorted to.1 In women, where
extirpation of the entire Madder has been twice resorted
to, the vagina has been used as a retentive sac for the
urine with some satisfaction; but in the male two other
methods have been suggested that are more worthy of
trial. Le Dentu, having accidentally wounded the ureter
in a gynecological operation, brought its kidney end to
the abdominal wall, where it was fastened by sutures.
The patient died on the thirteenth day. No urethral or
kidney changes were found. Pczzi had the same acci-
dent in an operation and resorted to the same expedient.
The patient recovered and uiinated through the abdomi-
nal wall for three months, when the discomfort of this
discharge demanded a nephrectomy, which was performed.
The ureter and kidney showed no abnormal changes.
While it is probable that in accidents of this nature, oc-
curring in the future, such methods of diverting the uri-
nary discharge will be but seldom resorted to, since the
union of a divided ureter has now been satisfactorily
proven to be capable of being accomplished by the
methods of Van Hook and Kuster, yet the results of the
abdominal attachment of the ureteral end have, in the
main, been encouraging. A better method than this,
however, exists. De Paoli and Brusachi have shown us, by
experimentation on animals particularly, that if a small
portion of the bladder should be left, let us say after ex-
tirpation of a tumor involving the ureteral orifices, the
ureters can be inserted into the portion of the remaining
bladder-walls, without subsequent contraction, by first
making an opening through the thickness of the bladder,
cutting away around this opening a small circle of the
mucous membrane, and then pushing through the opening
in the bladder wall the end of the ureter, having enlarged
the orifice of this by splitting it up a short distance, as is
usually done in the urethra in amputation of the penis,
and then stitching the ureteral mucous membrane to the
mucous membrane of the bladder. External to the blad-
der-wall this fixation is reinforced by other sutures. This
method is warmly indorsed by Guyon and Alberran, and
has been successfully resorted to in the human sub-
1 Chaput : Centrabl. f. Chirurg., No. 14, 1894, reports a case of im-
plantation of divided ureter into colon, with, five months later, no evi-
dences of renal infection.
162
MEDICAL RECORD.
[August iif 1894
ject by Penrose, of Philadelphia.1 Kummel, still bolder,
after removing the entire bladder in a woman, attached
the ureteral orifice to the vesical end of the urethra.
His patient, however, did not survive long enough to test
the value of this procedure. Novaro,* McArthur,* and
Baum have also implanted ureters into the bladder to re-
lieve utero-vaginal fistulas.
Another method has been suggested which is not so
attractive. It is based upon the fact that a ligature of the
ureter determines usually atrophy of the corresponding
kidney. It has, therefore, been suggested that in an ex-
tirpation of the bladder involving the ureteral orifice the
divided ureter be treated in this fashion.
This brief account of the methods of undertaking an
operation of this extent would hardly be complete without
a slight reference to the advantage claimed for the
enlargement of the operative field by symphyseotomy.
This section will permit of a separation of from six to
eight centimetres (two to three inches) and thereby the
lower portion of the bladder will be literally exposed.
From experiments upon the cadaver, as well as my ex-
perience on the living subject which is to be presently
related, I am convinced that this latter addition to vesi-
cal surgical procedures will rarely be needed. The
bladder can be removed, or rather that portion of it
usually involved in a neoplasm can be widely removed,
without much surgical difficulty, by the simpler measures
of peeling off the peritoneum, not only from its summit
and posterior walls, but from its lateral surface, aided
by the employment of the position of Trendelenburg.
My first experience in the removal of a considerable
portion of the bladder, and the ease with which the
peritoneum can be lifted from that organ, occurred in
1891, when a man, fifty-nine years of age, was admitted,
in the month of December, to my wards in the New
York Hospital, with a history-that eighteen months pre-
viously blood had appeared in his urine, which after an
interval of several months recurred and persisted up to
the date of his entrance into the hospital. He had but
slight pain in the bladder, with moderately frequent urina-
tion. The urine was more or less persistently bloody,
without evidence of renal disease or sugar. No stone
was found in the bladder by sounding ; the prostate was
normal in size ; bimanual examination gave negative re-
sults. A cystoscopic examination, under an anaesthetic,
revealed two tumors on the posterior wall, the right one
a little larger than the other. On December 26th, with
a Petersen bag in the rectum, into which was injected six
ounces of water, and with seven ounces of Thiersch's solu-
tion injected into the bladder, the patient placed in Tren-
delenburg's position, by a three-inch incision in the me-
dian line the bladder was exposed, the preperitoneal fat
" clawed " up from the pubes toward the umbilicus, and
the bladder then opened by a vertical incision. The lips
of this incision were held apart by silk ligatures. A single
tumor, the size of the distal phalanx of the thumb, was
found on the upper part of the posterior wall, somewhat
to the right of the median line. To effectually get be-
yond the growth the peritoneum was stripped off from
the summit and the posterior surface for a space reaching
from one seminal vesicle to the other and down nearly to
the prostate. In so doing, at one point a rent was made in
this membrane, but this was promptly sewn up with silk
sutures and gave rise to no further inconvenience. A
triangular portion, including the tumor, but going widely
from its base, about two and a half inches on each of its
sides, was finally removed from the posterior wall of the
bladder. As I found considerable difficulty in closing by
sutures the lower angle of the space thus formed in the
bladder-wall, I abandoned the attempt to close any por-
tion of the bladder, believing this to be safer for the pa-
tient. Iodoform gauze was therefore packed between
the bladder and the peritoneum, the bladder itself filled
with iodoform gauze around a rubber catheter passed to
» American Journal of the Medical Sciences, April, 1894.
* CentralbL f. Chirurg., No. 27, 1893.
» Trans. 111. Med. Soc., 1889.
&Hi of
Excision
Fig. z.
the bottom of the organ and the drainage accomplished
in this way, and by ordinary antiseptic dressings applied
over the wound in the ab-
dominal wall. The patient {Turner
did well, his wound very
nearly closed; but on Feb-
ruary 19th he was attacked
by erysipelas and died four
days later, seven weeks after
the operation. At the au-
topsy it was seen that the
suprapubic wound had very
nearly healed, the gap in the
bladder on its posterior wall
had closed over by a smooth
cicatricial surface, and ev-
erything promised well if
life had continued longer.
This line of excision of the bladder- wall is well shown
in Fig. 1, which accompanies this.
I. Excision of the Bladder for Epithelioma. Case I.
Epithelioma of the Bladder ; External Resection of the
Bladder-walls. — A man, aged fifty -five, entered the
New York Hospital, February 25, 1893, ^th ^
history that in August, 1891, he began to pass blood
with his urine. This persisted with every act of micturi-
tion for several months, when it stopped for four months
and then recurred. Other hemorrhages at much less in-
tervals took place, until April, 1892, when a suprapubic
cystotomy was done by Dr. Park, of Buffalo, and two
tumors removed from the bladder, one the size of a wal-
nut, and the other no larger than a bean. A fistula con-
tinued for a considerable time, but was healed at the end
of fourteen weeks.
In September, 1892, another hemorrhage occurred,
and since that time blood has at irregular intervals ap-
peared in the urine. On examination there was found
in the abdominal wall, just above the symphysis, in the
cicatrices of the previous operation and at its upper part,
a tumor the size of an English walnut, elevated above
the surrounding skin and reddened on its surface with an
indurated area surrounding its base about two inches in
diameter. A cystoscopic examination, made by Dr.
William K. Otis, revealed a tumor on the postero supe-
rior wall of the bladder. There were some enlarged
glands of a superficial character in each groin.
On March 1st, under ether, with a rectal distention
by a double Barnes bag containing eight ounces of water,
Skin
Lint of /
IncisiavL.^
^>Twnot&
Fig. ».
and a vesical distention brought about by the injection
of six ounces of Thiersch's solution, two curved vertical
incisions in the abdominal wall above the symphysis were
made, and surrounded the growth, which was readily
separated from the muscular tissues and was found event-
ually to be attached to the summit of the bladder. The
peritoneum was then pealed off by a blunt dissector, aided
by light cuts from a scissors, from the posterior wall of
the bladder down to the prostate, and on each side as far
as the seminal vesicles. This whole exposed portion of
the bladder was excised, including a papillomatous growth
August ii, 1894]
MEDICAL RECORD.
163
in its centre as large as a walnut, as well as the growth
rising out from the summit of the bladder (see Fig. 2).
The section of the bladder- walls passed at least from one-
half to three quarters of an inch beyond the growths in
all directions. The bladder was sewn without difficulty
from the bottom with interrupted catgut sutures, which
were purposely passed through all its coats ; and in one or
two places on its summit with silk-worm gut introduced
only through its muscular coat for additional support A
small opening was left toward the pubis, through which
was passed a Guyon double rubber-tube drain. The
wound in the abdominal wall was packed with iodoform
gauze and its upper end united by silk-worm-gut sutures.
Sterilized dressings were applied. The patient did well
after the operation, leaving the hospital eight weeks
later all healed, holding his water from three to four
hours. The capacity of the bladder was from four to
five ounces. About two weeks after the just-described
operation of exsection of the bladder, the glands in each
groin were also extirpated. A microscopic examination
in each of these two cases of resection of the bladder
showed the neoplasms to be epitheliomatous in character.
II. Double Castration and Complete Extirpation of
the Vesicals Seminales and Yasa Deferentia for Tuber-
culosis. — Germane to the foregoing subject of excision
of the bladder is the experience obtained in extirpating
the seminal vesicles. Every surgeon has been s.t times
disappointed, in practising the operation of castration on
one or both sides of the testes affected beyond salvation
by tubercular invasion, at his inability to divide the vas
deferens at a height satisfactorily beyond the reach of the
disease, even when this is apparently of testicular origin,
and is too often compelled to leave the stump of a
diseased cord in the wound, hoping that, as happens
elsewhere, nature's resisting powers may overcome the
probable small quantity of tuberculous material left.
All the more is this dissatisfaction increased when
he finds either that a tubercular knot exists at the same
time on the corresponding side of the prostate, or possi-
bly that a similar involvement can be detected in the
seminal vesicle of that side. It is only comparatively
recently that endeavors have been made with any en-
couragement to more radically rid the patient of his en-
croaching disease. Bungner l has advised that in castra-
tion the vessels of the cord should be separated at :he
inguinal ring from the vas deferens, duly ligated and
severed, and that traction should be then made upon the
vas deferens to such a degree that it would tear across
oftentimes at a considerable distanc 1 beyond the inter-
nal ring. This, however, is an uncertain procedure, and
while it is not attended with any risk it does not com-
pare in exactness or thoroughness with the methods that
have previously been suggested by Roux, of Lausanne,
or Villeneuve, of Marseilles. The latter advised that in
such cases the incision, for the castration should be ex-
tended in the abdominal wall up to and beyond, if nec-
essary, the internal ring, and down to the peritoneum,
which could then by the finger be separated from the
lateral walls of the bladder, using the tautened vas d f
erens as a guide until the top of the seminal vesicle was
reached, when the vas deferens could be divided and ex-
tracted. Roux suggested in these cases, where the pros-
tate or the vesicular seminales were involved, that a
semicircular incision should be made parallel to, and an*
terior to, the anus, and through this the rectum separated
from the prostate; and if the seminal vesicle was in-
volved, that at the base of the prostate a transver e inci-
sion should there be made in the fascia covering of the
seminal vesicles, whereupon this portion of the genera-
tive apparatus could then be readily peeled off from the
bladder and removed, when the castration, either pre-
viously begun or now undertaken, could be completed
after the separation and ligation of the vessels, by mak-
ing traction upon the vas deferens, when it ^ould come
out its entire length like an earthworm from its hole
without any further risk to the patient. The following
1 Centralbl. ftir Chirurg., No. 46, 1893.
case, in which this procedure was resorted to, will illus-
trate the ease, if not the efficacy, of this manoeuvre.
Cask II. Tuberculosis of Testicles, Prostate, and Sem-
inal Vesicles. — Ferdinand R , aged twenty- eight,
was admitted to the New York Hospital, October 1 9, 1 892,
with the history that he had had " inflammation of lungs ' '
when a child. When fourteen to sixteen years of age
had enlarged cervical glands, which did not suppurate.
Four years ago had gonorrhoea for six months ; a year
later a second attack. Some gleet noticed at times ever
since. Six months ago the left testicle was noticed to
be swollen to size of an orange. It became very tender
and painful. Treatment by cold and rest reduced it one-
half, which size persisted. He then suffered great vesi-
cal irritability, urinating every few minutes, noticing a
few drops of blood at meatus afterward. Two months
later right testicle was similarly affected, both testicles
remaining the same size for the past three months. Ves-
ical irritability less for two months, micturition every
hour. General health good. No tubercular family his-
tory.
Admission: Urine yellow, acid, 1.010, trace of albu-
min, pus, and blood.
Examination. — Epididymis on each side swollen,
globus major and minor enlarged, hard mass between
them. Each epididymis tender on firm pressure, skin
not adherent. Both cords enlarged, right more so.
Right seminal vesicles much enlarged, a nodule also felt
in right side of prostate. Tubercle bacilli found in
urine, but only when pressure per rectum was made in
the rectum on the prostate.
The seminal vesicle and prostate were therefore con-
sidered the foci of disease, and in the hope that relieving
the patient of these the bladder might be spared perma-
nent invasion a radical operation was advised and prac-
tised. Under ether an incision was made on right side
from lower part of scrotum carried up over inguinal canal.
Testicle and cord exposed and separated from speimatic
vessels at internal ring. Testicle softened in places and
showed several cavities filled with pus. Cord apparently
normal. Fascia of external oblique muscle cut through
over canal and cord, vessels separated as high up as possi-
ble, ligated, and cut. Here peritoneum was accidentally
opened about three fourths of an inch. This was closed
by suture. This rent was made in an endeavor to sepa-
rate the peritoneum from the lateral aspect of the bladder,
following the course of the vas deferens, as suggested by
Villeneuve; but it was not an easy thing to do, and in
carrying it out, as said before, the peritoneal cavity was
entered. In the left side an incision was made exposing
the testicle and cord, which were separated from the
vessels well up into the canal, vessels ligated and cut.
The testicles, free from the scrotum, but attached to
their cords, were left hanging at the internal rings.
Roux's operation was then chosen to follow, with patient
in lithotomy position A. Curved incision starting at
one side of anus was carried anteriorly to other side,
allowing the anus and rectum to fall back. Incision
carried up until prostate and bladder-wall were exposed.
Here the dense fascia binding down the vesicles to the
bladder was cut through transversely, giving ready access
to the ampulla of the vas- deferens and the seminal vesi-
cles. Right seminal vesicle found dissected free from
bladder and removed, also the affected portion of the
prostate, and subsequently the other vesicle. Both cords
with testicles and whole length of the vasa deferentia
were drawn out in front from the castration wounds in
scrotum. Then the fascia of external oblique was sut-
ured with catgut over a gauze drain. Skin closed with
catgut, similarly the incision on left side was treated.
The perineal wound was packed with iodoform gauze and
sutured with two sutures on either side of anus. Wet
dressing. Reacted fairly well.
The subsequent history of the patient was in brief that
for the first four weeks urination improved and the
tubercular bacilli disappeared, but this amelioration was
due to the effect of a small fistulous track that resulted
1 64
MEDICAL RECORD.
[August ii, 1894
from the wound in the prostate, and which persisted
for nearly seven weeks. After its healing the bladder
irritation increased, and injections every second day of
ten per cent, iodoform in starch or glycerine were re-
sorted to for some time with benefit. He passed then
from observation. The scrotal and ante-rectal wounds
healed satisfactorily.
III. The Implantation of an Artificial Testis after
Castration. — A case little less serious than those fore-
going is the attempt made to replace a testicle lost by
the operation of castration. A man, thirty-seven years
of age, who had had for nearly two years a tubercu-
lar involvement of both testes, the right being most se-
riously affected, was compelled by the advance of his dis-
ease to submit to castration. The left testis, being less
diseased, was saved by a process of scraping and packing
with iodoform gauze.
When before the operation I announced to him that
the right testicle was so much damaged that its loss
would be likely to ensue, he begged most piteously that I
should not remove the entire organ. This request I en-
deavored of course to comply with, but found it impos-
sible to do so ; but at the completion of the castration in
the ordinary way I was enabled to relieve his mental anx-
iety by resorting to an expedient which experience in
other directions had led me to believe might be success-
ful here, and that was tcf implant into the cavity of the
scrotum left vacant and surgically clean by the thorough
removal of the diseased parts, a ball of celluloid duly dis-
infected. This, about an inch in diameter, was placed in
the former site of the testis, and the skin drawn over
and properly sutured. Healing followed promptly and
without any difficulty, and the patient has now worn
this artificial testicle since May, 1893, with a content-
ed mind and proud yet of his virile powers. I was led
to this procedure, from two or three successful attempts
to use celluloid in overcoming defects and deformities.
Two years before, I had an opportunity of covering a de-
fect of the skull, produced by a compound depressed
fracture, by inserting in the space left after the removal
of the depressed bone fragments a thin plate of celluloid
one and a half inch by an inch in diameter. This has
remained in situ without any disturbance to the patient
since then. The little lad, the subject of this experi-
ment, has been already shown to you, but I beg to pre-
sent him again for inspection. The idea of using cellu-
loid as a material to replace bone or cartilage defects
originated in the Vienna school with an assistant of Bil-
roth by the name of Fraenkel.1 Since then it has been
resorted to a number of times for this particular defect in
the skull, and of late for defects elsewhere. It has been
applied, for instance, to replace a loss in the tarsal carti-
lage of the eyelid. It has also been applied to remedy
the removal of the edge of the orbit, and thus aid in
keeping the eyeball in position. It has been, moreover,
used, even immediately after resection of the superior
maxilla, in every case with advantage. Very recently I
have utilized it in three instances to overcome a deform-
ity of the nose from sunken cartilages, for the purpose
introducing a portion of the celluloid suitably shaped
to suit the different deformities ; placing the support in
position either from without through a small incision,
or better still, from within the nostril. The sugges-
tion of this way of overcoming a very troublesome nasal
deformity was made by Dr. Lewis A. Stimson, who
employed for this purpose either gutta-percha or alu-
minum. In my judgment, however, celluloid is a mate-
rial much better borne by the tissues than either of the
two substances just mentioned.
Following the example set forth in the case just re-
lated, I understand that another testis has been artificially
supplied, or simulated by a celluloid one, by my friend
Dr. Guiteras, in a case shortly to be published, and also
by Dr. Hartley in a recent case.
IV. Vesical Papilloma of Unusual Duration.— The
1 See Wiener klin. Wochenschrift, No. 25, 1890, No. x6, 1891, and
Frey, No. 3, 1893.
last case that I shall venture to bring to your notice, in
connection with genito urinary surgery, is one of a tumor
of the bladder, which, occurring in a man of fifty-two
years of age, possesses the points of interest presented
briefly as follows :
1. That it had existed for an unusually long time, for
the history showed that the bleeding had persisted off and
on for a period of thirty-seven years. This is beyond the
duration of the longest period mentioned by Guyon or
Alberran, which was in two cases respectively thirty and
thirty- one years.
2. That the diagnosis was made most satisfactorily in
this instance by the employment of Guyon's method,
viz., the urination of the patient into three glasses, in
the last of which the most and freshest blood was found*
Also, as a corroboration, that, after washing out the
bladder, a bimanual examination was made, the catheter
being left in situ, by which manoeuvre fresh blood was
pressed out in small quantities through the catheter, or
else was washed out of the catheter after it was withdrawn.
3. That in this case a cystoscopic examination failed
to reveal the existence of the growth. This investigation,.
I may add, was made at the hands of one who was partic-
ularly expert in the use of this instrument.
4. And what is, after all, of the most clinical impor-
tance, was that the tumor — a papilloma about one inch
and a half in length and one quarter of an inch in diam-
eter, and quite fibrous in character, with fringes on its
free ends — was situated just above and to the right side of
the meatus internus urinarius.. This tumor was detected
in a very ready manner after the suprapubic section had
been made, by the insertion of a large Ferguson's glass
vaginal speculum. This idea had been suggested by
Fenwick, of London, who used such a speculum as a
sort of caisson, even with the bladder more or less filled
with water or urine, in which case the speculum was to be
passed to the deeper part of the bladder, the imprisoned
water soaked or wiped out, and the bladder thus exposed
carefully inspected. I found it better, however, to wipe
out the bladder as well as possible, then introduce the
speculum and sweep it along the walls of the viscus ; and
in this instance, before very long was able to recognize
the tumor in the situation just described. Through this
same speculum, which was about one and a half inch
in diameter, I could and did seize the tumor with a for-
ceps and with a curved scissors cut it off, and then with
a Paquelin cautery lightly touched its bleeding surface,
and finally packed upon the wound, from which the
blood did not entirely cease by the light cauterization,
a wad of iodoform gauze and hold it there firmly until
all hemorrhage was checked. The whole procedure an-
swered so well these various ends that I beg to commend
to your notice the serviceability of this method of exam-
ination and operation. It commands a ready view of
the whole of the bladder in its lower and posterior parts,
which parts are most affected by growths. It enables one
to readily recognize the mouths of the ureter, and to pass
into them, if necessary, instruments for their further ex-
ploration, etc.
The bladder in this instance, after removal of the tu-
mor, was sewn snugly together, and the abdominal wound
left open. The patient made a prompt recovery, with a
very trifling leakage for eight days, and has remained
well since.
The tumor was a papilloma with a heavy fibrous
stroma.
The Czar gave the physician who treated him during
his attack of pneumonia last winter the sum of $30,000.
A Hew Hanging Machine is to be put to the practical
test soon in Connecticut. It is so constructed that the
weight of the condemned criminal stepping on a platform
sets in motion the necessary machinery for his suspen-
sion. Some people protested against its use on the
sentimental ground that the man hanged would be vir-
tually a suicide.
August ii, 1894]
MEDICAL RECORD.
165
A MODERN IDEA IN SCIENTIFIC MEDICINE.
By JOHN AULDE, M.D.,
PHILADELPHIA, PA.
The claim has been put forward, and not without show
jof reason, that the science of medicine lags behind the
other sciences, and that in consequence of this backward
condition not only is the average length of life less than
it should be, but also that there is an augmentation of
the total sickness. Admitting that preventable diseases are
Car too common, and hence, as a matter of course* the na-
tional vitality lowered in proportion, it is still doubtful if
the charge above quoted is entitled to stand, since the
fact is patent that much has been accomplished, even
within the past decade, to alleviate human suffering, to
control or modify disease, and to prolong life. It would
be foreign to the purpose of this article to take account
of numerous and substantial advances effected in this
direction, since its object is to direct attention to a mod-
ern idea in scientific medicine which gives promise of
working a revolution in methods of practice ; an idea
which involves new and important principles concerning
our conception of the phenomena of life itself.
. This modern idea, however, is not founded upon spec-
ulative investigation, for the facts it embodies and the
conclusions upon which it rests have long been recog-
nized by intelligent physicians on both sides of the At-
lantic. The novelty consists merely in the arrangement
of these facts, deductions, and conclusions which neces-
sarily lead up to this new departure in the domain of the-
rapeutics. Indeed, in the light furnished by our knowledge
of life, chemistry, experimental physiology, pathology,
and clinical observation, the truths here to be recorded
point to the pressing need for radical changes in methods
of treating disease.
Neither does it fall within the province of this paper to
criticise or expatiate upon the more recent plans that
have met with the approval of the foremost physicians
throughout the country. Suffice it to say that the facts
presently to be brought forward were practically incon-
ceivable without the knowledge recently acquired relat-
ing to antisepsis.
By way of recapitulation, and as a preliminary to the
following remarks, it should be stated that although a
period of thirty -five years has elapsed since Professor Vir-
chow, the eminent scientist, published his memorable
treatise upon "Cellular Pathology/1 but little, com-
paratively speaking, has been accomplished since that
time. Professor Virchow studied, and later depicted,
the retrograde changes occurring in the microscopic cell
from disease ; but no one has thought it worth while to
study and depict the nutritional changes taking place in
the living cell as a result of medication. The conse-
quence is, therefore, that very many remedies are given
on a speculative basis. True, a considerable number of
the medical profession now claim to practise what is
termed " rational1' medicine, as contra-distinguished
from empirical medicine; but when the question is
asked as to the precise influence which remedial agents
have upon nerve cells and upon protoplasm, no one can
be found competent to answer.
For example, enthusiastic claims have been made for
electricity, and we have in the State of New York, at
least, the anomalous spectacle of the same agent being
used both to kill and to cure. And when it is considered
that no systematic, thorough, and complete physiological
investigations have been made with a view to determine
the effect of this powerful agent upon the microscopic
cell, we may well pause before accepting literally the
conclusions of its active supporters. This reservation is
not pressed by reason of an absence of clinical results,
but rather for the reason that exact knowledge is still
wanting.
However, this method of study has recently attracted
the attention of the medical profession through the re-
ports of Professor Hodge, of Clark University. This in-
genious experimenter found, on exposing the nerve-cells
of honey-bees and pigeons to the stimulating effects of
the electric current, that certain appreciable changes oc-
curred ; but when the action was long continued, or the
current strength was increased beyon<j[ a variable point,
no characteristic change took place.
The experimental evidence undertaken with a view to
determine the physiological effects of remedial agents
upon the human economy points to the fact that the
true therapeutic value of a drug is by no means to be
measured by the mechanical effects produced, and it is
to be regretted that the disposition to study results rather
than methods and principles has found favor with the
profession, because of the vicious circle of reasoning set
up and the unstable foundation it affords. It is this cir-
cumscribed medical horizon which has so seriously han-
dicapped the present generation of physicians. In sur-
gery the conditions are different, since the results at-
tending the use of antiseptics naturally developed the
principles upon which antisepsis depended, and thus a
foundation was firmly established for asepsis, or the
treatment of wounds by exclusion of the septic material.
The rational, treatment of disease should be based upon
a knowledge of the effects which medicinal substances
produce upon the functions of the cell ; and since the
cells in different portions of the human economy have
special functions to perform, and therefore vary in
their structure, it follows that no one remedy is likely to
affect all cells in precisely the same manner. It must be
evident, therefore, to the most superficial observer,
that the rational treatment of disease should be based
upon the therapeutics of the cell ; and to be efficient
we must consider the effects of drugs which are seen as
well as those which are unseen, as there is no doubt in
the minds of clinicians that metabolic changes occur
which are beyond our power to demonstrate or compre-
hend.
The remarkably favorable results attending the use of
cold baths alone in typhoid fever furnish evidence that
the economy, unaided by medicines, can withstand and
finally eliminate the poison of this disease, and to the re-
flective mind it shows that the ability to resist disease
depends upon the integrity and function of the cell — cell
metabolism. Indeed, in view of the large mortality in
this disease treated by the routine method as contrasted
with the low percentage of fatalities with the bath treat-
ment, we are almost forced to the conclusion that medi-
cation has been responsible for more deaths than recov-
eries.
Mercury and arsenic may be selected to represent the
effect which poisons have upon metabolism (tissue-
change). Being foreign substances and distributed over
the system through the blood and lymph, the organism
is intent upon their elimination because they are proto-
plasmic poisons. While we may trace the former to the
liver principally, and the latter to the pulmonary struct-
ures or the skin, where they are finally eliminated, their
elimination, when given in medical doses, is always at-
tended by more or less cellular activity beyond the nor-
mal— usually spoken of as inflammatory action. Where-
ever found, they act as protoplasmic poisons, and it is
this property which gives them their therapeutic virtues
— when properly administered.
Cellular therapy is concerned in promoting stimulation
without irritation and subsequent depression, which is ac-
complished by selection of the proper remedy and regu-
lation of the dose. It should be borne in mind that both
substances mentioned are active poisons, and that how-
ever administered this peculiarity remains, ;'.;., the min-
imal dosage lessens the degree of toxicity, but produces
no change in the action, although it modifies the effect.
Now, to illustrate the underlying principle of the mod-
ern idea which I wish to develop, suppose a physician
desires to relieve some chronic cutaneous ailment; he
administers arsenic either because he knows it is " good "
for such cases, or for another, apparently better, reason,
namely, because he is aware that the drug is largely
eliminated by the skin, and that through this process of
1 66
MEDICAL RECORD.
[August ii, 1894
elimination cellular activity will be increased^ Still,
this latter reason is extremely unsatisfactory, since it
lacks definiteness, and besides, the claim will be set up
that it would be a contradiction of physical laws to as-
sume that protoplasmic poisons will stimulate the action
of organic cells whose constituent elements are princi-
pally this peculiar substance. It will be asserted that a
disordered condition of the cutaneous structure means a
debilitated or exhausted state of the protoplasm compos-
ing the cells, and that whether we consider the physical
or nervous mechanism concerned in promoting their
activity, it would be equally unfortunate to expose them
to the disturbing and depressing influence of a rank
poison.
This process of reasoning, however, can easily be set
aside as fallacious, since clinicians well know the stimu-
lating effects of arsenic in all cutaneous affections. The
scientific explanation appears to be that as all poisons
are irritants, the degree of irritation may be so modified
by dosage that the irritation is limited to that of mild
stimulation. Thus, the prick of a pin is stimulant, while
the stab of a bowie-knife may prove fatal.
The idea of treating diseased conditions of the human
organism by the exhibition of medicaments which tend
to the restoration of the function of the cells in the part
affected is a very seductive one, but its practical adapta-
tion is attended with difficulty. The obstacles in the
way of its tentative employment in many diseases, how-
ever, are not insuperable, owing to our knowledge con-
cerning the physiological action of drugs. Thus, a drug
which is eliminated through the skin, kidneys, liver, or
pulmonary apparatus, will usually increase the functional
activity of those structures,' necessarily through augmen-
tation of cellular activity. But there is a limit to stimu-
lation thus produced, because when the dose is large, or
the remedy long continued, the initial stimulation will
be followed by depression. The basis, therefore, upon
which cellular therapy rests, is that of stimulation with-
out irritation, which can be accomplished by the selection
of the proper remedy and regulation of the dose.
This brings us to consider the vis medicatrix natures as
a factor in resisting disease, really nothing more than a
supposititious entity until within the recent past, when we
have begun to fathom the mystery of cell function and
cell-life.
In order to render comprehensible what follows, it will
be necessary to recapitulate some of the more important
conditions dependent upon cell function essential to the
enjoyment of health ; and this will afford, by reflection,
a bird's-eye view of the so-called vis medicatrix nature*
as it is now understood. To maintain good health a
person should have a sound digestive apparatus. This
trite observation has more significance than would appear
at first sight, owing to the important changes which oc-
cur after the ingestion of food, changes besides those
incident to the conversion and absorption of the differ-
ent kinds of food- stuffs. Reference is had to " digestive
leucocytosis " — we may call it a vital process — a phe-
nomenon characterized by the rapid multiplication of the
white blood-corpuscles, a peculiarity which was also noted
by Professor Virchow. Slightly modified, many of these
leucocytes become active agents in the destruction of
micro-organisms and their products. They enact the
role of scavengers, and are freely distributed throughout
the system along with the red blood-copuscles which
cany oxygen to every part.
By way of digression, it may be mentioned that this
function of the red blood-corpuscles is essential to the
welfare of the tissues. The oxygen is taken up by the
protoplasm, which in turn gives off carbonic acid and
other waste-products, and loaded with this burden the
little cells return to the lungs, discharge their cargo, and
again take a new supply of oxygen. It is unnecessary
to dwell upon this peculiar and interesting function,
known as internal respiration, except to note, in passing,
the use made of the oxygen by the protoplasmic cells.
In the first place, they act as storage-tanks, giving off
the gas as required to keep up the functional activity
(combustion) ; in the second place, they can convert this
gas into ozone, which is far more active than the oxygen
itself.
The presence of oxygen in the blood, in the proto-
plasm, and in the intercellular fluids is not in itself suffi-
cient to maintain the tissues and fluids of the body in a
thoroughly antiseptic condition, owing to the active
tissue-change, along with the production of waste products.
It remained, therefore, to discover the causes at work
which enabled the system to resist disease, and scientists
have been richly rewarded by their investigation of the
function of the white blood-corpuscle. From present
indications this discovery promises to become the miss-
ing link in the so-called vis medicatrix natura, as will
presently appear. More than ten years ago Professor
Metschnikoff taught that leucocytes or phagocytes per-
formed an important service to the human organism,
namely, that they enveloped or surrounded bacteria and
destroyed them as well as bacterial products. Within
the past year, however, several scientists have demon-
strated that leucocytes, through their nucleus, produce a
phosphorized proteid termed nuclein, which possesses
active germicidal properties. These researches covered
not only the test-tube observations, but experimental
studies upon animals, and showed conclusively that solu-
tions of nuclein employed in seasonable time would con-
fer immunity against disease, and thus a new factor was
added to the modern idea of cellular therapy, that of
nuclein therapy.
The development of this modern idea in scientific
medicine, as will be apparent from the foregoing brief
sketch, is but a question of time, since it hinges alto-
gether upon actual facts, speculative hypotheses being
kept entirely in the background. Even now, clinicians
and experimental physiologists are earnestly at work in
the expectation that they can further advance the art of
healing, and doubtless, ere long, we shall have the satis-
faction of asserting that practical medicine is really in
fact, as well as in name, scientific medicine.
14x1 Walnut Street, Philadelphia, Pa.
REPORT OF COMPLICATED CASES INVOLV-
ING UTERUS, TUBES, AND OVARIES,
TREATED SUCCESSFULLY; WITH A PLEA
FOR CONSERVATIVE SURGERY IN DEAL-
ING WITH THESE APPENDAGES.
By PAUL OUTERBRIDGE, M.D.,
ATTENDING GYNECOLOGIST AT NEW YORK CANCER HOSPITAL ; ACTING ATTENDING
GYNECOLOGIST AT WOMAN'S HOSPITAL OP NEW YORK ,* ATTENDING PHYSICIAN AT
NEW YORK LYING-IN ASYLUM ; ATTENDING GYNECOLOGIST AT DEM1LT DISPEN-
SARY; MEMBER OP NEW YORK OBSTETRICAL SOCIETY ; MEMBER OF HOSPITAL
GRADUATE SOCIETY ; MEMBER OP ALUMNI ASSOCIATION OP NEW YORK HOSPI-
TAL ; MEMBER OP ALUMNI ASSOCIATION OP WOMAN** HOSPITAL, ETC.
This subject is one that demands special attention from
the gynecologist of today, for operators, although more
careful at the present time than for years past, are still
prone to remove tubes and ovaries that, in my opinion,
could be retained by the patient to very great advantage,
if given a chance through conservative surgery to regain
their functions. There are, of course, cases of salpingitis
which time alone will cure ; others that can be and are
relieved by the various non- operative and conservative
methods advised by the specialist ; and still others in
which abdominal operative measures, either radical or
palliative, are imperative to effect a cure.
Now it is not to the first class of cases that I purpose
to devote this paper, but to those in which laparotomy is
indicated.
Dr. Polk, of this city, deserves the greatest praise for
the pioneer steps taken by him in calling our attention
to the importance of saving the uterine appendages in
cases requiring laparotomy, and in which there is the
slightest chance of being conservative. Martin, of Ber-
lin, was also one of the first to call attention to this
point. Their work was brought to our attention about
four years ago. Dr. Thomas, * believe, has also advocated
August ii, 1894]
MEDICAL RECORD.
167
the same doctrine and reported as cured cases which re-
quired abdominal section, and in which the tubes were
not removed, but simply the adhesions were freed and
the tubes and ovaries left. Since first hearing Dr. Polk's
remarks on this subject, I have made it a practice to save
wherever it seems practicable to do so. I am very sorry
to see that he at present advises removal of the uterus
when the tubes are removed.
I have come to believe, after studying carefully the
various cases, both with and without the presence of the
menstrual function, that menstruation is essential to a
woman's comfort and happiness. In the lower animals
we find few if any superfluous organs, and when we con
template the nervous system of mankind, the complicated
and delicate adjustment of which renders it all the more
sensitive to interference, we cannot but regard it as es-
sential that the human being should remain intact in the
matter of organs exercising a powerful influence on the
nervous system. Yet many operators assure their patients
that the deprivation of the menstrual function will be at-
tended by no discomfort or loss of happiness, but merely
by sterility.
A statement in detail of the symptoms of patients suf-
fering from the effects of loss of the appendages is im-
practicable within the limits of this article, but I hope at
some future time to treat more fully of the matter.
Meanwhile I will confine myself to reporting cases in
which laparotomy was essential, but in which tubes and
ovaries were allowed to remain.
The first, a Mrs. L , of Brooklyn, was examined by
Dr. Bushong, who is associated with me at the Demilt
Dispensary, and myself. The uterus was firmly fixed,
retroflexed, the tubes and ovaries matted to its side and
behind it The course of treatment followed was several
weeks' local tamponading and counter-irritation by Mon-
sel's solution. Finding that this could not relieve, and
that it was, in fact, entirely inadequate, I advised
strongly that she go to the hospital and submit to opera-
tive measures. She seemed reluctant to lose the append-
ages, but expressed perfect willingness to undergo the
operation when informed that the appendages would not
be removed unless their removal should be absolutely es-
sential.
The patient was thirty-eight years of age, married, had
had two children the last six years before operation.
She entered the New York Cancer Hospital, February 4,
1 890, and had operation. House staff assisting. Median
incision. Uterus retroflexed, bound down, tubes en-
larged, congested, and their numerous adhesions aided
in holding the uterus down. Ovaries at first could not
be found, as the whole pelvic viscera were matted to-
gether. All the adhesions were carefully separated by
manipulation. The right tube was very much enlarged,
and at its fimbriated extremity did not seem pervious.
Its canal was entered by cutting in line with the tube
toward the uterus. This was laid open for about one and
a half inch, and as there was a thin and slightly puru-
lent discharge present within the tube, it was thoroughly
cleansed with hot water and a sponge. There was very
little hemorrhage. After this a probe was passed down
through the tube into the uterus without difficulty.
Thorough irrigation was done, and one catgut suture was
put in at uterine end of the tubal incision. The left
tube was in about the same condition, except there was
no purulent-looking fluid, and it was incised in a similar
manner ; but no probing was attempted, and no suture
applied. The ovaries were enlarged and hardened, con-
taining a number of small cysts which were incised with
knife, permitting thorough escape of all fluids contained
in them. The uterus and appendages now assumed a
normal position, but fearing that they might again be-
come attached posteriorly, I stitched the round ligaments
to the anterior abdominal wall with four catgut sutures,
two on either side. The stitches were taken about half
an inch from the uterus, the gut being of a kind that
would hold for at least five days. The abdominal wound
was closed with usual silk-worm sutures. The uterus at
this time was thoroughly-forward and held there by the
the suttlres in round ligaments. Patient had a little ten-
derness over abdomen, liver, and pelvis for a few days, with
some rise of temperature. Bowels were moved third day,
as is my custom, with salines. Patient went on and'
made good recovery, being discharged, with uterus in
good position and slightly movable, on March 2, 1890.
Two years afterward die became pregnant and came to
see me at the dispensary several times during the carry-
ing term. She seemed to carry the child very comfort-
ably. The adhesions formed by suturing the round liga-
ments to anterior abdominal wall never seemed to cause
the slightest trouble. I am curious to know whether the
adhesions still exist and are simply stretched, or whether
they gave way completely during the ascension of the
uterus.
She gave birth to a child January 16, 1893, and Dr.
Fulda, of 107 Kent Street, Brooklyn, attended her. She
says that the labor was a natural one. The utezus is now
in the natural position.
In a similar case, where the patient had never had
children, I operated, in 1890, at the Woman's Hospital.
In this instance all adhesions were loosened, the tubes
cut up, cleansed, etc., and the uterus was held forward,
the round ligaments being stitched to the anterior ab-
dominal wall. The patient made a good recovery,
though she complained of pelvic pain and had a profuse
uterine discharge for some time after the operation, for
which she was treated locally until it cleared up. This
was undoubtedly a gonorrheal case. The uterus is now
in good position and the patient free from pain, though
she has never had children.
Case three, unmarried. Done at Woman's Hospital
the past summer. In this case suspected gonorrhoea to
be cause of retroflexion and adhesions. Patient had
been in hospital a long time, complained of much pain,
had recurrent attacks of pelvic peritonitis, and did not
improve with treatment. Laparotomy performed. Con-
siderable ascites in abdominal cavity, adhesions all broken
up. Uterus held forward by stitching round ligaments
to anterior wall. In this instance tubes were not divided
and thorough curettement was not done, although it is
my custom to do it thoroughly in cases where I suspect
gonorrhoea. The uterus was held in good position by
operation. Patient did very well indeed for ten days,
when, three days after removal of sutures a small abscess
appeared in the lower end of the abdominal wound. This
was opened at once, and within a few days there developed
phlebitis of right leg and she was confined to her bed for
some weeks. The position of the uterus was, however,
good, and the organ fairly movable. In this case I believe
there must have been some infection of the tubes before-
hand. I am not aware of the present condition of this
patient, but I am not inclined to believe that she has been
perfectly relieved. Probably another operation will be
necessary to effect a cure.
In dealing with the uterus itself it is also well to be
most conservative, and at present we are, I think, too
much given to extirpation for a simple fibrous growth of
the organ, and even a simple pyosalpinx.
I do not wish to convey the idea that I do not believe
in extirpation of the uterus when there is any suspicion of
malignancy, or even when the uterus is riddled with pus,
for my views in these cases are radical. Immediate and
thorough removal of the uterus and all available tissues,
is then, in my opinion, the only proper course to pursue.
I should like, however, clearly to express myself as being
utterly opposed to removal of uterus for a small, simple
fibroid, or for a pyosalpinx, unless the uterus itself is
thoroughly riddled with the geims. In support of this
position I refer to several cases in which a cure has ap-
parently been effected.
Case I. — Mrs. M , private patient of my friend
Dr. J. A. Campbell, with whom I saw patient, in con-
sultation, October, 1892. The case had been previously
diagnosed by us, and, after consultation, we concluded
to remove the fibroid, and, if possible, without removing
i68
MEDICAL RECORD.
[August ii, 1894
uterus or ovaries, as the patient w*as most anxious to have
children. Laparotomy was done. Dr. Campbell assisting
me, early in November, 1892. A large fibroid, weighing
six and a half pounds, was removed from the fundus of
uterus, care being taken to dissect off the peritoneal coat
and turn it over or back. After this was done a curved
scissors was used in cutting off as much of the surround-
ing tissue as possible. In fact it was removed down to
uterine tissue. Then the peritoneal flaps that had been
sewed were sutured over with a continuous silk stitch,
thus covering the raw excavated surface. The ovaries
and tubes were fairly normal and were left intact. An-
other small fibroid, about the size of a small eggt was re-
moved. Patient made an excellent recovery under Dr.
Campbell's management, and within a few days Dr.
Campbell has reported to me that the patient is pregnant
about seven months, and is apparently in first- class con-
dition.
Case II. — Mrs. C , operated on June, 1893, at
Cancer Hospital. Large fibro cystic tumor of ovary and
tube, weighing about eight pounds, and consisting prin-
cipally of solid fibrous tissue, with small, broken-down
cavity in its centre. This stump was very large and was
treated similarly to the one just mentioned. Patient
made a good recovery, and has gained about forty pounds
since the removal of the tumor. She is now perfectly
well.
I must confess that in this last case my first thought
was to extirpate the uterus also, but I believe the woman
is very much better for having the uterus and other ap-
pendages left. I have shelled out a number of fibroids
from uterine wall by doing laparotomy first, then cutting
into the uterine wall and shelling fibroid out. After
which the two uterine edges are stitched together with
continuous catgut or silk suture. My results in a con-
siderable number of these cases have been invariably
good, and I can unhesitatingly recommend this pro-
cedure.
I have, in addition, removed a number of large fibrous
growths from broad ligaments, the first about two years
ago in private work, and the last very recently at the
Cancer Hospital. The growths ranged in size from a
small orange to a man's fist In most of these cases the
tubes and ovaries were apparently normal and were left.
But in the last case the tube and ovary on the side where
the growth was situated were removed, as they were bruised
rather much in the removal of the tumor, which, as can
be easily understood from the situation in the broad liga-
ment and extending down below the cervix, was very
difficult indeed to remove without removing the uterus
and all. All these cases have been satisfactory, and the
last one will, I believe, prove a success in every way.
I have also operated successfully in a number of liga-
mentous cysts. In most of these I have been successful
in saving the tubes and ovaries. Much care is always
taken, after the removal of the intra ligamentous cysts and
fibroids, to stitch the divided surfaces of the broad liga-
ments together, thus preventing many adhesions and
much inflammatory exudate ; in other words, leaving the
pelvic organs in as normal a condition as possible.
A good rule in conservative surgery, or in abdominal
surgery of any kind, is to cover all denuded surfaces where-
ever there is available tissue with which to do it.
In closing, I would say that as soon as the abdominal
cavity is opened, and before systematically attempting re-
moval of any abdominal or pelvic growth, it is of the
highest importance, in every case, to make an exact diag-
nosis of the appendages, uterus, and, in fact, of the gen-
eral abdominal cavity.
Further, it must never be forgotten that to be conser-
vative in the matter of removing organs that can be saved
is the highest and most advanced surgery.
The Medioal Officer of Health to the City of London
receives a salary of $7,500, and an additional sum of
$1,000 as analyst; but he is obliged to give his whole
time to the duties of the office.
A CASE OF CHRONIC PERITONITIS, WITH IN-
TESTINAL AND ABDOMINAL FISTULA— EN-
TERORRHAPHY— RECOVERY.1
By FREDERICK HOLME WIGGIN, M.D.,
PRESIDENT OF TUB SOCIETY OF ALU MM I OF BtLLSVUS HOSPITAL ; VISITING SUK-
GBOM TOTHI CITV HOSPITAL, GrNKCOLOGICAL DIVISION.
The three great dangers the surgeon has to encounter in
dealing with the abdomen and its viscera are sepsis,
hemorrhage, and intestinal adhesions. Of these the last
is by no means of the least importance. When not caus-
ing immediate death by intestinal obstruction, it fre-
quently defeats the object of surgical interference — the
complete restoration of the patient to health; and in
many cases, while removing the danger of sepsis, it sub-
stitutes that of intestinal obstruction ; while the pain is
relieved for a short time only, if at all.
The attention of the writer was forcibly drawn to this
subject, some years since, by the inspection of an abdomi-
nal cavity and its contents in a patient who had died of
intestinal obstruction twelve months after an apparently
successful operation for pyosalpinx. This examination
revealed such extensive adhesion of the intestines that
the question arose whether the patient would not have
been better off if the original operation had not been
performed. The conditions found would have made an
operation for the relief of the obstruction, which was by
a band low down in the pelvis, impossible. The opera-
tion was performed in strict accordance with the tech-
nique of the day, and was not followed by any signs of
sepsis. The wound healed primarily, the patient's bowels
moved early, and in fact she made a rapid recovery.
But although her sepsis was relieved, her pain soon re-
turned, and she had at short intervals recurring attacks
of intestinal obstruction which were easily overcome by
mild measures. Finally, being away from her home
when an attack of intestinal obstruction came on, her
physician, ignoring her previous history, gave croton-oil
and other cathartics ; the violent peristalsis induced forced
such an amount of gut under a band that it became
strangulated, and after some days1 delay it became gan-
grenous and perforated, with a fatal result. A similar his-
tory has followed successful operations of this nature so
often that the question is frequently asked, Does surgery
do what it claims— cure the patient?
The gynecological service at the City Hospital re-
ceives, for one reason or another, many cases that have
had celiotomies performed at other New York hospitals,
which have eventuated in adhesions, sinuses, and ventral
hernias. They are sent here for secondary operations,
having been probably reported in good faith by the
operators as " successful " cases. It is for the purpose of
calling attention to this subject of intra- peritoneal adhe-
sions, and to offer a suggestion for their prevention, as
well as to provoke discussion, that the report of the fol-
lowing case, which has given the title to this paper, is of
interest.
A. W , a female, about twenty-three years of age,
was admitted to the Penitentiary Hospital on BlackweU's
Island, April 27, 1892. Her history previous to coming
under my care in February, 1894, is as follows : She said
that after her first menstruation, which took place at the
age of thirteen years, she had had an attack of spinal
meningitis, and had not menstruated again for two years.
Then menstruation had gone on regularly, and had been
of the tri weekly type. It had been profuse, lasting
seven days, and being accompanied by much pain. She
had had no children. One miscarriage at five months
had occurred during the summer of 1891. Soon after
this she had had a syphilitic eruption, with pains in her
bones and an iritis. During the winter of 1890-91 she
had had a localized pain in the left inguinal region, which
had been more severe at the menstrual periods. There
had also begun to be difficulty and pain on defecation.
» Read before the Fifth District Branch of the New York State Med-
ical Association, at its Tenth Annual Meeting, held in Brooklyn, May
32, 1894.
August ii, 1894]
MEDICAL RECORD.
169
In the autumn of 1891, she had received a kick over the
seat of pain, and after this the pain had become worse,
and had been accompanied by constant headache and
nausea. She had then become addicted to the use of
morphia and cocaine. Her bowels had moved regularly.
It is noted in the hospital records that a vaginal examina-
tion, made in May, 1892, showed her uterus to be slightly
anteflexed, enlarged, and tender, with a pin-hole os, and
the left ovary to be somewhat enlarged. Again, on No-
vember 30th, a vaginal examination revealed the left ovary
enlarged to the size of a hen's egg, and also a salpingitis
of the right tube. Rectal examination disclosed a strict-
ure at two inches from the anus.
On December 14, 1892, the rectal stricture was incised
and divulsed, and on January 6, 1893, a coeliotomy was
performed, and both tubes and ovaries removed. In
breaking up the adhesions about the right tube, it was
ruptured, and some yellowish pus escaped into the peri-
toneal cavity. It was removed by sponges wrung out in
a 1 to 20 carbolic acid solution. No further particulars
are given except that the wound was closed by silkworm-
gut sutures passing through all the layers. Primary
union occurred except at one point, near the lower angle
of the incision. A week after the operation a probe was
introduced at this point, and pus welled up from the
wound. On the fourth day after the operation there
was a free escape of pus from her rectum. Notwithstand-
ing her sepsis her bodily temperature did not rise above
ioo°, and no antipyretics were used. ' On August 14,
1893, it is recorded that the sinus still persisted, and that
the patient was suffering much pain. A secondary coeli-
otomy was performed by the surgeon on duty. After
the incision had been made, so many and firm adhesions
were found that the wound was closed without any fur-
ther interference. After the wound had healed, the
sinus remained patent, and the former symptoms contin-
ued unabated. A vaginal examination made in Decem-
ber, 1893. revealed a large tumor on the patient's right
side, which was very painful. The propriety of an oper-
ation was considered, but before it was done there was a
free discharge of pus per rectum, and the tumor subsided.
On taking charge of this service, February 1st of this
year, I found this patient in a deplorable condition, suf-
fering from continuous pelvic pain. Examining her
with one hand on the abdomen and the other in the
vagina, a decided resistance and fulness were encoun-
tered, and there was marked tenderness in the right iliac
fossa. The uterus was fixed. The sinus at the lower
angle of the old cicatrix was patent, and discharged pus.
A rectal examination revealed a stricture of large calibre,
and an ulceration at two inches from the anus. The pa-
tient earnestly requested that something be done for her
relief. After careful consideration of the case, operation
was decided upon, and performed on February 14th.
The incision was made in the line of the old cicatrix,
splitting the sinus, which was found to pass into a cavity
formed by adhesions of the intestines to the anterior ab-
dominal wall, to themselves, and to the uterus, and
bounded in front by the bladder. Into this cavity was
poured a fifteen-volume solution of hydrogen dioxide,
and after this had been allowed to remain for a few min-
utes, it was sponged away and the adhesions broken up.
As the intestine was freed from the right side of the
uterus, a fistulous opening was discovered, which was
closed as soon as the intestine had been sufficiently freed
to allow of its being brought outside of the abdomen.
This closure was effected by scarifying the peritoneal coat
of the upper side, the lower side being already denuded,
and by introducing a single row of Lembert suture.
The appendix was adherent low down in the right iliac
fossa, and was freed, but not removed. After the adhe
sions which formed this abscess cavity had been broken
up the intestines were found to be very much tangled
and matted together. These adhesions were broken up
partly by the finger, and partly by dissection. The
omentum, which was adherent, was ligated and removed.
At one point the peritoneal coat of the intestine was
ruptured over an area "measuring % X J^ of an inch.
It was repaired by Lembert sutures. The hydrogen
dioxide was freely poured into the peritoneal cavity, and
after a little delay, the cavity was flushed with normal
salt solution (0.6 per cent.), and the cavity left full of the
same. The temperature of the solution was 1150 F.
The edges of the old sinus were scraped with the sharp
spoon, and the wound closed with silkworm gut sutures
passing through all the layers. No drainage was em-
ployed. The time occupied by the operation was two
hours. Only eight ounces of ether were used, but the
patient took the ether badly, and this much prolonged
the operation. Although suffering from shock, she ral-
lied well on the introduction of hot saline solution into
the abdominal cavity, aided by the hypodermic injections
of glonoin and strychnia. Her bowels moved shortly
after the conclusion of the operation, and again on the
third day, although morphia was employed more or less
freely. No cathartics were given after this, her bowels
moved regularly several times a day. The patient had
very little nausea. Beef peptonoids were given within
twelve hours after the operation, and were followed by
peptonized milk and semi liquid food on the fourth day.
Her temperature, pulse, and respiration became normal on
the sixth day. Her pain was relieved. The wound
healed primarily throughout. Following the operation,
there was a decided improvement in her general appear-
ance. On March 20th, it was noted that she was in
better health than she had been for two years previously.
A vaginal examination at this time showed the uterus to
be freely movable. There was no evidence of adhesions
or of tenderness in the pelvis. Six weeks after the oper-
ation the patient was in sufficiently good condition to
submit to the removal of three inches of her rectum, and
she is now in good health, with the exception of some
nervous disorder.
As the technique has been alluded to, it may be well
to state that in this, as well as in all other abdominal
operations performed within the past eighteen months by
the writer, all chemicals except hydrogen dioxide have
been avoided, reliance being placed entirely on steriliza-
tion of instruments by boiling, and on the use of steri-
lized salt solution, with the avoidance of the use of
sponges. The main point of interest in this case, aside
from the number of celiotomies submitted to by this pa
tient, and the severity of the last one, is the free user of
the hydrogen dioxide for the purpose of destroying the
old abscess cavity before breaking up the adhesions, and
the closing of the abdominal cavity after filling it with
the saline solution, for the definite purpose of preventing
the formation of new adhesions. Further experience
gathered during the past winter has confirmed the claim
made in a former paper, that closing the abdominal cav-
ity after filling it with hot sterilized salt solution, lessens
shock, prevents the formation of adhesions, aids in the
readjustment of the intestine and omentum to their
proper position, and lessens the danger of septic perito
nitis. To this I may add that after operations where it is
so used there is little nausea, and an absence of the in-
satiable thirst which formerly tormented these patients,
and that the bowels act more freely, often of their own
accord, in spite of the fact that morphia is used whenever
indicated on account of restlessness. My opinion is con-
firmed in the belief that hydrogen dioxide is a safe and
sure disinfectant for the peritoneal cavity. I have used
it with satisfactory results in more than twenty cases.
In conclusion, I would like to call attention to the
fact that, although the duration of the operation was two
hours, only eight ounces of ether were used. The shock
following an operation is, in my experience, more de-
pendent on the amount of ether employed than on the
duration of the operation, although this is of importance.
Had not experience given me faith that by the use of
salt solution adhesions once broken up could be pre-
vented from reforming, that in hydrogen dioxide there
is a safe and certain weapon for preventing and over-
coming sepsis in the peritoneal cavity, and that with the
170
MEDICAL RECORD.
[August il, 1894
closed ether inhaler a long operation could be performed
with the minimum amount of ether, and therefore with
little shock, the above described operation would not
have been justifiable, and would not have been under-
taken.
55 West Thirty-sixth Street.
INTERNAL URETHROTOMY FOR STRICTURE.
By T. E. SCHUMPERT, M.D.,
SHREVKFORT, LA.
SURGEON SHRHVEPORT CHARITY HOSPITAL, AND MEMBER NATIONAL ASSOCIA
TION RAILROAD SURGEONS.
In discussing the treatment of stricture of the urethra
this paper concerns organic stricture only ; but before
entering upon its treatment proper, we will recapitulate
briefly the pathology of stricture, and look casually at the
anatomy of the penis; by so doing we will be better able
to treat intelligently this disease. Its idiopathic etiology
in vastly the majority of cases is gonorrhoea, though we
do have some cases from traumatism to the perineum or
urethra, by say a kick, a fall astride a box or fence, a
bruise while riding bare-back, or on the horn of a saddle,
by the use of imperfect instruments, or breaking one in
the urethra. It is claimed by some, too, that strictures
are caused by too strong injections. I believe it is pos-
sible to make an injection strong enough to produce a
stricture by using some very powerful caustic, but in
meeting the indications of a gonorrhoea, this is but rarely
if ever done, the subsequent stricture to these gonorrhoea
injections being only coincident. I use at pleasure for
cystitis a ten, fifteen, or even twenty grain to the ounce
argent, nitrosae solution, injected into the bladder after
a thorough catheterization, and allow the patient to
void it through the urethra, without any evil effects. It
is what, then, that produces it in gonorrhoea ? The ure-
thritis per se. Eighty five per cent, of all strictures are so
caused.
The male urethra is about eight inches long, and
divided into the prostatic (one and one -half inch),
membranous (three-quarter inch), and spongy or pendu-
lous portion which occupies the remainder of its length.
It is flexible and of an unequal breadth at each of the
different divisions, being broadest at the prostatic,
narrower at the spongy, and narrowest at the membra-
nous portion, and any portion of the urethra that is not
dilatable is strictured. The urethra is related to the cor-
pora cavernosa as a ramrod is to the barrel of a double-
barrelled shotgun, the corpora cavernosa incorporating
about one-third the circumference of same when distend-
ed, with its sides not in apposition as the meatus would
seem to indicate, but the roof and floor kiss each other
in perfect co-aptation.
Stricture may be of such a mild type as only to involve a
thickening of the mucous membrane, or the inflammatory
process may lead out and invade the delicate erectile tis-
sue, thereby causing a proliferation of the connective-
tissue element and an increase in the thickness, density,
and non-elasticity of this membrane at the site of strict-
ure, which may be single or multiple. This pathologi-
cal process takes place just beneath the mucous mem-
brane, and not on its surface, as was formerly believed,
and as the stricture grows older this transverse non-
elastic band grows tighter and contracts more firmly.
We have linear, annular, and tortuous strictures. They
are also divided into passable and impassable, according
to their degree of perviousness to a filiform bougie ; of
course, if this instrument can be made to enter, it falls
under the former class, but if this be impossible, under
the latter.
About seventy five per cent, of strictures are single.
Otis places the location of the majority of strictures
within one and one quarter inch of the meatus, the
next most common site being about the middle of the
pendulous urethra. Thomas has failed to find in two
hundred and seventy autopsies, or in any patient, a pros
tatic stricture, i e.y a stricture within one and a half
inch of the bladder, that portion also which lies beneath
and behind the arch of the pubis, and which therefore
from the field of operation is most obscure and diffi-
cult of access. Walsh found in one hundred and eighty-
five cases one stricture of the membranous urethra that
involved also a portion of the prostatic urethra, so we
may very safely eliminate this portion of the urethra
from the stricture field; and the fact that this can
be done is but another trace of the Almighty's wise and
sympathizing hand, for even though he has rightfully
cursed the nation with this malady, he places it within
comparatively easy reach of the surgeon. Strictures do
occur, however, sometimes as far back as the posterior
membranous urethra, i.e., four and one-half to six inches
from the meatus.
It is a popular idea with the majority of our profession
(prejudiced by results antedating antisepsis) that the cut-
ting operation should be the last resort, that it should be
used when all else has failed, as the last alternative, and the
instruments recommended for this little operation are al-
most too numerous to mention ; but among the most promi-
nent are filiform bougies, bougies not filiform, sounds,
guides, probes, rapid dilators, urethrotomes, directors me-
atometa, urethrometa, bistouries, etc. I think the reason
the average practitioner doesn't operate on his own cases,
but instead takes them to a surgeon or a specialist, is be-
cause whenever the patient is presented the operator
shoves under the practitioner's nose such an elaborate dis-
play of mysterious instruments, all of which the latter,
without thinking, believes to be necessary to make the ex-
amination or perform the operation, that he himself is
humiliated, and the magnitude of the operation propor-
tionately exaggerated. I have a record of thirty* nine
urethrotomies performed by myself, thirty five of which
were internal, including four impassable ; the remaining
four were external urethrotomies. The latter were among
the first operations on the urethra that I ever did ; they
were two with and two without a guide, one of which
gave me as much trouble during the performance of the
operation, and caused me as much apprehension during
the after treatment, as any surgery I have ever participated
in. I have since become so impressed in favor of the
internal operation that I have never yet had occasion to
return to it again. I have treated a great many strictures
by dilatation, but so far as my experience goes it has only
been palliative, for most invariably the patient would re-
turn again during the course of a few years with his same
old trouble, notwithstanding the fact that he had been
taught and ordered to use the bougie himself once or twice
a month. This was not done, of course, or it could not
have possibly closed ; but at the same time, as long as it
is necessary to use an instrument this disease cannot be
considered cured. I find that internal urethrotomy gives
the best results and is justifiable in any case occupying
the pendulous urethra, and all strictures that I have yet
seen in this locality are accessible by the method which
I am about to detail, which requires a set of sounds, a
bistoury, grooved director, and a set of bulbous bougies or
urethrometer ; this latter instrument, however, is not es-
sential, though it may often be used very conveniently in
locating strictures and testing their extent. It, at any
rate, is a very ingenious little instrument, and reflects
credit on its inventor, Professor Otis. It is generally
conceded by the profession, I believe, that bougies or
sounds should be used if it be possible to pass one ; if re-
peated efforts be made without avail, however, then ex-
ternal urethrotomy as the last alternative must be resorted
to ; but before proceeding with this cutting operation,
while the patient is yet under the anaesthetic, they say
another attempt must be made at introducing a filiform
bougie, which, if successful, defers the operation perhaps
indefinitely. For an external urethrotomy it is best to
make an incision two and a half or three inches long,
and the greatest precautionary measures must be observed
if performed without a guide, else serious damage might
be inflicted ; the wound is then left to heal by granula-
tion. All impassable strictures are said to be suitable cases
August ti, 1894]
MEDICAL RECORD.
171
for this operation, but none else. The wound made in
an external urethrotomy is necessarily large, the opera-
tion a long and tedious one, two hours at times may be
employed in performing it, fever runs high; it is with
difficulty the patient is kept clean, and the operation is not
at all free from danger. Wyeth, Otis, Thompson, and
quite a number of others have invented instruments for
internal urethrotomies ; these instruments are necessarily
large, heavy, and therefore cumbersome ; the blade of
none of them extends beyond the shaft, and therefore are
not intended for impassable strictures ; they do beautiful
work, however, on strictures admitting a No. 7 sound.
The bistoury which I use has a perfectly straight shank,
seven inches long, with a blade extending from its point
one-half inch back, and presenting not exceeding one-
quarter of an inch beyond the front surface of the shank ;
the back of the blade is exactly on a straight line with the
back ot the shaft, even to its point. My grooved di-
rector is seven inches long and fork shaped, with the han-
dle of the fork representing the groove of director and the
prongs the handle ; it is made of sufficient strength to ad-
mit of considerable pressure without bending ; the strength
of the director, however, must not lie in its back, but
sides only, as the back must be thin in order to allow the
back of the knife to approach as nearly as possible the roof
of the urethra, thus enabling the operator to incise the
stricture through its entire diameter. Now, the patient
having been placed in the usual position, and a stricture
diagnosed, if it be meatal surgeons all agree that it should
be cut with a bistoury, and in this locality a director is
not indicated ; but if it be lower, this latter instrument
becomes imperative. With the grooved director and bis-
toury which I have described, all pendulous strictures
have fallen in the field of internal urethrotomy and easily
available. The penis is held at right angles to the body
with the left hand of an assistant, while with his right he
holds the director firmly against its roof, with the groove
of director presenting toward the patient's feet, the penis
in the meanwhile being kept somewhat extended. If the
stricture be passable, the operator then, with the bistoury
in his right hand, glides it down the director until in the
locality of the stricture, this point being marked by the
thumb and second finger of his left hand, which press
gently the sides of corpora cavernosa in aiding to keep it
perfectly steady, while the index finger is held in the same
locality but against corpora spongiosa to direct the
blade of the knife, which may plainly be felt as it cuts
through the stricture, first in front, then on either side.
If the stricture be impassable, the director is introduced
until its blunt end comes in contact with the face of the
stricture, the penis being held as before if in the upper
pendulous portion ; but if lower and possibly in the an-
terior membranous urethra, after the director and knife
have been introduced beyond suspensory ligament, the
penis is tilted forward to an angle of about 45 °, the di-
rector pressed firmly in the direction of symphysis pubis
and downward until in contact with the stricture ; the
knife is now pressed well back against the director, then
downward until the resisting stricture yields ; three inci-
sions are then made as before described. By actual ex-
periment on the cadaver, I find that I am able to reach in
most cases by this means the membranous urethra. This
operation is extremely simple, very easy, and usually re-
quires but five or ten minutes, is performed with a very
limited, inexpensive outlay of instruments, and I never
expect an untoward result ; is more cleanly, as the urine is
voided per viam naturalem instead of through a vicarious
passage in a very clumsy location. The main points to
be guarded are, first, to have a reliable assistant, who
will hold the penis and director perfectly steady and ex-
actly as directed by the operator, who must himself see to
it that the end of director is in contact with face of
stricture, that it is in perfect line with the penis, and be
very careful to pass his knife exactly in that line. After-
treatment consists in first washing out the urethra with
peroxide hydrogen, then injecting copiously with gr. vj.
to § j. of boracic acid ; this is done seven or eight times
during twenty four hours, until all discharge ceases, and
a large sound introduced once in four or five days for the
first month, once a week the second month, once in two
weeks the third, and during the next two months twice cr
three times ought to suffice. I usually, at the same time,
put the patient on some alkaline diuretic, santal midy
being my preference, which is also an astringent antisep
tic, having special ac ion on mucous surfaces. In conclu-
sion, I would like to say that I have succeeded in passing
filiform bougies that had resisted repeated previous at-
tempts, by instructing the patient to allow his bladder to
become distended with urine, then thoroughly cocainizir g
the urethra and allowing him to void his urine while the
attempt is being made ; this method is especially applica-
ble to cases of valve stricture. In doing an external
perineal urethrotomy once (without a guide) that was
baffling entirely my skill, I found that much aid was given
by the introduction of a bougie from behind after a supra-
pubic cystotomy had been performed. I cut strictures
indiscriminately as regards to class, and always in three
directions ; a sound corresponding with the full capacity
of the urethra should be used at once. This operation
may be performed with pain reduced to a minimum by
the use of cocaine and Bumstead's deep urethral syringe.
The incisions must be made in the long axis of the penis ;
when they heal, they do so with an elliptical patch for
each incision, thus increasing the calibre of the urethra by
the insertion of a new-formed tissue which is pathologi-
cally different to that of the stricture. It intercepts the
force of this contracting band and establishes another in
a direction that rather favors the normal calibre of the
urethra.
A CASE OF NON-HEREDITARY FRIEDREICH'S
DISEASE.1
By CHARLES E. NAMMACK, M.D.,
ATTENDING IHYSICIAK TO NSW YORK HOSPITAL, OUT-PATIENT DBPAXTMBNT.
After the elaborate critical digest of Ladame,* supple-
mented as it was by the scholarly article of Byron
Bramwell in his magnificent " Atlas of Clinical Medi-
cine," ' it would seem that little could be added to the
literature of Friedreich's ataxia. Yet, Bramwell states
that very few isolated cases have been recorded, and
thinks it " not unlikely that the isolated cases (cases in
which only one member of the family is affected) pass
unrecognized." This view is shared by Ladame, and
emphasized recently by the publication of an isolated
case by Hector Mackenzie,4 who states that the alternative
title, hereditary ataxia, for Friedreich's disease may have
something to do with preventing its due recognition.
Eight days before the writer saw Mackenzie's article,
a little girl was brought from Yonkers to the New Yoik
Hospital with the following interesting personal history :
Mary B , aged fourteen, born after a normal labor,
began to have unsteadiness in walking when she was five
and a half years of age. Previous to this time she had
an attack of measles at the age of two and a half yeais,
a second attack of measles while it was prevalent in the
family at her fifth year, and six months later had scarlet
fever, followed by the unsteady gait. Her parents think
that diphtheria did not accompany the scarlatina. Her
gait has become progressively worse since. Some time
after the development of ataxia in her lower limbs, she
was annoyed by jerky movements of hands and arms
when writing, and was finally obliged to leave school.
She had headache every morning, and occasional shoot-
ing pains in her legs. She has had nocturnal enuresis
since infancy, but lately has been troubled by inconti-
nence in the daytime also. Her case has been variously
1 Presented at the New York Academy of Medicine, Section on
Pediatrics, April 12, 1894.
• Brain, 1890.
•Vol. I., Part I., Edinburgh University Press, 1891.
4 American Journal of the Medical Sciences, April, 1894
172
MEDICAL RECORD.
[August 11. 1894
diagnosticated as diphtheritic multiple neuritis, chorea,
precocious locomotor ataxia from inherited syphilis, etc.
This is not surprising when we reflect that Friedreich's
ataxia is one of the rarest of all known forms of nerve
diseases, that the great majority of medical men have
never had the opportunity of seeing it, and further, that
they do not expect to meet with it in an isolated form.1
This child's family history is unusually good. She is the
oldest of seven children. One baby died at five months
of "inward spasms due to teething." The other five
are living and healthy. Both parents accompanied her
to the hospital and were apparently perfectly sound and
healthy. Three other children in the family have now
passed the age at which the unsteady gait began in Mary,
without showing any symptom of it, although their im-
munity cannot be guaranteed from this, as stated by
Soca.3 Many exceptions to the rule formulated by him
are on record.8 Neither parent knew of any neurotic or
degenerative tendency among the grandparents, uncles,
aunts, or cousins, except that one paternal aunt died at
the age of twenty- two of "consumption of bowels,"
after an illness of three years. Another paternal aunt
died of endocarditis, contracted during the blizzard of
1888. Four aunts and uncles are living and well. Con-
sanguinity did not exist between Mary's parents, nor had
either ever suffered from alcoholism, Blight's disease, or
syphilis. The writer considers it improbable that her
conception might have occurred while either parent was
under the influence of alcohol. Mother has had no still-
births or miscarriages. There is no knowledge that any
near relative has ever been ataxic or club-footed.
Living
Father .
Mother.
fMary....
Sisters,
J Alice
lRo«e.
(Anne
Father's Mother.
Father's Father.
Mother's Mother,
39
37
77
80
76
Condition
of Health.
Age
at
Death.
Cause How
of i long
Death. Sick.
I
5 mo. Convulsions? 1 day.
Excellent.
Excellent. | .
Excellent.
I Excellent.
Friedreich's Disease 8} yr's.
I Excellent.
Excellent
Excellent.
Excellent.
'Excellent. 1
Excellent.
Mother's Father 53 y'rs. Pneumonia. lod'ys.
The symptomatology of the case at present is as follows :
The gait is very unsteady and rolling in character, and
child is unable to stand with the eyes closed. Muscular
power in the legs is good, considering that the child can-
not actively exercise. Dynamometer records, thirty in
right hand, and twenty-two in left hand. Hand grasp
seems almost as strong as in other children of her age.
The knee-jerks are absolutely lost. She has some ataxia
in the upper limbs, but can thread a needle, and her
manner of picking up a needle from the table has not
the so-called "bird of prey" movement.4 She pre-
sents the characteristic foot deformity of this disease.
Each foot is stumpy and short, and appears to be com-
pressed from before backward in the antero posterior
diameter. The instep is highly arched and the dorsum
of the foot very prominent. The first phalanges, espe-
cially of the great toe, are over extended and the tendons
of the extensor proprius pollicis muscles stand promi-
nently out. The feet are cold, and of a purplish color.
Lateral curvature of the spine is present. The speech is
low-toned, monotonous, and harsh, but not "scanning,"
as in multiple sclerosis. Nystagmus is evident when eyes
are moved laterally or upward, or when the object is
fixed.
Pupils are equal, of medium size, and respond both to
light and to accommodation. No oculomotor paralysis.
Ophthalmoscopic examination by Dr. Leroy Pope Walk-
er, shows that the temporal half of each optic nerve is
very pale and the nutrient vessels diminished. This con-
dition is considered to be fairly attributable to the child's
1 Bramwell : Atlas Clinical Medicine, p. 42.
* Ladame: Brain, i8qo. * Bramwell : Atlas, p. 35.
« Brain, 1890, p. 478.
evident anaemia. Choreic like twitchings are not present
now, but the history shows that they existed in an earlier
stage of case, and more than one physician has treated
the child for chorea. Her facial expression is anxious,
rather than vacant. She does not have the attacks of
impulsive laughter often noticed in this disease. She
suffers from palpitation of the heart on walking, but has
no valvular lesion. Anaemic bruit is present* in vessels
of neck. Her headache is distinctly frontal. She does
not feel dizzy in walking, but is unable to co-ordinate
her movements. Sensibility of the skin to touch, heat
and cold, and pain is found to be unimpaired, although
not exhaustively tested. Special senses not affected.
Child is bright and intelligent, and not irascible. Her
sense of the posture of limbs is good.
The clinical assistant who first saw the case at the hos-
pital considered it to be locomotor ataxia without Argyll-
Robertson pupil, a not impossible combination. The
writer changed the diagnosis to that of cerebellar tumor
without increased knee-jerk, which is also a possibility.
But the ophthalmoscope showing absence of optic neuri-
tis or of postneuritic atrophy, a more careful review ot
the case was made and the correct diagnosis arrived at.
The pathological anatomy and prognosis are so fully
treated in the articles of Ladame and Bramwell as to ren-
der unnecessary any mention in this communication.
The treatment is the same as that of locomotor ataxia.
Suspension has been tried in some of the recorded cases
without any benefit. Lena, an Italian writer, has re-
ported 1 two cases treated by injections of organic nervous
extracts after the method of Dr. C. Paul.
Non hereditary cases may occur with more frequency
than is usually supposed. The " Index Medicus " for 1893
gives sixteen references to twenty three cases of Fried-
reich's disease, of which four were isolated cases, no other
member of the family being affected. Thus Destree2
records a case, aged twenty-one, brothers and sisters
healthy, father an alcoholic, died of consumption, one
paternal uncle epileptic. Senator * had a case in one of
five sisters.
McCaw4 publishes a case in which the hereditary his-
tory broke down at every turn. Strong history of tuber-
cle in this family. Chauffard 5 presents an isolated case
which began at the remarkably early age of three and
one half years.
To these can now be added Mackenzie's case and the
writer's. It would seem to be desirable that other non-
hereditary cases should be reported, in order to eradicate
the fixed idea that Friedreich's ataxia is necessarily a
family disease. The lesion in Friedreich's disease is a
combined sclerosis of certain tracts in the posterior and
lateral columns of the cord, together with the vesicular
columns of Clarke in the gray matter, and the posterior
roots. The entire cord is also congenially smaller than
the normal. The diseases with which it is likely to be
confounded are locomotor ataxia, insular sclerosis, ataxic
paraplegia, chorea, and cerebellar tumor. The differen-
tial diagnosis is clearly given in the article by Bramwell
previously alluded to.
It has been suggested by one writer • that lateral curva-
ture of the spine may give rise by pressure to cord symp-
toms, but a study of the case cited will show many and
marked differences in its symptomatology from that of
Friedreich's ataxia. Orthopedists generally do not accept
the conclusions therein advanced, but agree with Brad-
ford and Lovett that lateral curvature never gives rise to
cord symptoms.7 Although the author predicted that
literature would soon teem with cases similar to his, the
ensuing two years have not brought to light the expected
inundation.
99 East Twenty-fourth Strkit.
1 Morgagni : Milano, 1892, xxxiv., 630-652.
• Journal de Med., Chir. et Pharmacol. Bruzelles, 189a, p. 773.
■Berlin klin. Wochenschrift, 1893 p. 489.
• London Lancet, 1893. "•• 4*4-
• Semaine Medicate. Paris, 1893, xiii.. 409-411.
« Mbdical Record, May 98, 1893. p. 604.
» Ibid, p. 605.
August ii, 1894]
MEDICAL RECORD.
173
INCONTINENCE OF URINE AND FAECES,
CURED BY CIRCUMCISION.
By H. L. ROSENBERRY, M.D.,
MENOMINKK, MICH.
I wish to report a case that has been very instructive to
me. In September, 1893, I was called to see a child
with incontinence of urine and faeces. The child seemed
to be as healthful as the average four-year old, and aside
from this difficulty had never taken any medicine. In
making an examination I discovered what had appar-
antly been overlooked by the former medical attendants,
an elongated prepuce. I said to the parents that the
child should be circumcised without delay, as that might
account for the dribbling of the urine, but supposed
there was entire absence of the sphincter anL
On the following day the child was anaesthetized and
the circumcision performed. It healed nicely. At the
time of the operation a digital examination revealed a
patulous anus with no sign of a sphincter muscle. Sup-
posing it to be absent I, of course, thought there would
be no help for the incontinence of the faeces. When
complete healing had taken place the bowel trouble en-
tirely subsided, but he still had trouble with the retention
of urine. I tried various remedies, and finally used the
atropia (T^ Wyeth's hypodermic) tablets, with instruc-
tion to cease when dryness of the throat appeared. The
child is more robust than before and has fully recovered.
I am at loss to explain the process, but simply relate it
as a fact. Will your readers cite to me similar cases if
they know of such?
AN UNUSUAL ACCIDENT TO THE RESPIRA-
TORY TRACT.
By M. D. BRIGGS, M.D.,
CHAMFLAIN, M. T.
On the evening of January 25, 1894, Ernest L ,
aged seven, was brought to my office by his parents with
the following history : About one hour previously, namely,
about 6 p.m., while chewing a mouthful of dried peas*
with which he had been playing, he had a little griev-
ance and commenced crying. In the midst of his sob-
bing he sucked some of the partially chewed peas into
his windpipe, and at once began to choke and strangle.
His father immediately seized him and used such meas-
ures as he was able for his relief, such as clearing out the
mouth and throat, inverting the child, and thumping his
back. He recovered his breath, after which an emetic
was given and the child brought with all haste to my
office, something over two miles.
On examination I found him breathing easily and
quietly, but the stethoscope revealed plainly the fact that
some of the material had entered the respiratory tract.
The laryngoscope was unsatisfactory, as the attempt to
use it brought on a severe attack of dyspnoea, which
subsided after a moment or two. Realizing the gravity
of the case, I advised taking the child by first train to
Montreal, as it could be easily reached in two or three
hours, hoping that something there might be done to
save him. They decided to take my advice and left my
office, while I prepared to accompany them. In about
five minutes a messenger came for me in great haste from
a neighboring store where they had stopped to make a
purchase.
I found the boy in a state of complete apnoea, cya-
nosed, pulseless, and apparently dead. Finding the
heart still beating I immediately laid him on the counter,
in a position to do a quick tracheotomy. I had bared
the throat, found my landmarks, and in another instant
would have made the incision, when there came a slight
gasp. After a few seconds another came, and I laid
down my knife. In a few minutes he was breathing
fairly well, but lay in a semi-conscious condition. There
was no further thought of Montreal, nor even of taking
him home. A room was secured at the nearest hotel
and he was removed thither. Another severe attack of
suffocation came on as soon as we reached the hotel, in
which the boy went through another terrible death- strug-
gle, and lay apparently dead on the bed, only to again
revive for a repetition of the dreadful ordeal, for these
attacks of laryngeal spasm occurred again and again.
Dr. J. M. Hackett and Dr. L. C. Dodge were called
in consultation. All concurred in an almost hopeless
prognosis. Tracheotomy seemed a forlorn hope, and
was considered only as a measure for the relief of the
laryngismus. The parents desired anything that would
promise even a measure of relief. So I did a trache-
otomy with careful attention to details. There was no
more spasm of the glottis, but the operation gave no re-
lief to the dyspnoea and cyanosis, which steadily in-
creased. Sharp hissing sounds could be heard through
the tracheotomy tube coming up from below. Death
took place about twenty-one hours from the time of the
accidental entrance of the partially masticated peas into
the respiratory tract. An autopsy could not be ob-
tained.
A FAMILY HISTORY OF DIABETES.
By GEORGE A. PHILLIPS, M.D.,
SLLSWOKTH, MB.
A boy eight years of age was seen by me in January
of this year, with well-marked symptoms of diabetes
mellitus, excessive thirst, emaciation, urinating four to
six quarts daily, specific gravity of urine 1.046, with sugar
in considerable quantities. The interest of the case lies
in the fact that three brothers of his mother died of the
same disease, their ages respectively three, eight, and
seventeen, the diagnosis almost established by the history
obtained by a member of the family was confirmed by
communications from Dr. Thomas, of Brewer, Me., and
Dr. F. O. Perry, of Orland, Me., the physicians who at-
tended the children who died. The mother of the child
whose history is given above, and a sister to those who
died, has occasional symptoms of the same disease.
There were five children, three dying of diabetes, one of
typhoid fever, and the mother of child referred to.
HAVE THE RED BLOOD CORPUSCLES AMCE-
BOID MOVEMENT.
By WILLIAM MOSER, M.D.,
PATHOLOGIST TO ST. CATHARINE^ HOSPITAL, BROOKLYN.
It is generally supposed that the red blood corpuscle is a
" fixed " cell, i.e., a cell not capable of amoeboid motion
like the white blood corpuscle. My observations are
not in accord with this general belief. It is true that
the red blood corpuscle, when obtained fresh (by pricking
the finger-tip) and examined under the microscope, will
not exhibit any property of amoeboid movement, much less
would it do this if the blood was heated and stained.
The blood corpuscles when examined fresh rapidly be-
come dehydrated, a dark ring soon forms on their outer
border, looking like a membrane, many of them become
shrivelled, " cremated," the cell soon dies. But in cer-
tain media like the urine they retain their vitality and
certain fundamental differences can be noted. In over
one hundred specimens of nephritic urine, containing
blood-cells, I was positive that in every instance I could
detect in most of the red blood- cells movement. In
some cells I could see how the cell would retract in cer-
tain places, some becoming semilunar in shape, others
could be seen taking on various shapes, reminding one
of the condition known as " poikilocytosis " seen so fre-
quently in progressive pernicious anaemia. Again the
ordinary round shape would become long and narrow,
and by waiting a few seconds it would again regain its
rounded outline. All this could be seen and demon*
strated in urine containing many blood cells. In short,
it behooves us to examine the red blood corpuscle in the
urine more closely.
158 Ross Strut, Brooklyn.
174
MEDICAL RECORD.
[August ii, 1894
f£)?00ttess of fjfoflital jfcietuce.
Bacteria in Human Milk. — Dr. Ringel contributes
the report of a series of investigations upon the bacteria
found in human milk. Various observers had reported
having found the staphylococcus aureus and albus, as
well as the streptococcus, both in healthy milk and in
that from mothers suffering from puerperal fever. Es-
cherich examined 25 women. Of these, 24 specimens
were sterile and 1 contained bacilli. He again examined
13 with puerperal fever, and found staphylococcus in 12 ;
4 being of the white and yellow variety intermixed ; 8
the white only, and 1 of an uncertain form. Cohn and
Neumann experimented on 43 cases of milk from healthy
women, and found 36 containing staphylococcus albus,
1 staphylococcus aureus and pyogenes, 3 staphylococcus
pyogenes albus and streptococcus pyogenes ; in 2 all the
above forms were united. The writer made a series of
investigations, drawing and using milk from the deeper
parts of the breast only, the experiments being made
under the strictest antiseptic precautions. The milk was
taken from 12 healthy and 13 unhealthy patients. The
results were as follows: 3 specimens were sterile; 17
specimens contained staphylococcus pyogenes albus ; 2
specimens contained staphylococcus pyogenes aureus ; 1
specimen contained staphylococcus pyogenes albus and
aureus ; 2 specimens contained staphylococcus pyogenes
albus and streptococcus pyogenes. An examination of
the mouths of nursing infants revealed corresponding
bacteria in their secretions. — The American Journal of
the Medical Sciences.
A Hew Method of Using Cocaine for Local Ansssthe-
sia. — Krogius (CentralbLf. Chir., No. n, 1894) de-
scribes a new method of producing cocaine analgesia,
which is based on the fact that, when a solution of this
agent is injected into the subcutaneous tissue near to a
nerve-trunk, it causes loss of sensation over a large zone
corresponding to the peripheral distribution of this nerve.
In order to reach the selected nerve-trunk with certainty,
and to apply the cocaine to several of its branches at the
same time, the author, in injecting the subcutaneous tis
sue, passes his needle across the long axis of the limb,
and as the needle is thrust along, the solution is gradu-
ally discharged. An injection made in this way across
the root of a finger will, in the course of ten minutes,
result in analgesia of the whole digit, not of the skin
only, but also of the tendons, the periosteum, and all the
deep structures. If one or two injections be made trans-
versely near the wrist, a considerable extent of thg palm
of the hand may be thus rendered analgesic. The sensi-
bility of the ulnar side of the hand as far as the roots of
the last two fingers may, it is stated, be abolished by in-
jecting a solution of cocaine over the ulnar nerve at the
back of the elbow. By injecting over both supra-orbital
notches, analgesia may be produced in the whole of the
middle portion of the forehead. The analgesia caused
by this method of using cocaine attains its greatest inten-
sity and extent from five to ten minutes after the injec-
tion, and is maintained for a quarter of an hour or even
longer. The author injects only a weak (two per cent.)
solution of cocaine, and keeps the patient recumbent for
at least a quarter of an hour after the operation. This
method has been practised with success at Helsingfors, in
two hundred minor operations, such as amputation of the
fingers and toes, excision of palmar fascia, and phimosis.
Compression of the Umbilical Cord During Delivery
by Forceps Dr. Swayne has recently again directed at-
tention to the danger to which the child is exposed dur-
ing delivery by forceps, from pressure of the extremities
of the blades on the umbilical cord, should it be so situ-
ated as to be compressed when the forceps has been ap-
plied ( The Lancet) In a former communication on the
subject Dr. Swayne instanced 153 cases of forceps deliv-
ery. In 23 of these the child was either born dead, or
died soon after delivery ; in 4 out of these 23 cases he
attributed the death to compression of the cord by the
forceps — that is to say, that this injurious compression
had been noticed in the proportion of once in 38 cases.
Since the time when this series of cases was published,
Dr. Swayne has had 71 forceps cases, with 10 deaths of
infants, and among these 10 stillbirths there were 2
cases in which the child's death was due to pressure of
the forceps on the cord. In this second series, then,
the accident in question occurred once in 35 cases — not
very different from the frequency noted in the preceding
series. Spiegelberg's estimate of the foetal mortality in
forceps cases is seventeen per cent. It certainly seems to
be the fact, as Dr. Swayne says, that this particular dan-
ger— that is to say, compression of the umbilical cord by
the forceps — has not received perhaps so much attention
as it deserves. Dr. Swayne still agrees with a passage
which he quotes from a paper by Dr. Galabin, published
in 1877, namely, " that it has not been shown that the
majority, or any considerable proportion, of the stillbirths
which now occur in Britain would be preventable by a
more timely resort to forceps."
Skin-grafting for Keloid. — Broca recently excised from
the back of the hand and thumb an extensive keloid fol-
lowing a burn. The growth was half a centimetre in
thickness, and held the hand at a right angle to the fore-
arm. A flap from the abdomen was then grafted upon
the hand and its pedicle severed in thirteen days after
the operation. There were no drawbacks of any kind,
and complete motion in the hand and wrist was restored.
Ingrowing Hairs. — Dr. Guthrie calls attention to a
condition of ingrowing hairs, which presents itself in the
form of bluish- white pimples, varying in size from a pin's
head to a small pea, situated usually about the chin where
the beard grows the thickest. Careful inspection of the
unshaved chin and cheeks will show here and there the
presence of ' ' giant hairs. ' ' These are dark in color, and
as thick as hog's bristles. The slightest traction with
forceps suffices to painlessly remove them. The thicken-
ing is due to the deposit of a dark, soft material, which
envelops the hair throughout its extent. This layer can
be scraped off, and is soluble in liquor potassse. The
hair itself is also thickened, and its structure is blurred
and indistinct. It is probable that the little bluish- white
pimples form by the growing within the hair-follicle of
what remains of a broken, thickened, and brittle hair.
The condition occurs most commoifly on a bearded
face, but it is sometimes observed in other situations, as
the axilla, the pubes, the periphery of the hairy scalp.
Under the latter circumstances the condition is depend-
ent rather on a blockage of the orifice of the hair-follicle
than upon disease of the hair itself. Sometimes, instead
of a single hair, such a follicle will contain a minute
ring-shaped tress, composed of a dozen or more fine
hairs. These are particularly common about the under
surface of the penis, where they often suppurate and dis-
charge a foul smelling mixture of pus and decayed seba-
ceous matter. In treatment giant hairs should be re-
moved by means of forceps, but it is essential that no
force be used. When the little nodules have formed,
the overlying surface should be sterilized and an in-
cision made with a sharp tenotomy knife. A portion
of hair will present, and can easily be extracted. — Medi-
cal News.
A Canadian View of Russia — The Canadian Medical
Record regrets that the next International Medical
Congress will be held in Russia, " as we fear very few
will trust their lives in that barbarous country/ ' and
thinks that " Vienna or even Montreal would be a much
more acceptable and more accessible place." Montreal
might be more accessible to the inhabitants of the North
American Continent, but we assure our esteemed con-
temporary that Russia is not such a dreadful place.
Many of its inhabitants go clothed and eat with forks,
and the nihilists seldom kill more than sixteen visiting
doctors in a week.
August ii, 1894]
MEDICAL RECORD.
175
Medical Record:
A Weekly Journal of Medicine and Surgery.
GEORGE F. SHRADY, A.M., M.D., Editor.
Publishers
WM. WOOD & CO., 43, 45, & 47 East Tenth Street
New York, August 11, 1894.
TOTAL EXTIRPATION OF THE UTERUS IN
DISEASE OF THE ADNEXA.
The importance which this subject has assumed of late
is shown by the prominence assigned to it in Society
discussions, notably that held before the American Gy-
necological Society at its recent meeting. The general
practitioner who is not familiar with the rapid advances
in gynecological surgery is apt to be somewhat appalled
by the confident assertion that the uterus should be extir-
pated in all cases in which the adnexa are removed, on
the ground that the organ itself, being diseased at the
same time, is not only useless, but remains as a constant
source of discomfort, and even of danger, to the patient
This, in a word, represents the dictum of the most ad-
vanced school, which as yet has but few followers among
us. A further argument, which appeals strongly to
abdominal surgeons, is that by removal of the uterus in
cases of extensive suppurative disease of the adnexa, per-
fect drainage is secured per vaginam— the method which
is now recognized as the ideal one — as was foreshadowed
by Sims a quarter of a century ago. To this the more
conservative reply that securing vaginal drainage by
hysterectomy is too heroic a procedure, since the same
result can be obtained by retaining the uterus and drain-
ing through Douglas's pouch.
As is usually the case when a novel and radical surgi-
cal operation is first advocated, the adherents of hyste-
rectomy and its opponents see only their side of the
question. Reading the enthusiastic statements of the
former, the occasional operator would infer that nothing
was easier and safer than the extirpation of the uterus
after removal of the diseased adnexa — in fact, that it was
comparable with a simple ovariotomy. But it must be
remembered that the few surgeons who report such re-
markably favorable statistics are unusually skilful opera-
tors, who have acquired their special aptitude by a
wide experience in hystero myomectomy. An operation
which is easy for them is formidable to one of limited
experience in this work. Therein lies the danger to the
rank and file of coeliotomists, whose name is legion.
The technique of the operation is the main difficulty
in the way of the unqualified acceptance of the proposi-
tion that a uterus without its tubes and ovaries, and es-
pecially a diseased uterus, becomes a useless appendage,
and should therefore be extirpated. No reasonable gyne-
cologist can deny that the uterus is frequently a source of
trouble, that it may be the cause of persistent pain and
hemorrhages, and be open to repeated infection (gonor-
rhoea! or septic) months, and even years, after the removal
of the diseased adnexa. Hence, even the most conser-
vative acknowledge that there are cases in which it
must be admitted that it would have been better if
the organ had been removed at the time of the op-
eration. But is hysterectomy under these conditions
to be recommended to the profession at large? To this
we reply unhesitatingly in the negative. Given a case
of double pyosalpinx with firm intra-pelvic and intesti-
nal adhesions in which considerable manipulation has
been necessary, we affirm that many patients are not in a
condition to bear the extra amount of shock involved in
removal of the uterus. In spite of the advantages afforded
by Trendelenburg's posture, there are few surgeons who
can complete the additional operation in " twenty min-
utes," as is claimed by its advocates. So far as our ob-
servation goes, twice that time- is requited. We have
yet to see a case in which a difficult salpingo- oophorec-
tomy was supplemented by extirpating the uterus, when
the shock was not most marked, and the convalescence,
when recovery followed, protracted.
This point was emphasized by Dr. Coe in reporting a
recent case to the New York Obstetrical Society, and
was dwelt upon by Dr. Bache Emmet in the discussion
before alluded to. The latter gentleman also raised the
pertinent question whether a patient in private practice
would consent to such a radical mutilating operation for
disease of the adnexa, if she were consulted beforehand.
To perform such an operation without her full knowledge
and co operation would be assuming a responsibility
which few would care to take, even in this radical age.
We doubt if the average woman would be sufficiently in-
fluenced by the arguments which appeal so strongly to
the abdominal surgeon, as to take the additional risks
involved in total extirpation.
THE STATUS OF CHRISTIAN SCIENCE IN NE-
BRASKA.
A Christian scientist in Nebraska was recently tried be-
fore the District Court of Gage County, Neb. , on the charge
of practising medicine contrary to the statutes of that
State. He was acquitted by the jury, but the prosecut-
ing attorney carried his exceptions to the Supreme Court,
where they were sustained. Judge Ryan handed down a
decision in which he said that the fact to establish a State
Board of Health, to regulate the practice of medicine
in Nebraska, is as much directed against any unauthor-
ized person who shall profess to treat any physical or
mental ailment of another, as against one who practises
medicine as the term is generally understood.
The section of the act upon which this decision was
based reads as follows : " Any person shall be regarded
as practising medicine, within the meaning of this act,
who shall operate on, profess to heal, or prescribe for,
or otherwise treat any physical or mental ailment of an-
other. But nothing in this act shall be construed to
prohibit gratuitous services in case of an emergency, and
this act shall not apply to commissioned surgeons in the
United States army and navy, nor to nurses in their legi-
timate occupations, nor to the administration of ordinary
household remedies."
This law is certainly rigid, but not too much so, and
176
MEDICAL RECORD.
[August ii, 1894
any suffering that might arise from a too strict applica-
tion of it is prevented by the emergency clause. It
would be impossible for a layman to be punished for
saving life in the absence of a physician, as has actually
occurred in France.
THE EYE AND SURGICAL TREATMENT OF
EPILEPSY.
There has been beyond any doubt a factitious promi-
nence given to the treatment of epilepsy and other ner-
vous disorders by surgical treatment of the eye muscles.
It is the general opinion of neurologists that there is lit-
tle or nothing to. be gained by it, while, on the other
hand, much harm may be done.
Dr. Casey A. Wood, of Chicago, has recently {New
York Medical Journal) gone over the subject very thor-
oughly, and has called attention to the numerous cases of
epilepsy on record which have been cured by minor sur-
gical operations of various kinds. His conclusions are
worth presenting here : He says.
" 1. Heterophoria in some form, latent or manifest,
can be shown to exist as an ocular condition in fully
ninety- five per cent, of all individuals.
" a. Alone and when associated with ametropia it is
not an uncommon cause of so-called asthenopia.
" 3. In the latter case the correction of the accom-
panying refractive error in the large majority of cases re-
lieves all the symptoms set up, both by the ametropia and
muscular anomaly ; when it does not, the heterophoria
may be said to be responsible for the asthenopia.
"4. It is highly probable that when epilepsy is in part
or wholly the result of eye-strain other evidence of the
latter is present.
"5. It must follow from the foregoing that in the eye
treatment of epilepsy of any decided degree the correc-
tion of the ametropia, and not the correction of the
heterophoria, is the first and most urgent duty of the
ophthalmologist, and that in cases where both are cor-
rected at the same time it is fair to suppose that the re-
sults, if any, are due to the ametropic correction.
" 6 . In cases of epilepsy with heterophoria and emme-
tropia, or where the correction of refractive errors has
failed to relieve the asthenopic symptoms and the produc-
tion of orthophoria is followed by cure of the epilepsy
and the asthenopia, it is just to say that the operation on
the eye muscles or treatment of them has produced the
effect of stopping the convulsions.
" 7. In the absence of ocular symptoms, apart from
the epilepsy, an operation upon the eye muscles stands
in the same therapeutic relation to a cure or relief of the
disease as do other surgical procedures that have during
the past century been in vogue, such as tracheotomy,
setons, ligature of the vertebral arteries, trephining,
odphorectomy, circumcision, castration, the actual cau-
tery, the resection of stray scars, and so on.
" 8. These operations bring about a cure or relief of
the epilepsy (both idiopathic and hystero-epilepsy) by
their powerful mental effect upon the patient — a truth
long recognized by neurologists.
" 9. Genuine cures of epilepsy by eye treatment of
any kind must necessarily be confined to those cases
where a faulty ocular apparatus acts as a peripheral irri-
tant. It remains yet to be shown that anomalies of the
extrinsic muscular portion of that apparatus are to any
large extent responsible for the seizures of epilepsy.
" 10. The eye treatment of epileptics who present
signs of ocular distress has not received that attention
which the importance of eye-strain in the category of re-
flex irritants seems to call for. The eyes should be care-
fully examined in every case of epilepsy where asthe-
nopic symptoms are present or are suspected.
"11. I question the wisdom of encouraging the pro-
fession, and through them the laity, to believe that every
case of idiopathic epilepsy is a suitable one for eye treat-
ment, but prefer to say that only those cases are fit sub-
jects, in the proper scientific sense, for eye treatment
whose visual organs are palpably the source of irritation,
giving rise to symptoms generally included under the
term eye-strain.
"12. That when all remedies fail, some such opera-
tion as Reynolds suggests— easy to perform, perfectly
safe, and yet of a severity and character tending to make
a lasting impression on the patient's mind — is indicated.
I would suggest the removal, at intervals, of small pieces
of skin from various parts of the body, the denuded spots
being allowed to heal by granulation."
APPARENT DEATH BY ELECTRICITY.
At a recent meeting of the Biological Society of Paris,
Dr. d' Arsonval reported the case of a workman who was
caught between two cables conveying electricity from the
station of La Chapelle to that of Epinay-sur-Seine. The
current measured 5,000 volts, and the man received the
full discharge for a period of five minutes which elapsed
before the current was shut off. It was not known at
first what caused the disturbances noted in the current,
and the man was not discovered until forty minutes later.
He was then apparently dead, but attempts were made to
resuscitate him by artificial respiration after Sylvester's
method. These failing, resort was had to rhythmical trac-
tions of the tongue. Respiration was in this way gradu-
ally re established and the man made a quick recovery,
being none the worse for his experience except that he
suffered from the burns. The reporter believed that death
from electricity is not immediate, but follows asphyxia
and syncope, conditions which may often be removed by
treatment. If this is so, may the criminals executed in
this State be said to be killed by electricity or during
the autopsy ?
Reformatories and Jails. — An exchange says that
there are 1,758 county jails and but 44 juvenile refor-
matories in the United States. In Great Britain there
are over 400 reformatories and industrial schools for
juvenile delinquents, and the number of prisons has been
reduced from 113 to 57 within the past ten years.
The Oldest Man in the World. — A Frenchman now
living in Russia is said to have attained the immense age
of one hundred and twenty- six years. From a very in-
teresting account of his life, just published in a Russian
journal, it appears that he was born in Paris on April 17,
1 768. He has a vivid recollection of the " Terror. ' ' He
joined Napoleon's army in 1798. He fought in the
battles of Austerlitz and Jena, shared in the campaigns
of Egypt and Spain, and finally was one of the four hun-
dred thousand men who followed Napoleon to Moscow.
August ii, 1894]
MEDICAL RECORD.
*77
UDexrja at ttue W&ttk.
The Cholera Epidemic in Europe shows no signs of
abating as yet. The disease is raging in many provinces
of Russia and in Galicia, and lurks obstinately along the
shores of certain streams in France, Belgium, and Holland.
In St. Petersburg there were 313 new cases and 240 deaths
reported for the week ending August 4th, and in the city
and province of Warsaw during the week previous the new
cases numbered 553 and the deaths 296. In sixteen in-
fected districts in Galicia there were 126 new cases and
83 deaths on August 5 th and 6th. In many towns in this
province all industry and commerce are at a complete
standstill ; the rich have fled and the poor are left in a
starving condition. In Holland the disease is present in
Amsterdam, Haarlem, Halfweg, Dordrecht, and Maas-
tricht, 26 new cases and 13 deaths having been reported
in these places on August 1st. Deaths from cholera have
also taken place in Dantzic and other towns in Eastern
Prussia. The North German Lloyd and Hamburg Amer-
ican Steamship Companies are about to erect buildings at
IUowo and other places on the Russo German frontier for
the detention and examination of intending steerage pas-
sengers to this country. The stations will contain dis-
infecting apparatus for baggage and clothing, and bath-
ing-places for the emigrants.
Openings for the Unemployed. — The war between
Japan and China promises to be a protracted one, and
it is probable that the services of foreign surgeons will
be in demand in the Japanese army and navy, if not in
the Chinese also. Yet we would not advise young sur-
geons to go to the expense of a trip to Japan without
having some definite assurance that their services will be
wanted. And furthermore, a law was passed in i860
making it a penal offence for citizens of the United
States to take part in a war against a friendly nation.
That probably, however, would not apply to the case of
non-combatants such as surgeons and nurses.
The Plague is still epidemic in Canton in virulent form,
the mortality being ninety per cent, of those attacked.
For the three months ending July 1st it is estimated that
forty thousand deaths have occurred. Cholera has also
made its appearance there in epidemic form.
The British Medical Association. — A number of Amer-
icans were announced to be present at the meeting of the
British Medical Association in Bristol last week. Among
them were Drs. J. J. Chisholm, G. M. Gould, J. L.
Thompson, G. T. Stevens, Henry D. Chapin, W. P.
Northrup, and Dillon Brown. Dr. Northrup, in addi-
tion to several communications of his own, read a paper
on intubation for Dr. Joseph O' Dwyer, who was unable
to accept the invitation to be present in person.
The Erenoh Society of Dermatology and Syphilog-
raphy held its fifth annual meeting at Lyons on August
2d and two following days.
Dr. William J. Little, of London, " the father of Eng-
lish Orthopedy," died on Saturday, July 7th, in the
eighty-fourth year of his age. He was for many years
physician to the London Hospital and lecturer on the
Practice of Medicine in the college. His first work, " A
Treatise on Club foot and Analogous Distortions," was
published in 1839, and his last, on "Id -Knee," written
jointly with his son, Mr. £. Muirhead Little, in 1882.
Soon after that he retired from practice to pass the re-
mainder of his days at his country residence.
Dr. Judson B. Andrews, Superintendent of the Buffalo
State Hospital for the Insane, died in Buffalo, August 3d,
aged sixty years. He was a graduate of Yale College in
the class of 1855, and received his medical degree in 1863.
During the War of the Rebellion he served as a captain in
the Seventy-seventh New York Infantry, which was organ-
ized at Saratoga, but resigned July 16, 1862. He is also
credited with service as a surgeon in a Connecticut regi-
ment, but his name does not appear in the New Englard
roster of volunteer officers. He was ex-President of the
Brie County Medical Society, a founder and ex- President
of the New York State Medical Association, as well as
ex President of the Psychological Section of the Ninth
International Medical Congress. In 1892 he was elected
President of the American Medico-Psychological Asso-
ciation. His many years' service as Assistant Superin-
tendent of the Utica Asylum, as Superintendent of the
Buffalo Asylum since it was opened in 1880, and as the
working editor of the American Journal of Insanity, well
qualified him as an expert in his chosen department, to
which, indeed, he contributed many enlightened reforms.
The first French Congress of Internal Medicine will
be held in Lyons, under the presidency of Professor
Gailleton, mayor of the city, during the week beginning
on Thursday, October 25 th. Medical men of any na-
tionality may take part in the proceedings on payment
of a subscription of twenty francs, but ail communications
must be in the French language.
The Medical Publishers' Association meets at Hot
Springs, Va., August 13th and 14th.
The American Journal of Insanity will hereafter be
published in Chicago, under the managing editorship of
Dr. Richard Dewey. The Journal has become the organ
of the American Medico-Psychological Association, but
its general form and scope will remain unchanged.
Insanity and Crime.— At the meeting of the British
Medical Association, just held at Bristol, a discussion on
" The Law in Relation to the Criminal Responsibility
of the Insane" took place before the Section on Psy-
chology. It was opened by Dr. L. A. Weatherly, who
advocated a change in the English law on this subject.
At present the law is that if the accused was con-
scious that the act was one which he ought not to do,
and if the act was contrary to law, he is punishable. Dr.
Weatherly maintained that if it is proved that the ac-
cused is certifiably insane, and further, that the crime
charged is the outcome of his mental disease, he is en-
titled to a verdict of insanity and should be placed under
treatment in an asylum for the insane and not be pun-
ished as a criminal.
The Babathu Leper Asylum. — The annual report of
this asylum for 1893 h^ te*n received. The superin-
tendent acknowledges with gratitude a ready response
to his appeal for increased donations, but says that the
need for help is still urgent. Several contributions were
received from friends in the United States. For. the
benefit of those interested in the study of leprosy some
excellent photographs have been taken of a group of
i78
MEDICAL RECORD.
[August ii, 1894
the leper inmates, and are sold for the benefit of the
asylum at one dollar per copy, including postage, and a
short history of each person. The address of the super-
intendent is Dr. M. £. Carleton, Sabathu, North India.
Pregnancy at an Advanced Age.— In the Berlin In-
telligenzblatt of July 5th, among the death notices was
one of Frau Marchoun, sixty* eight years of age, the
cause of whose death was said to be puerperal fever.
A Monument to Volkmann.— At the recent bicen-
tenary celebration of the University of Halle, a monu-
ment to Professor Richard v. Volkmann was unveiled
with appropriate ceremonies.
A Medical Monk. — Dom Sauton, a Benedictine
monk, and a doctor of medicine as well, who recently re-
turned to Paris from a mission, both religious and scien-
tific, to the lepers of the Scandinavian Peninsula, has
started again on an extended tour among the lepers of
Asia Minor and Greece, and will visit Japan and the
Sandwich Islands before returning to France.
Dr. Charles B. Briggs succeeds his father, the late
Dr. W. T. Briggs, as Professor of Surgery in the Univer-
sity of Nashville.
The St. Louis "Clinique." — Dr. Emory Lanphear
has assumed the editorial management of the above-
named journal.
Sterilization of Doctors. — It has been proposed by
Gutmann that stations be erected in convenient localities
in cities and large towns where physicians may go to
be thoroughly disinfected immediately after they have
visited a case of infectious disease, and before paying
any further visits. The operation will take about fifteen
minutes, and then the doctor may go about his business,
proud in the consciousness of being clean and no longer
a menace to the health of his fellows.
The Iowa Public Hall Association, whose aim, as an-
nounced in the notice of meeting, is purely philanthropic,
will hold its fourth annual session in Des Moines, Sep-
tember 6 and 7, 1894. Membership in the Association
is not limited to medical men, but all interested in the
prevention of sickness are eligible.
The American Electro - Therapeutic Association
will hold its fourth annual meeting at the Academy of
Medicine, in this city, on September 25, 26, and 27, 1894.
An interesting programme is announced. The President
of the Association is Dr. W. J. Herdman, of Ann Arbor,
and the Secretary, Dr. Margaret A. Cleaves, of New
York.
Diphtheria Germs in Cheese. — The Board of Health
in this city recently received a telegram from the Secre-
tary of the State Board of Health, stating that some
cheese which had been shipped to a firm of provision-
dealers contained Loeffler's diphtheria bacilli, and re-
questing that samples be submitted to the bacteriologist
of the Department for examination. This was done,
with the result of proving that the suspicions of the State
Board were well founded. The shipment consisted of
three thousand pounds, and the entire lot has been
seized and destroyed. There was diphtheria in the
family of the farmer from whom the milk was obtained.
The tests thus far made have been culture- tests, but in-
oculation experiments are to be made on guinea pigs.
Mr. Gladstone's Byes are now reported to be so much
improved that he is able to dispense with goggles.
Thyroid Extract has lately been recommended in the
treatment of obesity. But it is well to remember that
this is a dangerous substance, often causing great weak-
ness of the heart, and it should be used with caution.
An International Congress for the Protection of In-
fancy will be held in Bordeaux, commencing July 22,
1895. The work of the Congress will be divided into
three sections: 1, Physical protection, in which ques-
tions of day nurseries, infant and foundling asylums, etc.,
will be discussed ; 2, moral protection, in which will be
considered orphan asylums, country homes, the rescuing
of abandoned children, etc., and 3, administrative pro-
tection, in which the various laws, existent and proposed,
relating to the care of young children will be discussed.
Dr. Hans Buchner has been appointed Professor of
Hygiene and Director of the Hygienic Institute in
Munich, to succeed Professor von Pettenkofer.
A Royal Doctor. — The Lancet, with inconceivable
temerity, makes the awful suggestion that the infant son
of the Duke of York be educated as a physician or sur-
geon. It might not be a bad thing for the young man
to be provided with a livelihood in case anything should
happen to interfere with the exercise of his hereditary
profession. Edward Albert Christian George Andrew
Patrick David Wettin, M.D. Lond., F.R.CP. Edin.,
F.RX.S.L, Defender of the Faith, etc., etc., would be
quite imposing.
The American Public Health Association will hold
its twenty-second annual meeting in Montreal, on Sep-
tember 25-28, 1894.
Students in Leipsic. — The University of Leipsic is
disturbed by the gradual decline in the number of its
students. Twenty years ago it stood at the head of Ger-
man universities, while to day it has a thousand less than
Munich, and twice that number less than Berlin. Those
that remain are studiously inclined, however, for they re-
cently held a meeting in which a resolution was passed
to abstain from beer drinking in the forenoon, on the
ground that early beer interfered with honest work.
The Earning Value of an Bye Mathematically Ap-
praised—The earning value of an eye depends on vari-
ous conditions ; it is evidently greater if the remaining
eye has poor sight than if the remaining eye has good
sight ; for in the first case its loss would practically be
equal to the loss of both eyes. Professor Zehander has
furnished us with a formula by which the earning capacity
of the remaining eye (and consequently the earning value
of the lost eye) can be appraised for the manifold con-
ditions of sight. The normal sight of an eye being
valued at 100, the earning capacity of the remaining eye
is i±jl$jl±jl = 662<i per cent., hence the loss of one eye
amounts to 33^ per cent, of the former earning capacity,
provided both eyes had full vision. But suppose the vision
of the remaining eye is only four-fifths, its earning capacity
would be i±y4'g = 53^ ; hence the lost eye would have
an earning value of 46^3 per cent., and thus the loss in
earning capacity can be estimated under all conditions if
in the above formula the degree of vision of the remain-
ing eye is substituted for 100.— Journal of the American
Medical Association.
August ii, 1894]
MEDICAL RECORD.
179
jfocietg Reports*
drimsstzss of American |p«jsictatis
and gvtXQzaus.
Third Triennial Meeting, held in Washington, D. C,
May 29, jo, ji, and June 1, 1894.
AMERICAN NEUROLOGICAL ASSOCIATION.
Twentieth Annual Meeting, held at Washington, D. C,
May 29, jo, ji, and June 1, 1894.
(Continued from page 90.)
Third Day, Friday, June ist.
The Treatment of Convalescence and the After-care
of the Insane. — Dr. Henry R Stedman, of Boston, con-
sidered the dangers attending convalescence in insanity
and the precautions necessary to prevent relapse or pro-
long remissions. General rules and advice regarding the
prevention of insanity are not regarded even by predis-
posed subjects, and are practically of but little use. The
case is different when once an attack of insanity has
been experienced. Although in certain cases the proper
conduct of convalescence is vital to mental health, the
study of this period is confined to a few scattered sug-
gestions in the works on insanity. Instances of abrupt
recovery, with almost no convalescent stage, are rare.
Although it may happen in chronic cases, it occurs, as a
rule, in those of short duration — notably confusional in-
sanity and the. toxic and neurotic insanities.
Lucid intervals or spurious convalescences differ often
in no respect from genuine recovery, with the single and
essential exception that the sleep does not improve or is
worse. This is a valuable indication in the prognosis of
permanent return to reason.
To the cardinal signs of convalescence should often
be added the disappearance of decided fear of a return of
the attack and dread of the stigma to follow. It is im-
portant to be informed regarding normal and usual phys-
ical troubles of the patient, as their reappearance is an-
other and valuable indication of recovery ; so, also, a
knowledge of the sequence of immediate prodromata of
an attack. They are often repeated in reverse order
while the patient is getting well.
Complete mental rest during menstrual epochs, so
highly important at this time, is often disregarded, and
application of the mind, even to a slight degree, in study
or other work, is equally to be deprecated.
Early discharge from the asylum, or from special care
away from home, is to be advised against, as a rule, espe-
cially in cases of melancholia with a history of suicidal
attempts and after acute mania, the most exhausting
form of insanity, and one which leaves the patient par-
ticularly susceptible to slight influences for a long time.
On the other hand, we should frequently advise early
removal in other cases convalescing from melancholia,
particularly when homesickness is a marked feature and
occasionally when there is refusal of food. Certain cases
of mild mania, also paranoiacs who are independent in
the asylum and actively oppose treatment, are steadied
by outside life. A change also works well until its
novelty has worn off.
The first year or so after recovery is a very critical
time. The reader gave a number of indications in spe-
cial cases and suggestions for prevention of relapse.
The above remarks applied chiefly to well-to do pa
tients. An important branch of this subject is the
means for the after-care of the pauper insane. There is
practically no provision outside of asylums for this class,
and practically little advice or other help is given these
unfortunates on leaving asylums. While for the physi-
cally sick, on the other hand, there is abundant provision
for their care during convalescence, and the discharged
convict is greatly helped and encouraged by charitable
societies for the purpose. Asylum physicians often hesi-
tate to set certain patients at liberty whose mental condi-
tion seems to have so far improved as to make it useless
to keep this class longer under care (and even some who
have fully recovered), for fear that, thus suddenly thrown
on their own resources, without oversight, or perhaps
means of support, they will fall back into their old habits
of life which gave rise to their insanity. This fact, and
their delicate mental condition, often render them easy
victims to designing people.
These and other reasons have led to the formation, in
France, of protective societies, called " Societies of Pat-
ronage " under official auspices. Their duties are to aid
convalescent or recovered pauper patients by gifts of
money, clothing and tools, redemption of articles in
pawn, payment of rent, admission to convalescent
homes in cottages intermediate between confinement
and complete freedom, or in hospitals or house of refuge,
securing situations for them, and finally their supervision
wherever employed. This work continues during the
first month or two after the patient's discharge. Similar
societies or means of relief have been adopted in Eng-
land and Scotland. They were described in detail.
There is no better work on the score of both humanity
and public economy than the adoption in this country
of similar means for the prevention of insanity.
Dr. E. D. Fisher was of the opinion that patients left
the asylum too early. In cases where they are oversen-
sitive regarding their previous incarceration, some-
thing must be done to care for them and obviate a re-
lapse. He was in favor of establishing convalescent
homes for such patients, and spoke at length in confirma-
tion of the views of the author of the paper.
Dr. Dercum thought this matter a very important
phase in the care of the insane. It is, however, quite
difficult to deal with individal cases. Where the element
of exhaustion was a prominent causative factor, the pa-
tient required detention and care much longer.
Dr. Starr was glad to know that Dr. Stedman favored
the earlier removal from asylums of melancholies. One
of the chief difficulties was in controlling the family, who
did not know how to manage the patient after his return.
Dr. Jones, of Minnesota, said that in Minnesota,
since the word asylum had been changed to that of hos-
pital, it had tended to remove any of the supposed stig-
ma that has been usually attached to people who have
been in institutions for the insane.
Dr. Knapp and the President concurred in the views
expressed by the reader of the paper.
Dr. Dana said that the subject was of great economic
as well as medical importance ; he would suggest that a
committee be appointed to investigate the matter.
This suggestion was then presented in the form of a
motion, which was carried. The President then appointed
as a committee Drs. Stedman, Dana, and Dercum.
Exhibition of a Suicide's Brain with Two Pistol ball
Wounds. — Dr. Burt G. Wilder, of Ithaca, exhibited a
specimen and showed a dozen photographs of various as-
pects and blackboard diagrams of the left side and of a
transsection at the level of the fatal wound.
W. I. B., dentist, thirty-five years of age, of Ithaca, N.
Y., on April 7, 1894, was found in his office, dead,
a ^ revolver clasped in his right hand. There were
two bullet-holes — one in the middle of the forehead, the
other in the right temple, neither ball having emerged.
In accordance with his written directions, the brain was
preserved in the museum of Cornell University as speci-
men 3,129.
The first ball, presumably deflected by the skull, passed
caudo-ventrad to the cranial floor and was reflected dor-
so-caudad at nearly the same angle to a point just ceph-
alad of the precommissure, where it lodged, having merely
abraded the mesal surface of the left frontal lobe. The
second ball entered at the right sub frontal gyre, passed
obliquely sinistro-caudo- dorsad, tore the callosum and
intervening structures, and emerged in the second left
central fissure. Since there was no suspicion of foul play,
and documents in the deceased's handwriting declared
i8o
MEDICAL RECORD.
[August ii, 1894
his intention to commit suicide, the case exemplifies the
possibility of two self-inflicted bullet-wounds of one brain.
The fissures present many peculiarities. The most
perplexing is the apparent coexistence of two central fis-
sures on each side. The only two such cases hitherto
observed were recorded by Giacomini and Calori. Sui-
cide had been committed by a grandfather and one uncle
and attempted by another uncle.
Dr. Dercum had examined a large number of brains of
the insane, but he had never seen such an instance as that
presented by Dr. Wilder.
Dr. Dana said that he had no doubt that the anterior
of the two fissures was the fissure of Rolando. The in-
terruption of this fissure on one side by a bridging con-
volution was extremely rare and very interesting. The
brain presented a unique fissuration. He could not
understand how a primary fissure like the Rolandic could
be doubled in any event, and was skeptical of the genu-
ineness of reported cases.
Infantile Hemiplegia, Imbecility, and Epilepsy;
Craniotomy; Marked Improvement. — Dr. Edw. B.
Angell, of Rochester, reported a case and read a paper
with the above title. The salient features of the case
were forceps delivery, succeeded by double ptosis, occa-
sional tonic spasm of right arm, contracture, and hemi-
palsy of right hand. Physical and mental development
were slow, and epilepsy, with three to five seizures daily,
supervened three months prior to the operation. At
time of examination the child was partly imbecile.
Skull measurement gave a cranial index of 77 ; palate
was high-arched, teeth jagged, and right wrist and hand,
much smaller than left, were helpless.
A diagnosis was made of pressure in neighborhood of
the hand-centre of left motor area, due either to a hemor-
rhagic plaque or cyst. Craniotomy was decided upon, as
a tentative measure, with a view of relieving pressure and
consequent symptoms, while avoiding the greater risk of
opening the dura necessary to removal of the cyst-wall.
The operation was performed March 13th last, and, upon
removal of the trephine button, a subdural hemorrhagic
cyst was found. The cranium overlying the cyst had be-
come very much thinned, and was freely cut away beyond
the limits of the cyst. By an aspirating needle a half
drachm of fluid was removed ; otherwise the dura was not
injured. The scalp incision healed readily ; but, through
an overtight bandage, oedema developed, and by the
eighth day caused sufficient pressure to develop a hard
convulsion and high temperature. With the remedying
of this, marked improvement in all the symptoms ensued.
1 At the present time (three months after the operation)
there has been no recurrence of the epileptic attacks,
while there has been a commensurate improvement in the
mental and moral condition.
Dr. Mills considered it presumable that the cyst
which was not opened was a porencephalic cavity, and
that opening and draining it would have been useless.
Dr. Putnam agreed with Dr. Mills. He said it was
rarely possible to remove a cyst satisfactorily. In a case
seen by him the cyst was tapped and the drain left in.
Improvement followed.
Dr. W. A. Hammond spoke of two cases on whom
craniotomy was performed. One was eighteen years of
age, and became an imbecile as a result of an injury to the
head. He remained in this condition four years. After
operation there was improvement at the end of two
months. At the end of a year the improvement was
marked. In the other case, of a similar character, the
operation was followed by improvement.
The President said cysts differed in character. The
superficial cysts were due to meningeal hemorrhage during
labor, and could be satisfactorily treated by operation.
Dr. Angell, in closing the discussion, said this was not
a case of porencephaly, but an arachnoid cyst from a
meningeal hemorrhage.
Infantile Amyotrophic Lateral Sclerosis of the Fam-
ily Type. — Dr. Charles Henry Brown, of New York,
gave the history and report of a case of this kind. The
disease occurred in a boy fifteen years of age. There
was marked emaciation, particularly in the upper part of
the body, and paralysis and atrophy of all the facial mus-
cles, excepting those of mastication. Fibrillary twitch-
ings were present all over the body. The superficial and
deep reflexes were active. Ankle clonus was demonstra-
ble. There was double lateral curvature of the spine.
Mentally the boy was fairly bright. He cries readily
and is amused at trifles. Is microcephalic, and acts and
appears like a child of ten. There are evidences of a
general arrest of development. Dr. Brown considers his
case as belonging to one of the family types of infantile
progressive bulbar paralysis, plus the same implication
that is found engrafted upon the progressive poliomyeli-
tis of adults, and which gives us amyotrophic lateral scle-
rosis. In muscular myopathies the respiration is not in-
volved. The upper facial muscles are usually unaffected,
and the " taper mouth " is not observed. The atrophy
is more irregular, more bilateral ; that is, it is worse on
one side. Electric reactions are not of especial impor-
tance in diagnosis. In some reported cases of infantile
progressive bulbar paralysis they are normal ; in others,
degenerative.
To place this case among the scapulohumeral or facio-
scapulo humeral types of muscular atrophy is out of the
question. Though the neck is much thinned, the scap-
ulohumeral group and the back muscles are generally the
best the patient has. What muscles he does possess are
active, and the exaggeration of reflexes, the fibrillary
twitchings, and the retractions of tendons that are present,
though slight, preclude a peripheral origin of the disease.
As far as is known, no case of the kind has ever been re-
ported and diagnosticated as infantile amyotrophic lat-
eral sclerosis of the family type. Hoffman's case, a boy
aged eleven years, closely resembles it. Here, too, there
was marked labio-glosso laryngeal paralysis, great emaci-
ation of upper extremities of the trunk, extending down
below the hips, together with exaggerated reflexes in
the lower extremities and diminished reflexes in the
upper. In Hoffman's case the atrophy was probably too
extreme in the upper extremities to admit of much re-
sponse. In all the cases reported of these bulbar dis-
eases belonging to groups of family types there has been
marked difficulty of respiration and special implication
of the upper branch of the trifacial nerve.
Dr. Knapp showed a microscopic specimen from a case
of amyotrophic lateral sclerosis which occurred in a man
aged fifty years. The disease progressed very rapidly.
He died at the end of fourteen months of broncho-pneu-
monia. There were no bulbar symptoms. The section
presented showed marked vascularity in the sclerosed
portions of the cord.
Dr. Putnam reported an analogous case of bulbar pa-
ralysis in a young child.
Dr. Preston, of Baltimore, had seen a child two years
of age in whom spastic symptoms, such as exaggerated
knee-jerk and ankle clonus, developed soon after an attack
of acute poliomyelitis.
Ingravescent Cerebral Hemorrhage Treated by Liga-
tion of the Common Carotid Artery.— Drs. F. X. Der-
cum and W. W. Keen, of Philadelphia, presented a joint
paper with this title, reporting two cases. In the first
case the symptoms pointed to a slowly progressive capsu-
lar hemorrhage, extending over three days before ligation
of the common carotid was resorted to. The symptoms
were steadily progressive and threatened a fatal termina-
tion. Ligation of the carotid, as proposed by Mr.
Horsely, promptly arrested the symptoms, and the man
made an excellent recovery. Months afterward merely
symptoms of a spastic hemiplegia persisted, but they were
not very marked.
The second case was one in which the symptoms
pointed to a progressive hemorrhage occupying eight
hours. The patient's condition was so grave at the
time of the operation that little was hoped from it ; and
indeed it proved useless, patient dying several hours
afterward.
August ii, 1894]
MEDICAL RECORD.
181
Dr. Dercum pointed out that the class of cases in
which benefit is to be hoped for from ligation of the
common carotid are those in which the hemorrhage is
decidedly ingravescent in type. He also dwelt upon the
difficulties of a differential diagnosis between hemorrhage
and thrombosis in such cases, and pointed out that even
in case of an error in diagnosis it could not be said that
the operation involved additional risk to the brain.
Finally, he suggested that, instead of ligation of the ves-
sel, the expedient of compression of the common carotid
should be tried in every case of apoplexy as soon as the
physician arrived. A surgeon is not always at hand, and
besides compression of the carotid is so simple a proced-
ure that a bystander can easily be instructed to apply it.
Dr. Frank Fry, of St. Louis, knew of several in-
stances in which the operation had been done. All
proved fatal. He believed that none of them were in-
dicated or justifiable.
Dr. Knapp believed that the neurologist does not see the
case until it is too late to make a satisfactory diagnosis.
The President thought the chief difficulty was in
diagnosis, and that the hemorrhage was usually a self-
limited one.
Dr. Dercum, in closing the discussion, said the opera-
tion was only indicated where the diagnosis of ingraves-
cent apoplexy was definite.
Merycism. — Dr. W. A. Hammond, of Washington, de-
fined this condition as the functions of rumination and
remastication in the human subject. Only about fifty
cases have been reported. Several cases were referred
to, among them that of the distinguished physiologist,
Brown S6quard, who had acquired it as a result of experi-
ments performed upon himself. The case reported was
that of a young man, whose mental condition was impaired
and who was also the subject of merycism. No special
treatment was undertaken against the merycism, but the
patient was trephined with the purpose of improving his
mental condition. There were no unusual features con-
nected with the operation ; but it was noticed that re-
gurgitation did not occur with the meals he subsequently
ate till on the fifth day, when there was a slight return.
Eight days later a similar button was removed from the
corresponding part of the left side of the skull. From
that time (about six months ago) till the present there has
been no regurgitation.
Whether the cure of the merycism in this case was di-
rectly due to the operations on the cranium or the re-
sult of the mental improvement is a question which it
would be difficult to answer.
Dr. Knapp was unaware that so few cases had been re-
ported in this country. Two cases had come under his
notice. Both were physicians in good mental condition.
He thought a distinction should be made between con-
genital and acquired merycism.
Dr. Lloyd believed that some cases should be consid
ered as a neurosis allied to hysterical vomiting, such as
regurgitation from the oesophagus.
The President had seen a man who had conquered
the habit by the exercise of his own will. His views
were in accord with those expressed by Dr. Lloyd.
Dr. Hammond said that acquired merycism was al-
ways due to overloading the oesophagus and to the bad
habit of rapid eating. He thought it extremely doubt-
ful as to its being a neurosis.
Chronic Chorea. — Dr. Lloyd, of Philadelphia, exhib-
ited a large number of sections from the mid brain, pons,
medulla, and spinal cord of a case of chronic chorea.
Election of Members. — The following named gentle-
men were elected to active membership: Dr. Ira Van
Gieson, of New York ; Dr. E. B. Lane, of Dorchester,
Mass. ; and Dr. E. D. Bondurant, of Tuscaloosa, Ala.
Election of Officers. — The officers elected for the ensu-
ing year were : President* Dr. Philip Coombes Knapp,
of Boston ; Vice-Presidents, Dr. F. X Dercum, of Phila-
delphia, and Dr. W. A. Jones, of Minneapolis; Secre-
tary and Treasurer, Dr. G. M. Hammond, of New
York.
AMERICAN CLIMATOLOGICAL ASSOCIATION.
Eleventh Annual Meeting, held in Washington, D. C,
May 29, 30, 31, and June 1, 1894.
(Continued from page 124.)
Fourth Day, Friday, June ist.
Rarity of Phthisis in the Highlands of Pennsylvania
and Hew York. — Dr. Guy Hinsdale, of Philadelphia,
read a paper with this title : He said that, if a physician
were asked to name a district most free from phthisis in
New England or the State of New York, he probably
would name the Adirondacks. He wished to draw atten-
tion to a near-by region in Pennsylvania and New York,
measuring 12,000 square miles, where the death rate
from phthisis was as low as 1 in 1,091 persons living.
He proceeded to describe the tier of counties plotted on a
map, and said that as the maritime tier of counties was ap-
proached in New York there is an increasing death-rate.
The region in Pennsylvania and New York under dis-
cussion had a population of sixty- two per square mile.
It was largely an agricultural section. He claimed for
it elevation and an equable temperature. The moun-
tains were covered with vast areas of hemlock.
During May, June, July, August, and September, it
offered an excellent climate. November to April, it was
solid old-time winter weather. The area generally was
broad, high table-land. Pneumonia and pleurisy are un-
common. The mountain- tops are above fog and moist-
ure. In McKane County in 1880 there were 1,330 liv-
ing to each death from phthisis.
The paper was discussed by a number who knew the
region well and endorsed the statements of the speaker.
Meteorological Data of Colorado. — Dr. Samuel A.
Fisk, of Denver, Colo., read a paper on this subject.
He dwelt on the known advantages of Denver. Its
high elevation, a mile above sea- level, its dryness, etc.
He classed Denver among the cool climates. The winds
were from the south — dry winds. It is not the windy lo-
cality that many fancy. The climate is mild and there
is less wind than in Philadelphia and New York." Col-
orado is peculiarly suited for life out of doors, due to
pure air and sunshine.
The dust-storms in Colorado were made too much of
by outsiders. In fact the dust did no harm, a fact too
well known to admit of argument. He deemed the damp
air of the East more harmful in lung cases than dust in
the West. /, : "
Mr. Mark W. Harrington, of Washington, wished to
supplement what had been said. He spoke of sunshine <
and wind, saying that the latter is a variable quantity.
The velocity of the wind increases as we ascend. At the
level of the street it is one thing, another half way up a
high building, and still another on its top, as proven by
the anemometer.
Dr. Fisk closed the discussion. He said the soil was
dry and porous in Colorado. There was dust. Solar
radiation made the atmosphere very dry. Patients from
the East should be sent to a doctor in Colorado who
knew the climate. He would advise on the proper local-
ity.
Sensible Temperatures. — Mr. Mark W. Harrington,
chief of the Weather Bureau, Washington, read a paper
with this title. The term "sensible temperature" was
one of his coining. It was the temperature felt by
the skin, that which is felt at the surface of the skin, as
on the back of the hand. On a sensible temperature de
pends our sense of comfort in hot weather. High shade
temperatures do not necessarily mean discomfort, if the
dew point is low. In may be 1 2 70 F. in the shade, but the
temperature felt by the skin may be 45 ° below that, ow-
ing to the temperature at dew point. On a chart he
showed the shade temperatures and dew points. Where
the shade temperature and dew point intersected, it in-
dicated the real or sensible temperature, being that felt
by the individual.
By way of contrast, he made a comparison at no° F.
182
MEDICAL RECORD.
[August ii, 1894
and 1 15 ° in the far West, where such a high temperature
may be less trying than 8o° or 900 at the seaboard. The
sensible temperature of £1 Paso, Tex., is similar to that
of Erie, Pa.
There are localities in the United States where the
thermometer may run up to 1 200 to 1400 F. in the summer.
The direct rays of the sun seem to exert a special stimu
lus on organic structures. The color of clothing is of
less consequence than its looseness.
Dr. Guy Hinsdale dwelt on the value of the paper ; it
had unfolded a new and very instructive way of looking
at the weather maps. In future, in consulting a weather
map, we should make the correction, *.*., the difference
between shade temperature and dew point, to obtain the
sensible temperature. All know of the necessity of
making barometric corrections for reliable readings'; the
same now will be necessary for thermometric.
Dr. Robert H. Babcock, of Chicago, said the matter
had a practical and important bearing on the clothing
of our patients. Patients should wear woollen underwear
all through the summer, that they may not be exposed to
too sudden changes, particularly patients suffering from
pulmonary diseases.
In closing, the Hon. Mark W. Harrington said that
the subject was new. He expressed the hope that phy-
sicians would perfect it. He asked the question, what is
the temperature of the vapor of perspiration ? He an-
swered his query by stating that in a freely perspiring
surface the temperature must be greater than that for the
evaporation of pure water, as perspiration is not a pure
fluid.
Beriberi. — Dr. Judson Daland, of Philadelphia, read
a paper describing several cases of beriberi, as studied by
him at the Philadelphia Quarantine in a mixed crew
in a vessel from the East Indies. Temperature normal ;
heart murmur; epigastric tenderness; finger-tips anaes-
thetic; again hyperaesthetic ; blood examined found
to be normal.
Second case : Patient weak ; oedema in places ; much
dyspnoea on exertion ; pulsating jugulars ; extensive ner-
vous disturbances; anasarcous; tricuspid murmur; ex-
amined blood, it was normal ; searched for parasites in
blood, none were found ; anaesthesia of nasal and buccal
mucous membranes ; no knee jerk ; lungs normal ; dila-
tation of right and left ventricles ; changes in cutaneous
sensibility ; in short, a case of neuritis.
The third case was much the same as Nos. 1 and 2.
He deemed the cases interesting, as beriberi is rarely
recognized in this country. It is a disease of the South.
All his cases were sailors. Their diet had been salt-fish
of poor quality and rice.
Etiology. — A disease of the East and West Indies.
Poor diet is deemed a predisposing cause. Dr. Ashmead
thought it due to causes produced in vessels with cargoes
of sugar. A fermentative action. Men had no symp-
toms of scurvy. He thought it a peripheral neuritis.
First the Egyptians in the crew were affected, then the
others.
Dr. A. Gihon, of the U. S. Navy, was quite fa-
miliar with beriberi ; had seen it during his sea service.
Saw eight or ten cases last fall when the Brazilian men of-
war were in New York Harbor. The cases described by
Dr. Daland were admirable word pictures ; such cases got
well under good diet and improved hygienic conditions.
He deemed beriberi a disease of malnutrition. He
did not believe that sugar cargoes had anything to do
with it. Certainly the Brazilian men-of-war were not
sugar-laden. To repeat, he believed it to be a simple
disease of malnutrition.
Dr. William H. Daly, of Pittsburg, thought it might
be due to ptomaine intoxication. There was no degener-
ation or disease properly so called. Thought that there
might be digestive fermentation and subsequent ptomaine
intoxication.
Dr. Wolfred Nelson, of New York, asked Dr. Dal-
an i if any chemical or microscopical examination of the
urine had been made.
Dr. Guy Hinsdale, of Philadelphia, deemed it a dis-
ease of nutrition, and referred to the views of Dr. Ash-
mead, who thought it due to carbonic-acid poisoning
from cargoes of sugar.
Dr. Robert H. Babcock, of Chicago, asked if all re-
covered. Wanted to know if they were cases of acute
cardiac asthenia with dilatation, such as we meet in
typhoid and kindred conditions.
Dr. Daland, in reply, said, that the cardiac condition
was very interesting ; all recovered perfectly. He deemed
it a neuritism and not a degeneration. As to Dr. Hins-
dale's question, including that of carbonic- acid poison-
ing, he thought it a specific infectious disease associated
with neuritis. Thought that the crew had been unruly
and had been punished by way of the stomach. To
repeat, the hearts returned to their normal condition. It
was as Dr. Robert H. Babcock had supposed, a simple
cardiac asthenia, due to want of tonicity in the cardiac
muscle, where dilatation results from weakness. Reply-
ing to Dr. Wolfred Nelson, he said that but one test had
been made of urine; he failed to remember that it was
abnormal.
Dr. Wolfred Nelson referred to his having seen the
disease while practising within the tropics in South
America. Such cases generally died of general anasarca.
Dr. Landon Carter Gray, in his book, included beriberi
in his article on " Neuritis," and such it seemed to be.
Malaria. — Dr. William H. Daly, of Pittsburgh, Pa.,
read the next paper, having for title : " Some Practical
Observations on So called Malaria. ' ' Dr. Daly thinks the
malarial germ one of the infusoria, got in water in low-
lands and swampy regions. Referred to cases due to
drinking well-water from such lands. He did not deem
vapors in marshes as productive of malaria. Some be-
lieve that malaria invades at night, that the poison is
breathed into the system. He believes that the poison,
or germ, is in the water. The habitat of the germ is in
the soil. That water in malarial districts always contains
the germ. So-called malaria is a water-born disease,
the same as cholera.
Malarial fever in the United States is clearly a pre-
ventable disease. In the Southern States animals suffer
from it. Well-water in the South caused malaria.
Those drinking pure cistern- water escaped. The latter
were healthy and ruddy. To repeat, malaria gets into
the body through the food channels.
Dr. Gihon, of the United States Navy, thought it due
to aqueous vapor as well.
Dr. Wolfred Nelson referred to an extended visit by
him to the island of Cuba, and related the experience of
his friend, the late Dr. John Hartmann, formerly physi-
cian to the Uruguay Mining Company, near Santiago de
Cuba. The company employed hundreds of Spaniards.
They were divided into a day and a night shift. The
night-gang slept by day and took a hearty meal on go-
ing to work. The day-gang, of course, slept by night.
Not a single case of malaria in any of its multiple forms
developed in the night- gang, while the men who slept
by night and worked by day had malarial and bilious
remittent fevers constantly.
Dr. William H. Daly closed the discussion by stat-
ing that in five years he believed his views would be ac-
cepted by the profession at large.
Physical Signs of (Edema of the Lungs.— Dr. W. C.
Glasgow, of St Louis, Mo., read a paper entitled " The
Physical Signs of Cellular (Edema of the Lungs, Consid-
ered in their Relation to the Pathological Changes."
The paper dealt with cases in his practice. He deems
the disease due to sepsis. He detailed the symptoms dur-
ing life, and the changes found post mortem.
Said disease might be due to a gas-producing organism.
The signs and symptoms are very perplexing, and often
contradictory. He got riles resembling bronchitic riles.
Said that there were different degrees of infiltration in
the cell walls and bronchial mucous membrane, not as
stages but as types. Infiltration was sudden, and resolu-
tion may occur as quickly.
August ii, 1894]
MEDICAL RECORD.
183
The Groise Isle Quarantine Station. — Dr. Wolfred
Nelson, of New York, informally brought to the atten-
tion of some of the members a number of photographs
made by him last fall while at the Grosse Isle Quarantine
Station, in the St. Lawrence, below Quebec. The situa-
tion is an ideal one, an island twenty-four miles down
the river, six miles from one and four miles from the
other shore. It was an old time and thoroughly organ-
ized Government station ; forty buildings were up ; the
majority fully equipped with the latest appliances. They
*vere divided into first, second, and third classes, all in
different localities. In case of an emergency three
thousand immigrants can be housed. The disinfecting
plant is wholly of Canadian manufacture. So extensive
is it that the effects of one thousand immigrants can be
-disinfected daily— dry heat, then live steam at a tempera-
ture of 2300 F.
Dr. F. Montezambert, Superintendent of the Dominion
Quarantine System, is in charge. He has a trained staff
under him. There is a special staff for service afloat.
Canada to day has a station second to none.
The Society was then adjourned, to meet next year in
West Virginia.
THE NEW YORK PATHOLOGICAL SOCIETY.
Slated Meeting February 28, 1894.
George C. Freeborn, M.D., President.
Papillomata and Papillomatous Cysts of the Ovary. —
The President presented a series of specimens of papil-
lomata and papillomatous cysts of the ovary.
Case I. — These specimens were removed by laparotomy
by Dr. George M. Tuttle. The patient was thirty years
of age, and the mother of two children. Four months
previous to the operation she first noticed a tumor in the
left iliac region. Since then she had lost flesh and had
had considerable pain. At the time of operation, the
abdominal cavity contained a small quantity of clear
serum. A large papillomatous cyst, adherent to the
omentum, was found on the left side, and a papillary mass
on the right. The left ovary consisted of an irregular-
shaped, lobulated mass of papillary growths, measuring
&*4 ctm. in its long, and 6 ctm. in its short diameter.
The slightly enlarged tube was attached to the mass by an
elongated and thickened mesosalpinx. Its fimbriated end
was occluded and rounded off. Section through the mass
showed an irregular shaped ovary containing a few fol
licular cysts embedded in the papillary mass. The left
ovary was reduced to a thin-walled oval cyst, to the
upper surface of which was attached a slightly enlarged
tube. Growing from the upper and anterior portion of
the external surface of the cyst, and extending to the tube,
was a lobulated papillary mass, measuring 9^ ctm. in
length, 7 ctm. in thickness, and projecting 5*4 ctm.
above the surface. On the posterior surface of the cyst
there were also a few small isolated papillary masses. The
tube was slightly enlarged, its fimbriated end occluded,
and its surface covered with adhesions. Section showed
a small portion of ovarian tissue containing a few small
cysts, forming the upper portion of the cyst- wall, the re-
mainder being thin fibrous tissue The internal surface
of the cyst was studded with papillary outgrowths, vary-
ing in size from that of a pin head to that of a cherry.
From the surface of the remains of the ovary there was an
outgrowth of papilloma. At the external end of the re-
mains of the ovary was a second cyst, containing a small
papillary mass.
Case II. — These specimens were removed from a pa-
tient in the service of Dr. C. Cleveland, in the Woman's
Hospital. She was unmarried, and thirty years of age.
Ten months previous to operation she noticed an enlarge-
ment of the abdomen, and six months later three gallons
of a light brown fluid were removed from the peritoneal
cavity by tapping. At the operation, six months later,
two and a half gallons of the same kind of fluid were re-
moved. The right ovary showed an oval cyst, 7x5
ctm., from the end of which projected an irregular, lobu-
lated papillary mass, 10x8 ctm. Longitudinal section
through the cyst and papillary mass showed that the cyst
grew from the end of the ovary. It was thin- walled and
had a lobulated papillary mass, 4X2^ ctm in size,
growing from the internal surface of the cyst- wall, and ap-
peared to be continuous with a similar mass attached to
the outer surface of the cyst. The remains of the ovary
were triangular in shape, measured i}4 x 4}£ ctm., and
were surrounded by a mass of papillary growth. The pap-
illary mass was divided into three lobes, each of which
was attached to the ovary by a distinct pedicle. The
left ovary was an irregular, papillary mass, n x Sj4 ctm.
Section through the mass showed its central portion to
be composed of an oval ovary, 5X3 ctm/ The ovary
contained several small cysts. Along the upper surface
of the ovary there was attached a slightly enlarged Fal
lopian tube. The papillary mass was composed of three
lobes, which were attached to the surface of the ovary by
distinct pedicles. Two of these were rather broad, the
third was long and slender, and was attached to the outer
end.
Case III. — These specimens were examined at the re
quest of Dr. George M. Tuttle, who had removed them
from a married woman, fifty- two years of age, the mother
of four children. The menopause had occurred six years
previous. Eight months before operation she noticed an
enlargement of the abdomen and oedema of the lower ex-
tremities. At the time of the operation a tumor of the
abdominal cavity was found extending above the umbili-
cus. The inguinal lymph nodes were enlarged. Upon
opening into the peritoneal cavity a moderate amount of
clear serum was found. On the right side was a tumor
growing from the ovary and extending out between the
folds of the broad ligament. The omentum was adherent
to its surface. The left ovary and tube were normal.
The omentum showed a papillary mass the size of a cherry
attached to its lower border. Microscopical examination
showed a small papillary mass distributed very generally
over the surface of the trabecular.
Case IV. — The specimen was removed from a married
woman, thirty years of age, who was in the service of
Dr. C. Cleveland iu the Woman's Hospital. She gave a
history of gradual enlargement of the abdomen extend-
ing over a period of six months previous to her admis-
sion. During the six weeks prior to operation there was
a rapid accumulation of the ascitic fluid, with loss of flesh
and strength. Laparotomy was performed and revealed
both the ovaries and tubes converted into papillary
masses, and so firmly adherent to the pelvic tissues that
they could not be removed. The omentum was found
adherent to the uterus and intestines and filled with a
mass of small cysts. The portion of the omentum pre-
sented was removed and the abdomen closed. The pa-
tient died twelve hours after the operation, of exhaustion.
No autopsy was permitted. The specimen consisted of
a rectangular piece of the omentum, measuring 1 2 j£ x 1 1
ctm., with an average thickness of 20 mm. The entire
specimen consisted of a mass of small cysts, thin-walled,
and containing papillary masses and a clear, thin fluid.
Case V. — This specimen was removed by laparotomy
from a woman, twenty-six years of age, who was admitted
to the service of Dr. Outerbridge in the Woman's
Hospital. The history stated that she was married, but
had had no children. Two years previous to her admis-
sion she had sharp pain in the left iliac region ; one year
later she noticed a tumor and also oedema of the lower
extremities. The specimen was removed by laparotomy,
and consisted of four thin-walled cysts grouped around a
central dense mass, from which there sprung an irregular
papillary growth. Section showed all the cysts more
or less ovoid in shape, the largest measuring 10 x 8
ctm. ; the next in size, 9x6 ctm. ; the next, 8x5^
ctm., and the smallest, 6x4^ ctm. The interior of all
the cysts was more or less studded with papillary out-
growths. The central dense mass was the remains of the
ovary, from the surface of which grew the papillary mass.
i84
MEDICAL RECORD.
[August iit 1894
Case VL — This specimen was removed by Dr. F. H.
Markoe. It was a multilocular cyst 10 x 12 ctm. The
Fallopian tube was attached to the surface of the cyst.
Section showed three principal cysts with thin walls, the
internal surfaces of all being studded with various-sized
papillary outgrowths.
A Cylindroma of the Scalp. — Dr. £. K. Dunham pre-
ssnted a cylindroma of the scalp. The tumor was about
one and one fourth inch in diameter, one half inch
thick, and lenticular in shape, and was situated in the
anterior portion of the scalp in the median line. It had
been growing slowly for two years, and was regarded as
a recurrence in the cicatrix left after the excision of an
old wen. After the removal of this tumor the patient, a
man aged seventy, lived for one year without any sign
of recurrence, and then died of apoplexy. An examina-
tion of the first sections had led him to think it was an
epithelioma, but careful examination of the thinner sec-
tions showed it was a sarcoma, and one in which certain
elements had undergone hyaline degeneration. Micro-
chemical tests were made for hyaline material, but with
negative result. The specimens exhibited under the
microscope showed the alveoli filled with small, round
cells, and among these cells small hyaline bodies. The
speaker said it had occurred to him that these hyaline
bodies were degenerated capillary vessels, but he was
doubtful about this because he had been unable to find
any transition forms, and moreover, there was hyaline
degeneration not only of the bloodvessels, but of the
fibrous tissue, as the capsule exhibited the same degen-
eration.
Dr. £. Hodbnpyl agreed to the diagnosis of cylin
droma, but objected strongly to the use of the term
" cylindroma/' which was vague and unsatisfactory.
Congenital or Infantile Myxoedema — Dr. W. P.
Northrup presented photographs of three cases. These
cases were being treated by the internal administration
of the glycerine extract of the yearling sheep's thyroid.
It had been found that a daily dose of three drops kept
the temperature at about the desired point — ioo° F.
The photographs showed very well the peculiar physical
characteristics of these children.
Carcinoma of the Liver, Stomach, and Lungs. — Dr.
E. Hodenpyl presented specimens from a case of carci-
noma of the liver, stomach, and lungs. The case was re-
markable on account of the enormous extent of the lesion,
the very short duration of the disease, and the very mod-
erate discomfort which it caused. The patient was a man,
forty six years of age, whose family history and previous
history were negative. His last illness dated back to the
latter part of October, 1893, when he began to experience
a heavy sensation in the upper part of the abdomen, and a
distress after eating, which, however, was not aggravated
by eating. There was no vomiting, pyrosis, or eructa-
tion of gas. He gradually developed dyspnoea. When
admitted to hospital, on January 31st, he was moderately
emaciated and pale; the urine was normal. Physical
examination showed the heart and lungs to be normal.
Hepatic dulness began in the fifth space, and ended two
inches below the free border of the ribs. The spleen was
not enlarged. There was a good deal of constipation,
but no vomiting, while he was in the hospital. He died
comatose. At the autopsy the left lung was found
studded with a moderate number of yellowish- gray nod-
ules. The right lung was considerably compressed, the
liver was enlarged, the gall bladder normal, and the
cystic duct pervious. Extending along the entire length
of the lesser curvature of the stomach, but not involving
either the cardiac or pyloric orifices, was a large card
nomatous nodule the size of a small orange, and adjoin-
ing it a thickened portion of new-growth and a large
area of ulceration. The liver, together with the pan-
creas and stomach, weighed fourteen pounds.
Hypertrophy of the Prostate ; Carcinoma of the
Bladder ; Hydronephrosis ; Ohronio Bright' s Disease. —
Dr. Hodenpyl also presented specimens removed from a
man, ' sixty-six years of age, who was admitted to the
hospital on February 20th. It was impossible to obtain ,
an accurate history from him. He had been quite in-
temperate. He said that about two months before ad- j
mission he became very obstinately constipated, and !
there was inability to urinate except in small drops. On
admission, there was oedema of the legs, scrotum, and
penis ; his temperature was ioo° F. ; respiration, ao.
The urine was very bloody, alkaline, had a specific grav-
ity of 1.013, aQd contained seventy-five percent of al-
bumin by volume. The daily quantity of urine voided
for three successive days was six, two, and sixteen ounces
respectively. The urine was drawn by the catheter
while he was in the hospital, and was always very bloody. *
Physical examination showed fluid in the abdominal and
pleural cavities.
The chief point of interest in the case was found on
the peritoneal surface just adjoining the right kidney — a
series of intercommunicating sacs, many of them ending
in blind pouches with thickened edges. Some of them
were ulcerated. The ureter passed over this curious mass
into the kidney. The speaker said he was unable to ex-
plain this condition except on the supposition that it was
either a secondary growth or foetal remain. He would
report upon it more fully at another time.
Dr. T. S. Southworth presented the lungs from the
twin of the child whose lungs were presented by him re-
cently. This child was fifteen months old, and weighed
at birth four pounds and a half. Last May it had severe
pertussis, and in the third week of the disease a broncho-
pneumonia for six weeks. After this it gained slowly up
to five weeks ago. Two weeks ago it developed fever,
and fine crackling riles over the chest, anteriorly and
posteriorly, with a temperature of ioo° to 1030 F. It
died suddenly. At the autopsy the left lung showed ad-
hesions posteriorly, and the right lung general firm adhe-
sions, evidently older than in the other lung. The bron-
chial glands were markedly enlarged on the right side,
but were not cheesy. There was consolidation and a
fairly uniform white mottling of the right lower, right
middle, and posterior half of the right upper lobes.
There was also consolidation of the posterior half of the
lower lobe of the left lung, with the same mottling. The
spleen was much enlarged and congested. The mesen-
teric glands were not enlarged. This child was also sup-
posed to be tubercular, but the lung showed the form ot
bronchopneumonia not infrequently mistaken for tuber-
culosis. It was worthy of note that notwithstanding the
history the bronchial glands were not cheesy.
Absoess of the Liver Mistaken for Empyema. — Dr.
J. M. Byron reported this case. The case occurred in
Bellevue Hospital, and the diagnosis of empyema was
made because exploratory puncture and the physical
signs pointed to this condition. An opening was made
on the right side at the usual point, and some pus with-
drawn. The man died, and on autopsy absolutely noth-
ing was found in the pleural cavities except a very slight
pleuritis on the right side. In the posterior and upper
part of the right kidney, however, was a very large ab-
scess cavity, which communicated with the operation
wound. The diaphragm .was intact. There was no ul-
ceration in the intestines, or anything to account for this
abscess in the liver.
Exophthalmic Goitre. — Dr. Henry Power reported
a case of exophthalmic goitre treated with the thyroid
extract ; death in six weeks. The only other case of the
kind, so far as he knew, had been reported by Dr. Owen,
in the British Medical Journal. His own patient was a
Swedish domestic, twenty-four years of age, in whom
rather large doses of the thyroid extract were used — seven
to nine drops three times a day. At first there was gen-
eral improvement, and shrinkage of the tumor to half its
former size, but this was followed by a return of the
former condition, and by a deterioration of her general
health. The dose was quickly reduced, and finally
stopped, but three weeks after the last dose the patient
became comatose and died. At the autopsy, which was
made twenty four hours later, it was noted that there
August ii, 1894]
MEDICAL RECORD.
185
was marked emaciation, together with enlargement of
the thyroid. The heart, lungs, and kidneys were nor-
mal ; the uteras was small and of the infantile type ; the
spleen was not enlarged. The thymus was present ; it
measured 3^ x ^ x }i inches, and weighed 13
gm., after partial hardening. The thyroid showed
great symmetrical enlargement, and weighed 40 gm.
after partial hardening. The brain could not be ex-
amined. Microscopical examination of the thyroid
showed the stroma normal, and the epithelium greatly
proliferated. Some of the alveoli were lined with cu-
boidal epithelium, others with cylindrical cells, while
others again had no regular lining. The stroma of the
thymus appeared to be normal ; the cells stained with
difficulty. The liver contained some fat. The kidneys
were tabulated and contained hyaline casts. They also
showed degeneration and congestion.
Cancer of the (Esophagus.— Dr. Henry P. Loomis
presented the specimen. The patient was a man, fifty-
three years of age, who had an excellent family history,
and also a good previous history, except that he said he
had had a slight bronchitis for many years, His last ill-
ness began last August with anorexia, uneasiness in the
epigastrium, and slight vomiting. The pain was most
intense in the left hypochondriac region and near the
xiphoid cartilage. For two months he could only take
solid food with difficulty, and then finding that solid food
caused pain he swallowed nothing but oatmeal and milk.
On admission he was very greatly emaciated, had a hag-
gard, apathetic expression, and vomited curdled milk.
Physical examination of the abdomen showed an area of
flatness about four inches in diameter, with its centre one
inch below the xiphoid cartilage.
The autopsy was made thirty six hours after death.
No pathological lesion was found in any of the organs
or tissues until the stomach and oesophagus were opened.
A firm, dense, cancerous infiltration was found in the wall
of the lower portion of the oesophagus and the oesophageal
end of the stomach. About three inches of their walls were
infiltrated with a dense mass which narrowed the opening
of the oesophagus into the stomach to such a degree that it
was with difficulty that an ordinary penholder could be
introduced down the oesophagus. There was no ulcera-
tion or involvement of the rest of the stomach wall. The
infiltration presented the ordinary appearance of a scir-
rhous cancer. There was marked atrophy of the intes-
tines. The patient apparently died of inanition due to
mechanical obstruction, which interfered with the intro-
duction of food into the stomach.
Cancer, the speaker said, was the most frequent form of
tumor met with in the oesophagus, and statistics showed
that the seat of the tumor in this case was the most fre-
quent portion involved. The extreme narrowing of the
tube was due partly to the infiltration, and partly to the
contraction of the newly formed connective tissue as
the result of the irritation of the new growth. The dense
infiltration no doubt produced the feeling of obstruction
which was constantly referred to by the patient during
life. The absence of ulceration was unusual. The
oesophagus and stomach at the site of the cancer were
tightly bound to the cellular tissue behind them. The
tumor was diagnosticated during life, and an operation
advised. If this advice had been followed, no doubt the
patient's life would have been prolonged considerably by
the establishment of a gastric fistula.
Primary Tumor of the Heart Wall.— Dr. H. P.
Loomis presented a specimen of tumor of the heart wall
which had caused sudden death. At the request of the
coroner a post mortem examination was made on W.
J , thirty-five years of age, who was found dead on
the floor of his bedroom by the servant who came to
awaken him in the morning. A friend, in whose room
he had spent the previous evening, testified that he left
him about eleven o'clock, apparently as well as ever ;
but on being questioned further, the witness recalled the
fact that his friend had complained of some distress over
his heart two or three times while they were together.
The man must have died immediately on reaching his bed-
room, for he was found stretched on the floor with his hat
grasped in his hand. Careful inquiry was made of his
friends, who stated that he had not been sick for years,
nor had he even complained of feeling ill during the
month preceding his death. He had attended regularly
to business. He was a moderate drinker, but at times in-
dulged to excess. No syphilitic history could be ob-
tained. The autopsy was made twelve hours after the
body was found. He was a robust man, of excellent
physique, and weighed one hundred and seventy-five
pounds. There were no marks of external injury. The
liver and kidneys showed the lesions of extreme passive
congestion, with moderate cirrhosis of the liver. A most
careful examination of all the other organs, including the
brain, failed to reveal the slightest abnormality until the
heart was opened. Here a lesion was found — one of
the rarest met with in post mortem examinations. A
circumscribed tumor of a yellowish- white color, firm in
consistency, noncapsulated, was found embedded in the
anterior wall of the left ventricle. Its dimensions were
# x i^A x 2 inches, and it involved over one- third of
the wall of the left ventricle. Neither the endocardi-
um nor the pericardium over the tumor was involved.
The heart weighed sixteen ounces. The left ventricle
was very much dilated, and as a result there was marked
insufficiency of the mitral valve. There was no hyper-
trophy of the heart wall. The valves were normal, as
was also the endocardium. A large, soft, red, non- ad-
herent blood- clot filled the cavity of the left ventricle.
The right ventricle was free from blood, slightly dilated,
and its wall was somewhat thickened. The coronary
arteries were normal. The thoracic and abdominal aorta
showed the lesion of an extensive aortitis, involving the
greater portion of its inner coat. A section cut so as to
include the heart wall and the greater portion of the tu-
mor showed on microscopical examination that it was
composed of small round cells, with here and there, near
the centre, cheesy spots. In a few places, giant cells
could be seen, as also amorphous basement substance be-
tween the round cells. In places young connective-tissue
formations could be seen. The tumor was moderately
supplied with small blood-vessels in its outer portion. It
was not encapsulated. The round cells could be seen
running between the muscle fibres in its external zone.
Sections of the tumor were stained for tubercle bacilli
with negative result. Gram's method failed to reveal
the presence of any micro-organisms. From a careful ex-
amination of all portions of the tumor an unqualified
diagnosis of a syphilitic gumma was made. This diagno-
sis was later confirmed by Dr. T. M. Prudden, who ex-
amined the specimen.
Primary tumors of the heart are exceedingly rare, al-
though secondary tumors are not of infrequent occur-
rence, especially secondary carcinomata. Virchow in
his Archives, vol. xv., describes the following tumors as
being found in the heart wall: sarcomata, fibromata,
lipomata, myxomata, and syphilomata. The last he
says is among the rarest tumors met with. This is the
second case of primary syphilitic gumma which the
speaker had met with in the last ten years, the other case
being that of a prostitute, thirty years of age, who died
of lobar pneumonia. The present case is also of interest
because it was no doubt the indirect cause of the man's
sudden death, which must be explained by the sudden
over- distention and inability of the left ventricle to empty
itself. Nearly one-half the muscle fibre of the left ven-
tricle wall was destroyed by the new growth.
Syphilis is known to affect the heart in two ways, viz. :
1, by the formation of a gummy tumor, as in this case ;
and 2, by setting up an indurated myocarditis, the local-
ized and extensive fibrous indurations in the muscle tissue
being generally associated with a fatty degeneration of
the muscle fibre. Cheesy masses are often found in these
indurated areas, and the question has been raised as to
whether they may not be gummata in process of ab-
sorption. Lancereaux mentions two cases of waxy de-
1 86
MEDICAL RECORD.
[August ii, 1894
generation of the heart wall which he refers to as one of
the manifestations of tertiary syphilis, but his observations
have not been confirmed by other observers. No doubt
syphilitic gumma in various stages of development and
metamorphosis is the most characteristic lesion of tertiary
syphilis affecting the heart.
Carcinoma of the Wall of the Stomach. — On behalf
of Dr. Le Fevre, Dr. Loomis also presented a specimen
of carcinoma of the wall of the stomach. The specimen
was removed from a married woman, thirty-one years of
age, whose family history was good. She had enjoyed
good health up to six months after her last confinement,
or up to one year and nine months ago. She was slightly
anaemic at this time, but quickly recovered. Five months
later she came under Dr. Le Fevre's care, complaining
of very severe pain in the stomach, accompanied by
vomiting. Her weight had been reduced in a short time
from one hundred and forty pounds to one hundred and
fifteen. She improved temporarily under tonic treat-
ment. Four months later there was extreme pain in the
epigastrium, radiating through to the angle of the left
scapula. With this there was incessant vomiting and
also some fever. Six days later, the thickened wall of
the stomach was mapped out by physical examination.
She then passed from under his observation. She was
reported to have suffered constantly. She never vomited
blood. At the autopsy, the body was found to be ex-
tremely emaciated ; the lungs, liver, and intestines were
normal ; the uterus and ovaries were also normal. The
stomach was adherent to the spleen, and these were ad*
herent to the upper portions of the intestine. There was
very extensive cancerous infiltration of the wall of the
stomach, beginning at the pylorus, and involving by far
the greater portion of the stomach. Incidentally, the
heart was of interest, for, while presenting no organic dis-
ease, it was as small as the heart of a child.
Dr. Byron said he had examined some of the sections
of the tumor of the heart wall, and the structure was not
at all characteristic of gumma of the heart. The round-
cell infiltration was very extensive and uniform, and all
of the cells seemed to be nearly of the same age without
any discernible degeneration in any portion of the tumor.
The giant cells, which reacted to eosin almost like mus-
cular tissue, seemed to him to be simply muscle fibres in
which the inflammation had given rise to the prolifera-
tion of the muscle nuclei.
Dr. Loomis said that as the case had been variously
diagnosticated as interstitial myocarditis, abscess of the
heart, sarcoma of the heart, etc., he would be very glad
to have the specimen examined by the Committee on
Microscopy. He did not think, however, that it was
possible that the giant-cells were really muscular nuclei.
The specimen was referred to the Committee on Mi-
croscopy.
The society then went into executive session.
Stated Meeting, March 14, 1894.
George C. Freeborn, M.D., President.
Tuberculosis of the Bladder and Kidneys. — Dr. W.
G. Le Boutillier presented specimens from a case of
the above. They were removed from a man thirty-five
years of age, who had one testicle removed ten years be-
fore, probably for tubercular disease. There was no his-
tory of the beginning of the tuberculosis. At the time
of death there was tuberculosis of the lungs, of one hip-
joint, and of several vertebrae. The pelvis of each kid-
ney contained a mass of cheesy material and several
cheesy masses also in the cortex. The right ureter was
much dilated, but there was no evidence of obstruction.
While the patient was under observation some of the
urine was injected into a guinea-pig to confirm, if pos-
sible, the tubercular nature of the disease. The guinea-
pig was found dead about eight weeks later, and exami-
nation showed cheesy masses at the site of the inocula-
tion and also general peritonitis and tubercular lesions of
the lungs and spleen. Tubercle bacilli were found in the
patient's urine.
Bovine Tuberculosis. — Dr. George P. Biggs pre-
sented portions of organs showing the characteristic
lesions of bovine tuberculosis. The specimens were
brought to him by a veterinarian, who stated that large
numbers of tubercles were found in the lungs, heart,
mesenteric glands, mediastinal glands, peritoneum — in
fact in all of the organs. The animal was a Jersey cow,
and its milk had been used up to about two weeks before
the animal was killed. It had been slightly ill for a few
weeks, and had had a slight dry cough, which, however,
two veterinarians had said was of no significance. The
animal also had a good deal of difficulty in breathing,
and examination showed a large number of dry rales.
The specimens presented comprised portions of the liver,
spleen, lungs, mesenteric glands, and udder. In the
section from the udder there were no distinct giant cells,
but rather epithelioid tubercles. The tendency to casea-
tion was very marked. The speaker said these caseous
masses usually became encysted, and after considerable
time underwent calcification. Unfortunately no exami-
nation was made of the milk. Among the characteristic
features of tuberculosis might be mentioned, (1) a series
of outgrowths from the serous membranes often attached
together like bunches of grapes; (2), the tendency to
calcification ; and (3) the proneness to the formation of
fibrous tissues.
Dr. Le Boutillier asked for further information re-
garding the diagnosis of bovine tuberculosis. He under-
stood that recently the diagnosis had been made by in-
jections of tuberculin.
Dr. J. S. Ely said that for some months past he had
been examining material sent him by the cattle inspectors
of the State Board of Health. They have been using tuber-
culin quite extensively and with good results. Last No-
vember he went to Barren Island to see some condemned
animals slaughtered. Out of the seventy- two cattle, sixty-
eight had given the characteristic reaction with tubercu-
lin, and after slaughtering, just sixty- eight of the animals
were found to be tubercular. The normal temperature
of cattle was higher than in the human subject, about
roa° F. After the injection of the tuberculin, the tem-
perature rose within seven hours to 1040 or 105° F., and
in the course of four or five hours more, fell to the nor-
mal. This was considered the typical reaction. The
herd referred to was a valuable one, being worth about
thirty thousand dollars, and consequently the owner had
employed several veterinarians to examine the cattle.
One prominent veterinarian said they were not tubercu-
lar, and another coincided in this opinion, yet many of
the animals when slaughtered showed lesions nearly as
pronounced as those seen in the specimens just presented.
Dr. T. M. Pruddbn said that a farmer came to see
him recently in regard to a herd of Jersey cattle which
he suspected had become infected with tuberculosis.
Only about thirty cattle seemed to be sick, and as these
thirty gave the characteristic reaction with tuberculin,
they were killed, and were found to be tubercular. The
owner then determined to sacrifice an apparently healthy
animal to determine still more definitely the value of
this test. An animal which did not give the reaction
with tuberculin was slaughtered and was found to be free
from tuberculosis. The power of this breed of cattle to
produce milk and butter seemed to be at the expense of
their resisting power to tuberculosis. The very long
series of experiments of Dr. Ernst, published before the
Association of American Physicians in Washington some
years ago, and a similar series in Germany, showed that
it was not at all necessary to have any involvement of the
udder to have tubercle bacilli in the milk.
Osteosis of the Skin of the Foot.— Dr. Warren
Coleman presented the specimen. He said that in
March, 1892, Dr. Sherwell presented a case to the Der-
matological Society for diagnosis. The patient, a girl
six years of age, of American parentage, had an erosion
in the sole of the left foot which the mother had first
August ii, 1894]
MEDICAL RECORD.
187
noticed about two and a half years previously. It was a
thickening of the skin and subcutaneous tissue, occupying
about one-third of the plantar surface of the foot, chiefly
under the os calcis, and a little to the outer side. It was
learned that a year and a half after the lesion in the sole
had appeared, the fourth toe became involved, and grad-
ually increased in size, the skin of the entire toe taking
part in the process, though the lesion was most advanced
in the distal phalanx. The enlargement was symmetri-
cal, and the toe attained a dianieter of 1 ctm. At
that time Dr. Sherwell described the condition as
follows : " The lesion now consists of a plaque of
cartilaginous hardness, studded here fend there with
tubercular nodosities, about six in number, the whole
occupying about one-third of the external plantar surface
of the left foot. The skin and subcutaneous cellular tis-
sues are all involved in the process, s.ill the plaque can
be moved relatively freely over the subjacent tissue. The
epithelial tissues, while somewhat thick and horny,
present no other unusual features. There are few sub-
jective symptoms while the foot is at rest, but on account
of the hardness it is difficult to walk upon, it seeming to
act as a foreign body without the irritation the latter
would cause. The little patient always walks on the
ball of that foot. The lesion on the fourth toe is of the
same relatively painless character, and is curiously
clubbed on top, and the peculiar cartilage like feel is also
present On no other part of the limbs or body is any-
thing that is abnormal. The child is of healthy parents
as far as can be ascertained, and is a healthy child. I
cannot class the trouble as scleroderma or carcinoma en
cuirass t, and present her for diagnosis."
In December, 1892, the plaque and fourth toe were
removed by operation and were hardened in alcohol. It
was noticed at the operation that in cutting out the
plaque the knife met with more resistance beneath it
than normal subcutaneous tissue would have offered, even
in the sole of the foot.
It was learned from Dr. Sherwell that the growth had
recurred and was now advancing. The scar was adherent
to the bone, and in front of the scar the skin and sub-
cutaneous tissue were infiltrated with a substance which
from its hardness and resilience seemed to be cartilage.
It was of new formation, having appeared since the time
of the operation. Dr. Piffard decalcified a portion of the
growth in a two per cent, mixture of nitric acid and
ninety-five per cent, alcohol, and as an examination of
sections from this piece showed a general infiltration of
the skin with bone, rather than a distinct tumor forma-
tion, he suggested the name "osteosis." The body of
the plaque, its advancing edge, and the toe were ex-
amined. The latter was cut at two different levels —
through the body of the phalanx, and through the artic-
ular cartilage — with a view of determining the origin of
the process. The staining of the cells was somewhat in-
terfered with by the use of this mixture for decalcification.
Twenty different sections were studied.
The sections through the body of the plaque showed
cancellous bone close up to the epidermis. The spicules
varied in size and shape, and were irregularly distributed
throughout the tissues. The interspaces were filled
chiefly with fat-cells, blood-vessels, and a loosely woven
connective tissue. Small nerves were found here and
there. The sweat-glands and their ducts appeared nor-
mal. In this part of the growth the spicules were the
most abundant, which would account in part for its
greater hardness, but they were also smaller. There
were irregularities in their size and shape apparently due
to absorption. Frequently distinct rows of cells might be
seen along the sides of the spicules, but as a rule they
did not lie under a definite membrane. Large multi-
nucleated cells were sometimes associated with them, es-
pecially where the spicules were thinnest. Mingled with
the fet-cells generally in the interspaces was a tissue of
marrow-like structure, consisting of uni-nucleated cells a
little larger than lymph-cells, the nucleus occupying
nearly all the protoplasm. The large multi-nucleated
cells occurred with these, and fine connective-tissue
fibres ran among them all in different directions. Some
of the spicules consisted merely of a homogeneous
ground substance with rounded or flattened cells scattered
through it ; in others, the cells were branched, and ar-
ranged in irregular rows, or were disposed in concentric
rows around a central opening. No distinct fibrillation
could be made out in any of them. As a rule, the spic-
ules were composed of irregular lamellae, between which
were branching lacunae, filled with bone corpuscles.
Small blood-vessels were included in the larger masses of
bone, and in rare instances the lamellae were arranged
concentrically around them, but there was a lack of
regularity characteristic of the Haversian system in the
disposition of the bone corpuscles. The connective
tissue immediately under the epidermis was very dense,
in fact, was almost tendinous in structure.
The edge of the plaque was not so thick, and con-
tained less bone than the part just described. It con-
tained also masses of cartilage. Some of the cartilage-
cells were branched. There was also reason to believe
that a transformation of fibrous tissue into cartilage was
taking place, for cells immediately adjacent to cartilag-
inous masses might be seen increasing greatly in number,
and arranging themselves between bundles of dense fi-
brous tissue, and becoming flattened out. They were of
the same size, shape, and appearance as the outermost
cells of the cartilage, and merged imperceptibly into
them. They corresponded very closely with cells in a
like situation in an ossifying tibia from a six months'
foetus. There was an entire absence of rows of osteo-
blasts around these centres. .This transformation was
suggested in certain sections from the older part of the
growth, but in them, as a rule, the ossification of carti-
lage already formed was the most prominent feature.
The method by which the cartilage extended would ex-
plain the absence of a periosteal layer, but without a
periosteum it was not so clear why the osteoblasts ar-
ranged themselves in definite rows along the sides of the
calcareous cartilages.
In all essential details ossification was proceeding
regularly. Many of the spicules had ossified only so far
as the deposition of calcareous granules in the cartilagi-
nous matrix without any noticeable change in the appear-
ance of the cells. As ossification proceeded the cells
swelled up, but did not, as a rule, arrange themselves in
any characteristic* manner. Rows of osteoblasts de-
veloped along the sides of the cartilaginous masses, with
or without the occurrence of the large multi-nucleated
cells or osteoclasts. Then the irruption commenced.
The irregular openings found in many of the spicules
might be explained in this way, for they contained both
kinds of cells. The presence of these large cells, or
osteoclasts, in certain of the spicules would also suggest
this formation having burrowed there from the side.
Only in exceptional instances did the osteoblasts lay
under a definite membrane. Where ossification was
complete, both osteoblasts and osteoclasts had disap-
peared, and the bone had an irregularly lamellar or con-
centric arrangement. The lacunae were branched, and
filled with bone cells. There were several areas in which
typical ossification occurred, with marked swelling of the
cells, their arrangement in definite rows, irregular ab-
sorption of the cartilaginous matrix, and the entrance
of blood-vessels into the spaces thus formed.
A section through the body of the phalanx of the toe
showed a notable absence of new bone in the dermis and
sub-dermic tissues. An excessive development of very
dense, almost tendinous, fibrous tissue was the principal
cause of the increased diameter of the toe. All the nor-
mal elements of the skin were present. The central
canal of the bone contained spicules of irregular shape
and arrangement, with fat cells and blood-vessels filling
the interspaces. The number of bone corpuscles was
noticeably small and there were no osteoblasts along the
sides of the spicules. In the cartilaginous ring which
surrounded these and to which they were attached, ossi-
i88
MEDICAL RECORD.
[August ii, 1894
fi cation proceeded regularly. Bat there was no perios-
teum, even here, and at irregular intervals around its
periphery the transformation of fibrous tissue into carti-
lage, with a consequent extension of the ring, was more
evident, than in sections from the edge of the plaque.
Where the cells were distinctly cartilage-cells, and even
where they had begun to swell and arrange themselves in
a definite manner for ossification, fibrous bands could be
seen running among them. Instead, however, of the
cells arranging themselves in rows at right angles to the
advancing line of ossification, they became grouped,, ap-
parently, from repeated subdivision, the number of cells
in such group being a multiple of two. At this point
absorption began with the subsequent building up of the
spicules that were left. The cells in the outer part of
the cartilage where it was extending were flattened, and
some of them were slightly branched.
Concerning the sections through the articular cartilage,
it was worthy of note that a true epidermic formation,
consisting of all the layers quite perfectly developed, ran
in crescentic form one-fourth the way around die bone,
and almost immediately adjacent to it. A number of
sections, as well as the block from which they were cut,
were carefully examined to make sure that this did not
result from an accidental infolding of the skin.
It would appear that primarily there was a hyperplas-
tic formation of very dense connective tissue, that this
was transformed into cartilage, which was extended by a
further transformation of the adjacent fibrous tissue and
the subsequent ossification of the cartilage. This trans-
formation of fibrous tissue into cartilage could not be
regarded as a pure metaplasia because of the marked cell-
proliferation accompanying it There was nothing to
warrant the belief that the lesion originated from the
periosteum or pre-existing cartilage. The increased size
of the toe was principally due to an excessive develop-
ment of fibrous tissue. The extension of the cartilagi-
nous ring seemed to be simply a part of the general process,
and not the starting point of it. If the process had
begun by an extension of the pre: existing cartilage it
would be reasonable to suppose that the plaque would
have been attached to the underlying bones, but such
was not the case. While it was true that bone was pres-
ent throughout the entire depth of the sections, ossifica-
tion had been completed in the parts just beneath the
epidermis. As it was probable that the ossification be-
gan in the cartilage first formed, the speaker thought the
transformation first occurred in the dermis itself, or im-
mediately below it. Metaplasias, both physiological and
pathological, were of common occurrence, but as Ziegler
had said, these metaplasias " are confined to the con-
nective tissues; fibrous tissue, cartilage, bone, mucous
tissue, and adipose tissue, are, so to speak, potentially con-
vertible." The sesamoid fibro-cartilages formed in ten-
dons might be cited as instances of the transformation of
fibrous tissue into cartilage. Arterial sclerosis sometimes
resulted in the formation of cartilaginous patches in the
walls of the vessels. In myositis ossificans there was a
transformation of fibrous tissue into bone. The prone-
ness of hyaline cartilage to ossify was well known.
The most rational explanation of the etiology of this
case seemed to be that it was due to a congenital disposi-
tion to hyperplasia and metaplasia of the connective tis-
sue in the derma and subdermic structures. Syphilis
might be excluded, and it could not be ascribed to any
special irritation resulting in an inflammatory condition,
as the history showed a notable absence of signs of in-
flammation. When bones developed in abnormal situa-
tions in the body they were usually the result of long-
continued irritation leading to inflammation. In rider's
bones we had an example of bone formation from long-
continued pressure, though the ossification might be at
times of syphilitic origin.
Occlusion of the Ileo-osBoal Valve by a Plug of Mn-
ons: Extreme Interstitial Emphysema of the Lungs.—
Dr. Jambs Ewing presented the lungs, ileum, and colon
which had been removed from a child who died fourteen
hours after, birth. The presentation was L. O. A. and
the labor natural. The second stage lasted one hour.
There was considerable asphyxia of the child at birth, so
that four mouth to mouth insufflations were made, after
which it seemed to breathe naturally. It was not long,
however, before the breathing again became bad, and the
child cyanotic, and these symptoms persisted until death.
One hour after death the autopsy was made. The ab-
dominal wall was tense and protuberant. The liver,
which had been pushed upward, descended as the abdo-
men was opened. The lower six inches of the ileum
were found collapsed. Above this point the intestine
and stomach were excessively distended with gas. The
lower two feet of the ileum contained a tough cord of
mucus which protruded through the ileo caecal valve and
completely occluded it. Six inches above the valve it
formed a plug which was not easily detached. The
lungs showed great compression, especially in the lower
lobes, and while they were largely atelectatic they were
not consolidated. Scattered over both lungs were many
prominent vesicles showing extreme interstitial emphy-
sema. Two or three large vesicles covered two-thirds of
the internal surface of the right lung. The cerebral si-
nuses were intensely engorged. There was a large blood
clot in the stomach. Blood serum was oozing from the
nostrils.
The speaker said he had been unable to find in the
literature any reference to such a peculiar mucus cord as
the one found in the ileum. The enormous quantity of
air in the stomach and intestine was accounted for by
the insufflations, the air having expanded somewhat
probably under the heat of the body. The distention
interfered with respiration and proved the immediate
cause of death in the infant already asphyxiated. It had
been stated by Delafield that distention of the stomach
with aerated mucus might become a serious complication
in bronchitis in infants. Possibly the emphysema was
caused by the forcible insufflation, but this hardly seemed
sufficient to explain it. Most writers on the diseases of
children stated that the chief cause of interstitial emphy-
sema was violent expiratory efforts with obstruction to
the expired air. While there was no consolidation the
compression of the lung from the abdominal distention
produced atelectatic areas. The hemorrhages and
venous congestions were due to the asphyxia, which was
the manner of death.
Dr. Prudden said he saw this mucus cord, which re-
sembled a tape-worm in many respects, although anyone
would avoid confounding the two.
The Society then went into executive session.
Haughty Editors. — A Philadelphia contemporary says
that a gentleman who entertained with a banquet the
American Medical Editors' Association in San Francisco,
is reported to be actively interested in a much advertised
secret nostrum.
Death of a Lady Bicyclist.— The death of the lady
cyclist from syncope after a bicycle ride is, of course, the
text for many fraternal warnings, and advice to lady
bicyclists to give up the enjoyment of an exercise in
which it is feared they may indulge to excess. They are,
of course, told by some that bicycling is unladylike, if
not unwomanly, and that women do not know how to
practise the careful restraint in such matters to which
men are accustomed. They may very well afford, how-
ever, to treat all this sage advice as at least superfluous.
So far from being unsuited for woman, bicycling is an
exercise in which they may indulge with perfect security,
and generally with much advantage. We are persuaded
that they are as little prone to excess in athletics as are
the generality of men, and within reasonable bounds we
should like to see cycling as generally practised by
women as by men, and it would be greatly to the advan-
tage of many cycling clubs and cycling resorts that the
lady-like element should be more largely introduced. —
British Medical Journal. ,
August ii, 1894]
MEDICAL RECORD.
189
OUR LONDON LETTER.
(From our Special Correspondent)
THE EXTRA MEETING OF THE MEDICO CHIRURGICAL SO-
CIETY— LAWRIE OF HYDERABAD ON CHLOROFORM — DIS-
CUSSION OF HIS VIEWS — A MUNIFICENT ENDOWMENT
OF SCIENCE — THE INSTITUTE OF PREVENTIVE MEDICINE
— mr. a. balfour, m.p., on science — the college
of surgeons election — sir george humphry — the
apothecaries company. — threatrnings of cholera
circular of local government board — hospital
sunday fund — discontent of some supporters —
the chelsea hospital inquiry — baronetcy for the
duchess of york's accoucheur — fellows and mem-
bers OF THE ROYAL COLLEGE OF SURGEONS.
London, July 7, 1894.
The extra meeting of the Royal Medico-Chirurgical So-
ciety which I announced as arranged for in my last, was
held on Tuesday. The object being to enable Surgeon
Lieutenant- Colonel Lawrie, while in London, to state
his views on chloroform. These views will be familiar to
your readers from the report of the Hyderabad commis-
sion, of which Dr. Lawrie is the father. It is there-
fore unnecessary to give an abstract of his communica-
tion to the Society, but the conclusions he submitted
were: i. That chloroform had no direct action on the
heart In support of this he explained an enlarged pho-
tograph from the fed animal in a cross-circulation experi-
ment in which chloroform sent to the heart alone pro-
duced no effect whatever. 2. In a similar experiment
chloroform sent to the brain alone produced its usual
effects by acting on the brain centres. 3. He showed
the difference from the same illustrations between taking
respiration or pulse as a guide to the effect of chloroform
when the respiration was regular. 4. Similar differences
under the same conditions, but when respiration was ir-
regular from vagus stimulation. 5. He exhibited a trac-
ing to show that chloroform anaesthesia without respira-
tory complication was free from risk.
Looking at the discussion that has taken place on the
Hyderabad commission Dr. Lawrie could not expect
these conclusions to meet with unanimous assent, but he
must be gratified with the amount of support he received
at the Society and the great respect shown to his labors
by even those who cannot endorse his views.
Drs. Gaskell and Shore both spoke. It is known that
their experiments do not exactly coincide with Dr. Law-
rie's- They admit that respiration fails first, but they
think chloroform has also a direct action on the heart.
In one of their cross-circulation experiments the respira-
tion continued five minutes after the heart ceased to
beat. Dr. Brunton suggested that peptones which had
been used to prevent clotting of the blood, being poison-
ous, might account for some of the results, and held that
it was certain that chloroform paralyzed the respiratory
centre before affecting the heart. He speculated a little
on the possibility that the increased consumption of
meat of late years may have some relation to the in-
creased fatality of chloroform, especially as strong,
healthy men, on full diet, gave most trouble, and were
more likely to have alkaloidal products circulating in the
blood.
Mr. Horsley felt sure Dr. Lawrie was right as to most
cases, and he exhibited a series of tracings on the screen
to show the mode of death in bullet wounds of the brain,
and said it was precisely similar in all cases of cerebral
compression. Mr. Bailey said the pulse should be
watched as well as the breathing. Dr. D. Buxton
thought a considerable proportion of deaths were due to
carelessness, and only a few to primary action on the
heart, but he admitted that probably the secret of safety
was to watch the breathing. Dr. D. Newman had seen
two cases of cardiac failure, and in one of them the pulse
stopped, although breathing continued and. air entered
the chest freely. He thought the respiratory centre
more likely to fail than the heart. Dr. Hewitt also men-
tioned a case in which respiration continued though no
pulse could be felt at the wrist, and he thought that we
should be led into difficulties if we looked to the respira-
tion alone in profound anaesthesia. Dr. Lazarus-Barlow
exhibited a tracing taken directly from the heart of a
curarized animal, to show that cardiac failure began with
the commencement of inhalation, respiration failing
later. Dr. Silk declared that an increased number of
deaths had taken place since the Hyderabad report, and
that though respiration should have primary attention
the pulse must also be watched.
Dr. Lawrie in reply remarked that the sudden stoppage
of the heart in the cases mentioned could only have
been produced by stimulation of the vagus through the
respiration — that the experiments of Dr. Lazarus-Barlow
indicated some damage to the circulation in the lungs.
He had found no difference in the effects of chloroform
on Europeans and natives. In seven hundred cases the
pulse had been carefully watched, but gave no indication.
Finally, he said it is impossible to teach a careless man
to give chloroform safely.
Mr. Mond has endowed scientific research in a munifi-
cent manner. He has bought the Earl of Albemarle's
mansion, contiguous to the Royal Institution, and pre-
sented it to that body. Further, he proposes to meet
the cost of converting it into a laboratory, and equip-
ping it for chemical and physical research. He intends
also to endow it with sufficient income for maintaining it
and employing a skilled staff. This splendid addition to
our scientific resources is to be called the Davy- Faraday
Research Laboratory, and its establishment is expected to
cost Mr. Mond some ^100,000. The old country is not
yet destitute of munificent donors.
The British Institute of Preventive Medicine is in a
fair way of success. The site has been purchased and
some important sums have been secured, e.g., ^10,000
from the Grocers' Company— one of the most liberal of
the city companies ; ^20,000 from the Berridge trustees,
and a further ^25,000 is about to be handed over from
the same source. The College of State Medicine will
also hand over its plant and money to the Institute, in
value above ,£4,000. Some of the investigations I have
mentioned in previous letters were carried out for the
Institute, and now that a suitable building is about to be
erected the silly opposition of the antis to this under-
taking may be diverted into other channels.
Mr. Arthur Balfour, who so rapidly rose to the highest
position in Parliament, is a metaphysician of no slight at-
tainments and a profound economist. Speaking last
week at thd Economic Association he touched on scientific
investigations with a light but firm hand. He said the
public had never yet mixed themselves up in these matters
without spoiling the investigations and doing themselves a
great deal of harm. . When the public took up a question,
party feeling — necessary in political affairs — was sure to-
come in and as sure to produce disastrous results. He in-
stanced the question of vaccination, which the doctois*
thought they had settled on scientific principles, but on
which a section of the public who had not studied it in the
scientific spirit were determined that their feelings should
override science. Not being a doctor he would not pro-
nounce as an expert, but he had no doubt that if scientific
questions were to be decided by universal suffrage, only
harm could be done to this suffrage, while it would be abso-
lute ruin to science. If science is wrong, he said, it could
only be got right and turned into the direction of truth by
giving it free play outside altogether the influence of popu-
lar forces. The idea that a section of the public had an*
opinion worth having on such subjects was to him ab-
surd.
The elections at the Royal College of Surgeons took
place on Thursday (5th).
Messrs. Howard Marsh and Reginald Harrison were-
re-elected, and the third vacancy was filled by the elec-
tion of 'Mr. JameS Hardie, of Manchester. The provin-
190
MEDICAL RECORD.
[August 11, 1894
cial Fellows have, therefore, again succeeded in placing
one of their number on the Council.
Sir George Humphry has continued to improve, and
is now able to take carriage exercise.
. The apothecaries' company has issued a calendar, and
an interesting document it is, showing that it has done
good work for the profession in the past.
London, July ax, 1894,
Uneasiness is felt in many quarters at the recrudescence
of cholera on the continent, which is becoming in some
countries serious. About two hundred attacks a day in
St. Petersburg, and outbreaks much nearer our shores
are certainly enough to make sanitary authorities anx-
ious. The local government board has issued a cir-
cular urging the utmost vigilance as to all suspicious cases
and promising favorable considerations to any proposals
to add diarrhoea to the list of notifiable diseases for the
remainder of the current quarter, after which the danger
may be considered over for this year. In former epi-
demics the disease has been more fatal in the second year
oi its invasion, and many are accordingly asking each
other whether we are now in the second year, or whether
the cases last year were only stray ones, brought by ships
and infecting a few persons in communication with them.
If so the present may prove to be the first year of an inva-
sion should it pass our boundaries. If otherwise, and last
year is to be reckoned as the first of an epidemic, the
seeds, so to say, of the disease have been sown sufficiently
broadcast to cause anxiety. Our sanitarians speak con-
fidently of our preparedness, though they admit the exist-
ence of weak spots in our armor, and if once an epidemic
gains a footing there are many inland towns and villages
but ill prepared to meet it
Above ^42,000 has already been received for the Hos-
pital Sunday fund, and this is nearly ^3,000 more than
last year's collection, while other sums have yet to come
in. Much credit is due to the Lancet for the spirited
way in which it has contributed to the success of the
fund. I am, therefore, rather sorry to notice that your
powerful contemporary seems inclined to consider the
management of the fund immaculate and endeavors to
account for the discontent that has been evinced in a
manner that facts will scarcely support. " Bad manage-
ment " is the excuse put forward for refusing to in-
clude some institutions in the distribution. The truth
is, in some cases, the so unfairly stigmatized management
is the expense of each patient, especially in dispensaries
and out patient special institutions. These expenses con-
sist largely in the use of drugs and appliances which the
specialists say cure the patients and which, being costly,
are not much used at great hospitals where rJatients are
hurriedly got through in a few seconds each. I know that
in some cases this contention is not without foundation.
The supporters of the fund are apt to be angry too,
when a sermon is preached on behalf.of some institution
selected by the preacher or his people, and when boxes
are distributed to collect for such charity. Now it is
really the management of the fund that has led to this
action. The large hospitals, which, of course have the
first claim, have their friends on the committee and very
scant justice has been done to small, especially special
hospitals. The prejudice against specialism has been
fostered by the fund committee and their officials do
not hesitate to express it. What more natural than that a
preacher interested in a special hospital, knowing its
working, and perhaps taking part in its management,
should say, if you refuse to include this charity in your
list I will give my collection to it alone? This kind of
thing will increase if lay officials are to reflect the preju-
dices of a party. In the interest of hospitals I deprecate
such divisions, although I am not quite sure that they
may not eventually prevail and do good. For, after all,
what is ^40,000 for the rich metropolis to raise ?
The committee appointed to investigate the charges
brought by the medical officer of health (Dr. Louis
Parkes) against the Chelsea Hospital for Women has
issued its report. They say it was the duty of Dr.
Parkes to notice the matter, but they do not understand
why he omitted to inform the vestry that at the time he
presented his report the hospital had been empty for
three weeks, and that he had received a letter from the
secretary stating that the works would be carried out as
soon as possible and completed before patients were
again admitted. They further state their opinion that
a large number of the deaths were due to septicaemia,
and that septic temperatures did not prevail in the prac-
tice of every member of the staff. This seems to me
rather a lame conclusion or else an insinuation, unjusti-
fiable unless supported by facts, in which case it should
have been plainly stated. The medical officer of health
attributed the mortality to insanitary conditions. The
committee of inquiry offers no conclusion on this point,
which is a vital one.
The occasion of the birth of a son to the Duke of
York has been taken by the Queen to confer a baronetcy
on the physician-accoucheur — Dr. John Williams — who
has also attended other members of the royal family,
and is one of our most eminent obstetricians.
The fellows of the College of Surgeons have held
their meeting and congratulated the council on its con-
cessions. The two societies almost approached each
other and the sooner their rivalry disappears the better.
There was no room for the latest of the two, but the mat-
ter only concerns the exclusive fellows. The council
has issued a series of regulations for the meetings of
members. They are admirably adapted to prevent these
members from doing anything except at the council's bid-
ding.
The constitution of the college needs radical reform.
The slight changes granted to the fellows induces them
to ask to have them embodied in a new charter. If the
members do not obtain some recognition in any such
proposed instrument, they should combine to oppose it,
and the privy council would no doubt accord them a
hearing before recommending the grant of the charter.
THE PATENT MEDICINE SCOURGE.
To thb Editor op thb Medical Record.
Sir : The sad death of the young woman, Natalie D ,
which recently occurred in Montreal, should serve as a
warning to the public, and stimulate the medical pro-
fession to enter a vigorous protest against the patent
medicine scourge which is now raging throughout this
continent. At the inquest, held on the body of the de-
ceased, the coroner read a few letters from some women
asking for these pills which the deceased had taken for
the purpose of procuring, abortion. He stated that he
produced these letters to show what great evils such arti-
cles could do.
Your readers are only too well aware that the advertis-
ing columns of almost every daily and weekly newspaper
— and also of magazines, almanacs, and pamphlets — con-
tain glowing descriptions of the " miracles " which have
been performed by Dr. So-and so's pills, or some one
else's marvellous medical " discovery." Surely it is time
that the medical profession stepped in, and, una vouy
urged the proper authorities to place more stringent reg-
ulations on the sale of dangerous and poisonous prepara-
tions. We have only to glance through the advertising
columns of reputable publications, and we shall find the
narrative of some unfortunate sufferer, who pathetically
relates how he or she has been snatched from the very
jaws of death, after having unsuccessfully consulted (?) all
"the leading physicians" in that particular section of
the country. As a rule, a crude portrait of some vigor-
ous looking individual adorns the account in order to
render the narrative the more attractive, and the more
effectually to catch the public eye. I believe it was the
late Lord Chief Justice Coleridge (England), who stated
that a country was composed of so many millions of peo-
ple principally consisting of persons possessing a natu-
rally dwarfed intelligence ; and . no more satisfactory
August ii, 1894]
MEDICAL RECORD.
191
evidence of this can be afforded than the fact that a
patent medicine speculator has only to advertise a new
and startling " discovery/1 and he will immediately re-
ceive numerous testimonials extolling his remedy, and
thanking God that such a benefactor to the human race
has suddenly sprung into existence. It is surprising to
find how large a number of persons consult physicians now-
adays who frankly confess that they have been habitually
using a certain much-lauded pill, or some other com-
pound, which has probably been purchased at a neighboring
general store; and only as a final resort have the purchasers
been at length compelled to seek medical advice ; nor
can it be disputed that thousands of women annually im-
peril their lives by employing dangerous patent medicines
for escaping the consequences of marriage, or to avert
the trouble arising from illicit sexual union.
The time has arrived when both the medical profession
and the public should be protected from a traffic which
is hurtful to the community and is slowly undermining
the practices of qualified medical men. It is almost un-
necessary to point out that no case can be successfully
treated unless the whole history, symptoms, and environ-
ment of that particular case be properly studied and un-
derstood. Furthermore it is a lamentable fact that, in
all likelihood, many lives are lost which may be directly
attributable to the reckless use of some obscure concoc-
tion entirely unsuitable to the disease for which it is ad-
ministered. It is readily conceivable that, among the
many thousands who purchase popular nostrums, and
rely solely upon their supposed curative powers, not a few
go from bad to worse ; and only when too late do they
hasten to seek sound, practical, and judicious counsel
from an intelligent medical practitioner.
R. H. Phillimore, M.D.
COOKSHIKB, QUKBEC, CANADA,
Juiy 23, 1894.
POLITZER'S OPINION ON MEDICAL EDUCA-
TION IN AMERICA.
To the Editor or tmb Mboical Record.
Sir : The article in a recent issue under the heading " Is
there a Need for more Medical Schools ? " recalls to mind
an interesting lecture which was delivered before the
Medical Society of Vienna, by Professor Politzer, in
March last.
The meeting was open to all physicians, and many
Americans, including myself, took advantage of it.
Professor Politzer, it seems, was sent by the Austrian
Government to the United States to investigate the medi-
cal institutions, hospitals, and surgical and medical ap-
paratuses.
What he said regarding our medical institutions was
certainly displeasing to the Americans ; nevertheless, it
was true. He said that the United States, with a popula-
tion of sixty or sixty-five millions, had one hundred and
forty eight medical schools, while the total number of
medical schools in Austria and Germany together was
twenty nine. Russia, with a population of about one
hundred millions, had nine medical schools.
He also mentioned other European countries with a
similar ratio. Regarding the formation of medical col-
leges in the United States, he said that all that was re-
quired to organize a college was a few doctors and an
appeal to the Legislature for a charter, which was always
granted. This remark was greeted with considerable
laughter.
He said that almost every city of any considerable size
had one college, some two — and that new ones were spring-
ing up every day — and that occasionally one dropped out
of existence. Some of our schools gave degrees in two
years, but he was glad to find that some of the better
schools had increased the time to four years. In Austria
and Germany a five-and-a-half years' course is required.
Oar hospitals and surgical instruments he praised very
highly.
Oliver A. Blumenthal, M.D.
£01 Waikbn Street , Syracuse, N. Y.
i^edixal Stems.
Contagious Diseases — Weekly Statement. — Report of
cases and deaths from contagious diseases reported to the
Sanitary Bureau, Health Department, for the week end-
ing August 4, 1894.
Tuberculosis
Typhoid fever
Scarlet fever
Cerebrospinal meningitis
Measles
Diphtheria
Small-pox
Cases.
Deaths.
85
9i
21
7
40
5
2
7
27
5
146
37
6
1
The Late President of the French Republic and his
Surgeons. — The Progr is Medical of June 30th gives, on
the authority of Professor Poncet, of Lyons, the follow-
ing details as to the surgical treatment pursued in the
case of the late President of the French Republic. The
wound was inflicted at a quarter past nine in the even-
ing, and M. Poncet, who was at once summoned, found
M. Carnot in a state of collapse, and with the aspect of
one at the point of death. Tearing open the shirt and
underclothing, M. Poncet found to the right of the line a
alba, about three centimetres from the ensiform cartilage,
parallel to the edge of the false ribs, a wound from
twenty to twenty-five millimetres in length, from which
black blood was oozing. He contented himself in the
first instance with applying a handkerchief lightly to the
wound, and with the view of preventing fatal syncope,
he placed the President as nearly in a horizontal posi-
tion as the carriage would allow, and strove to rouse him
by speaking to him and occasionally tapping his face
with his fingers. On the way to the Prefecture, distant
about one kilometre, the President, who was uncon-
scious, retched two or three times, but did not vomit.
On arriving at the Prefecture he was laid on the bed
with his head low, and while waiting for aseptic instru-
ments M. Poncet applied iced compresses to the abdomen.
A few minutes later, considering surgical interference to
be urgently necessary, he, with the help of Drs. Masson,
Monnoyer, Demandre, and Lupine, and in the presence
of Professor Gailleton, Mayor of Lyons, and Drs. Kelsch,
Albert, Fabre, and Rebatel, performed a local laparot-
omy, no anaesthetic being given on account of the col-
lapsed state of the patient. An incision of ten to twelve
centimetres was made and progressively extended as the
necessity arose ; this incision was a prolongation of the
wound made by the assassin's dagger. A considerable
quantity of blood escaped, and M. Poncet, introducing
his left forefinger into the depth of the wound, was able
clearly to make out on the anterior surface of the left
lobe of the liver, near the suspensory ligament, a wound
of the same dimensions as that in the skin. Separating
the edges of the wound with forceps he saw, a little
above the costal arch, the wound in the liver, into
which the forefinger penetrated to a depth of two to three
centimetres. Such rapid examination as was possible
failed to reveal any lesion of the gallbladder, stomach,
intestine, etc. At this stage of the operation Professor
Oilier arrived, and M. Poncet haying shown him the
nature of the wound, and the impossibility of suturing
the wound in the liver — a procedure, moreover, which
appeared to be useless in view of the fact that the bleed-
ing could at once be stopped by pressure — it was agreed,
having regard to the collapsed state of the patient, sim-
ply to plug the wound. Some fibres of the rectus, which
interfered with the manipulations, were divided by an-
other incision of five to six centimetres inward toward
the middle line. The wound was plugged with iodoform
gauze ; then compresses of sterilized gauze were applied
and fixed in place by a body bandage drawn moderately
tight, while an assistant kept up slight pressure with his
hand. At the beginning of the operation, when the first
192
MEDICAL RECORD.
[August ii, 1894
incision was made, the President recovered conscious-
ness, and said in a clear voice, " Oh ! doctor, how you
hurt me." From that time he seemed to recover
strength a little and answered questions with perfect
distinctness. He was given small pieces of ice and a
little iced champagne, and two subcutaneous injections
of a gramme of ether were administered at an interval
of twenty to thirty minutes. The President complained
of a certain difficulty in breathing and of pain in the
stomach and loins. At half-past twelve his voice was
still resonant, and he expressed his gratitude for what
was being done for him. A minute or two later there
was some return of the hemorrhage, and convulsive
movements occurred which caused the intestine to show
a tendency to protrude through the wound. At thirty-
eight minutes past twelve he died. — British Medical
Journal.
The Anti diphtheria of Klebs. — Dr. Oscar Vulpius
applies the liquid with a long-handled camel's-hair brush,
which is readily managed, first to the tonsils and soft
palate, and, after thorough cleansing, to the pharynx.
With restless children one must be cont&t with imper-
fect treatment, and even with one application ; even the
liquid may be expelled by vomiting before, indeed, it
can reach the membrane. The results as noted include
a marked subsidence of the fever; the membrane may
remain entirely unchanged during the treatment, nor,
indeed, does this treatment prevent the tendency of the
process to invade the trachea and bronchial tubes, con-
sequently it has no influence in preventing croup. How-
ever, as it is important that the remedy shall be brought
into close contact with the diseased surface, it should be
again applied as soon as the membrane is coughed up.
In his series of cases, nineteen in number, the percent-
age of deaths was 52.6 ; omitting one case of the rare ac-
cident, late secondary hemorrhage after tracheotomy, the
rate falls to fifty per cent. Whether with an improved
anti-diphtherin, or with possibly a combination with this
of a diplococcus poison, better results may be obtained,
the future only will determine. — Deutsche medicinische
Wochenschrift, 1894, No. 6, S. 127.
Thyroid Feeding in Myxcedema.— Dr. S. J. Meltzer
reports in the New Yorker tnedicinische Monatsschriftt
No. 4, 1894, an interesting case of myxcedema in a
woman, thirty-seven years of age, successfully treated
with powdered thyroid extract. At the time of the reporj
the improvement, as shown by photographs, was most
marked, and there was every reason to anticipate a com-
plete recovery.
Some Ancient Theses for the Degree of X.D. Paris.
— M. Jules Roger, in his interesting book, " M6decins,
Chirurgiens, et Barbiers," gives the following list of sub-
jects of theses sustained* in old times before this faculty :
1572. La necessity de la mort est elle inn6e? 1576.
Le foetus, ressemble-t-il plus in la mere qu'au pere ? 1 5 89 .
L'air est il pins n£cessaire que la nourriture etlaboisson ?
1622 L'eau est- elle plus salutaire que le vin? 1639.
Doit-on saigner une jeune fille folle df amour? 1643.
S'enivrer une fois par mois est-il salutaire? $1646. La
femme est- elle un ouvrage imparfait de la nature? 1662.
Le libertinage amene-til la calvitie? 1668. Les Pari
siens sont ils sujets a la toux quand souffle le vent
du nord? 17 14. Quel est le plus salutaire, de l'eau pure,
du vin pur, ou du vin melange* d'eau? 1745. Les littera-
teurs doivent-ils se marier ? 1)£ naivetk of the preceding
questions is charming, but he must have been a courage-
pus man who, even in 1646, could gravely ask the ques-
tion, " Is woman an imperfect work of nature ? " — Brit-
ish Medical Journal.
Cancer Houses.— Several correspondents of the Brit-
ish Medical Journal have reported instances in which
the successive occupants of certain houses have died of
cancer. In many cases there was no history of heredity,
and often there was no relationship between the persons
successively attacked with the disease.
A Convivial Occasion. — The doctors of the Girondc
dined together on Sunday, June 17th, at Pauillac, and
the banquet was, according to the Echo, moistened by
2x8 crus and 340 varieties of wine. The carte was in
twelve pages, setting forth in elegant typography the vir-
tues of the most reputed crus and the most famous yean.
There were 1,400 bottles to 170 doctors. This goes
ahead of the annual banquets of the Maine State Medi-
cal Society.
Lucky Numbers and Lucky Medical Students.— Two
French medical students, M. Gustave Lefilliatre and M.
Georges Labey, had recently a letter from a solicitor
named Leger, of Marines, Seine-et-Oise, stating that the
late Dr. Dubois, a medical man at Chars, had left a will
by which he bequeathed all his surgical and medical ap-
pliances, free of legacy duty, to two students obtaining
their degree at the examination next after the decease of
the testator. The two students selected were to be those
who came out No. 14 and No. 84 in the list. At first
it was thought the letter was a hoax, but the two young
men went to the place indicated, and were there duly
presented with an exceptionally fine collection of instru-
ments and accessories of all kinds for division between
them. They learned that their being specially chosen
was due to the fact that the deceased doctor bad twice
passed an examination, and that he had on those occa-
sions been No. 14 and No. 84 on the lists.
Professor Gussenbauer, the newly appointed incum-
bent of the Chair of Surgery in the University of Vienna
has been elected President of the Twenty-fourth Con-
gress of the German Society of Surgery to be held in
1895.
Profitable Quackery in Bussia.— The police in Kicff
recently made a domiciliary visit to the proprietor of
some "magic pills," a former blacksmith in Warsaw. In
searching his effects they found 3,782 letters containing
orders for pills, with enclosures amounting in all to over
$5,000. The letters were from persons of all classes, in-
cluding priests, apothecaries, and government officials.
Sanitation Sunday. — We have labor day and hospital
Sunday, and other interesting memorial occasions, but
the English churchman goes ahead of the record and pro-
poses a " Sanitary Sunday." The Church Sanitary As-
sociation suggests that the seventh Sunday after Trinity
be known as Sanitation Sunday, because the gospel for
this day contains the record of Christ's disciples distribu-
, ting wholesome food to those who were already in the
enjoyment of fresh air, pure water, and abundant light,
thereby indicating the Divine will that man shall enjoy
fulness " as well for the body as the soul."
Instruction in Dentistry in France. — In the French
Budget for 1895 is an appropriation of $15,000 to pro-
vide for the organization of chairs of dental surgery in
several of the medical schools of the country.
Contract Medical Practice. — The London (Ont.)
Medical Society has been deliberating on the question of
contract or lodge practice, and offers the following sug-
gestions looking to its abolition or restriction: "1.
Apply for legislative authority to prohibit contract prac-
tice. With the prevailing contract rates at $1.00 and
$1.50 per member, this prohibition might be shown to
be in the interest of the public as well as 'the profession,
inasmuch as indifferent service is a natural result of in-
adequate remuneration; or, 2. Apply for legislative
power to fix a minimum tariff of contract rates. A
Toronto medical journal, in December, 1893, claims, on
the authority of a distinguished actuary, that the proper
remuneration for contract practice in Canada is $4.00 a
year per member ; or, 3. Apply to the Legislature for
power to frame and enforce a code of medical ethics,
with a view to control the evil ; or, 4. Address an ap-
peal to every registered practitioner to discountenance
the system. The influence of such an appeal coming
from the representative body of the profession would
tend to bring the practice into disrepute.11
Medical Record
A Weekly yournal of Medicine and Surgery
Vol. 46, No. 7.
Whole No. 1241.
New York, August 18, 1894.
$5.00 Per Annum.
Single Copies, ioc.
©riflitial %x\it\**.
ANATOMY OF CLUB-FOOT.
By FRANK HARTLEY, M.D.,
NIW YORK.
In the Annals of Surgery of March, 1894, will be found an
article written by the author of this paper, entitled " The
Operative Treatment of Club foot/' in which the records
of twenty six cases operated upon from 1886 to 1893 were
detailed. It was recommended in that article that in the
minor cases, before the thirtieth month of life, mechanical
fixation with or without tenotomies and fasciotomies were
sufficient. After that age in the child, tenotomies and
fasciotomies were to be combined with a talus extirpa-
tion in all cases where the equinus was the prominent de-
formity and the varus slight, provided the tenotomies
and fasciotomies had not completely reduced the de-
formity.
In those cases where, in addition to the equinus, the
varus was marked, a limited cuneiform osteotomy in-
volving only the processus anterior calcanei and the ar
ticular surface of the cuboid, was to be added, if neces-
sary.
In the adult, after the usual tenotomies and fascioto-
mies, a cuneiform osteotomy involving parts of the os
calcis, cuboid, neck of talus and scaphoid, was recom-
mended if the equinus was relieved after tenotomy. If
the equinus was not thus relieved, either a partial or total
talus extirpation was to be combined with a cuneiform os-
teotomy at Chopart's joint. It was also stated that the
severest forms of club foot (inveterate cases) were only
cured by both of these procedures. To-night I wish to
give the results of a dissection of two. feet which repre-
sent perfectly the highest degree of this deformity, and,
in my opinion, substantiate the view taken in so far as
the inveterate cases are concerned.
This specimen represents a club foot of congenital
origin and of twenty-two years' standing, in which the
rotation inward of the leg is marked, and the position of
extreme supinative plantar flexion and adduction is pres-
ent in the foot.
The movements of the joint surfaces were all limited.
In the talo-crural joint, the movement was confined to a
simple gliding in which the anteroposterior was less
marked than the lateral motion. In the talo-calcanean
joint scarcely any movement was appreciated. In Cho-
part's joint a movement corresponding to flexion and
extension was more marked than in the other joints. In
none of the joints was there more than a gliding move-
ment in one or more planes. These movements produced
only a limited change in the relations of the different
bones of the foot to one another or to the leg. The
borsse found consisted : 1, Of a large multilocular cavity
covering bearing points of pressure which are sure to be
the anterior process of the calcaneus and the dorso lateral
surface of the cuboideus; 2, of a smaller multilocular
bursa covering the neck of the talus and the lower por-
tion of the external malleolus. The ligaments were not
peculiar nor of interest. On the external border of the
foot a large amount of fibrous tissue was present, and
many new bands of this tissue seemed to be added to
the normal ligaments. Upon the inner border and sole
of the foot the fibrous tissue was not so extensively de-
veloped, although the plantar ligaments were well marked,
thick, and out of all proportion relatively to the mus-
cular tissue. The anterior annular ligament was well
developed, thick, and strong. The external annular lig-
ament consisted of a firm broad band covering the pe-
roneal tendons as they passed to the posterior surface of
the calcaneus. The internal annular ligament was well
marked but very short, on account of the position of the
foot. The muscles, which in the leg and foot show a
marked atrophy with fatty and connective-tissue trans-
formation, had the following relations, which were pe-
culiar:
1. The tibialis anticus passed over the lower third of
the tibia, from without inward, to the inner surface of the
internal malleolus, whence it descended to its insertion.
2. The extensor proprius ^ollicis passed through a
separate compartment of the annular ligament over the
Fig- 1. — Antbkior Vibw : x, Anterior annular ligament ; a, tibia is anticus ;
3, extensor hattucis; 4, extensor longus digitorum ; 5, peroneus tertius,
inner surface of the internal malleolus, close to and in
front of the tibialis anticus. It divided into two ten-
dons which were inserted into the second phalanx.
3. The extensor longus digitorum passed over the
outer third of the anterior surface of the tibia, in a groove
bounded by two well-marked prominences. It was cov-
ered by the annular ligament. It divided into four ten-
dons, which passed obliquely inward over the heads of
the first and second metatarsal bones to the four toes.
4. The peroneus tertius passed obliquely outward to
the base of the fifth metatarsal bone over the cuneiform
bones.
5. The extensor brevis digitorum ^is scarcely observ-
able except for its tendons.
6. The peroneus longus and brevis passed beneath a
strong and narrow band of fascia, extending from the
external malleus to the calcaneus, and representing the
external annular ligament, around the external and pos-
terior surface of the calcaneus (infeiior surface) to their
194
MEDICAL RECORD.
[August 1 8, 1894
insertions. The former did not touch the cuboid bone.
It passed above the level of the anterior process of the
calcaneus obliquely, directed from without downward
and inward. The latter, after passing over the anterior
process of the calcaneus, descended upon the lateral
border of the cuboid bone to its insertion.
7. The tibialis posticus passed to the inner side of the
internal malleolus, its posterior border, beneath it, and to
its insertions.
. 8. The flexor longus digitorum passed to the outer
side of the tibialis posticus, beneath the internal malleo-
. lus, to its insertion.
9. The flexor longus pollicis passed through a well-
marked groove in the tibia, external to the flexor longus
digitorum, beneath the internal malleolus, and was lost
in the muscles of the foot.
The relations of the bones of the foot to one another
Fig. a. — Latbkal Vikw :
1, External lateral liga-
ment ; a, peroneus longus ;
3, peroneus brevis ; 4, ten-
- do Achillis.
Fig. 3. — Posterior Vikw: x, Tendo AchillU;
a, peroneus longus ; 3, peroneus brevis. ; 4, tibialis
posticus and flexor longus digitorum ; 5, flexor
longus hallucis ; 6, abductor minimi digiti.
and to those of the leg, were in general as follows : Most
striking in this respect was the angle formed by the
bones of the leg and the calcaneus. The position of the
calcaneus was one of marked plantar flexion. Its long
axis formed, with the articular surface of the tibia, an
angle of 8o°. If we consider the mid-position of the
foot (talus or calcaneus) to the leg to be one of a right
angle (900), and allow 390 for the extreme of normal
dorsal or plantar flexion, we have here 41 ° of a forced
plantar flexion of the foot. Less striking, but no less
important, is the supination of the calcaneus, which,
when measured, shows an increase of 500 over the nor-
mal position of adult bone. There is a slight adduction
of the calcaneus present, which amounted to about io°.
On account of the forced plantar flexion, the supination
and adduction, the superior articular surfkces are altered
in their relative position to the talus, and to the tibia and
fibula. Besides the articular surface for the talus, we have
upon this surface, just in front of the tuberosity, nearthro-
ses for both the tibia and fibula. That for the former is
continuous with the external third of the articular surface
j&&
FlG. 4.— Anterior Virw : i. Tibia ; a, internal malleolus with nearthrosis be-
tween it and scaphoid and internal cuneiform ; 3, external malleolus articulation
with talu» ; 4, talus— body ; 5, neck of talus— inward angle, downward angle,
oo* ; 6, navicular bone ; 7, talo-navicular articulation, situated entirely upon the
inner side of neck ; 8, nearthrosis between internal malleolus and navicular hone ;
9( internal cuneiform ; 10, middle cuneiform ; it, external cuneiform ; 12, nearthro-
sis betwoen internal cuneiform and internal malleolus.
for the talus, and is situated upon the superior surface
(really internal). That for the latter is situated upon the
external surface (really superior).
The processus anterior of the calcaneus is large and
prominent. It sustains the greater portion of the weight
Pig. 5.— Posterior View : 1, Calcaneus ; a, nearthrosis between external
malleolus and calcaneus just in front of the tuberosity and internal to nearthrosis
between calcaneus and external malleolus, concealed from view here, is the near-
throsis between the tibia and calcaneus ; 3. talus, all that can be seen from this
view ; 4, internal malleolus, articulating with the talus but with the navicular and
internal cuneiform by nearthrosis ; 5, sustentaculum tali, maintaining articula-
tions by nearthrosis with the navicular bone : 6, internal surface of calcaneus ; 7,
8, mark the relations of peroneus longus and brevis ; 9, articulations of cuboid
with inner surface of sustentaculum tali ; 10, zi, ia, cuneiform bones ; 13, navic-
ular bone.
of the body. Situated upon the internal surface of the
neck of the calcaneus is the articulation for the cuboid.
The talus is situated in the angle formed by the bones
of the leg and the calcaneus. Its superior surface articu-
lates with the tibia, and is external so far posterior as to
August 1 8, 1894]
MEDICAL RECORD.
*95
be continuous with the inferior articular surface in its
outer half, and only separated from the internal half of
the same surface by a 5 mm. strip of non-articular bone.
The shape of the body is triangular with the apex pos-
terior, and with the superior and inferior surfaces looking
respectively upward and downward and backward.
The neck of the talus forms with the body an angle of
450 for the inward displacement, and of 900 for the down-
ward displacement.
The outer angle of the neck is less prominent than the
internal. Upon the internal surface of the neck is an
oval facet for articulation with the navicular bone, the
long axis of which is placed at an angle of 450 to the
long axis of the neck.
ITie navicular bone articulates with the neck of the
talus only in the external portion of its posterior surface,
while the internal portion of the same surface is non-
articular and is bent sharply upon the outer segment.
The long axis of the navicular bone (i.e., transverse)
is nearly parallel with that of the neck of the talus.
a neck. The body is triangular in shape, with its apex
posteriorly. The superior articular surface looks directly
upward, and is continuous along the outer half with the
inferior articular surface at the posterior border, while
along the inner half this surface is separated from the
inferior by a 5 mm. strip of non-articular bone. The
inferior articular surface is directed downward and
backward. The outer half is convex, and is directed
outward. The inner half is concave, and is directed
•slightly inward. The facet for the internal malleolus
situated nearer the anterior than the posterior surface of
the body is broad, flat, and continuous with the superior
articular surface. The facet for the external malleolus,
situated near the posterior surface of the body, is narrow
and is separated from the superior articular surface by a
strip of non- articular bone. Just in front of the inferior
articular surface is a very small articular facet for the an-
terior and superior surface of the sustentaculum tali.
Upon the inner side of the neck of the talus is situated
the articular facet for the navicular bone. The facet is
Fig. 6. — F. Caixankus.— i. External surface; a, nearthrosis for external malleolus, just internal to it is the nearthrosis for tibia (concealed here) ; 3, articular sur-
face (external) for talus, the posterior portion of this surface articulates with the tibia; 4, processus anterior calcaneij; 5, tuberosity. G. 1, Internal surface; a,
intern?) portion of articulation for the talus, the superior border of which is continuous with the surface seen F 3 ; 3, sustentaculum tali ; 4, articulation for cuboid ;
5, marked ridge of bone continuous with the sustentaculum overhanging and articulating with the cuboid at posterior internal angle ; 6, non articular, superior surface
of neck, covered by neck of talus.
H. Talus and Olc\neus — Internal Surfaces. — 1, tfody of talus triangular in shape ; 2, neck of talus; 3, point at which superior and inferior surfaces
are continuous ; 4, articulation for navicular bone ; 5, sustentaculum tali ; 7. nearthrosis with neck of talus ; 8, 9, articulations for cuboid.
I. Talus — Aiiewior and Supe-ior View. — 1, Super-articular surface for tibia ; 2, articular surface for fibula ; 3, non-articular surface for fibrous bands
between two articular surfaces of the fibula uniting the fibula and talus : 4, body of talus ; 5, neck of talus ninety degrees downward, forty-five degrees inward.
I. Inferior and Iters- nal View.— i, Inferior articular surface for calcaneus; a, articular surface for fibula; 3, nun-articular surface for fibrous bands to
fibula ; 4, tibia articular surface.
K. Navicular B n- — Posterior View : 1, Oval articular surface for articulation with inner surface of the ueck of the talus; a, internal border; 3, external
border ; 4, second tuberosity, place where it ought to be.
L. Superior View. — 1, External border ; 2, internal border ; 3, posterior border ; 4, superior surface.
If. Anterior and Inferior View. — 1, Anterior surface of cuneiform bone ; 2, inferior surface very narrow as coppared with the superior surface in L. 4 ; 3,
internal border ; 4, external border.
This bone presents two nearthroses. One for the an-
terior surface of the sustentaculum tali ; the other for the
internal malleolus at its anterior and inferior angle.
The superior surface (anterior) is broad. The inferior
is narrow. The external is narrower than the internal.
There is no tuberosity present, nor does this bone articu-
late with the cuboid. The transverse axis forms with
the transverse axis of the cuboid an angle of ninety de-
grees.
The cuboid bone articulates with the anterior process
(i.e., neck) of the calcaneus upon its internal surface, in
such a manner that the weight of the body is in part
sustained by the dorso lateral surface. There is no sul-
cus for the peroneus longus tendon, nor is the tuberosity
present. The three cuneiform bones articulate with the
navicular and cuboid in the angle formed by them.
Their position is one of marked supination, adduction,
and approximation of the inner and outer bones toward
the plantar surface. This approximation diminishes
gradually as one passes beyond to the metatarsal and
phalangeal bones. Considering these bones more care-
fully, we find that the talus is made up of a body and
oval in shape, and its long axis forms with the' long axis
of the neck an angle of forty-five degrees. The outer
and anterior angle of the neck is much less prominent
than the internal and anterior angle. It seems to be
cut away. It is more rounded. The neck itself is some-
what flattened from above downward, and is rounded
from side to side. The long a*is of the neck forms with
the antero-posterior axis of the body an angle of ninety
degrees and with the transverse axis an angle of forty* five
degrees.
Calcaneus : The position of this bone is first one of
nearly full extension (plantar flexion). It forms with
the tibia an angle of eighty degrees. It is also supinated
sixty degrees, so that the nearthrosis for the fibula k
situated upon the superior and external border, and that
for the talus upon the inner surface adjoining the near-
throsis for the fibula. The bone is also adducted ten de-
grees.
Upon the superior surface we have four articular sur-
faces for the talus, tibia, and fibula. In the position in
which the bone articulates these surfaces look upward in
general. The articulation for the fibula looks upward,
196
MEDICAL RECORD.
[August 1 8, 1894
outward, and slightly forward. Just in front of the tu-
berosity is also a plane articular surface looking upward
and inward, for articulation with the outer third of the
posterior border of the tibia. This surface is continuous
with the outer portion of the articular surface for the
talus. These two surfaces are nearthroses. Anterior
and internal to them is the articulation for the talus,
which is inclined outward for the outer half, inward for
the inner half. It is concavo-convex, with its long axis
from without downward, forward, and inward. It ex-
tends so far forward as to be closely applied to the ar-
ticulation for the cuboid. The sustentaculum tali is
rudimentary, placed at a very low level upon the inner
side of the bone, and articulates with the talus and na-
vicular bone. The processus anterior is enlarged both
in heighth and breadth. The body and neck, including
the processus anterior, present a marked concavity upon
the internal surface, which is increased in appearance by
the enlarged tuber calcanei and anterior process.
The articular surface for the cuboid is entirely upon
the inner side of the processus anterior, with its long axis
at right angles to that of the calcaneus. This surface is
oval in shape and is composed of two portions: The
lower for articulation with post and external angle of the
cuboid ; the upper, which is situated just beneath and
Fig. 7.— N. Cuboid. — 1, Inferior surface; .*, interior border; 3, exterior border ; 4, anterior sur-
face ; 5, articulation with calcaneus.
O. Antkkior and Internal Surfac*.— i, Anterior surface ; 2, internal surface with articulum for
cuneiform. P. — 1, Posterior surface composed of two surfaces, the one external or inferior marked for
the calcaneus, the other, marked a, at the posterior internal angle for calcaneus insertion of susten-
taculum tali.
<J. Tibia akd Fibula. Posterior Vibw.— 1, Groove marked for tibialis posterior and flexor longus
digitorum ; a, groove for flexor longus pollicis ; 3. articular surface for calcaneus ; non-articular sur-
face for fibrous bands attaching the fibula to calcaneus and talus : 6, posterior border of inferior tibial
articular surface with articular surface for calcaneus ; 7, articular nearthroses between.
R. Fibular C alc an ku ^Anterior of Samb.— i, Internal malleolus ; a, facet for articulation
with navicular bone ; 3, outer border of facet for articulation with cuneiform bone.
anterior to the sustentaculum tali, for articulation with
the posterior and internal angle of the cuboid.
The internal border is narrower from above down-
ward and longer from before backward than is usually
the case. The tuberosity is wanting.
The anterior and posterior articular surfaces approach
one another inferiorly. The posterior surface is concave
and encroaches upon the external aspect of the bone,
leaving a surface upon the inner posterior (posterior sur-
face) free from cartilage. The cuneiform articular sur-
faces (anterior surface), besides being inclined inferiorly,
are slightly displaced toward the external border. The
bone is therefore more triangular in shape in two direc-
tions, i.e. , toward the planta pedis and the external border.
There is no articulation with the cuboid bone. The long
axis*of the navicular bone is parallel to the long axis of
the neck of talus. The nearthroses present exist between
the internal border and the malleolus, between the sus-
tentaculum tali and the inferior surface near the posteri-
or border, and with the talus at the junction of its body
and neck.
The cuboid bone is more quadrilateral than is normally
the case. In new bone and in the adult cuboid, between
the outer and inner border is respectively fifty per cent,
and fifty seven per cent. In our club foot, however, this
relation is raised to sixty six per cent. , which is in part due
to the lessened oblique position of anterior articular sur-
face. This articular surface forms with the external bor-
der in the new born cuboid an angle of 720, in the adult
790. In our specimen it is 820. The tuberosity of the
cuboid is wantiog, so that the height of the bone, espe-
cially at its posterior border, seems deficient. There is
no articular surface for the navicular bone.
The posterior articular surface occupies more of the
external surface than usual. This concavo convex looks
backward and slightly outward, and is continuous with
a nearthrosis upon the posterior and internal angle for
articulation with the calcaneus just beneath and anterior
to the sustentaculum tali.
The articular surface for the external cuneiform bone
is well marked, occupying nearly one fourth of the inner
side. It is raised above the surrounding surface with its
articular face directed downward and backward, but in
the articulated bone backward and upward.
The cuneiform bones are arranged rather behind than
alongside one another. Their posterior surfaces are ob-
liquely inclined, so that they look backward and upward,
i.e. j the lower border projects further backward than the
upper border. Otherwise these bones present few
changes of importance.
In the metatarsal bones the rotation of
the diaphysis inward 900, and greater de-
velopment of the posterior surface upon the
internal than posterior surface, are the only
noticeable features.
The tibia and the fibula are rotated in-
ward about their long axis. The malleolus
externus is anterior to the malleolus inter-
nus. The transverse axis of the talo crural
joint is from in front and externally to be-
hind and internally; with the transverse
axis of the body these axes form an angle
of3o°.
Upon the fibular end, two articular sur-
faces are found, one for the talus and one
for the calcaneus (a nearthrosis). These
are separated by a non articular surface.
Upon the tibial end three articular surfaces
are found, one for the talus, one for the
scaphoid, and one for the internal cunei
form. The two latter are nearthroses.
In the clubfoot of the new-born, the
neck of the talus is not only increased in
length, but its downward and inward in-
clination is respectively 45 ° and 65 ° —
against 150 and 45 ° in the normal new-
born talus. This inclination of the neck
accounts for the plantar flexion, according to Hueter.
Kocher, however, does not entirely agree with him in
this view, since the talo-crural joint is in plantar flexion,
as shown by the displacement of the superior articular
surface backward and the meniscus found at the poste-
rior border of this joint.1
The angle between the axis of the leg and the talus in
calcaneus was one hundred and fifty degrees, as found by
Kocher in the club-foot of a year old child. Plantar flex-
ion is possible to one hundred and thirty degrees. This
leaves twenty degrees of forced flexion in this case. In
our specimen there is an angle of one hundred and
seventy degrees present, so that we have forty-one degrees
for a forced plantar flexion.
The articular surface for the navicular bone is entirely
upon the inner side of the neck, oval in shape, with its
long axis midway between the horizontal and vertical
planes. In severe cases, the shape of this articular sur-
face is rounded and its long axis is vertical. In our case
this articulation has its long axis midway between a ver-
tical and horizontal plane.
In the two cases examined by Kocher a great differ-
ence existed in the form of the neck. In the one-year-
old club- foot the neck was abnormally long. In the
1 Dissection by Kocher.
August 1 8, 1894]
MEDICAL RECORD.
197
new-born club-foot the neck was only lengthened upon
the outer side, in so far as the anterior end of the navicu-
lar articulation begins on the mesial side, while it is
shortened upon the mesial side by the displacement of
the articular surface. This difference in the length of
the neck and the position of the talo-navicular facet is
explained by Kocher as follows : " If in utero the press*
ure continues till birth, the growth of the neck is hin-
dered and the anomaly consists in the displacement of
the articular surface.'1 After birth an unhindered
growth takes place, because the opposing pressure of the
navicular bone is reduced on account of the imperfect
play of the muscles and their unfavorable position. If,
however, the pressure is relieved in utero, the length
of the neck is evident at birth.19
The superior articular surface of the talus is displaced
posteriorly, so that the cartilage approaches nearly to the
posterior inferior border. It appears longer and nar-
rower than is normally the case. In our specimen, this
articular surface is continuous with the inferior articular
surface in the outer half. The lateral articular surfaces
are very unequally developed. The external is filled
with fibrous tissue in the posterior portion, while its an-
terior part is pushed nearer the neck. The internal is
very small. In this particular our specimen is similar.
In the calcaneus die changes are simply an excessive
representation of the foetal over the adult bone. The
articular surface for the talus inclines onward and back-
ward, and its highest point does not reach the highest
point of the bone. Anteriorly, it extends close to the
cuboid articular surface ; such a position of the articular
surface forms supination. The body of the calcaneus
and the neck are of equal length. The processus ante-
rior is greatly developed in height and is out of all com-
parison with that of the new-born. The long axis is so
bent upon itself that a concavity exists upon the inner
side, and the tuber calcanei and processus anterior appear
strongly bent to the same side. The articulation for the
cuboid is entirely upon the mesial side of the neck.
This bend in the axis of the bone and the position of
the cuboid articular facet produce great displacement of
the fore-foot at Chopart's joint.
The sustentaculum tali is placed at a much deeper
level, and is very imperfectly developed. In extreme
cases it is wanting, since the supination of the foot pre-
vents its growth from pressure upon the malleolus in-
ternus. The similarity between our specimen and the
new-born club-foot is striking, except for the degree and
die nearthrosis. In the navicular bone, the lateral
border is narrower than normal, while the inner border
is thicker. This change is ascribed to the freedom from
pressure for the inner border, and to the plantar flexion
and supination for the external border.
The anterior and posterior articular surfaces nearly
touch upon the inferior surface. The cuneiform articular
surfaces are displaced toward the mesial border, while
the talus articular surface reaches less closely to the in-
ner border than is normally the case. These changes
are evidences of pressure in the sense of adduction. The
navicular bone is consequently triangular in shape, being
narrower externally and toward the planta pedis.
The tuberosity is wanting or rudimentary. The
changes in the cuboid are not so constant nor marked
as in the calcaneus. As before stated, the relation of
the inner to the outer border in percentages is fifty
degrees for the new-born and fifty seven for the adult
(Arby) cuboid. In club-foot, however, the anterior
and posterior articular surfaces converge less externally,
and the bone is more quadrilateral. It is principally,
however, the anterior surface which inclines less oblique-
ly outward and backward. The tuberosities cuboidii
which bound the posterior border of the sulcus for
the peroneus longus are not developed, so that the ver-
tical diameter is much diminished. The thickening of
the bone behind the sulcus is scarcely noticeable. The
tuberosity is not developed, as its relations to the tendon
have been lost by the displacement of the tendon upon
the calcaneus. The similarity between these two bones
(i.e., navicular and cuboid), in the new-born and in our
specimen, are marked. The cuneiform bones are ar-
ranged behind rather than alongside one another. Their
posterior surfaces incline obliquely backward. The
tibia and fibula are less altered. They are rotated in-
ward (most marked) in their lower third. The malleo-
lus externus instead of being posterior is anterior, and
the transverse axis of the joint runs from behind and in-
ternally outward and externally.
It is also interesting to note the new articular facets
found in club foot. In the club-foot of the new-born
child new articular facets (nearthroses) are developed.
1. On the mesial side of the malleolus internal is found
an articular facet which articulates with a similar facet
upon the mesial and superior surface of the navicular
bone. This articulation is entirely separate from the
talo-navicular joint, and against its capsule rests the
tibialis posticus tendon as it ascends beneath the navicu-
laris. 2. Between the internal malleolus (its inferior
surface) and neck of the talus. 3. Between the malleo-
lus externus and the calcaneus.
In our specimen the nearthroses are more numerous,
and are as follows : 1. Between the posterior border of
the tibia and the calcaneus. 2. Between the internal
malleolus and the navicular. 3. Between the internal
malleolus and the cuneiform (internal). 4. Between the
external malleolus and the calcaneus. 5. Between the
sustentaculum tali and the inferior surface of the na-
vicular bone. 6. Between the navicular bone and the
talus at the junction of the body and the neck. 7. Be-
tween the posterointernal border of the cuboid and the
calcaneus beneath and anterior to the sustentaculum tali.
The tendons in club- foot of the new born vary as fol-
lows:
The flexor longus hallucis runs in a groove on the
talus and tibia into the soft parts beneath the plantar
fascia, without touching the calcaneus.
The peroneus longus runs from the malleolus externus
over and beneath the calcaneus. It does not touch the
cuboid bone. The tibialis posticus runs from the pos-
terior surface of the tibia over the border of the malleo-
lus internus. These changes in the position of the ten-
dons existed also in our case, though their displacement
was more marked than has been described in the club-
foot of the new-born or child.
These changes in the shape of the bones, the displace-
ment of the tendons, the approximation of the points of
origin and insertion of the muscles, and the new articular
facets, are sufficient evidences of a force exerted upon the
foot in the sense of plantar flexion at the ankle-joint, and
supination and adduction in the talo- tarsal joint This
pressure, which is produced in utero, can be seen in the
great majority of new born children, but in so mild a
degree that walking alone is sufficient to produce enough
formative and dorsal flexion to correct it.
Chondrification is complete by the seventh "or eighth
week of foetal life. The articulations begin to be formed
at this time, and are completed at the fourth month.
Short and slight pressures within the joint, owing to the
softness of the cartilaginous skeleton, and the rapidity of
growth in the foot, cause from this time on deformities in
the bones, and secondarily in the position of the ten-
dons.
Since the abnormal positions take place before the
use of, and at the time of, the formation of the muscles,
rectification does not take place afterward, because the
bones have become altered in shape and the muscular
attachments are approximated.
The earlier in foetal life such malpositions are initi-
ated, the more pronounced will be the subsequent de-
formity.
After birth the muscles tend to maintain or increase
an existing deformity. In the adult congenital club-
foot, however, there is added another factor in the pro-
duction and intensification of the deformity, namely, in
the weight of the body in walking. These changes, so
198
MEDICAL RECORD.
[August 1 8, 1894
far as this dissection has shown! consist : 1, In an exces-
sive increase of the deformities found in the bones of
the new-born. 2, In additional nearthroses. 3. In an
increased plantar flexion at the talocrural joint. 4.
In a marked supination and adduction in the calcaneus.
5. In an extensive displacement of the navicular and
cuboid bone to the mesial side of the talus and cal-
caneus. 6. In a pronounced rotation of the tibia and
fibula.
A normal foot at rest is one in which the position is
one of moderate supination, slight adduction with plan-
tar flexion. The axis in such a foot runs in a frontal di-
rection from right to left in the talo-crural joint, and
the motions of flexion and extension take place upon the
axis. Flexion is always accompanied here with slight
adduction. All muscles before this axis are dorsal flex-
ors (extensors). Those behind it are plantar flexors
(flexors).
The mid-position is one in which the foot is at right
angles to die leg, i.e., ninety degrees. Dorsal and
plantar flexion can be carried to thirty-nine degrees in
addition. Pronation and supination occur between the
tarns aad the foot, /.<?., the talus, the calcaneus, cu-
boid, wad navicular bones. The axis of motion is, if
costumed forward and backward, through the calcaneus
from behind, outside and below, anteriorly above and
within, passing through the sustentaculum tali and the
neck of the talus. On account of the direction of this
axis we must consider it as made up of three axes : a sag-
ittal, about which pronation and supination occur; a
perpendicular, about which ab- and adduction occur ;
and a frontal, about which flexion and extension occur.
With supination, adduction and plantar flexion take
place. With pronation, abduction and dorsal flexion.
The muscles situated externally to this axis are pro-
nators, abductors, and dorsal flexors. Those situated in-
ternally are supinators, adductors, and plantar flex-
ors. For this reason, the tendo Achillis lying behind
the axes in the talo-crural joint and to the inner
side of the axis of motion in the talo-calcanean becomes
a plantar flexor at the talo-crural and a supinator at the
talo-calcanean. Hence all tendons situated behind
and to the inner side of these joints cause, when short-
ened, first plantar flexion at the talocrural, and subse-
quently plantar flexion, supination, and adduction in the
talo-caloanean and navicular joints.
It must be remembered, however, that even the mid-
position in the adult is attended with a slight supination
in the talo-calcanean joint, and that in the new-born this
supination is often quite pronounced. For this reason a
greater frequency exists in all deformities tending to
varus over calcaneus or calcaneo-valgus. Such supina-
tion in foot axis corrected by the simple mechanism of
walking is overlooked as being a deformity, and only that
degree is so classed in which supination is not corrected
by walking. Leuffenbach, Hueter, and Adams have
shown that this difference in the axes of motion in the
foot of the new-born and that of the adult allows of a
greater supination without an increased plantar flexion
and adduction in the former, while in the latter greater
pronation is allowed. In the new-born the special
characteristics of the talus are increased length of the
neck and its downward and inward direction, with an
articular surface upon its inner side, the angles of dis-
placement being 15 ° and 45 °, respectively. The long
axis of the articular surface is midway between a vertical
and horizontal plane and is oval in shape, whereas in the
adult this surface is in a transverse plane and is ovoid.
This difference is due to the fact that the axis of talus in
the child is nearer the axes of motion between the talus
and calcaneus than in the adult, and hence the motion
at the talo-tarsal joint is more extensive and the joint
surface more rounded. In the calcaneus, the great
length and heighth of the processus calcanei, the oblique
inclination of the superior articular process to the inner
side, and the deep position of the sustentaculum tali, are
the principal features. The inclination of the superior
articular process downward and inward mainly, and to a
less extent outward, favors supination. The reverse is
the case in the adult, where pronation is favored. In the
new-born the length of the neck is equal to that of the
body. In the adult it is only one-third to one half the
length of the body, owing to the pressure of the cuboid
bone in the pronated position. The sustentaculum tali
is deeply placed and slightly developed. The reverse
condition is present in the adult.
Very slight differences exist in the cuboid except in
the length of their outer borders. In the new-born this
is represented in per cent, as 500 of the inner border.
In the adult it is 57 °.
In the treatment of a congenital club foot it is neces-
sary to reduce the plantar flexion, the supination, the dis-
placement at Chopart's joint, and the rotation of the leg
inward. This replacement of the foot must be done so
that the normal axes of motion are restored as completely
as is possible. This can.be accomplished either by the
development of new articular facets with perfect motion,
or by the extirpation of bone and syndesmotic or anchy-
losed joints with less perfect motion. The important
period of life for the accomplishment of a complete res-
toration of the foot with perfect motion is, strictly speak-
ing, the first thirty months of life. During this period
the growth of the foot is relatively greater than any other
part of the lower extremity.
Mechanical force and at the most tenotomies and
fasciotomies are sufficient to correct deformities at this
time. After this period great reliance upon the develop-
ment of new articular facets becomes less and less, and
we must trust more and more to operative procedures,
viz., tenotomies, fasciotomies, talus extirpations, and
cuneiform osteotomies. Which of these operations we
select, and the particular method by which we accomplish
them, is to be decided by the kind of deformity, the de-
gree, and the special peculiarity of the case. For the more
pronounced deformities of early youth, where mechanical
treatment, fasciotomies, and tenotomies have been un-
successful, or where no treatment has been used, the talus
extirpation alone, or with a very, limited wedge between
the os calcis and cuboid bone, or within the os calcis,
allows a flexion of the foot to 90 ° at the talo-crural, a
relief of the supination in the os calcis, and a reduction
in the displacement at Chopart's joint. In the adult the
question becomes one of the extent of the equinus over the
varus, or whether they are both equally marked. If the
equinus is the marked deformity, provided tenotomy has
not allowed of its reduction, talus extirpation. If varus
is the marked deformity and the equinus is relieved by
tenotomy, cuneiform osteotomy at Chopart's joint If
both are equally involved in the production, talus extir-
pation and cuneiform osteotomy. It should be the aim
of the operator to relieve the deformity completely and at
once. No apparatus, except possibly a high-soled shoe,
is required when this is accomplished. No one would
think of resorting to osteotomy or extirpation of the talus
as a primary operation in the growing foot. It is enough
here to divide the tendons and fascia wherever they op-
pose a replacement of the foot, and an appropriate after-
treatment. In the foot, however, where growth is com-
pleted or nearly so, the conditions are not the same.
Tenotomies and fasciotomies are done as a preliminary
step in the operations of talus extirpation or cuneiform
osteotomy, in order to determine how extensively they are
to be carried out. No single method of operation , whether
it be in the class of tenotomies, fasciotomy, or a bone
operation, will suffice in the compound deformities of the
third degree, and there should be no hesitancy in carry-
ing out the idea of complete and immediate restoration
of the foot in adults, especially, for the mortality, under
antiseptic precautions, is less than one per cent. In fifty
cases of inveterate club-foot in which a bone operation
has been done, I have never seen a death, nor a case of
infection except in one case. This case was operated
upon a second time with a good result, the whole course
of the treatment lasting five months.
August 1 8, 1894]
MEDICAL RECORD.
199
THE VALUE OF ELECTRICITY IN DIAGNOSIS
AND PROGNOSIS OF AFFECTIONS OF THE
PERIPHERAL NERVES.1
By WILLIAM M. LESZYNSKY, M.D.,
NBW YOKK.
LBCTUUR ON MENTAL AND NBRVOUS DISEASES AT THE NBW YOKK POST-
GSADUATS MEDICAL SCHOOL ,* NEUROLOGIST TO THE DKMILT DISPENSARY,
*TC
Having been asked to limit my remarks to the value of
electricity in the diagnosis and prognosis of disease of
isolated peripheral nerves (neuritis and nerve injuries),
I shall only venture to present some of the most promi-
nent features relating to this subject.
It would be superfluous before such a body to dwell in
detail upon the essential methods of an electrical exam-
ination, or to refer to the various batteries. Whatever I
may say will no doubt seem trite to the critical members
of this Society, who are all more or less familiar with the
use of electricity in diseases of the nervous system. To
other physicians, not endowed with such special knowl-
edge, a discussion of this nature is not only timely, but
of the greatest practical importance.
During the last ten years I have devoted much time
and attention to the study of electrical reactions, par-
ticularly in the various forms of disease affecting the
peripheral nerves, which so often result in motor paresis
or paralysis. My conclusions are therefore based upon
personal observation in a large number of cases, and are
in a great measure confirmatory of the claims of others.
It has been very aptly said : " The popular theory is
that the carrying out an electrical investigation requires
no special training, and is within the reach of anyone
possessing a battery and a superficial knowledge of the
medical applications of the current to the human body.
. . . The ablest physician, the most consummate
neurologist, if he has not submitted himself to the con-
ditions required, and passed through the ordeal of dis-
cipleship, will fail to obtain reliable results. . . .
But little additional light is shed upon the practical is-
sues of the case by the reaction in a typical instance of
infantile or lead paralysis, or of advanced progressive
muscular atrophy. Where electro diagnosis is of para-
mount importance is at the beginning, during the insidi-
ous stage of numerous neuropathies.9
Comparatively little, or no attention at all, has been
given by the general practitioner to the subject of electro-
diagnosis, while the neurologist devotes too little time to
its study. In all discussions or teachings on medical
electricity too much stress has been laid upon its po-
tency or uselessness as a therapeutic agent; while its
importance in diagnosis and prognosis has been insuf-
ficiently recognized or neglected. The preliminary
steps toward success in the study of the affections of the
peripheral nerves, particularly where paresis or paralysis
is a prominent symptom, consist in the acquirement of a
practical familiarity with the position of the principal so-
called " motor points," and a correct interpretation of
the various electro diagnostic phenomena resulting from
an examination of the nerve- trunks and muscles.
By this means we can satisfactorily determine, in the
vast majority of cases, whether the disease is situated be-
tween the nucleus and the periphery of the motor nerves,
or elsewhere. In two similar cases, whose pressure paral-
ysis is of equal severity, the anatomical causes may vary
considerably in their extent and intensity. It is only
after an electrical examination that any conclusion can
be drawn as to the approximate degree of damage to the
nerve.
We are also enabled to state, almost accurately in
many instances, what the probability is as to recovery,
and to express an opinion as to the duration of the paral-
ysis:
1. Preservation of faradic irritability in nerve and
muscle, with only very slight decrease as compared with
>Read at the meeting of the New York Neurological Society!
February 6, 1804.
* De Wattevfife.
the healthy side, when found two weeks after attack, is
of favorable import. Recovery usually takes place spon-
taneously within a few weeks (sep Cases I. and II.).
2. The faradic irritability in both nerve and muscles
may be very markedly diminished and accompanied by
change in the character of the muscular contraction,
which is slow and somewhat protracted. This may be
associated with "qualitative" as well as "serial"
changes found upon examination with galvanism, i.e.,
the galvanic excitability in the- nerve is present, though
diminished, while in both nerve and muscle AnCC >
CaCC (the contraction at the closure at the positive pole
is greater than at the negative). This has been desig-
nated by Erb as the partial reaction of degeneration.
It has been known to ultimately advance to complete
R. D. Recovery usually takes place in a few months.
3. When die faradic irritability is lost in nerve and
muscle, the prognosis remains doubtful. It it usually
accompanied by loss of galvanic excitability in the nerve.
When galvanism is applied to the muscle it contracts
slowly, and the reaction may he wore marked at the
anodic opening than at the catbadic closure. There
may also be increased irritahiKEr in the muscle as shown
by a marked contraction being elicited by a current
which has no effect whatever upon the healthy side.
This constitutes the reaction of degeneration (R. D.)
and is of grave significance. The prognosis is doubtful
or bad, due consideration being observed as to the cause
of the lesion. These patients do occasionally get well,
but more rarely when the facial nerve is affected than the
nerves of the extremities. As a matter of fact the mus-
cles involved may show various gradations in the charac-
ter of their galvanic reaction. In my experience the
persistent increase in the galvanic excitability influences
the prognosis more unfavorably than a mere change in
the polar reactions. This I have found to exist in cases
of facial paralysis, but I have never seen a case of long
standing — a year or more — where a reaction in the mus-
cles to galvanism could not be demonstrated.
In the extremities, however, it is well known that
when recovery does not take place, and the musculature
atrophies, the galvanic irritability gradually diminishes,
and ultimately no contraction can be obtained even with
the strongest currents.
It has always seemed to me that there is a decided dif-
ference in the course of a facial paralysis as compared
with that of nerves in the extremities. It is rare to see
atrophy of the facial muscles after a persistent paralysis
from the usual causes, while in the extremities atrophy is
not at all uncommon. The return of faradic irritability
in the facial muscles does not necessarily imply a recov-
ery from the paralysis. I have found it present in cases
that were from two to ten years' duration and of un-
doubted peripheral origin. See Case III., in which R. D.
had been present and six months later faradic irritability
returned, but motility was not restored.
The following case is still under observation : Annie
D , thirteen years "of age. Left peripheral facial
paralysis of ten years' duration. Right facial nerve re-
acts to faradism 30 mm. ; left, 35 mm. ; right facial
muscles, 32 mm. ; left, 35 mm. (slow).
In the Berliner klin. Woehenschr.> October 16,
1893, Placzek reports four cases of peripheral paralysis
(facial nerve, 3 ; brachial plexus, 1), that had existed for
periods ranging from two years to twenty- five years
(2, 9, 12, 25). Faradic irritability was preserved in both
nerve and muscles. There was only slight quantitative
decrease. Galvanic excitability was only slightly in-
creased. The character of the muscular contractions was
normal. Thus it is clearly shown that despite the paral-
ysis having persisted unchanged for many years, and the
nerve being impervious to the strongest voluntary im-
pulses, its reaction upon electrical excitation indicates
only a slight quantitative change in irritability. He asks
" How are these phenomena to be reconciled with the
current teaching as to the existence and course of periph-
eral paralysis ? "
200
MEDICAL RECORD.
[August 1 8, 1894
The only explanation given is based upon the assump-
tion of Erb, that the conductivity in nerves depends on
the axis cylinders, while that of electrical irritability
exists in the medullary sheath. This view has been con-
firmed by the experiments of Schiff and Griinhagen.1
Placzek therefore concludes that in the cases reported
the presence of an axial neuritis may be the cause of the
apparently irreconcilable phenomena. I would hardly
be willing to admit that these cases vitiate the teachings
as to the usual course of the electro diagnostic phenom-
ena. It seems to me that 'in old cases accompanied by
the persistent classical reaction of degeneration, in which
there is complete motor paralysis and muscular atrophy,
the difference between the two classes is merely one of
degree as to the pathological process.
A further study of the electrical reactions in old cases
of peripheral paralysis may show that in the absence of
atrophy the faradic irritability will be found present in
every case.
On the other hand, motility may be restored in mus-
cles of the extremities, yet faradic irritability may re-
main absent, or R. D: way be demonstrable.
It is well to bear in mind that the same electro-diag-
nostic phenomena occur whether the lesion be situated
in the nucleus or in the course of the nerve trunks.
When an eye muscle is paralyzed it is either the result
of a lesion at the nucleus, in the trunk or branches of
the nerve, or in the intramuscular nerve-elements them-
selves. The action of the current cannot be sufficiently
circumscribed in order to produce isolated contraction
of individual muscles. Even if such an examination
were feasible, electricity could not aid us in making a
diagnosis as to the location of the pathological process.
As an element in prognosis it is valueless for the same
reason.
The direct application of an electrode and the current
to the ocular conjunctiva is a painful procedure and is
rarely tolerated by the patient. Since the use of cocaine
it was hoped that electricity could be applied to the in-
dividual ocular muscles after producing anaesthesia of
the surface of the eyeball. This hope has not been real-
ized. It has been advised, and also attempted, to pierce
the conjunctiva with a needle attached to one of the
poles of the battery, and thus apply the current directly
to the affected muscle. The writer has tested this as a
method of treatment in a number of cases, but was
forced to abandon it. Even in the hands of an expert
it is not unattended with danger to the delicate structures
of the eye. This is especially so regarding the use of the
galvanic current. The facial nerve and the nerves of
the upper extremities are the most accessible to electri-
cal examination, as well as the most frequently affected
by disease. The following histories selected from my
case books will serve to illustrate the practical utility of
electricity as an aid in diagnosis, and also as an auxiliary
method in establishing an almost absolute prognosis :
Case I. Peripheral Facial Paralysis {Traumatic). —
November 1, 1892. A. K , a boy, ten years of
age, was struck by a base-ball on right side of face, and
all branches of the nerve became paralyzed within
twenty four hours. He was seen three days after the
injury, when paralysis was found to be complete. There
was also slight disturbance of the sense of taste on the
anterior two-thirds of the tongue on the same side.
Slight diminution in faradic irritability in nerve and
muscles. Left, 10 mm. ; right, 15 mm. Two weeks
later the motility was returning in facial muscles, the
faradic irritability being only very slightly diminished
— 13 mm. Galvanic reaction normal. A favorable prog-
nosis was given. Complete recovery three weeks later
without treatment.
Case II. Peripheral Facial Paralysis from Exposure
to Cold. — November 9, 1893. Miss G , seventeen
years of age. When seen three days after beginning of
attack there was complete facial paralysis upon the right
side. No involvement of palate, but loss of taste on the
1 Zeitschr. f. Med., Bd. 29.
anterior two thirds of tongue on the same side. The left
nerve and muscles reacted to faradism 10 mm. ; right,
20 mm., showing an early decrease in faradic irritability.
November 16. — Faradism: Left, iomm,; right, 15
mm. Galvanic reaction normal ; prognosis, good.
December 3. — Faradism: Left, 10 mm ; right, 18
mm. Motility partly restored in facial muscles.
January 20, 1894 — No evidence of paralysis. Fara-
dism : Left, 10 mm. ; right, 20 mm. Complete recovery
within ten weeks without treatment.
Case III. Peripheral Facial Paralysis from Exposure
to Cold. — October 25, 1891. Miss K , twenty-four
years of age. After sailing in a storm became paralyzed
on right side of face. All branches involved. Was first
seen by me nine weeks after attack. Left nerve and
muscles reacted to faradism 14 mm. ; right, no reaction.
Galvanism: Left, 2 Ma CaCC, normal in nerve and
muscles; right, no reaction in nerve. Muscles react
slowly to 1 Ma AnCC > CaCC. In other words, the
reaction of degeneration is present An unfavorable
prognosis was given.
December 1. — The galvanic excitability in the muscles
is always found increased.
January 31, 1892. — Although the faradic irritability
has returned in nerve and muscles (quantitatively dimin-
ished) recovery is incomplete, and accompanied by
secondary contracture in the zygomatics.
June 4. — Condition unimproved.
Case IV. Peripheral Facial Paralysis from Expos-
ure to Cold. — February 13, 1893. Mr. ^ > mer*
chant, forty eight years of age. Two days after riding
on the platform of an elevated railroad-car during a cold
night he first noticed paralysis of the left side of face.
All branches are affected. No interference with taste.
Was seen three days after attack. Right nerve and mus-
cles react to faradism 14J mm.; left, 20 mm. (slow).
Galvanism: Right, \\ MaCC; left, 2 Ma AnCC =
CaCC.
March 1st. — Left, loss of faradic reaction in nerve
and muscles. Loss of galvanic irritability in nerve.
Facial muscles react slowly to 1 Ma AnCC > CaCC,
showing the reaction of degeneration. Prognosis doubt-
ful.
February, 1894 (one year after onset of attack). —
Recovery was almost complete except in lower facial
muscles.
Case V. Traumatic Neuritis of Left Ulnar Nerve.
— William H , born in England, thirty years of age ;
diamond polisher. Was first seen February 26, 1889.
Three weeks before he had been cut on the left wrist by a
broken bottle. The wound had healed. He complained
of numbness and tenderness on pressure over the ulnar
distribution in the palm. Causalgia : Severe pain at night.
Paralysis affecting the two ulnar fingers. There was anaes-
thesia in the hand in the course of the ulnar branches.
Some atrophy of the adductor pollicis and the hypothenar
group of muscles. Faradism : Right nerve and muscles,
14} mm.; left, no reaction below the wrist. Galvan-
ism : Ulnar nerve — right, 2 J Ma CaCC ; left, no reac-
tion in forearm. Muscles — right, hypothenar group in-
terossei and adductor pollices, 6 Ma CaCC ; left, hypo-
thenar group interossei, 6 Ma AnCC > CaCC, slow and
feeble.
April 5th. — Excessive pain had continued and pre-
vented sleep. Exploratory incision showed that the
nerve had been cut across by the injury, and it was found
in a condition of typical degeneration. The divided
ends were sutured and the wound closed.
May 14th. — Pain had subsided. Anaesthetic area had
diminished, and the tactile sensibility was improved.
Faradism: Ulnar nerve at elbow 15 mm., only in ad-
ductor pollicis. No reaction in hypothenar group.
Galvanism : 4 Ma AnCC, affecting adductor pollicis only.
October 24th. — The nerve conduction was steadily im-
proving, so that 5 Ma CaCC produced a reaction in the
hypothenar group. The strength in the hand rapidly in-
creased and it was ultimately restored to usefulness.
August 1 8, 1894]
MEDICAL RECORD.
201
Case VI.— Paralysis of Brachial Plexus {Bilateral).
— F. S , aged twenty-five, born in the United States,
porter. Was first seen by me September 6, 1890, and
gave the following history: While intoxicated he fell
asleep on the roof of his house, during a chilly night,
August 23d (two weeks ago). Was carried to bed in
the early morning and awoke in the afternoon with both
arms paralyzed. There was numbness in the arms and
fingers, which disappeared in a few days. No pain, no
history of syphilis or rheumatism. Lower extremities
not affected. While asleep on the roof he was wearing
a stiff shirt collar, and he was told that his head was ex-
tended backward.
The following condition was found upon examination :
Right upper extremity : Paralysis of deltoid, infraspina-
tus, teres minor, and biceps group. Paresis of supinators
and extensors. No triceps jerk. No atrophy. No
objective sensory disturbance, but some tenderness on
pressure over supraclavicular portion of brachial plexus,
causing radiation of pain through the entire arm. Me-
dian and ulnar distribution not involved. All nerves
and muscles react well to faradism, 23 mm., and also
upon irritation at Erb's supraclavicular point. Galvanic
reactions normal.
. Left upper extremity : Paralysis of deltoid, infraspina-
tus, and teres minor biceps group and latissimus dorsi.
Paresis of the subscapulars and teres major, triceps,
supinators, and extensors. No triceps jerk. No atrophy.
No sensory disturbance. Tenderness on pressure over
the brachial plexus in the neck. Median and ulnar
nerves normal. The deltoid, triceps, and biceps group
react well to faradism, 26 mm. ; musculo spiral nerve,
31 mm. ; extensors, 35 mm. (feeble). Galvanic reaction
normal. Both shoulder joints relaxed and paretic mus-
cles are flaccid. Lower extremities in good condition.
The treatment consisted in the application of blisters
over the points of tenderness and the use of the -galvanic
current A favorable prognosis was given. By the end
of October recovery was complete.
From the foregoing history the distribution of the
paralysis and the painful pressure points the diagnosis
was made of traumatic neuritis of the brachial plexus
resulting from pressure. The preservation of faradic
irritability proved of service in forming a prognosis.
This is representative of a class of cases of peripheral
paralysis where the faradic irritability is preserved (or
only slightly diminished) as well as all forms of sensation.
Case VII. Spontaneous Degenerative Neuritis of the
Brachial Plexus, ' — A man, thirty eight years of age,
shortly after exposure to cold (without antecedent history
of joint disease or injury) suffered from severe paroxysmal
pain in the left shoulder, rapidly followed by paralysis of
the deltoid. After short but varying intervals of freedom
from acute pain another paroxysm would occur, accom-
panied by additional paralysis. These attacks, extending
over a period of four weeks, involved all of the muscles
innervated by the circumflex, suprascapular, subscapular,
musculo- cutaneous, and musculo-spiral nerves. There
was anaesthesia in the domain of the circumflex, external
cutaneous, and radial nerves. Well-marked atrophy with
the reaction of degeneration existed in all of the paralyzed
muscles excepting the biceps group, in which only a
"partial R. D." was demonstrable. The median and
ulnar nerves were not involved. Almost complete re-
covery took place at the end of two years. The biceps
group, presenting "partial R, D.," recovered first, while
the supinator longus and the extensors of the forearm,
exhibiting " complete R. D.,M were the last to show signs
of improvement.
If electricity is to be of any service to us in ascertain-
ing whether the nerve-trunk has been divided or not as a
result of traumatism, the examination must be made as
soon after the injury as possible. We can then deter-
mine at once if special surgical interference is necessary.
1 ** A Contribution to the Clinical Study of Spontaneous Degenera-
tive Neuritis of the Brachial Plexus/' by the writer, Journal of Men-
tal and Nervous Diseases, January, 1890.
Should two or three weeks elapse before such examination
it will be impossible to state whether the absence of reac-
tion is due to traumatic neuritis or to complete division of
the nerve. Exploratory incision would then be called for.
The tests with the galvanic current require adequate
apparatus and a working knowledge of the relationship
between electro-motive force, resistance, and current
strength. It also requires much time, patience, and per-
severance. Hence its unpopularity.
The musculo-spiral nerve, which seems to lose its irri-
tability more readily than most of the other nerves of the
body, presents some special peculiarities that are worthy
of note. In apparently healthy people I have very often
failed to demonstrate the faradic reaction of this nerve,
and was unable to satisfactorily account for its absence.
This occurred, as a rule, in muscular individuals, in
whom the examination is occasionally difficult. With
the small electrode over the nerve I could not elicit a
response, even with strong currents, while the extensors
reacted normally upon direct excitation. In the ab-
sence of evidence of disease I attributed this failure to
the action of the current producing muscular contrac-
tions in situ sufficient to throw the electrode aside.
With the electrode, however, in the same position —
without having been removed — and the galvanic current
substituted, the response would take place promptly. It
may be that in some of the cases the faradic anode was
used, thus accounting for the absence of the usual reac-
tion (vide infra).
In the Berliner Deutsch. mcd, Wochenschr. , 1892, p*
747, Dr. Karl Gumpertz claimed that it was possible to-
make the anticipatory diagnosis of lead paralysis and
paralysis due to other forms of neuritis even in cases
where the typical extensor paralysis is absent, and where
the electrical reaction of the muscles suspected of disease
is shown by the direct examination to be practically
normal. He called attention to the fact that in the
musculo spiral nerve excitation with the faradic anode
fails to elicit a response, while with the faradic cathode
a distinct reaction is produced. Subsequently this claim
was found to be fallacious by Dr. J. J. Putnam,1 of Bos-
ton. He discovered that this peculiarity in reaction also
existed in a certain proportion of apparently healthy
people. I have been enabled to fully confirm the state-
ments of Dr. Putnam, but, like him, am at a loss to give
a satisfactory explanation of this phenomenon. While
the cathode of the faradic break current can easily be
recognized by its greater effect upon motor and sensory
nerves, this relative difference in the strength of the
poles and their action is insufficient to account for this
peculiarity.
I have thus far examined twenty three cases with the
following result : With the faradic anode over the nerve
no contraction could be obtained in three cases with a
strong and painful current, excepting in the supinator
longus. In two there was no reaction whatever in the
distribution of the nerve. In all of these five a com-
paratively weak current gave a well-marked reaction —
when the faradic cathode was applied. As was to be ex-
pected the extensors reacted normally upon direct exci-
tation, invariably requiring a greater length of coil at the
anode. I am making more extended investigation along
this line, and hope to report the result upon some future
occasion.
The following conclusions will no doubt serve to con-
trovert a number of popular fallacies relating to this
subject :
1. That the value of electricity as an accessory method
in diagnosis and prognosis of disease of the peripheral
nerves is not as universally recognized as its importance
demands.
2. That the result of this procedure often furnishes
corroborative and conclusive evidence where only a
provisional diagnosis has been made.
3. That the necessary technical skill in successfully
pursuing such investigation and correctly interpreting
1 Boston Medical and Surgical Journal, March 30, 1893.
202
MEDICAL RECORD.
[August 1 8, 1894
the result can only be acquired through special study
and practice.
4. That the use of the faradic current alone is quite
sufficient for diagnostic purposes.
5. That, as a rule, the galvanic current is supplemental
to that of faradism, and in the absence of faradic irrita-
bility in nerve and muscle it is of the greatest service in
prognosis.
6. That the discovery of the reaction of degeneration
is not an essential feature in the differential diagnosis as
to the location of the lesion.
7. That the peripheral nerve-fibres possess an inherent
power of regeneration, which seems almost unlimited,
the length of time required for the completion of the re-
generative process varying from a few weeks to seven
years or more. Therefore in severe forms of injury the
cause, degree, and character of the damage to the nerve
are often of greater importance in prognosis than the
demonstration of the reaction of degeneration.
8. That the presence of R. D. or partial R. D. is not
incompatible with the preservation of motility in the
same area. This paradoxical condition has been found
in cases of lead-poisoning, and a few others, but thus
far the cause has been inexplicable.
9. That strong currents are only rarely necessary.
The weakest current that will produce a distinctly per-
ceptible reaction is all that is requisite.
10. That a decrease or disappearance of faradic irrita-
bility in nerve and muscle simply denotes an interfer-
ence with the nutrition in the course of the motor tract
between the multipolar cells in the anterior horn and the
peripheral nerve distribution. It does not enable us to
judge of the nature of the pathological process.
n. That the character of the reactions does not differ
whether the lesion be situated in the cells of the anterior
horn, the anterior nerve-roots, the nerve-trunks, or in
their ultimate distribution. The same rule holds good in
reference to the various cranial motor nerves and their
nuclei, such as the facial, hypoglossal, and spinal acces-
sory nerves.
12. When the farado-muscular irritability is lost no
reaction can be obtained by a rapidly interrupted gal-
vanic current.
13. The secondary current from an induction coil
is the one generally used in testing faradic irritability.
Owing to its high electro motive force the resistance
encountered in the moistened skin may be considered
negligible.
14. The difference in the poles of the faradic current
is only a relative one, and cannot be determined by the
usual tests as applied to the galvanic current. The elec-
tro-motive force in the secondary coil is greater at the
"break" than at the "make." The electrode that is
felt to be the stronger in its action is usually considered
as the negative, or so called " faradic cathode."
15. In some apparently healthy individuals the mus-
culo-spiral nerve fails to react to strong currents applied
with the "faradic anode," while a comparatively weak
.current from the " faradic cathode " calls forth a quick
response.
16. In a case of undoubted peripheral paralysis the
faradic irritability may be preserved, but it almost in-
variably requires a stronger current to produce muscular
contractions than upon the healthy side (quantitative
decrease). [The writer has never seen a case where this
could not be demonstrated within a few days after the
onset of the paralysis.]
17. The character of the muscular reaction demands
attention. A slow and labored contraction associated
with decrease in faradic irritablity denotes degenerative
changes.
18. The faradic irritability may return in persistent
cases of peripheral paralysis without any perceptible im-
provement in motility.
19. Electro-diagnosis is inapplicable in paralysis of the
ocular muscles.
61 East Seventy-fifth Street.
SOME FURTHER OBSERVATIONS ON REFLEX
ASTHMA.
By LOUIS E. BLAIR, A.M., M.D.,
ALBANY, M. Y.
In an article published in the Philadelphia Medical and
Surgical Reporter for January, 1891, I reviewed a series
of thirty-five cases of asthma, and summarized the article
as follows : " I have thus dwelt at length upon the various
theories and views of writers, in order to show what the
advanced sentiment is in regard to this subject in medi-
cine, which evidently remains to be written. Its present
treatment by therapeutic means alone is very unsatisfac-
tory, as everyone will admit. Time-worn remedies have
been discarded for newer ones more encouraging, and
these in turn abandoned for others. There is no specific
for asthma. Each case must be. studied by itself. The
physician must satisfy himself as to the integrity of the
upper air passages, more especially the nasal cavities.
Here is the most prolific cause of asthma, a fact which
has now been fully proven by most careful writers, and
by most successful and convincing records of treatment.
In all of the thirty-five cases which I have treated, ab-
normalities of the nasal cavities were verified ; and in those
cases which were not benefited, I believe that other and
remote nervous disturbances were influential in keeping
up a reflex asthma."
One would think, from the number of articles which
have appeared on this subject in the last three or four
years, that all had been said in reference to it, and that
some unanimity of opinion existed, at least among spe-
cial workers, from the number of favorable cases which
have been reported. But such apparently is not the
case. One of the latest and best books on the throat,
namely, that of Greville McDonald, published in Lon-
don in 1892, discusses this theme from the standpoint
that the reflex theory cannot be well sustained by physi-
ological laws or practical results. His reasoning, ana-
tomically and pathologically, is, I think, defective,
while his experience with asthmatic subjects evidently
has been both a limited and only a partially successful
one, from his own statement. Nor do I think that the
English writers have yet grasped all the factors which
enter into the problems of cause and cure of this ail-
ment. They even go so far as to say, in their failure to
cure their patients, that, in the first place, they do not
meet with as many in their practice as compared with
their American confreres ; and, in the second place, it
is more distinctly an outgrowth of American neuras-
thenia, and the physicians on this side of the Atlantic
are accordingly better qualified to study causes and ap-
ply more suitable remedies, being, of course, more famil-
iar with the weaknesses and predispositions of their pa-
tients.
The first writers on reflex asthma believed that the
disturbing cause was most often found in the nasal pas-
sages, and was an obstructive one, and in some cases
brilliant results followed treatment. It is not necessary
to detail the work of the pioneers in this new field.
Suffice it to say, that a great many throat specialists be-
lieve that where there is no obstructive lesion there can
be nothing done for asthmatics who suffer either from
hay fever or perennial asthma. Bosworth, in his excel-
lent monograph on asthma, says : "A large majority, if
not all, cases of asthma were dependent upon some ob-
structive lesion in the nasal cavity. This is evidenced
by the immediate relief from the exacerbation by the use
of cocaine in the nose, in every case in which I have
tried it, and, furthermore, by the cure of so many cases
by the removal of the obstructive lesion in the upper air-
passages. ' '
I will admit that obstructions causing nerve irritation
ought to be removed, but there are many cases where no
obstructive lesion exists, or, at any rate, cannot be demon-
strated, and yet the cocaine applications suspend tem-
porarily the paroxysms of asthma. In these cases I be-
lieve there are exposed nerve-points, when in the nasal
August 1 8, 1894]
MEDICAL RECORD.
203
cavity, for example, which may be either sensory or part
of the olfactory system, which have become hypersensi-
tive nerve-tumors, and are just as effective in causing
asthma as obstructions or grosser lesions. The causal
and offending substances may be many, viz., tobacco
dust or smoke, finely powdered drugs, animal emanations,
odors from the stable, from the kitchen, odors from
crowded rooms, etc., any of such odoriferous particles
producing their distressing effects, depending upon the
idiosyncrasy of the victim. This term idiosyncrasy is
used for the expression of vitiated nerve centres, which
morbidly respond to causes, so slight even, which can-
not be appreciated by the physician, or sometimes even
by the patient.
One cause of failure in the treatment of reflex asthma,
supposed to have started primarily in the upper respira-
tory tract, has been that, after the surgeon has removed
the local causes of disturbance, he. has failed probably
in one of the most essential points in the treatment,
namely, to restore the tone of the weakened nerve-cen-
tres, where the "habit of asthma " has been firmly es-
tablished, and where at last local irritation, or even the
removal of it, has but a little influence in preventing the
nervous explosions. I have even found in some patients
that simple exhaustion from a prolonged day's work, the
fatigue of a railway journey, etc., would at night develop
into an attack of asthma, which could only be explained
by this extreme weakness in the nerve-centres inhibiting
the vaso- motor system of the bronchial tubes. For this
reason discredit has been cast upon the local treatment .
of asthma, where local disturbances have been believed
to have been eliminated and a cure has not resulted.
This so-called neurotic element in asthma, as pointed
out by Beard, is more of a result and not a primary cause
of asthma, I believe.
Greville McDonald, in his valuable treatise, fails to
grasp the value of this point in discussing the subject in
the chapter on " Nasal Asthma." He takes the view
that nasal obstruction is a cause of hay fever, and when
the nasal obstruction is eliminated patients frequently
develop asthma, a bronchial irritation further down, be-
cause the nasal passages having been rendered more pa-
tent, harm has been done the patient, and as a rule the
seeming improvement in the nose may be followed, and
moreover is apt to be followed, by the ^nore embarrass-
ing and persistent perennial asthma. " We must re-
member the possibility of rendering the asthma worse as
a consequence actually of the improved condition of the .
nose " (page 237). In the chapter on " The Nasal
Neuroses " he discusses the physiological reflexes, name-
ly, lachrymation, rhinorrhcea, sneezing, deglutition, and
coughing, and says : " But I have never seen any other
evidence of reflex action than those enumerated. Con-
sequently the question naturally suggests itself, why in
conditions of disease should we find reflex effects pro-
duced which cannot be provoked by physiological
means? Are we to assume that paths along which re-
flex actions take their course exist in pathological states,
though unknown in conditions of health ? " In answer
to this I would say that asthma is not a normal reflex,
and cannot be produced in a state of health. It is pre-
eminently a pathological condition brought about through
a long abuse and irritation of the nerve-centres in direct
communication with sensory nerve-branches distributed
more especially over the upper respiratory tract. Be-
sides, I would add that in practical experience I have re-
peatedly, in asthmatic patients, produced well-marked
paroxysms when probing gently over the various areas of
the nasal cavities for the purpose of completing a careful
diagnosis ; and in just such patients I have been able to
accomplish the most good where the reaction of asthma
from operative treatment has been most severe and most
marked, for I have always felt that I had reached a
source of irritation. Only recently this was forcibly
illustrated in a chronic asthmatic, a lady over sixty years
of age, while using the electro-cautery in reducing hy-
pertrophied and otherwise diseased tonsils ; such a severe
paroxysm of asthma was called forth that, for the time
being, it was not possible to continue the further treat-
ment. Bosworth has also called attention to faucial
irritation produced by an elongated uvula as causative of
asthma, and by removing it a cure ensued.
Experience has taught, then, that it is highly necessary
to place the upper respiratory region in a condition of
physiological repose if any permanent good is to be
looked for. Obstructions and sensitive areas must be
corrected. Indiscriminate use of saw, knife, and cautery
are to be condemned. Soothing oily sprays suitably
medicated, continued through a period of months, Will
aid greatly to restore the normal condition of things,
while the wholesale destruction of whole areas can only
result in harm. As was hinted at early in this paper,
the great source of failure has been in not looking after
the general condition of the patient.
The constitutional treatment of asthmatics has its cor-
relation in the tonic treatment of chronic syphilitics.
It is no secondary matter. Unless you have the blood
of the latter in a state of repair, it is useless to storm
them with heroic doses of mercury and iodide of potash,
for the depressing and depleting drugs will do more
harm than good. And so it is with the victims of
asthma. You have to deal with a depraved and vitiated
nervous system. An early and an earnest effort must be
made to build up their strength. After removing local
causes the next thing to do is to add nerve resistance.
It is a common occurrence to meet with cases which
have existed almost from birth, and the belief is firmly
established that nothing can be done; and laboring
under this erroneous idea, the patient has been content
with a moderate degree of health, has been afraid of ex-
posure to the summer air, dreading the dust and pollen,
while the winter cold and dampness have likewise been
a source of menace; and not having taken sufficient
out- door exercise, and not being able to follow, as a rule,
laborious duties, the individual has grown up with im-
paired strength and inability to pull out of a wretched
condition. It is often marvellous to see how rapidly
such patients improve after the proper treatment has been
instituted. I will instance only two cases, one, that of
a young man twenty- one years of age, who had been a
victim of asthma from birth, and was only able to work
at his trade as wheelwright and blacksmith about one-
fourth of the time. Within six weeks after his nose and
throat had been treated and a tonic nerve treatment in-
stituted, he was cured and gained eighty pounds in
weight in the following two years, while he did not lose
a single day from his work on account of his former
malady. The other patient had a history as follows :
Mr. V. H. R , aged forty-one, occupation, wagon
merchant, had a history of asthma and hay fever dating
back eighteen years. Had tried all sorts of patent
asthma cures ; had experimented at asthma sanitariums ;
had tried various climates and health-resorts, but all to
no purpose. Dust, the pollen of vegetation, tobacco
dust and smoke, the emanations of animals, odors from
the kitchen, the smell of horses or a stable, fatigue from
a day's work, the inability to sit in a crowded room or
where a number of persons congregated, like a church,
theatre, etc. , riding in a carriage, and many other slight
disturbances which are difficult to understand — all of
these causes precipitated an attack of asthma which so
exhausted his vitality that it was exceptional when he
was not compelled to go to bed at seven in the evening,
being no longer able to stay up. A more unpromising
case could not well be imagined. And yet, within ten
weeks after beginning treatment such as has been out-
lined, the patient was virtually a new man. In three
months he gained thirteen pounds in weight, and has
been quite free from all the annoying conditions which
made existence a burden to him for eighteen years. To
illustrate the marked change in this patient's case, where
formerly he could not even ride behind a horse, he re-
cently drove a team of horses himself thirty-three miles
over a dusty road without any sign of asthma.
204
MEDICAL RECORD.
[August 1 8, 1894
. The length of time that asthma has existed is no factor
in estimating the chances of a cure. The question is,
has any permanent damage been done to the nervous
system or air-passages? If so, then in either case the
prognosis will necessarily be a modified one.
204 Stats S tkhst.
INTRA -NASAL GROWTHS AS FACTORS IN
AURAL AND LARYNGEAL CATARRH.1
By SARGENT F. SNOW, M.D.,
AyRIST AND LtKYNGOLOGtST TO THK HOUSt OP THt GOOD SHKPHBKD AND THK
SYRACUSE PKCB DISPENSARY ; MBMBRK OP THK CENTRAL NEW YORK MEDI-
CAL ASSOCIATION, THE SYRACUSE ACADEMY OP MEDICINE, THE ONONDAGA
COUNTY MEDICAL SOCIETY, ETC.
Mr. President and Members : The paper I shall pre-
sent is one that I read before the Onondaga County
Medical Society September 15, 1891. My object and
apology for resurrecting it is twofold :
First; because it contains observations on the middle
turbinated region of the nose, which was then, and is
now, of great interest to me, and which I believe has
received too little notice even by the specialist, compared
to its fertility as a source of neuralgic and catarrhal affec-
tions.
Second, because I can report the result of treatment
in the patients mentioned.
Of the three cases mentioned, I would say, two oc-
curred in private and one in dispensary practice, illustrat-
ing, I think, the importance of intra-nasal disease as a
factor in middle-ear, pharyngeal, and laryngeal catarrh.
Hoping that you will pardon me, I read the notes as
in the original article.
Case I. — Mr. N , a young man twenty-five years
of age ; native born ; generally robust, and of good
family history. About four months ago he noticed an
impairment in the hearing of his left ear, and a con-
ti nuous noise as of escaping steam . This went on steadily,
and, when he came to me for treatment, I found the left
drum membrane slightly shrunken, with some opacity,
especially in posterior quadrant ; right drum membrane
somewhat inflamed around edges and over malleus;
left hearing distance, T^ ; right hearing distance, { J|,
or normal.
Examination by tuning-fork showed that in the left
ear the bone conduction was ten seconds better than the
air conduction ; right ear normal ; left Eustachian tube
alio in a state of catarrhal inflammation, air being with
difficulty forced through it.
With such proofs before us, we could not doubt that '
the trouble was one of catarrh of the middle ear. No
history could be elicited of acute trouble following any
of the exanthematous fevers, or of pain in ears at any
time; but by posterior rhinoscopy I found the post-
nasal space roomy, numerous varicose veins and in-
flamed patches scattered over surface of membrane,
particularly in neighborhood of Eustachian tubes; the
posterior ends of both middle and inferior turbinates
covered with pale, hypertrophied tissue. Anterior rhi-
noscopy showed septum a little deflected to right with
large spur in lower third touching and pressing against
inferior turbinated, and another marked thickening in
the upper third projecting in front of, and pressing
against, the middle turbinated, which was also enlarged ;
left nostril pretty well filled with hypertrophied tissue,
the whole bathed with more or less mucus.
Upon inquiry, I found that the nasal trouble had been
with him for a long time, while the ear affection was of
comparatively recent origin, and we cannot doubt that
it came by gradual extension from, or in sympathy with,
the catarrhal inflammation within the nose. Do not un-
derstand me to say, in all cases in which there are septal
deflections, ridges, or spurs, we will find catarrh of the
middle ear, or that all catarrhal conditions of the middle
ear come from septal deformities ; far from it I think
1 Read before the Onondaga County Medical Society September
15, 1891. Read again before the Syracuse Medical Association March
3i, 1893, giving result of treatment in the cases reported.
there are many such deformities that are perfectly inno-
cent, but I do believe that whenever a deformity or over-
growth in any portion of the nose causes a contact be-
tween two surfaces that are not normally in contact, we
will have a catarrhal inflammation arising from such a
contact, which, acting in conjunction with the climatic
influences we have in this section, is very liable to ex-
tend to either the ear or throat.
Professor St. John Roosa, John N. McKensie, and
other authorities consider that fully seventy-five percent,
of all ear troubles are caused by intranasal disease.
McKensie further says, in vol. viii. of the " Reference
Hand-book: " " It is impossible to exaggerate the part
which diseases of the nose play in the production of in-
flammatory conditions of the middle ear." And my ex-
perience thus far, gentlemen, fully confirms this view.
In fact, since my attention was particularly called to the
middle turbinated bodies by an article in the New York
Medical Journal, vol. li., p. 309, 1890, written by Dr.
O. £. Douglas, of New York, I have made more careful
examinations of this section of the nose, and, as yet,
have found no case of post-nasal, middle ear, or laryngeal
catarrh which was not accompanied by marked evidences,
past or present, of pressure or contact of some of the sur-
faces in this region. *
Many of these cases have shown a perfectly normal
condition of nose in lower third, both inferior turbin-
ated apparently healthy, and patients claiming that they
had no trouble in breathing, each nostril being perfectly
free ; their complaint, as they say, " is further back or
down," sometimes in the ear, sometimes in the larynx,
and often their only symptom is of " something drop-
ping into the throat."
A close examination of the upper portions of the nose
will show, almost invariably, some point or points of
contact between the middle turbinated and the septum
or the outer wall of the nose, which, though slight in
many instances, is, I believe, the cause of a great, and
perhaps the whole, part of the trouble, particularly if the
contact be persistent.
Case II. — Mr. F is a public speaker with the well-
known clergyman's sore throat. He has been troubled
since childhood witn nostrils closing up frequently, and,
at certain seasons of the year, having asthmatic attacks.
Often wakes and finds that he has been sleeping with his
mouth open; extreme hoarseness coming on with the
slightest cold; occasional ringing in the ears, and of
late an excessive amount of saliva. One year ago there
was a complete loss of voice for nearly three weeks.
Upon examination, I found the whole pharynx in-
tensely congested; posterior wall showing granulated
areas ; uvula (edematous ; anterior and lateral pillars of
fauces infiltrated. Post nasal space showed same gen-
eral appearance as the pharynx. An anterior view of
the nostrils disclosed to us the cause of his troubles, the
membrane of both inferior turbinated being puffy and
thickened, middle turbinated bodies very much over-
grown in bony and membranous formation.
There are, of course, many points of contact and some
inflamed and thickened tissue that must be relieved be-
fore we can expect to do our patient permanent good,
granting that the nasal abnormality is the cause of his
pharyngitis. In this instance, we have a man who uses
his voice excessively, and at times, when he is weary, I
have no doubt his vocal production is faulty. That, of
course, has its influence on his condition, and will have
to be looked into and corrected.
In support of this plan of treatment, I will quote from
Lenox Brown, of London, in his last edition of " Disease
of the Throat," p. 117. He says: "I have seldom
failed to find the cause of the vocal lesion in the nose or
pharynx, and a cure effected by surgical treatment of
those regions, supplemented by educational correction
of a functional fault in production."
I will not weary you with the full notes of Cask HI. —
Suffice to say that he is a German, age twenty-two, re-
ferred to me by Dr. S ; general health good ; been in
August 1 8, 1894]
MEDICAL RECORD.
205
this country one year, and for past three months has had
difficulty with his throat ; voice husky and easily fatigued,
it having been, at one time, entirely lost. He first
noticed a fulness in his head and nose ten months ago.
Examination showed a decidedly inflamed larynx,
pharynx infiltrated with a very red track extending up
along lateral walls to po&t nasal space ; turbinated bodies
puffy and in stage of commencing hypertrophy ; bony
union between left inferior turbinated and lower third
of septum ; many points of contact in both nostrils.
Topical applications to the vocal bands and pharynx
have reduced the inflamed conditions existing there.
Cleansing and applications to the nasal tissues, have
given him, for the present, a good breathing space,
though the bridge of bone and some points of contact
still remain.
Are we warranted in considering these contacts and
deformities as etiological factors of his laryngeal trouble?
Referring to Sajous's recent work on " Diseases of the
Nose and Throat," p. 336, we find that he says:
" Chronic inflammation of the vocal bands may result
from repeated attacks of subacute laryngitis in connec-
tion with acute pharyngitis, but in the majority of cases
it assumes the chronic form from the first, unpreceded
by acute symptoms. Hypertrophic rhinitis is a frequent
complication of this affection, the chronic catarrhal in-
flammation extending by continuity of tissue to the
larynx, which is itself made subject to all the exacerba-
tions which the nasal disease undergoes. A more fre-
quent connection between the two diseases, however, is
the irritation kept up by the post nasal discharges, which
either drop into the larynx, or trickle down along the
posterior pharyngeal wall until the interarytenoid com-
missure is reached; here they accumulate to a degree,
and maintain the posterior portion of the larynx in a
constant state of irritation, which is further aggravated
by the coughing and hacking induced. This cause of
chronic laryngitis is insisted upon by Bosworth, and I
can well confirm his opinion."
Regarding prognosis Professor Douglass, in his very
able article before referred to, says : " Chronic nasal
catarrh, so called, is not so difficult of cure as has been
supposed, for it is the result of removable causes in most
cases."
In the face of these authorities, and the light of our
present knowledge, what shall we do with cases of chronic
nasal, aural, and laryngeal inflammation ? Shall we patch
them up with a gargle or spray, and send them adrift to
soon become the prey of some quack who has push, en-
terprise, and the newspaper to help him ; or, shall we see
that they continue on to a removal of the cause, re-
lieving the point of contact or pressure by such opera-
tive procedure as may be necessary, and carrying out
the other treatment as may be indicated ?
If we follow our plain duty, I believe that our results
will be very satisfactory, and we can confidently expect
to soon throw off the weight of opprobrium that has been
hanging upon us as a profession because of our failure
in the past to cure " catarrh."
Since reading the above before the County Society,
gentlemen, I have continued treatment in the cases
mentioned. Perhaps a description of their present con-
dition will be of interest to you.
Case I. — The young man with middle-ear catarrh has
proved especially interesting to me, strengthening my be-
lief that pressure or contacts in the middle turbinated re-
gions, have a marked influence over middle-ear troubles.
During the first of his course of treatment I removed by
the saw the shelf of bone spoken of, and by the galvano-
cautery enough of the hypertrophied tissue to give him
sufficient breathing space, meanwhile treating the ear
carefully by inflation, vaporizing through Eustachian ca-
theter, etc.
At the end of three months we found that no improve-
ment had been made in his hearing distance, though his
nasal catarrh was considerably relieved. I urged him
to submit to a removal of a bean-like enlargement found
on each middle turbinated, pressing against the anterior
wall of the nose. This he refused, and I lost sight of
him until December 14, 1892, when he returned, and
examination showed right hearing distance fj#, left
hearing distance y^, a loss of three inches since first
examination.
During the six months following I operated on the
growths mentioned, with the result that his hearing dis-
tance in affected ear was increased to ^\, a gain of nine
inches. Unfortunately he was called out of town, and
we were again interrupted, though I am informed that
he continues to improve. The same aural medication
was given in this as in his first course of treatment.
If I had not already trespassed too much on your time,
I would read you notes of several more cases, in which
equally as good and better results have been attained af-
ter similar operation in the olfactory region, but in
which my most careful ear treatment had failed to in-
increase their hearing distance previous to relieving the
contacts and pressures in the upper regions of the nose.
Added experience and the recent observations of good
authorities, notably the article on " Cyst of the Middle
Turbinated Bone," written by Professor Charles H.
Knight, have substantiated the opinion I expressed in
1 89 1, that pressures or contacts in the middle turbinated
region were very important, and I would urge all who
are doing intra-nasal work to examine this section
thoroughly, not alone because of its relation to ear and
throat troubles, but because of its close connection with
asthma, hemicrania, and neuralgic affections of the
head.
Operations here are not necessarily painful, if two or
three applications of a twenty per cent, solution of co-
caine be carried well in and along the lateral surfaces of
the offending overgrowth; neither are they attended
with much danger if proper after-tieatment be given,
though close discrimination should be used about the ex-
tent and manner of operating, removing only such por-
tions as is necessary to relieve the pressure or contact.
Case II. — The clergyman has had a full course of
operative treatment, and a most satisfactory result.
During the past year he has had no attack of asthma,
no pharyngitis, laryngitis, or ringing in the ears ; neither
has he been bothered by repeated colds, nor a stuffed-up
nose. In a conversation last week he told me that he
could not estimate in money the benefit he had de-
rived. The specimens I now show you I removed from
his nose by the cold snare. As you will see, they are
partly cystic in character, and of unusual size (see photo-
graph).
Case III. — The young German continued his treat-
ment until the symptoms complained of were relieved,
the voice being fully restored. The shelf across left nos-
tril was removed by the electro-trephine, consequently
the pieces taken out were not saved, though I recollect
that it was a common osseous growth about an inch long.
In conclusion, let me say that I have no doubt the
notes of other specialists will show fully as good results
as those I have mentioned, and I would respectfully ask
the general practitioner to not pass over the articles in
his journals relating to rhinology, otology, or laryngology,
but stop and carefully read a few of them. If he does so,
I think disparaging remarks made about the treatment
of chronic catarrhal affections will be less frequent.
117 East Jefferson Strrrt.
The Duke of Westminster, although he is a vice-
president of St. George's Hospital, refuses, so it is re-
ported, to let any of his houses in the West End of Lon-
don to medical men, fearing that their presence will
frighten away his fashionable tenants.
206
MEDICAL RECORD.
[August 1 8, 1894
GUNSHOT WOUND OF LUNGS AND HEART,
WITH SURVIVAL OF PATIENT FOR FIF-
TEEN HOURS.
By JAMES P. MARSH, M.D.,
TROY, N. Y.
On April 19, 1894, at about 4 p.m., D. R , aged fifty
years, and previously in good health, received a pene-
trating wound of the thorax. The weapon used was pre-
sumably a revolver, shooting cartridges known as 32-
shot.
I was called and arrived about twenty minutes after
the reception of the injury. He was perfectly conscious
but in an extreme state of shock, pulseless at the wrist,
and the heart-sounds very faint. On the right side of
the thorax, in the posterior axillary line, and entering in
the seventh intercostal space, was a punctured wound,
but, noticeably, no hemorrhage occurring externally.
Over the entire right lung were numerous mucous rales.
Between the nipple and the sternum, on the left side, was
au area of blood extravasation about two inches in diam-
eter, and in the centre of this area could be felt a small
hard mass, presumably a bullet. While I was present
the patient only once raised a small amount of slightly
blood stained sputa.
I ascertained that after receiving his wound D. R
walked or ran some twenty feet and gave an alarm, be-
fore he sank exhausted and was carried into the house
where I found him. From the family physician, who as-
sumed charge of the case, I learned that D. R ral-
lied almost completely from the shock, that he did not
raise any bloody sputa, that there were no signs of peri-
cardial involvement, that the right thorax remained tym-
panitic anteriorly (as regards the posterior portion it
was not thought best to examine on account of the pa-
tient's condition), and that he was rational to the end,
which came at about 7.20 a.m. of April 20th, some fif-
teen hours after the shooting.
Dr. M. F. Phelan and myself having been directed by
the coroner to make an autopsy, we proceeded to do
so at 3 p m. on April 20th, the notes of which examina-
tion are as follows :
Rigor mortis pronounced. The body is well nourished.
Two inches to the left of the median line, and five inches
below the clavicle, is a marked dark blue discoloration of
the skin. This area is two and one half inches in diam-
eter and in the centre is a small hard mass, presumably a
bullet. On the right side of the thorax in the posterior
axillary line, and about three inches below the posterior
fold of the axilla, is a punctured wound with an area of
blood extravasation around it. This wound passes be-
tween the seventh and eighth ribs in an upward and for-
ward direction. There is also a marked bulging of the
right side of the thorax. There is emphysematous crep-
itation over the anterior part of the thorax, most
marked in the left infraclavicular and mammary re-
gions. An incision into the area of blood extravasation
in the left side reveals a bullet, 32-shot, embedded in
the subcutaneous fat one and three-quarters inch to the
left of the median line of the body.
Abdominal fat three-quarters of an inch thick, sub-
peritoneal fat normal. The diaphragm is at the fifth in-
tercostal space on each side. The stomach is distended
with gas. The bullet wound in the sternum is just within
the juncture of the same with the left fourth costal car-
tilage, and a transverse fracture of the bone is produced
at this point. The right pleural cavity contains one
quart of coagulated and fluid blood. Left pleural cavity is
normal. The pericardium shows anteriorly blood infil-
tration, and contains about one ounce of fluid and coagu-
lated blood. At the right superior side it is penetrated by
two bullet holes which are three-quarters of an inch apart.
The right auricle, at the dog's ear, has a small area of
extravasation, and apparently a small puncture exists.
The auricle opened shows a puncture about one line in
diameter, and this puncture is closed by a soft ante-mor-
tem clot one-fourth inch in diameter. The remainder of
the heart structure is normal.
The right lung shows a large ragged gash on the pos-
terior surface of the lower lobe, .which in extending to
the middle lobe is converted into a punctured wound
and passes out in the anterior and upper border, and
then gutters the upper lobe for about one inch.
The wound in the right thorax passes through the
seventh intercostal space, tearing away the lower border
of the seventh rib and about one inch of the intercostal
artery. The liver, intestines, and kidney are normal.
The brain is not examined. Track of bullet : It entered
at the seventh intercostal space in the posterior axillary
line, fractured the lower margin of the seventh rib, sev-
ering the intercostal artery, thence forward into the
outer and posterior surface of the lower lobe of the right
lung, thence through the central portion of the middle
lobe, and from thence to the lower and anterior surface
of the upper lobe, hence into the pericardium, again to
the auricle of the heart, thence out of the pericardium
into and through the sternum to the subcutaneous fat
where it was found.
From this it follows that D. R was in a stooping
position when he was shot. This adds another to the list
of cases of wounds of the heart which have occurred
without producing immediate death.
SKIN GRAFTING.
By WILLIAM H. MARCY, M.D.,
BUFFALO, N. Y.
Having washed the healthy granulations with mercuric
bichloride 1 to 3,000, or carbolic acid two percent., and
the part furnishing grafts with 1 to 1,000 bichloride,
and lastly with distilled water, instead of lifting the skin
with a needle, or instrument which injures the graft,
I have a sharp pair of straight scissors with two-inch cut-
ting blade. I press the open scissors upon the skin suf-
ficiently to bulge the integument between the blades, and
gently close, catching one end of the skin, and then in-
crease or lessen pressure according to the thickness of
the bulging skin, and at the same time cut. In this way
I can secure a graft from a millimetre to a centimetre
long, taking only the epidermis. The graft is then lifted
by a fine pair of tweezers from the blade of the scissors,
and placed, cut surface down, on the granulations. In-
stead of applying protective of pure rubber or gutta-
percha tissue, and over the protective a wet compress
followed by oiled silk, a pad of absorbent cotton and
bandage, I simply strap the grafts, after leaving them
exposed fifteen to twenty minutes, with adhesive plaster.
The strips are applied basket fashion, as one would strap
an ulcer. If a discharge is to be anticipated, we may
leave a small opening in the plaster to favor drainage,
removing the straps in thirty- six to forty-eight hours, or
we may remove the straps in ten hours, and allow dis-
tilled water to trickle over the grafts, then reapplying
the adhesive plaster. I now put on one or two turns ot
bandage, sometimes putting one layer of iodoform gauze
between the strap and bandage.
The advantage of the adhesive plaster is threefold,
viz., 1. You can press the grafts so tightly into the
healthy granulations that they cohere so that no dis-
charge can lift the graft from the granulation. 2. No
dressing will hold the grafts in place, keep the parts at
rest, and lessen the discharge so well as straps applied in
this way. 3. In removing the dressing there is no dan-
ger of the grafts clinging to the plaster, as the moisture
collects between the strap and graft, preventing adhesion.
Even after subjecting the tissues to an injection of co-
caine (four per cent.), I have dissected off grafts two cen-
timetres square, and they rarely fail to live when dressed
this way.
August 1 8, 1894]
MEDICAL RECORD.
207
'Medical Record:
A Weekly Journal of Medicine and Surgery.
GEORGE F. SHRADY, A.M., M.D., Editor.
Publishers
WM. WOOD & CO., 43, 45, & 47 East Tenth Street
New York, August 18, 1894.
THE DISPOSAL OF GARBAGE.
About ten years ago the city of New York purchased
Riker's Island for % 180,000. The purchase-money was
taken from funds of the Department of Charities and
Correction, the ultimate intention being to place some
institutions of that department on the island. The sug-
gestion was made that if the penal institutions were re-
moved from Blackwell's Island, the southern portion of
that island would make a fine public park. The penal
institutions could be transferred to Riker's Island, but as
preliminary to such transfer it would be necessary to re-
claim some hundreds of acres of submerged land.
Such reclamation has recently been attempted. Bulk-
heads were built about a portion of the submerged lands,
and refuse from the city was dumped there for several
months of the present year, until land to the extent of
about thirty acres had been " made." Thus far matters
seemed to progress famously.
But then came the hot weather of June and July, and
with it a natural sequence of events. About one-fourth
of the bulk of refuse used is putrescible matter — in other
words, garbage, well sown, of course, with bacteria.
Stimulated by the favorable weather and the abundant
food-supply, the bacteria proceeded to multiply and feast
after the manner of their kind, and in consequence the
new " land " at Riker's Island sent forth a stench that
was far-reaching and, to human olfactories, highly ob-
jectionable. As a further natural sequence of events,
the residents of such portions of New York as lie within
range, so to speak, of Riker's Island threatened the city
authorities with mob law if the nuisance were not
abated. So the scheme for making land at Riker's Isl-
and was prematurely interrupted, and the city authori-
ties were at their wits' ends to know how to remedy the
stupendous blunder they had made. Parenthetically,
one may wonder why they made the blunder in the first
place, since they had already had a similar experience at
Hart's Island. And for that matter, even without such
experience, it ought not to require occult powers of divi-
nation to predict that half a million tons of mixed refuse
piled together in one spot would produce a bad smell in
the present, and very undesirable building lots in the
future.
Be that as it may, the blunder was made. It is not
yet altogether remedied, nor is it plain as to how it can
be remedied. The temporary nuisance has, however,
been abated in a very interesting way. A unique dis-
infecting plant was established on a boat anchored beside
the island. This plant consists essentially of: r, two
dynamos; 2, four vats each capable of holding one
thousand gallons of sea- water; and 3, steam- pumps for
filling the vats and disposing of their effluent. In each
of the vats a set of four electrodes of platinum and zinc
are immersed, the current from each dynamo passing
through two sets of electrodes. When in operation,
chemical action in the sea-water is manifested by the
liberation of bubbles of gas about the electrodes. The
water acquires a distinct chlorine odor. What actually
occurs is the transposition of the chlorides of the sea-
water into hypochlorites, and, it is claimed, the produc-
tion of a certain amount of ozone. The germicidal
properties of the hypochlorites have long been well
known. The process of producing them on a large scale
from sea- water appears to be the discovery of Mr. A. E.
Woolf, who claims that the Hermite process now under
investigation in Europe (and recently described in the
Record) is an imperfect copy of his methods.
There is no room for doubt that the electrolyted sea-
water is a powerful deodorizer. At the rate of almost
one hundred thousand gallons a day, it has been sprayed
upon the offensive ground at Riker's Island for some
weeks past, and the entire surface of the putrefying mass
has been rendered inodorous, as we can testify from per-
sonal inspection. This, of course, is but a temporary
expedient. What will finally be done in the matter re-
mains to be seen.
It is said that our Street Cleaning authorities, encour-
aged by the apparent success of their deodorizing plant
at Riker's Island, have contemplated the establishment
of similar plants at the refuse dumps in the city, with the
intention of using the deodorized refuse to continue the
filling in at Riker's Island. Such a plan cannot be too
severely condemned. An almost irretrievable blunder
has already been made at Riker's Island — a blunder that
has cost the city dear, and which may prove even more
expensive to future generations. That the persons who
committed this inexcusable blunder should now talk of
adding to it in kind is nothing less than outrageous.
The matter is one that should have the attention of
citizens in general and physicians in particular. Public
sentiment should see to it that not another foot of ground
in or about New York is " made " of putrescible garbage.
Follies enough of that nature may be charged against
our predecessors. A generation that boasts the develop-
ment of a science of sanitation should not add to them.
To reclaim the submerged lands at Riker's Island, and
elsewhere, is a capital scheme. But before the refuse of
the city can be utilized for this purpose the putrescible
portion of it must be rendered innocuous by fire. No
other agent will fit organic matter for such use. With
non-putrescible refuse, and the ash of cremated garbage,
the city may reclaim hundreds of acres of valuable land.
But to attempt to reclaim these lands with mixed refuse,
as has been done in the past, is a crime against future
generations.
Chlorate of Sodium is highly recommended by Bris-
saud in the treatment of carcinoma of the stomach. He
gives it in doses of four to eight drachms per diem. The
presence of albumin in the urine is the only contraindi-
cation to the use of the drug.
208
MEDICAL RECORD.
[August 1 8, 1894
AN EARLY OVARIOTOMIST.
The younger, and most of the older, members of the
profession in America have little conception of the vio-
lent opposition there was, fifty and even thirty years ago,
to the performance of operations on the abdominal cav-
ity. Those who undertook such operations in the face
of almost universal condemnation did so with their repu-
tations in their hands. They believed they were right
and they had the courage of their convictions, but their
courage was of no mean order, and entitles them to
grateful recognition by posterity. We have all heard of
McDowell and Rogers and the Atlees, but we doubt if
the name of Dunlap is as familiar to our readers as it de-
serves to be.
At the recent meeting of the American Gynecological
Association in Washington, Dr. J. C. Reeve read a most
interesting memoir (New York Journal of Gynecology
and Obstetrics, June, 1894) of this pioneer ovariotomist,
Dr. Alexander Dunlap, of Springfield, O., whose death,
at the ripe old age of seventy- nine, occurred in January
last. Dr. Dunlap was born in Ohio, received his educa-
tion, both academic and medical, in that State, married
there, practised there, and died there. He was not a
cultured man in the ordinary acceptation of that term,
nor were books his companions. He studied, as most
men of his time were obliged to study, in the school of
experience. He knew little of what his predecessors had
done or his contemporaries were doing, but struck out
new paths for himself, undeterred by the reprobation of
others less original and less courageous, and, in his igno-
rance of what other great minds had conceived and exe-
cuted, unencouraged by their success.
Dr. Dunlap's first ovariotomy was performed in 1843,
and up to 1868 his cases numbered thirty- eight. Of
these nine had resulted fatally, one from an overdose of
morphine administered by mistake. During his entire
career he performed four hundred and twenty- eight ab-
dominal sections, with eighty-three per cent, of recoveries.
His method of operating was primitive in the extreme.
Dr. Reeve assisted him in some of his earlier cases, and
the following are his words in describing them :
" Scalpel, forceps, and director were the only instru-
ments provided. The abdomen was opened, the cyst ex-
posed, then incised with the scalpel, and its contents
caught in a wash-basin. Adhesions were separated as
the cyst was withdrawn, or the incision was extended
without hesitation in order to gain access to them.
Bleeding from separated adhesions was checked by the
application of cold water. In one case this was con-
tinued for twenty minutes and no evil results followed.
In closing the wound the stitches were not passed through
the peritoneum. The pedicle was transfixed with a lig-
ature of heavy silk, each half tied separately, then one
end carried around the whole and tied again ; one end
was then cut short and the other brought out at the lower
angle of the wound, there to haug until separated by
process of ulceration* This always required weeks, some-
times many months. In the case of a girl, aged thirteen,
operated on by the writer, where this plan was followed,
more than a year elapsed before the ligature came away,
and this in spite of all measures to hasten it. This mode
of treatment of the pedicle seems very strange in view of
the fact that in Dr. Dunlap's first case both ends of the
ligature were cut short, the pedicle dropped back, and the
wound closed. There is not the slightest probability that
Dr. Dunlap knew, even as late as 1868, that this was the
plan pursued by Nathan Smith, in 182 1, the second op-
erator in the United States, and by D. L. Rogers, of
New York, the fourth, in 1829. It looks very mych as
if, after his first case, he informed himself as to the plan
followed by McDowell and Atlee, and made this step
backward under the influence of their example. "
" The treatment received by Dr. Dunlap," says the
author of this most interesting biographical sketch, " was
of the same kind as that meted out to McDowell. The
comments of the Medico- Chirurgical Review of London,
then the leading journal of the world, upon his operation
are well known : ' We entirely disbelieve that it has ever
been performed with success — nor do we think it ever
will ! ' The extent, the bitterness, the persistency of the
opposition to ovariotomy, the denunciation of those who
performed it, can scarcely be imagined now. It is re-
corded in the pages of Peasleeand of Atlee. Nor was
this feeling confined to this country. Mr. Ernest Hart
has recently told us that in London, during the first at-
tempts at ovariotomy, Dr . Robert Lee, then the leading
obstetrician, openly stated that he was watching for a
fetal case that he might cause the operator to be legally
prosecuted ! He who now, after fifty years of service,
would indicate the most striking contrast between the
profession as it is to-day and as it was when he entered it,
would not find that contrast in the possession of anaes-
thetics nor in the triumphs of abdominal surgery, where
even ovariotomy has sunk to a position of minor impor-
tance ; but he would find it in the different spirit with
which new doctrines, new measures, and new operations
are received. The Zeitgeist of medicine has taken on an
entirely different form from that of a generation ago."
THE DEVELOPMENT OF THE RAILWAY
SURGEON.
The growth of the railway surgeon and of railway surgi-
cal service is, we believe, a feature of professional devel-
opment peculiar to this country.
There are at present 147,704 miles of railways in the
United States and Canada, and all but 17,088 miles are
watched over, more or less, by surgeons in the employ
of the corporations. The total number of railway sur-
geons is 5,466. The railways which possess a hospital
system cover 36,751 miles ; railways with a relief service,
13,446 miles; and railways with a surgical service and
chief surgeon, 44,281 miles. There is a National Asso-
ciation of Railway Surgeons with a membership of 1,767
and an organ called The Railway Surgeon.
According to this journal there are over 1 20 chief sur-
geons, representing 82,032 miles of railway employing
3,384 surgeons, "all of which [sic] are working har-
moniously under a chief surgeon, who in each instance
has, to a greater or less extent, charge of the surgical
department of the company he represents. We have
great reason to rejoice and be glad and to congratulate
this association on the work it has accomplished."
The Railway Surgeon admits that there are some who
assert that there is no special field for railway surgery,
which really cannot differ, so far as we can see, from any
other surgery. We have also heard the complaint that
August 18/1894]
MEDICAL RECORD.
209
railway surgeons were notoriously incompetent in neuro-
logical diagnosis, and that there was more need of rail-
way neurology and medicine than of surgery.
We have no doubt, however, that the organization of
railway surgeons into a national body will promote the
material interests of the surgeons and render the work
done by them more effective.
f|imr8 at tfoe WLztfo.
Fear of Premature Burial.— The will of the late Mr.
Edmund Yates contained a clause in which he expressed
the desire that his jugular vein should be opened imme-
diately after the physician had pronounced him dead, in
order to prevent any possibility of his being buried
alive. The medical man who performed the operation
was to receive a fee of twenty guineas.
The Inheritance of Insanity.— Dr. G. Fielding
Blandford, President of the Psychological Section of the
British Medical Association, took as the subject of his
opening address, " The Prevention of Insanity." One
of the most important factors in the etiology of the dis-
ease, he said, is heredity. Sir Benjamin Ward Richard-
son has made the assertion that insanity is transmitted
through the male line, but the speaker held that the re-
verse is the case, the taint passing through the female
line rather than the male. He did not, however, insist
so strongly on this point, holding that the safest rule
was that no one, man or woman, who had had an attack
of insanity, should marry.
Gift of Br. Wilson Fox's Plates of Diseases of the
Longs to Medical Schools.— In a letter to The Medical
Press and Circular, Drs. Sidney Coupland and W. R.
Gowers direct the attention of the managers of medical
schools in England, the Colonies, and America to the
fact that there is a considerable number of the surplus
sets of the colored plates of Dr. Wilson Fox's " Atlas of
Diseases of the Lungs." These contain the most perfect
representation of morbid states of the lungs ever pro-
duced. They will be of great value to medical schools,
if framed and placed in the museum or post-mortem
room. It is, therefore, proposed to give a set to each
medical school the dean or manager of which desires it ;
a certain number will be reserved until October to give
colonial medical schools an opportunity of obtaining
them. Each set contains twenty-five colored plates.
Brief descriptions can easily be prepared from the text of
Dr. Fox's atlas and affixed to the plates. The cost of
packing and transmission amounts to is. in the United
Kingdom, 2s. 6d. for America and the Colonies. This
sum should be sent, with the application, to Messrs. Min-
tern Bros., 84 Southampton Row, London, W. C.
The Cholera continues in somewhat milder form in
St Petersburg, the number of new cases averaging from
twenty to twenty- five per day, the mortality being, as
usual, about fifty per cent, of those attacked. Isolated
cases are reported from many towns throughout Holland,
showing a widespread infection in that country. All
steerage passengers for America sailing from Amsterdam
or Rotterdam are subjected to a five days' quarantine be-
fore being allowed to embark. Amsterdam and Maas-
tricht are the two cities where the disease prevails most
extensively. One death from cholera has occurred near
Cologne and several in the Danzic and Johannisburg
districts in Prussia. The disease has passed down the
river Pruth and invaded the surrounding districts in Bu-
kowina, the capital of that province, Czernowitz, being
seriously infected. The usual summer scare over a case
of cholera nostras, "which is pronounced by the doctors
to be a case of genuine Asiatic cholera, "is reported
from a town in Minnesota.
Lowered Duties on Drugs. — The Senate tariff bill
lowers the duty on a number of drugs, that on castor- oil
being reduced fifty six per cent, below the rate under the
McKinley law, and that on epsom salts thirty-four per
cent. Other reductions are, thirty per cent, on cod-
liver oil, fifty per cent, on bicarbonate of soda, twenty
per cent, on sublimed sulphur, eighteen per cent, on
refined camphor, and twenty-five per cent, on strychnine.
The duty on spectacle lenses. is reduced from sixty to
thirty-five per cent, ad valorem, a decrease of nearly
forty-two per cent.
Fourpenoe a Visit. — An English physician advertises
office consultations and medicine for fourpence, visits at
the patient's house, including medicine, one shilling, at-
tendance and medicine at the patient's home, 2s. 6d.
Sixty cents a week is not an excessive charge for medical
attendance, but it is probably all it is worth in the given
instance.
The Plague Bacillus. — Several investigators in China,
who have been studying the plague, have announced the
discovery of a bacillus, the micro organism in each case
being different from all the others. Although time alone
will decide which of these claims, if any, is well founded,
the presumption is that Kitasato's bacillus is the true
one. The disease still prevails in Canton, but has nearly
died out in Hong Kong. An official report places the
number of deaths from the plague in the latter city up to
the first of August at 2,504.
Women Medical Students in Glasgow. — At the
graduation exercises of the University of Glasgow, held
on July 26th, the degrees of Bachelor of Medicine and
Master in Surgery were conferred on Marian Gilchrist
and Alice Cumming. Professor Charteris delivered the
address to the graduates, and in congratulating the fe-
male recipients of degrees he expressed a hope that the
time would come when degrees would be bestowed which
would do less violence to the sex, and that they would
run as "spinster in medicine" and "mistress in sur-
gery." The abbreviation of M.S., however, would not
distinguish the sex. This is the first time in the history
of any of the Scottish universities that a medical degree
has been granted to a woman.
Intemperate Antivivisectionists. — On the occasion of
the meeting of the British Medical Association in Bristol,
the local temperance advocates of the place, taking ad-
vantage of the special opportunity of hearing the opinions
of the medical profession on the temperance question,
invited some of the leading medical visitors to a meeting
held at the Hall of the Young Men's Christian Associa-
tion. Mr. Joseph Storrs Fry, who had arranged to pre-
side, happened to be also the president of the local
Antivivisection Association. Several gentle members of
the British Women's Temperance Society, who are also
members of the Antivivisection Association, on learning
2IO
MEDICAL RECORD.
[August 1 8, 1894
that among the principal speakers was Professor Victor
Horsley, raised an indignant protest against this invita-
tion, and sent a deputation to Mr. Storrs Fry, calling
upon him to decline to preside if the invitation to Pro-
fessor Horsley was persisted in. Mr. Fry, instead of
complying, tendered his resignation as president of the
Antivivisection Society.
Professor Koch is reported by the cable to have gone
to Woerishofen to place himself under the medical care
of Father Kneipp, the clerical advocate of the cold- water
cure.
Typhoid Fever in Montclair. — Seventeen persons
were reported ill with typhoid fever in Montclair, N. J.,
on August 8th. It is believed by some that the disease
was conveyed in artificial ice made from undistilled
water.
Dr. Howard F. Mitchell died in Troy on August 6th.
He was a graduate of the University of Maryland.
Dr. John M. Todd, of Bridgeport, O., died at his
home on August 2d, at the age of sixty-eight years. He
had been an invalid for the past five years.
The Twelfth International Medical Congress, as is
now definitely announced, will be held in Moscow, in
August, 1896.
Awards at the Borne Congress.— In a recent notice of
the awards made at the Medico-Hygienic Exhibition held
at Rome in connection with the International Congress,
mention was accidentally omitted of Oppenheimer, Son
and Co., of London. This firm received the only gold
medal, so it is stated, that was awarded to any house from
English-speaking countries.
The American Association for the Advancement of
Science is in session this week in Brooklyn. The meet-
ing opened on Wednesday and will continue for a week*
The work of the Association is divided among nine sec-
tions, as follows : Mathematics and astronomy, physics,
chemistry, mechanical science and engineering, anthro-
pology, economic science and statistics, botany, zoology,
geology, and geography.
The American Academy of Medicine will hold its
nineteenth annual meeting at the " Waumbek," Jeffer-
son, N. H., on Wednesday and Thursday, August 29 and
30, 1894. The meeting is to be devoted chiefly to a
discussion of the condition of the dependent classes (the
young, the aged, the blind, delinquents, etc.) and the
relation of the medical profession to them. Reduced
rates from New York or Boston, and return, are offered to
members of the Academy. Dr. G. M. Gould, of Phila-
delphia, is the President, and Dr. Charles Mclntire, of
Easton, Pa., Secretary.
The American Pharmaceutical Association will hold
its annual meeting in Asheville on September 3, to 8, 1894.
The Iowa Public Health Association, not the Public
Hall Association, as the types made us say in a recent
issue, meets in Des Moines, September 6, and 7, 1894.
Anti-Cholera Inoculations. — There were eight hun-
dred and twenty-six persons inoculated in Calcutta for
protection against cholera during the month ending
June 24, 1894. Cholera occurred in three houses in
which inoculations had been made upon some of the in-
mates, but all the cases were among the uninoculated,
none of the inoculated being attacked.
Extra - Genital Syphilis. — The appearance of Dr.
Bulkley's recent work on syphilis insontium appeals
to have stimulated research in this field throughout
the world, and the reports of cases of innocent or rather
extra genital infection — for the latter is by no means al-
ways innocent, while genital infection may be, as many
a poor wife knows only too well — are appearing con-
stantly in our foreign exchanges. Of course the occur-
rence of syphilis sine coitu has long been recognized by
the profession, if not perhaps by the laity, but the mag-
nitude of the danger and the infinite variety of ways by
which the disease could be spread to the innocent were
not so fully appreciated before the publication of Dr.
Bulkley's timely treatise with the enormous list of cases
appended thereto.
The Canadian Medical Association will hold its an-
nual meeting in St. John, New Brunswick, August 22
and 23, 1894.
Eighty-five Thousand Dollars has been appropriated
by the Massachusetts legislature for improvements in
public hospitals and asylums in the State.
School Boards and Vaccination. — The Supreme Court
of Pennsylvania has confirmed the decree of a lower court
to the effect that school boards have the right to exclude
from the public schools children who have not been vac-
cinated.
Biots in China. — Several missionaries at Canton, Shek
Lung, and other places in China have suffered recently
at th* hands of angry mobs of natives. The riots were
started by reports that the missionaries were killing na-
tives to convert their bodies into medicine, and that they
were the direct cause of the plague.
The Metric System in Great Britain. — At a recent
meeting of the Council of the Pharmaceutical Society of
Great Britain, it was moved that after January 1, 1895,
a practical knowledge of the metric system of weights
and measures shall be required of all candidates for the
minor examination in the subjects of prescriptions and
practical dispensing, and that the Board of Examiners be
instructed to require from candidates a general knowl-
edge of posology in terms of the metric as well as the
British system of weights and measures ; and in practical
dispensing to compound medicines by the metric as well
as the British system of weights and measures. After
some discussion the resolution was altered to the effect
that the Board of Examiners should be requested to con-
sider the advisability of acquiring a practical knowledge
of the metric system of weights and measures for the
minor examination. In this form it was carried.*
An Inebriate Asylum in France. — The General
Council of the Seine has decided to erect a large insane
asylum at Ville-Evrard, in which there will be provision
for the reception and treatment of male inebriates. The
wing for this purpose will accommodate five hundred
patients. This will be the first institution of the kind in
France.
The Price of Opium has risen over thirty per cent, in
the past month or six weeks, by reason of the war between
China and Japan.
An International Medical Press Committee has been
formed for the purpose of providing greater facilities for
the report of the next International Congress.
August 1 8, 1894J
MEDICAL RECORD.
211
^ewiema and ^otic&s ot goalis.
A Text-Book of Gynecology. By James C. Wood,
A.M., M.D., Professor of Gynecology in the Cleveland
Medical College, etc. With 2 10 Illustrations. Phila-
delphia: Boericke & Tafel. 1894.
This is a practical treatise on gynecology as understood
at the present day. The author has put on record the
results of his own experience, supplemented by a careful
study of the teachings of others. A special feature of
this volume is the introduction of a large number of illus-
trations from specimens of the Museum of the Royal Col-
lege of Surgeons, London. The student, the general
practitioner, and even the specialist, cannot fail to be
interested as well as instructed by a study of these illus-
trations.
In the purely surgical treatment of the diseases peculiar
to women, Dr. Wood is found to be an advocate of
measures generally recognized as applicable in our country
at the present time. As regards medicinal therapy, the
author gives the usual list of drugs recommended by
homoeopathic practitioners.
The mechanical execution of the volume is quite good,
bat some of the drawings are too much blurred to be en-
tirely satisfactory. The work is sure to be appreciated by
all homoeopathic gynecologists, and will doubtless be con-
sulted by many practitioners of other schools. While
devoid of originality, the author has succeeded in faith-
fully picturing American gynecology.
A Practical System of Studying the German
Language. For Physicians and Medical Students.
For Self-instruction. By Albert Pick, M.D. Parts
I.-VL Newtonville, Mass.: E. S. Tanner. 1894.
This work is intended, as its title implies, as a help for
self-instruction to those whose linguistic ambition does
not go beyond the ability to read German medical works
and to converse with German patients in their own tongue.
This instruction is imparted by means of a series of short
essays on medical subjects in German, with an interlinear
translation and pronunciation. These are supplemented
in each lesson by a number of elementary phrases used
in conversation, and by some very brief, but sufficient,
remarks on grammar. If the system is carried out in the
remaining six parts as it is in those before us, the work
ought to prove very serviceable in imparting to the care-
ful student such a knowledge of medical German as
would enable him to read books and journal articles with
the aid of a dictionary.
Essentials of Nervous Diseases and Insanity : Their
Symptoms and Treatment. A Manual for Students
and Practitioners. By John C. Shaw, M.D. Second
Edition, Revised. Saunders' Question Compends,
No. 21. Philadelphia: W. B. Saunders. 1894.
The author states that this little book is not intended
to take the place of more complete works on nervous
and mental disease, but is to be used somewhat as a
primer 4br advanced students. There are forty-eight
illustrations, five sections, treating respectively of injuries
and diseases of the peripheral nerves, diseases of the
spinal cord, diseases of the brain, of functional nervous
disease, and insanity. The appearance of a second
edition so short a time after the issue of the first is, in
itself, commendation all sufficient.
Essentials of Anatomy. By Charles B. Nancrede,
M D. , Professor of Surgery and of Clinical Surgery in
the University of Michigan, Ann Arbor, etc. Fifth
Edition. Philadelphia, W. B. Saunders. 1894.
Only such facts as are really the essentials of anatomy
are here embodied, to render it possible for the future
practitioner to recall later such general impressions as
will make perfectly intelligible current medical literature.
The illustrations, one hundred and eighty in number,
are excellent.
A Text Book of the Diseases of Women. By Henry
J. Garrigues, A.M., M.D., Professor of Obstetrics
in the New York Postgraduate Medical School and
Hospital. Philadelphia: W.B.Saunders. 1894.
Dr. Garrigues's treatise on the diseases peculiar to wom-
en is a concise exposition of the modern status of gyne-
cology in our country. Special stress is laid by the author
on anatomy and embryology, and while this does not
make the book more valuable to the general practitioner,
it constitutes a feature that the scientific student will duly
appreciate.
The subject of treatment is also a distinguishing feature
of this new volume. The author has very sensibly adopted
the method of giving simple and undangerous methods
the preference over heroic achievements of " brilliant M
operators. The work can be earnestly recommended as
a faithful exponent of American gynecology, conceived
in a spirit of moderation and conservatism.
Pachydermia Laryngis. Klinische Geschichte von
Dr. Med. W. Sturmann, Berlin. Von der Berliner
Medizinischen Fakultat preisgekronte Schrift. Berlin,
Verlag von S. Karger. 1894.
A Prize Essay, of seventy pages, giving the clinical
history, treatment, etc, and literature of the subject
A Manual of Nursing in Pelvic Surgery. By Lewis
S. McMurtry, AM., M.D., Professor of Gynecology
in the Hospital College of Medicine, Louisville, Ky.
Louisville: John P. Morton & Co. 1894.
Out of "working notes" prepared by the author for
the use of nurses at the Jennie Casseday Infirmary for
Women has grown this complete and practical guide
for those engaged in the care of women with surgical
diseases peculiar to their sex. Its teachings are easily
understood, its form substantial and convenient, and its
ninety- two pages contain directions and hints of value
to those engaged in skilled nursing.
The Human Element in Sex : Being a Medical Inquiry
into the Relation of Sexual Physiology to Christian
Morality. By Dr. Elizabeth Blackwell. London :
J. & A. Churchill. 1894.
In this little work Dr. Blackwell handles a delicate sub-
ject in a delicate manner, yet is not afraid to speak out
when necessary in a way that permits of no misunder-
standing. The author holds that the ignorance of par-
ents concerning many of the essential facts relating to
sex is deplorable, and a cause of grave social ills, and she
offers this work to the medical profession " as an aid in
the instruction of parents and guardians of the young,"
which instruction she regards it as the duty of the physi-
cian to impart on every suitable occasion. She has done
a good work and done it well.
Les Universit£s des £tats Unis et du Canada, et
Specialement leurs Institutions medicales. Par le Dr.
O. Laurent, Agrege Suppleant a TUniversite de
Bruxelles. Vingt-deux Figures et Plans. Bruxelles:
H. Lamertin. 1894.
This is a very entertaining account of the universities,
medical schools, and hospitals of the United States and
Canada, written by one who has seen all he describes,
and seen it too with the eye of an intelligent observer.
All is not praise, for the author is quick to see defects
and ready to note them, but his judgment is in the main
sound. In Canada he draws a comparison between the
French and English universities by no means to the ad-
vantage of the former. The book contains a number of
illustrations of hospitals and university buildings.
The Bee-line Repertory. By Stacy Jones, M.D.
Philadelphia : Boericke & Tafel, 1894.
This is a pocket therapeutic guide for the homoeopathic
practitioner. It is arranged in such a way that those de-
siring to consult it may find just what to do for every
abnormal sensation or appearance in any part of the
body.
212
MEDICAL RECORD.
[August 1 8, 1894
Essentials of Practice of Pharmacy. Arranged
in the Form of Questions and Answers. Prepared es-
pecially for Pharmaceutical Students (Second Edition,
Revised). By Lucius E.. Sayre, Ph.G., Professor
of Pharmacy and Materia .Medica, of the School of
Pharmacy of the University of Kansas. Philadelphia :
W. B. Saunders. 1894.
This is one of the latest volumes of Saunders's Question
Compends, intended, as its title explains, for the use
of students in pharmacy. It appears to be admirably
arranged, and ought to be of great assistance to the con-
scientious student who is making a final review before ex-
amination.
De la Maladie de Basedow, et en Particulier de
sa Pathogenic Par Frederick Chamberlain, Doc-
teur en Medecine de la Yale Medical School, £tats-
Unis, Docteur en Mddecine de la Faculty de Paris.
Paris: Henry Jouve. 1894.
In this excellent monograph Dr. Chamberlain treats
quite exhaustively of exophthalmic goitre, and espe-
cially of the numerous theories held at different times and
by different observers of the pathogenesis of the affection.
There is a list of forty- two cases in which operative treat-
ment was undertaken, and the work concludes with a very
complete bibliography, from the article of Graves in 1835,
to one by Marie published the last day of February,
1894.
Traitement des R&tr&cissements par l' Electro-
lyse Lin£aire. Par le Dr. J. A. Fort, Ancien In-
terne des Hdpitaux, Professeur Libre d'Anatomie a
T rtcole Pratique de la Faculte de Medecine de Paris.
Paris: G. Masson. 1894.
In this exhaustive treatise of five hundred and fifty
pages Dr. Fort sums up all there is to say in favor of
linear electrolysis as a cure for stricture. In an intro-
ductory chapter the author speaks of linear electrolysis in
general, and in the fourth chapter describes the mode of
performing it, the intervening chapters being devoted to
a recital of one hundred and forty cases of urethral strict-
ure treated by this method. The next chapter contains
the histories of twenty-seven cases of complicated and ir-
regular strictures, and the good results obtained by the
author. The sixth chapter is devoted to a consideration
of the dangers of internal urethrotomy, and in the final
chapter are the resumes of several works bearing testimony
to the utility of the author's procedure. In the second
part Dr. Fort treats of linear electrolysis applied to the
relief of strictures of the oesophagus, and reports a num-
ber of cases (upward of thirty) in which this method was
successfully employed. This procedure has one great
advantage over electrolysis as usually practised in this
country, in that it is completed at a single sitting.
The Essentials of Chemical Physiology for the Use
of Students. By W. D. Halliburton, M.D.,
F.R.S. Pp. 166. London: Longmans, Green &
Co., 1893.
This book is written in order to supply the student with
directions for examining practically the most important
of the subjects included under the head of physiological
chemistry. It is also intended to serve as an elementary
text-book. It is well illustrated, and is more complete
than most of so called " Essentials " published for the
benefit of the student.
Outlines of Insanity, an Attempt to present in a Con-
cise Form the Salient Features of Mental Disorder;
Tabulated and Arranged for Facility of Reference when
drawing up Lunacy Certificates. Designed for the Use
of Medical Practitioners, Justices of the Peace, and Asy-
lum Managers. By Francis Walmsley, M.D. Pp.
154. London : The Scientific Press (Limited). 1892.
The purpose of this work is indicated fully in its title.
It is a short popular exposition of insanity. The author
has fulfilled his task creditably, and the book is printed in
excellent style.
Congenital Affections of the Heart. By George
Carpenter, M.D., Member of the Royal College of
Physicians, etc. London : John Bale & Sons.
The book under consideration is the embodiment in
printed form of demonstrations on congenital malforma-
tions of the heart, found of service to a class of students
who failed to find in ordinary text-books explanations
sufficiently precise and clear. The history of twenty-
two cases is given, all the theories as to cause are con-
sidered, and a very careful survey of normal embryonic
cardiac development is an interesting feature. As a sup-
plement to larger works, as those of Rokitansky, Kuss-
maul, Peacock, and others, this fills a distinct want.
Clinical Manual for the Study of Diseases of the
Throat. By James Walker Downie, M.B., Fellow
and Examiner in Aural Surgery for the Fellowship, of
the Faculty of Physicians and Surgeons, etc. New
York : Macmillan & Co. 1894.
For the use of students and practitioners, this manual is
dictated in great part by personal experience, and di-
vided into two sections. In the first systematic examin-
ation of the throat is discussed, together with the various
manifestations of disease. In the second and larger sec-
tion individual diseases are considered in detail, accord-
ing to their importance and frequency of occurrence,
and medicinal and surgical treatment. For a book of
small size, immense ground is covered and the sugges-
tions given are of practical value and utility.
Practical Lectures in Dermatology. By Condict
W. Cutler, M.S., M.D., Professor of Dermatology,
University of Vermont, etc. New York and London :
G. P. Putnam's Sons. 1894.
The excuse for this work, not the reason of its existence,
the author states in the preface to be the request of the
students in the medical department of the University of
Vermont to have the lectures delivered in 1892 and 1893
published for convenient and ready reference. Prepared
from stenographic notes, the fifteen lectures are here
given with substantial accuracy, and consider only those
diseases of the skin which every practitioner is called
upon to diagnosticate and treat in an intelligent manner.
The work is plain and practical, and commends itself to
any busy practitioner. And herein lies its " reason for
being/1 which needs no excuse.
Die Behandlung der Leukaemie. Kritische Studie
Von Dr. H. Vehsemeyer. Berlin: S. Karger.
1894.
In this brochure the author presents a very exhaustive
review of the various measures which have been tried
with more or less success in the treatment of leucocy-
thsemia. Dr. Vehsemeyer himself has had such good
results in one case treated with the fluid extract of bar-
berry, that he thinks this drug, or its alkaloid, berberine,
should be given a further trial.
A Modern Wizard. By Rodrigues Ottolengui. G.
P. Putnam's Sons, New York and London. 1894.
This is a story of medical art and crime ; of murfter and
the workings of the law ; of self-interest, detectives, and
hypnotism ; of pride, vain-glory, and hypocrisy ; of cli-
max, anti-climax, and finally life in-death by "sana-
toxine,M a deft preparation kept on hand by the unscru-
pulous hero to deprive himself of reason in order to escape
the just punishment of his manifold misdeeds. Dr.
Medjora, Spanish and beautiful, fascinating and mysteri-
ous, is left a raving maniac on the last page, after havirg
disposed of one or two wives according to scientific
methods, and been the prime mover in many schemes for
his own aggrandizement. The " Modern Wizard " is
intensely interesting, sometimes dramatic, and well writ-
ten at intervals. It leaves the reader breathless and in a
mixed frame of mind : why should an author of so much
ability write such a book, and why should a reader of
such intelligence read it ? This question each must an-
swer for himself.
August i8, 1894]
MEDICAL RECORD.
213
THE BRITISH MEDICAL ASSOCIATION.
Sixty second Annual Meeting, held at Bristol, July 31
to August 4, /8p4.
Special Report for the M«dical Record.
First Day, Tuesday, July 31ST.
The first general meeting of the sixty-second annual
gathering of this Association was held on Tuesday morn-
ing, July 31st, and was numerously attended. The retir-
ing President, Dr. George Hare Philipson, of Newcastle,
occupied the chair. Having submitted the minutes, which
were confirmed, he said the signing of those minutes was
his last official duty. In vacating the chair he should
avail himself of the opportunity of again expressing to his
hearers his sense of the honor they had conferred upon
him. The remembrance would be one of the happiest
recollections of his life that he had occupied the chair, if
he might be allowed to say it, of the greatest medical as-
sociation in the world. He thanked them for the con-
fidence which had been reposed in him, and for the sup-
port he had received in carrying out the duties of his
office. He begged to offer them his congratulations upon
the meeting in Bristol, and especially upon the choice of
the distinguished physician who was to follow him in the
presidency. It was now his pleasure to invite Dr. Fox
to assume the office as President, and to offer him in his
year of office every good wish that he might have a pros-
perous and happy year.
The President elect remarked it was needless to say
how very much obliged he was to them for the cordial re-
ception of Dr. Philipson's introduction. He appealed to
the members to be brief and to the point in their speeches.
Dr. T. Bridgwater then moved a vote of thanks to
Professor Philipson, and that he be elected a Vice presi-
dent of the Association. Dr. Holman seconded, and the
resolution was carried with applause.
The report of the Council was then presented. It re-
ferred to the pleasure that was felt in accepting the in-
vitation to hold the annual meeting at Bristol. It was
remarked that the city of Bristol was the headquarters,
with Bath, of one of the oldest and most active branches
of the Association, and it was interesting to note that the
first anniversary meeting of the Provincial Medical and
Surgical Association, now the British Medical Associa-
tion, was held in Bristol in 1834, under the presidency of
Dr. Andrew Carrick. It was on record that two hundred
attended out of a total of three hundred and sixteen.
Since the annual meeting last year an important change
had occurred in the Association by the admission of medi-
cal women as members, and upward of forty had already
been elected. The financial results had been successful.
The revenue had been ,£35,367, or -£1,223 more than
last year, while the expenditure was .£30,126, or £1,021
more than last year, leaving a surplus or profit of £$ ,150,
which had since been invested. At the end of Decem-
ber the total excess of assets over liabilities was ,£55,906.
The number of members on the books last year was 1 4, 703.
Daring the year 988 new members had been enrolled, 203
had died, 398 had resigned, leaving on the books 15,090.
Among those members whose decease during the past
year the Council deeply regretted to report were : Sir
Andrew Clark, President of the Royal College of Phy-
sicians, whose many virtues and generous nature caused
him to be universally mourned by the profession ; Dr.
Brovn-Sequard, Dr. George Graham, an ex President of
the Melbourne and Victoria Branch ; Dr. James C. Phil-
lippo, the first President, and the founder of the Jamaica
Branch — the first recognized colonial addition to the As-
sxiation; and Surgeon- Major Parke, who received the
Medal of Merit in 1890 for his brave conduct in the
Stanley expedition.
Dr. J. Ward Cousins, President of the Council,
moved the adoption of the report and financial state-
ment. He said July 19, 1832, was a proud day for
the medical profession, when, their forefathers of the
British Medical Association were assembled in the Wor-
cester Infirmary to consider the proposal of Sir Charles
Hastings in reference to the formation of the Provincial
Medical Association. There were 140 present, and at
the first annual meeting in Bristol, in 1833, there were
200 present. The next meeting held there was in 1863,
and the Association then mustered 2,000 members:
Now they came again with a roll of over r 5,000, with
an organization scattered all over the world, with
Branches in India, Australia, New Zealand, Canada,
South Africa, and the Colonies ; and he need not tell
them a most interesting incident was the admission of
41 lady doctors. He wished all lady graduates in medi-
cine were members, and he firmly believed they would
be in course of time. Referring to the penal clauses of
the Medical Acts, he said they were practically moon-
shine. They could not get convictions. The Parlia-
mentary Committee were anxious to amend the Medical
Acts, as there was no doubt at the present time they
could drive a coach and-four through them. The Asso-
ciation desired to prevent the assumption of all sorts of
letters which assumed medical titles. Then there was
the University scheme, there was no doubt that required
the supervision of the committee. The law relating to
the employment of married women in factories was of
the utmost importance, because the health of the future
population of the country was connected with it.
Among other questions alluded to was the sale of poisons.
That was a move in the right direction. He owned, for
his own part, he should like to see some such system as
they had in France, under which the whole prescription
of the proprietary medicine was on the label. Then he
mentioned the Scientific Grants Committee, one of the
objects of which was to promote research. For three
research scholarships the Council selected gentlemen for
a term of years, and large sums had been granted for
scientific research. Dr. Cousins stated the Inebriates
Committee had been very active. As to the medical
charities, they would always be abused until human
nature was pulverized and made over again.
Surgeon-Major Ince then moved " That this meet-
ing regrets the great and growing increase in the annual
expenditure, as compared with the income of the Asso-
ciation ; and suggests to the Council the expediency of
a careful and substantial reduction thereof in all depart-
ments, especially in the matter of the editorial and office
expenses, which appear out of all proportion to the needs
and nature of the British Medical Journal. ' ' The Treas-
urer replied to the point raised in relation to the finances
and regretted the personal allusions, maintaining that
the editor had raised the Journal to the position of one 01
the best medical periodicals in the world. The editor
also replied, maintaining that he had always endeavored
to be impartial. He congratulated Surgeon Major Ince
for contributing to the gayety of the meeting, and left
the audience to judge whether he had given an example
of the self effacement he wished to apply to the editor.
Dr. Ince said his object had been served by the dis-
cussion and he would withdraw the resolution.
Mr. R. W. Doyne, representing the Oxford Branch,
moved an amendment to the report regretting that it
contained no reference to the question of Medical Aid
Associations, which had done so much injury by sweating
members of the profession. The amendment was sec-
onded by Dr. Mead, who said that very cruel cases had
come before him as Secretary of the Medical Protection
Association.
Dr. Cousins, then read the resolution of the Oxford
Branch : " That, in the opinion of this meeting, medi-
cal men ought not to meet in consultation medical of-
ficers of Medical Aid Associations (as defined by the
committee of the General Medical Council), and that
the Branch Committee should bring the matter before
the Central Council, and that they (the Central Council)
be urged to bring the matter before the annual meet-
214
MEDICAL RECORD.
[August 1 8, 1894
ing. ' ' He explained that the Council had resolved, with-
out expressing any opinion, as they had no evidence be-
fore them, that it would be better for the Branch to
bring the matter before this meeting.
Dr. Hardy moved the appointment of a committee to
consider the question, a proposition which was ac-
cepted by Dr. Cousins, whereupon Mr. Doyne withdrew
his amendment and the report of the Council was then
agreed to. The report of the Parliamentary Bills Com-
mittee was then discussed for some time, and eventually
its further consideration adjourned to the evening meet-
ing.
The Sermon. — At three o'clock in the afternoon a
special service fras held in the Bristol Cathedral in con-
nection with the Association's meeting. The mayor and
corporation attended in state, and they were followed up
the nave in procession by several members of the Associa-
tion Council. Seats in the nave were reserved for mem-
bers, and these, together with other portions of the cathe-
dral, were filled. Canon Ainger, Master of the Temple,
was the preacher, and selected as his subject "The heal-
ing by the Saviour of the woman with the issue of blood."
This poor woman, he said, had suffered many years,
and as St. Mark was careful to add, had endured even
worse from the physicians who had tried their various
experiments on her to cure her. And yet she was not
discouraged, for at last she had encountered a grave and
noble figure, moving to and fro among men, doing good
in various ways. What she had seen and heard of this
New Teacher gave her faith to believe that He was
destined to be her healer, and that no other treatment
would be of any avail. She mixed with the crowd who
followed Jesus, saying, " If I may but touch the hem of
His garment I shall be whole." Jesus's immediate reply
was very marked, and not just what might have been ex-
pected. The woman's words and actions seemed to
imply a purely mechanical view of the power of Christ ;
but our Lord at once pronounced it not to be supersti-
tion, but faith. Not something which degraded but that
which ennobled. The superstitious view of the healing
art had never died out, and never would. In these clos-
ing days of the nineteenth century much still existed, in
spite of education, so-called, in spite of improved schools
and school-boards. Within the last year the most revolt-
ing forms had been exposed to public gaze. But not in
exceptional and sensational shapes alone did it live in or-
dinary life. There was the credulity that believed in any
pretender to the physician's art, that rushed to purchase
any new medicine warranted to cure some disease that
had baffled the researches of the most learned men for
centuries. That state of things was always with us, a sign,
perhaps, he said, of widespread intellectual deficiency.
Yet in spite of education it throve amain. But in its
deepest causes it was a moral more than an intellectual
deficiency, this readiness to believe in sudden and un-
intelligible results rather than in the slow and patient
tracking out of the secret of man's constitution. There
was a love of, a craving for, magic deep seated in the
nature of us all. It was also found, in the art of testing
men's souls, the same deep and subtle tendency existed,
the marvellous loved for its own sake, or recognized only
in what was manifest to the eye rather than in the slow,
hidden workings of God's laws. This malady was inci-
dent to us all.
The preacher went on to say that Christ's whole life
was an example for the physician, and embodied the
principles of his art and science, because it pointed along
the road by which all advance in medicine, as in every
other science, has been attained by the faithful and ear-
nest watching and studying of Nature's methods, not
contesting and resisting them, but following, imitating,
and tracking out her laws and submitting to them.
The preacher alluded to the conspicuous ornament the
profession had lost since its last annual session, by the
death of Sir Andrew Clark. He might not be ranked
with the Hunters, the Jenners, the Pasteurs, but he did
a great work in promoting men's happiness. The phy-
sician of the soul must work on the same lines as the phy-
sician of the body. It was narrated of Sir Andrew Clark
that he once kindly admonished a lady patient by telling
her she got in the way of her own happiness. In con-
clusion, Canon Ainger said he should ill requite the trust
they had laid on him were he to be guilty of even seem-
ing.in these words to instruct them in the ethics of their
noble profession. He had touched upon that which was
common to their professions, the unchangeable aims and
methods of the true physician, whether of body or spirit
They and he might be alike laborers in the Lord's vine-
yard. Let them pray that their desire might be neither
to make proselytes nor to gain patients, but to teach
those who resorted to them for health the eternal signifi-
cance and responsibility of life, to make them to de-
sire and to have life, and to have it more abundantly.
An offertory was then taken on behalf of the Royal
Medical Benevolent College at Epsom.
Evening Session.
The adjourned general meeting was held in the evening,
when the President, Dr. E. Long Fox, Consulting Phy-
sician to the Bristol Royal Infirmary, delivered his ad-
dress. This, of course, took precedence of the various
business matters and discussions which had been post-
poned from the morning sitting.
Presidential Address. — Dr. Long Fox reminded the
meeting that thirty one years had elapsed since the Asso-
ciation last met in the historic city of Bristol, and men-
tioned a number of distinguished men who had taken
part in it, most of whom had ceased from their labors,
but a few were yet in our midst. Bristol had always
been distinguished by its ecclesiastical associations and
by its devotion to the crown, although it had its opin-
ions as to the collection of " ship money." Its citizens
had a sturdy independence of their own that often led to
riot, but it was famous for its healthiness and the lon-
gevity of its inhabitants, many of whom were nonagena-
rians. Its schools were among the best and the healthi-
est in the kingdom, and its enterprise and prosperity
might be gauged by the enormous increase of Clifton ;
its philanthropy was no less commendable, and the
" higher interests of man " had a prominent position in
its midst. Latimer and Ridley among its citizens paved
the way for the establishment of a freer and purer faith.
In Plato's " Republic " it was laid down that in order to
thoroughly understand and sympathize with sickness the
physician should himself be afflicted with many ills,
but that this was not necessary was proved by the at-
tention to the sick poor and the criminal, which was
part, and no unimportant part, of the duty of medical
men, whose temperance, philanthropy, and self-abnega-
tion were well known. It was also the duty of the phy-
sician to give his attention to the hereditary tendency
to crime, and to work against it and improve the un-
happy subject of an evil heredity.
All branches of the medical profession had progressed,
and even that of therapeutics was now conducted on
healthy and scientific lines. Medical science was cos-
mopolitan, and advancing, experieniia docet. How
much was owing to the medical officers of the army and
navy, who had opportunities of studying diseases in their
outset of which we, at home, only saw the ultimate re-
sults.
What use was the medical profession to the State,
which, after all, was composed of individuals, each of
whom it was the aim of the physician to render temperate,
strong, and wise? We are a nation of rulers, and the doc-
tors teach sanitary science, in the advancement of which
the medical officers of health are most important factors.
Jenner's discovery of vaccination laid the foundation
of the prevailing germ theory of disease, and is his
good work to be nullified by a crazy cry for the liberty
of the subject ? Bacteriology, antiseptic surgery (Lister-
ism), and the differentiation of the microbes of diseases
are of paramount importance, and it is marvellous, and
August 1 8, 1894]
MEDICAL RECORD.
215
not much to our credit, that in a country like ours the
State holds aloof from their investigation. Much, how-
ever, has been done to diagnose and remedy the various
diseases peculiar to different trades, and this partly owing
to the co operation of enlightened employers of labor, as
well as to the researches of such men as Ferrier and
Jackson. Investigations such ag. theirs have shown the
difference as well as the connection between the several
disorders that afflict humanity, and especially in the case
of paralysis that proceeds from alcoholic excess and simu-
lated locomotor ataxy. The experiments with thyroid
extracts mark the beginning of a new era in scientific
medicine.
Much study has been given to the various kinds of
idiocy, and particularly to that form that tends to make
the sufferer a criminal, who, instead of being punished by
fine and imprisonment over and over again, should be
taken care of and taught. It had been said that the pop-
ulation consisted of two classes only, the rogues who had
been found out, and the rogues who had not, but really
there was but a very small number of those who were
criminals by hereditary descent in the community.
Biological research had for its only object the benefit
of mankind, and the hard work and self-abnegation of
medical men in this direction were only typical of the
same qualities in the nation of which they formed part.
How much the State owes to its poor-law medical offi-
cers whose utterly inadequate remuneration it should
never have sanctioned.
There may not be many total abstainers in the ranks
of the medical profession, but there are a vast number of
advocates of temperance not in the use of alcohol only,
but in everything. Alcohol, however, has been proved
to be not a stimulant, but a depressant.
Dr. Russell Reynolds, President of the Royal Col-
lege of Physicians, proposed a vote of thanks to the Pres-
ident. He said that much as he admired the address,
what struck him, perhaps, most forcibly was the admi-
rable manner in which Dr. Lane Fox had omitted some
topics as well as dilated upon others. Jenner had a pred-
ecessor in bacteriology, namely Harvey, and that illus-
trious discoverer had been anticipated by a Scotch phy-
sician, Clarke.
Dr. White briefly seconded the resolution, which was
carried by acclamation, and Dr. Fox replied, stating that
he would not say much, as he had no voice left. He an-
nounced that the matters adjourned from the morning
meeting would then be resumed and those who were not
actively interested in them could leave, which the im-
mense majority did forthwith, only a small proportion
remaining to carry on the discussions.
The Medical Practice Act — The President then called
on Dr. Horder to resume the discussion on the Parlia-
mentary Bills Committee.
Dr. Horder proposed as an amendment : " That the
report of this committee referring to the proposed
amendment of the Medical Acts be referred back to
them for reconsideration.11 He said that in the opinion
of many gentlemen of the British Medical Association
those amendments were not good enough. What the
profession needed was that men outside the profession
who did not assume titles, but who practised the medi-
cal and surgical professions without calling themselves
doctors or licentiates of midwifery or surgery, or ac-
coucheurs, or anything else, should be prevented from
practising. With regard to one of the exceptions set
down by the committee, " a person shall not be guilty
of an offence under this act if he shows that he is not
ordinarily resident in the United Kingdom, and that he
holds a qualification which entitles him to practise medi-
cine or surgery in a British possession or foreign country,
and if he do not represent himself to be registered under
the Medical Acts " — under that exception they might be
flooded with men holding bogus qualifications from all
parts of the world. At present, they had ladies — it was
doubtful whether they were entitled to the name — and
gentlemen coming from America giving lectures in all
towns to males and females which could only be men-
tioned as indecent to the last degree. They did every-
thing they could to place themselves before the public,
and then simply swindled the folks out of their hard-
earned wages. If these exceptions to the 40th clause
which now existed were maintained, the country might
be flooded by such. If they were going to amend, why
not make a good business of it at once, and insist that
there should be reciprocity between the nations ? No
English doctor could practise in France without passing
their required examinations, however high his degree,
and it was not fair that that state of things should con-
tinue, seeing that doctors from other countries — France,
Germany, Italy, and so forth — were able to come here
and have their qualifications registered on the foreign
register. Let them deal with the Medical Acts in toto>
and not alone with the 1858 act.
Dr. Mead, in seconding the amendment, mentioned,
with regard to the qualifications, a case of the Hindu
oculists who were prosecuted at the Old Bailey. He said
what was wanted was an act making a little clearer what
was meant by obtaining money under false pretences.
This would put an end to the very dangerous system of
quackery, which allowed men to extort from the ignorant
sums of money. They wanted first a reform of the views
of the English judges, and secondly, some plain state-
ment of the law. They also required some amendment
of the law as to recovery of costs.
Mr. Ernest Hart said that instead of the Parliamen-
tary Bills Committee or himself being in any way desir-
ous of settling the matter themselves, or on their own
responsibility, the first thing they did was to lay the
facts before their solicitor, and to ask him for his advice
in making a new amendment clause. As that advice
hardly went fax enough, they took the benefit of the ad-
vice of the gentlemen who had been instrumental in
framing the Dentists Acts, which was more recent, and
with that help the clause was farther extended and
amended.
Mr. George Brown said it was not their duty to em-
ploy solicitors to tell them what they required and what
Parliament would pass, but to tell Parliament what they
wanted.
A motion referring back the subject of amendment of
the Medical Acts for reconsideration was then put and
carried.
Registration of Midwives. — Dr Lovell Drags said
the question of midwives9 registration was specially re-
ferred by the Parliamentary Bills Committee to that meet-
ing. The subject was one that had had very little jus-
tice, legislation being introduced without preliminary
inquiry and investigation. He had very great difficulty
in ascertaining at all the reason upon which this demand
for legislation was laid. It was said it would be a boon
to the poorer community, but it was not very difficult to
show that it could not achieve that object. He claimed
in England the poor received considerable assistance
from those who were the proper ones to give it — viz., the
doctors — and he was anxious to know how the proposed
measure could be in the interests of them, when it was
shown by the returns that in every foreign country the
death-rate was higher than in England.
Dr. Drage's time for speaking having expired he end-
ed by moving " That this meeting disapproves of the
principle of registration of midwives."
Dr. More Madden, in seconding the resolution,
agreed with the contention of Dr. Drage.
Dr. Woodcock said there had been a good deal of
misunderstanding as to the position of those who op-
posed registration. They were not for leaving things as
they were, for nothing could be worse than the present
state of things whereby women had been certificated, or
had diplomas issued to them, indicating that they were
worthy of the trust imposed upon them. In these days
of higher education, it was simply a reproach to the leg-
islature that they should be continued. The present
midwife was as much out of date as the barber- surgeon
2l6
MEDICAL RECORD.
[August 1 8, 1894
and the cunning leech of the past, and he maintained
that those who were to practise the obstetric art should
be as well trained in medicine and surgery as those prac-
tising any other branch of the profession.
Dr. Boxall agreed that the present state was really
disgraceful. How, then, could it be improved? Could
they get rid of the present mid wives ? If that could be,
he thought that would be the best solution, but was
afraid that was impracticable. The question was a
national one, affecting the community at large. The
select committee of the House of Commons took evi-
dence from all sides, and they reported very distinctly
in favor of registration. It was desirable to get the
midwives under control, but how could that be accom-
plished without registration ? That was not likely to
iajure the profession. It would not create a lot of mid-
wives, they did not want a single extra one, would rather
free themselves entirely. He hoped by such legislation
as seemed practicable the condition of the poor might
be improved, and the interests of the profession would be
duly preserved.
Mr. George Brown said the way in which the com-
mittee of the House of Commons conducted their in-
quiry showed clearly that their sympathy was entirely
with those who approved the registration, and he was
surprised that their report was not even more decidedly
in favor of the immediate passing of a measure for the
registration of Sairey Gamp. It was absurd for members
of Parliament to go behind the experience of a man like
Dr. Atthill and recommend the legislature to sanction
the registration of women after three months1 education.
After some further discussion the resolution was put
and carried by a majority of thirty four to thirteen, this
being the total present, and the report as amended was
then adopted.
Second Day, Wednesday, August xst.
The President read out a list of visitors to the
conference from various parts of the world, and also
mentioned that representatives were present from many
colonial Branches.
Dr. Ward Cousins stated that the Council received
that morning a very large metropolitan deputation,
headed by Dr. Russell Reynolds, inviting the Association
to London for its next annual Congress. The Council
recommended that they should accept the invitation, and
he need not tell them that the Council would do all in
their power to help the development of the meeting so
as to give entire satisfaction, not only to the whole Asso-
ciation, but to their metropolitan associates.. It would
be a great satisfaction to know that they had selected as
the President the President of the Royal College of
Physicians. He moved that the invitation to hold the
annual meeting for 1895 in London be accepted, and
that Dr. Russell Reynolds be nominated as the President-
elect. The President seconded, remarking he need
hardly say they could not have a better President-elect,
or a better place to meet in than London.
The Address in Medicine was then delivered by Sir
Thomas Grainger Stewart, M D., Professor of Medi-
cine in the University of Edinburgh, who said he did
not propose to give an address on the general subject of
medicine, but would select one special disease which had
been much talked about among us of late, namely, the
influenza, which, however, was no new epidemic, for
Randolph, the ambassador from Queen Elizabeth to the
Queen of Scots, described it accurately in a letter to
" Her Grace." It was called "the new acquaintance,"
because it visited everybody. There were three types of
the disease, the respiratory, the intestinal, and the ner-
vous, while its complications and sequels were numerous.
Some of the latter were purpura hemorrhagica, vom-
iting, anaemia, gout, diabetes, cardiac symptoms, dropsy,
pneumonia, phthisis, skin eruptions, sweating, affections
of the urinary and reproductive systems, albuminuria
hematuria, inflammatory symptoms as cystitis, and espe-
cially nervous, involving sight, hearing, and smell, some-
times increasing the power of these senses, but more
usually decreasing them. We had considerably increased
our knowledge of the histology of the disease. It had
one essential cause, the Pfeifferian bacillus, which was
always present and was never found in any other com-
plaint. The result of inoculation with the cultivated
virus was unsatisfactory, for no animal, except man, was
affected by this micro organism, not even the monkey.
This bacillus will only live in the presence of haema-
toglobin. It does mischief in many ways, but chiefly
by means of the poisonous products it sets up in the sys-
tem. Possibly it provided a nidus in which other poi-
sons found a chance of ready development at a time
when the power of resistance of the patient was dimin-
ished, for exhaustion favors the growth of micro-organ-
isms. Some white rats were inoculated with the bacillus
of anthrat, half their number were placed in a cage and
forced to work the tread-mill, the others were allowed
to rest ; the former developed the disease, the latter es-
caped
Two organisms coexisting in the same subject may
diminish the action of one or both ; as they may in-
crease it. The bacillus of tubercle when associated with
the gonococcus found in green pus renders the disease of
phthisis much more formidable.
Faulty innervation is at the bottom of heart and
stomach troubles following influenza. The malnutrition
of the tissues causes a poisoning of the nerves.
Causation of influenza is obscure ; it was once thought
to be propagated through the air. H.M.S. Stag was com-
ing up the Channel, when a man was taken suddenly ill,
and in twenty-four hours over one hundred men were
laid down with the influenza. No similar case has since
been recorded and no one takes the disease who has not
come in contact with someone else who had it. It mul-
tiplies with extraordinary rapidity, so that in twenty-
four hours a whole community may be affected.
The life-history of the influenza bacillus is peculiar —
it will not live in water, which is good news for the
teetotallers. It cannot bear drying and must be kept
moist like some people. (Laughter.) The disease might
be stamped out by isolating those affected. At all
events, delicate people should not frequent crowded
schools, theatres, or churches. Menthol and guaiacol
will destroy the bacillus, or at least considerably diminish
its activity ; the mode of administering is by laryngeal
injection, which is quite simple when you have found
out the way to do it. Phthisical people are the best
subjects for the experiment The victim should yield at
once — off to bed and take care of yourself.
Dr. F. Roberts proposed, and Dr. Shingleton Smith
seconded, a vote of thanks to the lecturer, the former
declaring that he was deeply interested by the assur-
ance that the bacillus will not live in, and cannot be
propagated by, water ; he also congratulated him upon
the honor the Queen had bestowed upon him.
Sir T. G. Stewart, in replying, said there was an old
Scotch proverb to the effect that the best mirror is the
eye of a friend.
The Middlemore Prise. — The President announced
that the Middlemore Prize for 1891 had been awarded to
Mr. Edward Treacher Collings, F.R.C.S., L.R.C.P., who,
however, was travelling in Persia.
Dr. Ward Cousins explained that the prize was .£50
interest on a sum of money left by the late Mr. R. Mid-
dlemore, of Birmingham, for the best essay on any sub-
ject in ophthalmology, medicine, or surgery.
Third Day, Thursday, August 2D.
Address in Surgery. — Mr. Greig Smith, Professor of
Surgery in the University College, Bristol, then delivered
the address in surgery, taking as his subject, " The Art
of the Surgeon.1'
After gracefully acknowledging the honor paid to
Bristol and himself in his selection for this duty he said
August 1 8, 1894]
MEDICAL RECORD.
217
that former orators bad chosen to sing paeans on our vic-
tories over science and glorified scientific heroes. It was
his intention on this occasion to leave science alone and
deal with the art, and how we trained men to practise it.
What was a surgeon ? A stranger might judge from a
study of door plates that there was no difficulty in answer-
ing ; but the word " Surgeon " on a door usually meant
that its possessor was capable of all branches of the heal-
ing art except surgery. The surgeon in these days of
high-sounding titles was almost alone in following a craft
called "handwork " whose title was needlessly humble.
The surgeon was first and foremost a physician. In
person or by. proxy he must lean on medicine. Besides
medical training he must have special education in his
handicraft. In old times the surgeon was the slave of the
physician, later his enemy, to day his equal and helper.
Their rivalry was now a goodly and a wholesome one*
Among other arts and crafts surgery was unique in the
breadth of its foundation on science. A surgeon must
know something of all the sciences, a good deed of a few,
and everything of two or three.
Was all our display of knowledge genuine ? Exami-
ners seemed to have their doubts, so fearful were they
apparently that the student's knowledge might trickle
away unless he were annually examined. When was the
importation of new subjects into the curriculum to stop?
The burden was becoming steadily heavier to bear.
Should we cast off some of it as cumbersome or useless?
Some said that we have too much anatomy, that it is
useless to the practical surgeon, and that physiology was
unstable and uncertain, that the young physiologist gives
a dose of castor-oil, on much the same principles that
his grandmother acted on. Pathology they said was the
science of too late. These men were as honest as their
opponents. From that very rostrum their views had been
proclaimed. He ventured to differ. If asked, " Are we
to lower surgery so that brains may not be strained ? " he
would answer, "Let surgery rise if brains fall!" He
would not cast away anything, but he would select, re-
arrange, and raise, and have more anatomy, physiology,
and more pathology.
The end of culture for the multitude seemed to be to
nibble at science, dabble at art, and drivel over the glori-
ous advances of the century. Surgery tolerated no daw-
dling or dilletanteism. The surgeon's knowledge must be
real and thorough and practical, and he must carry it
with him. He must have the real knowledge of the
artist begotten of personal labor and not of cribs and
mnemonics. That surgeon's armor was weakest at vul-
nerable points who was not protected by a complete
panoply of anatomical knowledge. The complete sur-
geon must not cease to learn anatomy in his lifetime.
Only the other day the attention devoted to the vermi-
form appendix had rendered our knowledge of its anat-
omy more perfect. Centuries of observation by the
morphologist were not equal for our purposes to the few
months9 work of the practical surgeon. No honest sur-
geon dare let himself remain ignorant of any new patho-
logical or physiological fact that might bear on his work.
Bacteriology was of supreme importance, and we dare not
stop anywhere in our studies so long as knowledge ad-
vanced.
There was real danger that the claims of science might
injure the art of surgery. It was a pity that science
should so often kill art. Certainly in surgery there was
no reason for this, but science and art could flourish to-
gether.
The art of the surgeon might be viewed from two
aspects; one side might be called mechanical, the other
was closely allied to a fine art. Easily learnt as the
mechanical side was it was worthy of being taught, and
it would be good for most surgeons to spend a month or
two in a mechanic's workshop. In respect of technical
sldll in handling, he would place surgeon's tools on a level
with the sculptor's spatula or chisel, or only a little
higher— they were mere accessories in the work of the
brain-compelled hands.
The other side of the craft he would venture to com-
pare with that which produced works of art This side
was far the most important The highest part of surgical
fine art — for surgery was nothing less — was braincraft
uttered through the fingers, not mere dexterity or cun-
ning. The ringer- surgeon began at the wrong end, he
ought to have been a button- maker. The important
sense of touch — the only one in which man excelled the
lower animals — was trained through the intellect as much
as the fingers, and was aided by other senses, especially
sight.
There were no limits to the demands made on the sur-
geon's tactile powers. Touch to the surgeon was what
hearing was to the physician. But it was always the in-
tellect that interpreted. It was as true now as twenty
centuries ago that " 'Tis mind that sees and mind that
hears ; all other things are deaf and blind."
The sculptor and the surgeon both dealt with the
human body. Each art demanded from its votaries ab-
solute fidelity to form ; ignorance led to grief in both.
Their ways of working were also alike. In each the true
artist went as far as necessary at once without trifling.
The surgeon who was not an artist was good at some
details, but not in all, and lacked a sense of true propor-
tion.
The world lost a great surgeon in Leonardo da Vinci,
and a great artist in Sir Charles Bell. What was the
teaching of this art of surgery ? There was no real teach-
ing of the art of surgery in this country. We had to
teach ourselves by experience alone. The young sculp*
tor might with impunity make and break figures, but the
young surgeon was not supposed to damage or destroy
human beings.
Artist and craftsmen learnt their work with a master to
correct their faults. Surgeons alone were unassisted in this
way in their art, although in his science the student had
guidance enough. Operative surgery on the dead body
was useful and indispensably but it was only a step
toward operating. The art must be taught to the young
surgeon while actually operating, and his mistakes
pointed out and his successes commended. What would
they not give now to have a Liston or a Syme at their
elbows to teach them? JTo imagine Liston, trained as he
was in the cruel and exacting school of preanesthetic
days, having before him our science was to realize the
ideal surgeon-artist.
Apprenticeship or pupilage would do something for
surgery, but we needed personal teaching in high art by
competent masters, as was done in medicine and obstet-
rics.
The state would only help those who helped them-
selves. Let us do so, and we might one day seek for a
Royal Academy of Surgery, and a school with teachers
attached.
One of the great surgeons of five hundred years ago
and more wrote, " Knowledge is created by additions,
the same man cannot lay the foundation and perfect the
superstructure. We are as children carried on the neck
of a giant; aided by the labors of our predecessors we
see all that they have seen and something beyond." Let
us in our love for the new science not forget the old art
Let us graft our new truths on the old stock that they
may long live and flourish.
Mr. Reginald Harrison moved a vote of thanks
to Professor Greig Smith for his interesting address, and
said the resolution only inadequately expressed the in-
debtedness of the Association.
Mr. Nelson Dobson, of Clifton, in seconding the res-
olution, said it was a peculiar privilege to do so on that
occasion of a large assembly thanking his neighbor
and friend. He further expressed the gratification of
his brethren who practised in the neighborhood that one
of them should have been chosen for this honorable dis-
tinction. The good old city of Bristol, he said, had made
the name of Smith famous in surgical history : '• Dick "
Smith and " Nat " Smith were familiar names until the
present day, and he believed that Greig Smith would
218
MEDICAL RECORD.
[August 18, 1894
also be remembered not only for his great achievements
in surgery, but for the address he had just delivered.
The resolution was carried by acclamation, and briefly
acknowledged by the Professor.
Most of the audience then dispersed, leaving only a
few members to transact the formal business, which was
at once entered upon.
This included the adoption of the Reports of the
Scientific Grants Committee, of the Committee on Legis-
lation for Inebriates, of the Therapeutic Committee, of
the Medical Charities Committee, of the Committee on
the Efficient Control of Railway Servants' and Mariners'
Eyesight, of the Committee on the Examination of School
Board Children, and of the Anaesthetics Committee.
(To be Continued.)
NEW YORK COUNTY MEDICAL ASSOCIATION.
Stated Meetings April 16, 1894.
Samuel B. W. McLeod, M.D., President, in the Chair.
The Paper Jaoket, its History, and Applications.— Dr.
J. Marshall Hawkes read a paper upon this subject,
and presented about a dozen illustrative cases. Since
Ambrose Pare, in 1 725, made his first jacket out of beaten
brass, the ingenuity of many men had been devoted to the
production of a jacket from material which should pos-
sess among other desirable qualities that of lightness.
Wood, woven wire, plaster of Paris, and various other
materials had been employed, but all were heavy with the
exception of felt, and this was objectionable because of
its thickness, tendency to break down, and to absorb the
perspiration. Plaster was not only heavy, but it disinte-
grated, absorbed the perspiratory products, became offen-
sive, was cumbersome, broke down, and became useless.
Dr. Hawkes came to make the paper jacket, alter trying
nearly all possible materials, in a case of injury to the
vertebral column in 1887* He was unable to adapt a
jacket which the patient could wear without undue suffer-
ing, until the use of paper was suggested by seeing some
workmen making buckets of this material. He then sus-
pended a patient, made a plaster mould on the nude body,
and from this mould made a solid piaster cast, over which
he constructed the paper jacket out of the best manilla
paper. Successive layers of paper were put on and made
to adhere by varnish, shellac, and various cement ma-
terials, until a thickness of about three thirty- seconds of
an inch was obtained. The weight was scarcely fourteen
ounces. According to the deformity to be treated, he
padded the plaster cast at projecting points and cut it
down at others on the opposite side, so that in time press-
ure reduced the projecting deformity and rilled up the
opposite cavity in the body of the growing subject. When
the jacket was removed it was replaced during suspension.
Many persons, especially girls, who refused to wear the
plaster and other jackets or apparatus because of their
clumsiness and weight, submitted to the application of
the paper jacket early and with pleasure, because of its
lightness, accurate fit, as if it were a corset, and because
of the marked comfort which it afforded. It was well
known that the weight of the jurymast or other support
attached to the plaster jacket tended to break it down.
The paper jacket being very strong, easily withstood the
strain. Dr. Hawkes knew of no disease of the spinal
column to which it was not applicable. It was important
that it extend well down over the hip, say to the inferior
spinous process, else the superincumbent weight of the
body would cause pressure pain along the lower border.
The importance of a snug, light, well- fitting, strong jacket,
the wearing of which would not be objectionable to the
most fastidious patient, was shown by the fact than aft
eminent surgeon had estimated that four per cent, of the
population had some defect of the spinal column. Among
the patients shown by the author were some of sensitive
spine in neurotic subjects, railroad spine, and deformities
from other injuries, lateral curvature, etc. None with
Pott's disease happened to be present.
Dr. A. B. Judson being requested to open the dis-
cussion, said : The management of these cases is the cause
of anxiety, because the patient and his friends do not
readily recognize the difference between lateral curvature,
which may persist without interfering with a long and
useful life, and Pott's disease, which is a destructive proc-
ess in itself and exposes the patient to the risk of ab-
scesses, paraplegia, greatly reduced stature, and serious
deformity. The apparatus shown is admirable and of
value in the treatment of certain cases, but in Pott's dis-
ease I would prefer an apparatus which enables us to
apply adjusted and regulated pressure directly to the pro-
jection in an anteroposterior direction. Pott's disease
is, with the exception of malignant disease, the most
serious affection which can attack the skeleton. In itself
the morbid process is curable, as is seen when it occurs
in the ankle, the knee, and the hip. It is noticeable that
the disease is more manageable in the smaller joints, evi-
dently for a mechanical reason. The muscles are more
able to arrest motion, and fixative apparatus is more effi-
cient if the portion of the body lying beyond the diseased
joint is of small siae. If the hip joint or the spinal joints
are in the acute stage of disease they are unavoidably dis-
turbed by motions in other parts of the body, but a digi-
tal ioint, for instance, may easily be kept motionless and
unoisturbed while violent motions are made in other parts
of the body. It is this mechanical disadvantage, suffered
by the carious vertebrae, which makes this disease almost
malignant in its persistence. With this in view we must
admire the zeal which Dr. Hawkes has infused into his
work. In this way alone can the details, which are so
large a part of all orthopedic work, be properly attended
to. In fact the personal element is as important as the
selection of a form of apparatus.
Dr. von Donhoff thought the claims made for the
paper jacket were well based. So far as scoliosis was con-
cerned, there was a tendency for it to go on increasing
in spite of mechanical treatment until nature arrested it.
He thought Dr. Vance, of Louisville, was first to use the
suspension apparatus. Dr. von Donhoff had come to re-
gard suspension as dangerous, and therefore applied the
jacket on a kind of hammock, in the horizontal position.
He believed he had himself first used paper, 1874 or 1875.
Dr. Newland expressed the opinion that the more
nearly one left the patient alone the greater would be his
success in the treatment of curvature of the spine. Where
a brace was called for the paper jacket would prove use-
ful, but it lacked some of the advantages pertaining to
aluminum.
Dr. Millikrn preferred the iron brace, but since pa-
tients could not always be seen frequently, the plaster
jacket had found a place. If one could prevent further
deformity he would do well. He thought Dr. Bryan, a
former Bellevue interne, first used plaster in this country.
He preferred putting on jackets in the horizontal posi-
tion.
Dr. Brothers thought aluminum wire would come to
be. used for jackets in preference to other material.
Dr. Judson remarked that Dr. Benjamin Lee, of Phila-
delphia, had used suspension before the date mentioned
by Dr. von Donoff as the time when Dr. Vance first em-
ployed it, and Dr. Lee said he got the idea from Dr. John
K. Mitchell, of Philadelphia.
Dr. Hawkes said, in closing, that he would not put
an iron brace on a child under any circumstances. He
did not believe any extension of the spine could be got
by placing the patient in the horizontal position. He
had never seen danger or injury from suspension. That
actual diminution of deformity had been effected was
shown by the successive casts.
To say to a patient that her only hope lay in nature
arresting further progress of the deformity, and then ask
for a fee, reminded him of a picture in a comical paper,
representing a bruised and dilapidated individual in the
presence of a soothsayer who, having read in his past
history that he had met with some accident, and predic-
ted that he was to fall heir to a hundred thousand dol-
August 1 8, 1894]
MEDICAL RECORD.
219
lars, extended his hand with the remark, " Two dollan,
please."
Quinine Amaurosis.— Dr. J. Herbert Claiborne
read a paper in which he described a case of quinine
amaurosis, mentioned the rarity of the affection and the
symptoms usually accompanying the condition. There
were about fifty-five cases on record. His own case was
seen with his father in the South. The eyes were examined
also by Dr. Knapp. The man had been taking consid-
erable quinine, and on one occasion, in order to prevent
recurrence of symptoms and assure rest, he swallowed
nearly a handful of two- grain quinine pills. Following
which was blindness which had persisted since, or about
three years. There had been only sufficient improve-
ment to enable the patient to see slightly by reflected
light, less well by direct or strong light
The author reached the following conclusions with
regard to quinine amaurosis: 1, Quinine in toxic doses
may produce blindness ; 2, the toxic dose is distinctly
indeterminate; 3, the duration of the amaurosis varies
greatly; 4, the field of vision remains contracted; 5,
the central vision usually returns to normal ; 6. there is
color-blindness at first, color perception being ultimately
restored in the central field; 7, the ophthalmoscopic
picture is that of white atrophy ; 8, experiments on dogs
show that there is atrophy of the entire optic tract ; 9,
the same experiments show that the cells of the cuneus
are probably not affected ; 10, treatment is of no avail.
Dr. Claiborne's case was the severest on record.
The trouble with hearing had quite disappeared.
The discussion was participated in by Drs. Hepburn,
Van Fleet, Meeks, and the author. Dr. Hepburn
thought the most curious point in the case related was
better perception of light by reflected than by direct
light. The affection seemed to be peripheral, but
whether the toxic agent acted directly upon the nerve or
through the circulatory system was a question.
Ligation of Uterine Artery for Control of Hemor-
rhage in Tumors.— Dr. A. H. Goelet presented certain
gynecological instruments, and illustrated by drawing
ligation of the circular artery of the uterus for control of
hemorrhage due to tumors of the uterus, after the manner
practised by Martin, of Chicago. Dr. Goelet thought
he had done this operation before Dr. Martin.
The only danger was in tying the ureter and in sepsis.
Confinement was from one to two weeks.
Special Committee to State Constitutional Conven-
tion.— On motion of Dr. Frank Ferguson, the President
was empowered to appoint a special committee of five to
act with like committees appointed by other medical
societies, for the purpose of looking after matters medical
before the approaching State Constitutional Convention.
Dr. Charles J. Proben presented a specimen of tuber-
cular dachtylitis, Dr. Biggs having confirmed the diag-
nosis; also a specimen of broncho-pneumonia from a
child.
Stated Meeting, May 2i% 1894.
Samuel B. W. McLeod, M.D., President, in the
Chair.
The Medical Department of the National Guard, its
Status in Two Decades. — Dr. Joseph D. Bryant,
Surgeon-General of the National Guard of the State of
New York, spoke of the status of the medical department
ten years before and ten years since 1884. The National
Guard was composed of the military and naval service,
all told of about fourteen thousand men, fifteen thousand
being the legal limit. There were about five thousand
men in New York City, three thousand in Brooklyn,
twenty-five hundred in Albany and the country towns,
and about the same number in Buffalo and surrounding
counties. The National Guard served two important pur-
poses, viz.: to serve the State in case of riots, and to
form the nucleus of an army in case of war. The naval
reserves numbered four or five hundred. The men en-
listed for five years and drilled once a week for seven
months a year.
Medical Department. — This was made up of the sur-
geon-general, surgeons major, and assistant surgeons of
the rank of captain or lieutenant, in all about ninety
medical men. Then there was a hospital corps of in-
structed non* medical men, and hospital stewards, num-
bering about one hundred and fifty-six men.
Briefly stated, the duties of the medical officers during
ten years, prior to 1884, were simply to appear on dress
parade and to add to the social enjoyment of the officers
at whose pleasure they were appointed. They sighed
papers in a perfunctory way.
A change has been effected since 1884, and today the
duties of the medical officers, from the surgeon-general
down, were much more onerous. Scrutiny was not ex-
ercised in the appointments, and while the commanding
officer could name a doctor whom he would like to have
appointed his power ended there. Those selected had to
appear before a medical examining board, and not a few
of them had failed to pass the examination. The ap-
proval of the surgeon-general was requisite after the can-
didate had been recommended by the examining board.
Their duties, when appointed, were medical and educa-
tional. They had to examine every recruit and to look
after the health of the troops. The educational duties
were to give instruction to the hospital corps in the
matter of giving first aid to the injured, etc. The hos-
pital stewards were formerly undertakers, butchers, etc.,
while to-day they were required to be educated in phar-
macy. Formerly there was no regular hospital or am-
bulance corps, men acting only for the occasion, while
at present a certain number were appointed for this
position for the whole period of five years, and received
special instruction in the care of the wounded. At the
end of the period, if they passed the examination, they
were given a certificate and two badges, one being that
of the Red Cross.
They had thus built up in this State, as had been done
in a few others, a complete system corresponding to that
in the regular army.
After some remarks upon Dr. Bryant's paper by Drs.
N. H. Henry, A. M. Jacobus, Brothers, and the author,
the Society listened to the reading of the second paper
of the evening, by Dr. John G. Coyle, on
Membranous Enteritis, with Report of a Case. —
Dr. Coyle had found few cases reported, but believed
the condition was often overlooked because of neglect to
examine the stools. No fibres were found in the dis-
charged membrane, it differing from diphtheritic enteritis
in that regard. Some patients passed yards of mem-
brane resembling tape- worm, for which it had sometimes
been mistaken. The disease was chronic, attacks com-
ing on for slight cause in those who were susceptible.
The treatment related to diet, cleanliness by rectal ene-
mata, and catharsis as might be indicated. There was
little fever. His own patient was a woman, thirty-five
years of age, who had at times suffered from great dis-
tention and rumbling in the abdomen, severe abdominal
pains at the time of the attacks, headache, etc. The
condition probably dated from 1885, since which time
she had had attacks of dysentery, but membrane was dis-
covered only the past year, when Dr. Coyle began to
examine the stools, and since that time there had been
discharge of non- fibrous membrane in three attacks.
Dr. Gessner Harrison had seen one case of mem-
branous enteritis in a patient who supposed the cast was
part of a tape- worm and brought it to him. She said her
brother had been troubled in the same way.
In some closing remarks Dr. Coyle dwelt upon the
importance of carefully examining the stools in gastro-
intestinal troubles, just as one would examine the urine
in suspected renal disease.
Dr. T. H. Manley reported as delegate to the Inter-
national Medical Congress which recently met at Rome.
He pronounced the meeting a success, scientifically and
socially.
220
MEDICAL RECORD.
[August 1 8, 1894
THE NEW YORK PATHOLOGICAL SOCIETY.
Stated Meeting April u, 1894
George C. Freeborn, M.D , President, in the Chair.
Carbolic Aeid Poisoning. — Dr. H. P. Loomis pre-
sented the following : A man was taken suddenly ill on
the street and died before the ambulance reached him.
The autopsy showed that death was due to carbolic acid
poisoning. The specimens showed very well the extreme
congestion and corrosion of the larynx and oesophagus.
The tissues were very well preserved, although they had
beeto kept in a cool place for about one week without
any special preservative fluid.
Abscess of the Brain. — W. J , thirty four years of
age, was admitted to Bellevue Hospital in a somewhat
stupid condition. He answered all questions in a loud
voice. He had been complaining for two months pre-
viously of pain in the right side of the head and in the
right ear, and there had been a discharge of pus from
this ear for a short time, but it had ceased before his ad-
mission to the hospital. The day after admission he
suddenly developed paralysis on the left side, which was
more marked in the left arm. After a few hours the
stupor became profound, and he died the following day.
At no time was his temperature over 990 F. A diagnosis
was not made during life. On removing the brain there
was a peculiar yellowish appearance, but no evidence of
an abscess until the brain was cut open. The brain,
with the exception of an abscess in the temporal lobe on
the right side, was normal, as were also the other organs
of the body. The abscess in the temporal lobe was
marked by a cavity about an inch and a half in diam-
eter, and this cavity was rilled with thick, greenish pus.
The bones of the ear were cut open, and in the mastoid
cells and the petrous portion of the temporal bone col-
lections of pus were found. There was no meningitis —
in other words, no extension by continuity. The sinus
was thoroughly examined, but no thrombus was found.
Cultures were made only from the abscess, and these
showed the presence of the staphylococcus albus, the
cladothrix, the bacillus liquefacieus, and a diplococcus re-
sembling Frankel's, but its exact character had not been
positively determined.
Perforation of the (Esophagus of a " Sword swal
lower." — Dr. Loomis also exhibited the diaphragm, oeso-
phagus, and stomach from a man, thirty- nine years of age,
who had died within half an hour after admission to
Bellevue Hospital. At the autopsy, on removing the
sternum, the left pleural cavity was found to contain a
large amount of dark liquid with little oil globules float-
ing on top, and masses of what appeared to be fecal mat-
ter floating in it. The lung was compressed against the
spinal column, and the heart was pushed over to the mid-
dle line. There was an odor of acetic and butyric acids
in the liquid. Thinking that possibly the intestine had
ruptured through the diaphragm and had become strangu-
lated, it was next dissected out, and was found to be free
throughout its entire extent. . The diaphragm was then
examined and found intact. The lung was next carefully
removed, and was found to be completely atelectatic
After careful search it was found that the little finger
could be passed into the left side of the oesophagus a lit-
tle above the diaphragm ; in other words, there had been
a perforation of the oesophagus, leaving a clean cut, linear
opening, 2 ctm. in length, extending down to the
oesophageal opening in the diaphragm. There was no
evidence of ulceration or infiltration. On examining the
cardiac end of the stomach radiating lines were found
around the oesophageal opening, which seemed to have
resulted from injury. All three inner coats were gone,
and the peritoneum laid bare. No other part of the
stomach or oesophagus was injured in any way, and care-
ful search throughout the entire alimentary tract failed to
reveal the presence of any sharp pointed or sharp-edged
body ; in fact, no foreign body of any description was
found. Subsequent inquiry showed that this man had
been a sword-swallower, and had been performing almost
up to the day of his death. Probably the injury had
been inflicted by a sword.
Diverticula of the Sigmoid Flexure of the Colon.—
Dr. George P. Biggs presented the specimen. It was
removed from a woman, fifty five years of age, who died
of chronic tuberculosis, chronic diffuse nephritis, and
cirrhosis of the liver. About two inches above the brim
of the pelvis there was a hard mass in the posterior wall
of the sigmoid flexure of the colon, and on cutting into
this from the outer surface a pocket was exposed which
contained nearly one drachm of thick yellowish pus. It
measured 2 ctm. x 1 ctm., the longer measurement cor-
responding with the axis of the gut. The tissues around
this were distinctly indurated, although there was no
localized peritonitis, the inflammation being entirely in
the adipose tissue surrounding the sigmoid flexure.
After some difficulty a small probe was passed through
a small opening into the lumen of the gut. There were
a number of other diverticula.
This condition of multiple diverticula in the colon,
especially in the lower portion, would be found not to
be uncommon, the speaker said, if careful search were
made for it. These diverticula generally contained
fecal matter. He had never before seen them inflamed
as in this case, although there was no special reason why
this should not occur.
Dr. James Ewing said that he had recently seen two
cases of anaemic colitis with marked ulceration, in which
all the normal diverticula of the sigmoid flexure for
about one foot were much dilated, so that they were
capable of holding two or three drachms of fluid. They
were not, however, inflamed.
Diphtheria and Pseudo- diphtheria Bacilli.— Dr.
William H. Park presented cultures and cover-glass
"smears" of a number of varieties of diphtheria and
pseudo diphtheria bacilli, and briefly alluded to the views
that had been held by bacteriologists regarding the nat-
ure of these bacilli.
In 1888 Hofmann published the results of some in-
vestigations in which he stated that besides finding the
diphtheria bacilli in cases of true diphtheria, he had found
them in twenty-six out of forty-five throats in which
no diphtheria had existed. Some of these bacilli were
shorter, thicker, and more regular in form than the
Loeffler bacilli, and grew more readily on agar, the
growth being both more luxuriant and whiter. Others,
however, were in all respects identical with the Loeffler
bacillus except that those from healthy throats were not
virulent. He did not feel able to state whether or not
these two forms were identical with the virulent diph-
theria bacilli of Loeffler, or a different form of bacteria.
Loeffler himself, and most German writers have consid-
ered them to be altogether a different form of bacteria,
while Roux and Yersin, most Frenchmen, and some
Germans have looked upon them as identical. Roux and
Yersin in their studies on diphtheria gave careful atten-
tion to the relationship of the so called pseudo-diphtheria
bacillus to the true one. The majority of the bacilli
they studied were identical with the Loeffler diphtheria
bacillus in growth, size, and form, and differed simply in
not possessing virulence. Exceptionally they found
bacilli which were shorter, grew somewhat more luxu-
riantly on agar and in broth, and at a somewhat lower
temperature (20°-22° C.) than the true diphtheria bacil-
lus. This latter quality was sometimes only acquired
after the bacilli had grown some generations on artificial
media. The changes in reaction in bouillon caused by
the growth of the bacilli were the same as in the case of
true bacilli, but change to acid, and later return to alka-
line reaction was more rapid. It was noted that the
non virulent bacilli were only present in small numbers
in the throats, so that the serum tubes usually contained
but one to four colonies.
In a hospital for children in Paris, where cases of
diphtheria were occurring from time to time, cultures
were made from forty-five throats, and non-virulent
bacilli found in fifteen. In a village in France, by the
August 1 8, 1894]
MEDICAL RECORD.
221
coast, where no diphtheria had been present for a long
time, cultures were made from the throats of fifty nine
children living in a school, and in twenty six of these
non- virulent bacilli were found. In an examination of
ten throats of attendants in a diphtheria hospital non-
virulent bacilli were found once. Therefore in one
hundred and fourteen healthy throats the bacilli were
found seventy-two times. From these experiments they
concluded that a bacillus similar in all essential charac-
teristics with the diphtheria bacillus, except for its lack
of virulence, was a fairly common inhabitant of the
healthy throat.
With regard to its frequency in disease, it was noted
twice in six children with mild sore throats, and five
times in the throats of seven children in which the sore
throat was complicated with measles. They found that -
the cultures of true cases of diphtheria could be distin-
guished from those from healthy and diseased throats by
the fact that the cultures from true diphtheria con-
tained a great number of colonies of the bacilli, while
those in which non-virulent bacilli were present the
colonies were very few, there never being more than
from one to four present in one tube. Tins. would be a
valuable practical guide if it were only true.
The connection between the most virulent and the
non-virulent bacilli is shown by the gradations in viru-
lence of diphtheria bacilli. As a rule, the more severe
the case the more virulent the bacilli were found to be.
In cases which recover, the bacilli become less and less
virulent as convalescence progresses. It has been found
that throats recently the seat of diphtheria were more
apt to contain the non- virulent bacilli than were other
throats. They regarded occasional slight differences in
growth, shape, and staining as too slight and inconstant
to separate the virulent form from the non-virulent.
They regard a division founded upon the reaction to in-
oculation of the guinea-pig as an arbitrary one. It is
well known that there exist bacilli which exhibit all
grades of virulence in guinea-pigs, some causing certain
death, some marked local changes, some temporary and
slight oedema, and some causing no appreciable reaction
whatever. They believe that in order to prove the two
forms to be varieties of the same bacillus it is necessary
to first derive the non* virulent form from the virulent,
and secondly to derive the virulent form from the non-
virulent. The first they have accomplished, but in the
second they have failed.
When grown for a long time on agar a temporary
loss of virulence occurs. When the bacillus is grown in
broth through which a current of air is constantly pass-
ing, it is found that after two weeks the bacilli begin to
lose their virulence, and at the end of four weeks they
become harmless. A few days later the bacilli in the
culture will die. Just prior to this time when all living
bacilli produce non-virulent cultures, it has been found
that some would produce virulent and others non- viru-
lent cultures. When kept at 45 ° C. for three days the
bacilli were found to possess many of the characteristics
of the pseudo-bacilli. They were unable, however, to
give virulence to those bacilli which produced in guinea-
pigs no effect whatever. This was true both in those in
which the loss of virulence had been acquired artificially,
as in those in which it had occurred naturally.
Escherisch found in one city, out of seventy throats
examined, non-virulent bacilli in two, and in another
city, out of two hundred and fifty, they were present in
eleven. * In none of these was diphtheria present at the
time of making the cultures. The animal inoculations
were made from a forty eight hours' growth in glucose
alkaline broth, and the quantity injected was equal to
half per cent, of the weight of the guinea pig. With
these precautions he never found any bacilli which had
the characteristics of the diphtheria bacilli which did not
prove virulent in guinea-pigs. The pseudo-bacilli were as
described by Hofmann in some of his cases, viz., shorter,
plumper bacilli, and of fairly uniform size. The growth
on agar was more luxuriant, and in his cases whiter than
the Loeffler bacilli. This investigator has also called at-
tention to the fact that the pseudo-diphtheria bacilli show
a tendency to lie in parallel rows on a cover-glass, while
the Loeffler bacilli are collected together in a most con-
fused manner. A further and most important difference
was that the pseudo-diphtheria bacilli grown in litmus
bouillon turned it blue after forty eight hours, while the
true diphtheria bacilli produced acid, and turned the lit-
mus red. There were no exceptions to this rule, so that
where it was impossible to make animal inoculations he
considered this would prove to be in all probability a
certain guide in doubtful cases. With the true bacilli
there was no relation observed between the amount of
acid formed and the degree of virulence. . He, too, found
that in the milder cases, or during convalescence, the
bacilli were apt to be less virulent, but to this rule there
were many exceptions. This investigator concludes that
since we have found constant cultural differences to exist
between the true and pseudo-diphtheria bacillus, we can
give the pseudo diphtheria bacillus no diagnostic value,
and further, we do not find it a frequent inhabitant of
the throat.
The speaker, continuing, said that if time permitted a
more extended review of the results obtained by others,
we would still more clearly be brought to believe that
there are several varieties of bacilli grouped under this
name of pseudo-diphtheria bacilli, for how otherwise
could some observers affirm that the bacilli cause alkaline
bouillon to become acid, while others equally good as-
sert that it becomes alkaline ; or that some should find
them to be identical in all morphological and cultural
characteristics with the Loeffler bacilli, while others find
distinct and constant differences? Dr. Park said that
in the large number of experiments carried out in the
laboratory by Mr. Alfred L. Beebe and himself, they
had met with numerous examples of all the forms de-
scribed. Cultures from 330 non - diphtheritic throats
gave, in 22, virulent Loeffler's bacilli ; in 21, non* viru-
lent characteristic bacilli ; and in 28, Hofman's pseudo-
bacilli.
Dr. Park then offered the following classification, and
presented to the Society cultures in bouillon and on
agar, and cover-glass smears representing each of these
divisions :
z. Loeffler's Diphl/ieria Bacilli. — Found in cases of
true diphtheria, and in persons brought in contact with
them. They all produce the toxines described by Loef-
fler, Roux, Frankel, and others. They are subdivided
into, a, bacilli characteristic in growth, shape, and stain-
ing ; and b, bacilli not characteristic, but still having the
recognized slight variations only. All these produce
acid in their growths in broth.
2. Probably Loeffler's Diphtheria Bacilli.— They agree
with the above classes in every way except that they have
no virulence when injected in animals, and do not pro*
duce the toxines. They are found in healthy throats.
3. Probably not Loeffler's Diphtheria Bacilli,— The
growth on agar and serum is far more luxuriant than is
ever seen with true bacilli. They first make the litmus
cloudy, and then give the acid reaction. They are sub-
divided into, a. Shorter, plumper bacilli which usually
stain evenly. They grow rather more quickly on agar,
frequently give rise for the first twenty- four hours to a
cloudy broth, and give an alkaline reaction with litmus
bouillon. (Probably a subdivision could be made here
into those causing a luxuriant growth on agar, and those
which do not do so, and which are plumper.) b. Bacil-
li shorter and plumper than is usual in Loeffler's bacilli,
but taking a fairly characteristic stain. This third class
is found in healthy throats, and more rarely with diph-
theria bacilli in cases of diphtheria.
Dr. H. D. Chapin asked in regard to examinations
made several weeks after dipntheria.
Dr. Park replied that if one followed them up for six
weeks, they would be found to become less and less viru-
lent while retaining their morphological appearances.
He had not examined them after six weeks, but at this
222
MEDICAL RECORD.
[August 1 8, 1894
time they were apparently in about the same condition
as in children in whom they had been found, and yet
who had not developed any symptoms of diptheria. The
diagnosis was made chiefly on the stain, and the varied
size and shape of the bacilli. These characters ranked
next in diagnostic value to animal inoculations.
The Society then went into executive session.
OUR LONDON LETTER.
.(From our Special Correspondent )
CHELSEA HOSPITAL — MEETING OF GOVERNORS — RESIGNA-
TION OF STAFF — HEALTH CONGRESS IN LONDON — RE-
CEPTION BY LORD MAYOR — SUCCESSFUL MEETING — WORK-
HOUSE BARRACK SCHOOLS — DEPUTATION TO GOVERN-
MENT— INQUIRY PROMISED — MASSAGE SCANDALS — THE
BRITISH MEDICAL ASSOCIATION WEEK.
London, July a8, 1894.
The troubles of the Chelsea Hospital for Women are not
yet over. On Tuesday last there was a special meeting
of the Governors to consider the report of the Committee
of Inquiry. Lord Cardigan took the chair, and an-
nounced that as far as practicable the recommendations
would be carried out. He could not, however, see how
the lay members of the Board could control the staff or
even ascertain that their work was at all times properly
carried on. They must depend for their knowledge on
the medical members of the Board, and the staff were thus
represented but did not form a majority of the Board, and
his Lordship held that this was quite right, in which
opinion most men of experience will probably concur.
It was announced that in order to give the Board and
Governors a free hand in the reorganization of the hos-
pital the staff had all resigned, but were willing to con*
tinue their services pending the appointment of their
successors. Dr. Fenton, on behalf of the staff, accepted
the recommendations of the committee and pointed out
that Dr. Parkes had withdrawn the expression in his re-
port as to the "justifiability" of certain operations.
This expression, I remarked at the time, was certainly
not a proper one from a medical officer of health, who
could not pretend to any expert surgical knowledge.
Dr. Fenton pointed out that although retracted by Dr.
Parkes this is not so well known as it ought to be. In
regard to the mortality, Dr. Fenton produced statistics
showing that in the special departments of large general
hospitals there had sometimes been even a higher death-
rate. Thus, as an example, the rate in ovariotomy had
varied in six hospitals between 4.3 and 22.2 percent.,
and Chelsea did not reach this maximum in spite of its
sanitary defects. This only shows that it is impossible
to draw conclusions from a percentage calculated from a
few cases. After the meeting the Board of Management
held a sitting in order to proceed with the reconstitution
of the hospital. I hear that they will proceed to elect a
new staff. To me it seems they might well follow the ex-
ample of the late staff and resign their position ; for, after
all, the Committee of Inquiry condemned the Board of
Management, and if anyone should resign they should,
and the Governors should proceed to a new election.
But then, Governors are, as a rule, merely subscribers —
only a few take a real interest in such things and leave
the work to those who do. These give their services and
have a claim for consideration in case of mistakes or
neglect, and nothing worse is alleged. At the same
time the medical staff equally give their services and are
not responsible for management. But then the medical
officers are the readiest scapegoats, and in every alleged
abuse are sure to be blamed. Then they resign and
others are only too anxious to jump into their shoes.
This is the usual end of every hospital scandal.
The Health Congress has met this week in London.
This meeting was arranged by the British Institute of
Public Health at their Congress last year, which was held
in the University of Edinburgh, when on the proposition
of the Lord Mayor of London it was decided to meet
this year in the metropolis. All the sanitary authorities
in the kingdom were invited to send delegates, and
nearly two thousand were appointed. On Wednesday
they were received at King's College, by Dr. Littlejohn,
President, and Sir C. Cameron, Vice-President. On
Thursday there was a great meeting at the Mansion
House, the Lord Mayor in the chair, supported by the
sheriffs and other city officials in their robes of office.
Professor William R. Smith, the new President, having
been installed read his address, which appropriately
dealt with the question of the Local Government of Lon-
don. Curiously enough, on the eve of the Congress, the
British Medical Journal came out with a spiteful little
article evidently intended to spoil the meeting. People
asked each other what it meant. It was said that a
number of men had withdrawn, and hinted that the
Mansion House assembly would be a failure. It would
have done the editor good to see how little his own per-
sonal withdrawal, so ostentatiously announced, affected
the Congress. All sorts of comments are made, but no
one seems to know or care much in what way the mana-
gers have trodden on the editorial corns, but it is sug-
gested that there has been a lack of adulation toward the
D.C.L. The Journal has at the same time done good
by agitating about the barrack pauper schools, respect-
ing which it got up a deputation to the President of the
Local Governing Board, who promised some inquiry
either by a royal commission or a select committee of
the House of Commons. It is not impossible that such
inquiry may be more extensive than asked for. If that
be the case so much the better. We need full inquiry
into our Poor Law system rather than investigations
restricted to one or two cases at a time. The deputation
which was received on Tuesday was a very influential
one, representing all parties, and including women as
well as men, a natural thing when the interests of chil-
dren are concerned. Sir John Gorst introduced the
deputation in a moderate speech which the minister lis-
tened to attentively and commended, but Mr# E. Hart
was reminded that his controversial speech went beyond
his brief. He certainly deserved the rebuke as the sen-
sational statements he made were evidently intended for
an outside audience. Mr. Shaw-Lefevre looked at the
question as a grave one, and as he promised to bring it
before his colleagues in the ministry with the view of ap-
pointing an inquiry, the object of the deputation was
obtained.
Vice seems ever ready to raise its head in large com-
munities. It is now asserted that some establishments
for massage are only brothels in disguise. The papers
are full of the subject, and Truth admits that its editor
has been for months informed of the existence of " facts
such as no decent person could contemplate without hor-
ror ! " It is to be hoped that this new scandal — the most
horrible of the many that have been exploited — may lead
to such action as shall deliver us from this form of the
social evil and some others with it.
London, August 4, 1894.
The centre of gravity of the profession, so to say, has
been shifted to Bristol for most of the week. Some went
off on Monday, especially officials, but most were con-
tent to take a morning train on Tuesday ; while others
waited till afternoon and so missed the first general meet-
ing and the sermon, but were in good time for the sec-
tions, which only began work on Wednesday morning.
As your several reporters will furnish you with foil ac-
counts of both the general meetings and the sectional
proceedings, I need only gather up in thb letter some of
the fragments of the more popular side of the week's do
ings.
The attractions to the general meetings are the ad-
dresses. At the conclusion of these, or, at any rate, after
the vote of thanks, there is usually a stampede, only a
August 18, 1894]
MEDICAL RECORD.
223
few enthusiastic members staying to transact formal busi-
ness, or join in discussions of which notices have been
given.
These discussions, however, are the only occasions on
which discontent can be expressed with the council or
officials. It is not to be wondered at that among so
many members differences of opinion and dissatisfaction
should be found, and it is well that expression should be
given to such sentiments. I hear, however, that the offi-
cials would like to suppress them. The policy of sitting
on the safety-valve is not a very safe one, and it is possi-
ble the officials may be convinced of this in an unpleas-
ant manner if they do not take warning. The editor
came in for the mingled manifestations of approval and
disapproval to which he is accustomed, but he is too
astute a person to push any further the considerable irre-
sponsibility which he has managed to attain.
The exhibitors of the Museum gave a musical conver-
sazione on Tuesday night, which was numerously attended
by the residents as well as the profession ; and then the
evening's proceedings, a new feature, proved most suc-
cessful. The band of the Royal Marine Artillery was
especially engaged, and played through a lengthy pro-
gramme of music which was thoroughly enjoyed. The
general meeting not being over till late prevented an
early attendance, but by 9.30 the guests arrived in large
numbers. There was a little speaking and the buffet
arrangements were on a most liberal scale, and great
satisfaction was expressed.
As to the Annual Museum, the present display is per-
haps the most attractive and comprehensive that has
been seen. The fine hall was most effectively laid out,
the stands uniformly placed with great taste, and novel-
ties shbwn on all sides, many coming under the head of
surgical instruments and appliances. One of the chief
features of the show was located in a small room, and
had been prepared by Messrs. Oppenheimer, Sons & Co.,
Limited, London, and was in charge of Dr. Sambon,
who has collected one of the largest assortments of an-
tiquities allied to medicine ever seen in England. He
proceeded with his researches for many years on behalf
of the Italian Government, and says he has found abun-
dant proof that the ancients had a more accurate knowl-
edge of human anatomy than is generally believed.
This he asserts by showing many well-executed specimens
of different parts of the human frame and its organs, in
terra- cotta, which had been given as votive offerings to
the deities, who were supposed to preside over the wells
believed to possess curative powers. He has fine models
of ears, eyes, fingers, and scalps, all of which he says were
thrown into these wells by persons who sought relief
from complaints affecting those parts of the body. These
all date from the Roman period, and display great skill, as
they were the work of ordinary potters. This is supple-
mented by some three hundred surgical instruments from
the pre-Christian days down to the fifteenth century, so it
will be gathered the show is intensely interesting. At
another stand were shown an interesting collection of
optical scientific instruments ; then there were stands to
show the many new departures in food and physic.
Messrs. Ferris & Co. made their stand the most attrac-
tive in the hall. Drugs naturally form a large portion
of the show, and they are supplemented by many special
preparations. The collection of surgical instruments is
most comprehensive. The ever-ready plaster caddy is
also shown as being Messrs. Ferris & Co.'s specialty, for
keeping all kinds of surgical dressings in perfect condi-
tion without waste, and always ready to hand.
On Wednesday evening, August 1st, a series of enjoy-
able entertainments took place at Clifton College.
These were arranged by the President and Executive
Committee, and will be long remembered as forming one
of the leading social features of the Bristol Congress. It
was numerously attended, and the performances of the
Orpheus Glee Singers were much appreciated. These
singers have a reputation which is not confined to Bris-
tol ; no one could have gone away dissatisfied, for the
members of Bristol's great choir acquitted themselves
admirably. At the end of the concert there was an
organ recital, and late as the hour was before it began,
very few of the guests left before it terminated. Supper
was served in a large tent, and after partaking of it we
went and paid a visit to the Zoological Gardens, which
were charmingly illuminated during the entire evening.
This most enjoyable conversazione was brought to a
close by a display of fireworks closing with a set piece,
"The Good Samaritan," which was a well carried-out
pyrotechnic performance. Then God Save the Queen
was played and we each retraced our ways to our
various hotels.
At 11 o'clock on the same day there was a grand
organ recital at the Colston Hall by the organist of the
Bristol Cathedral ; invitations were freely distributed and
there was a large gathering. The programme was se-
lected with a view to displaying the great compass of the
organ, and in this was very successful. Moreover, the
items were full of tune and finish and much appreciated.
I must not forget the opening ceremony of the Clifton
Pump room and Spa, which was publicly inaugurated on
August 1st by the Mayoress of Bristol, and has been
undertaken and completed by Geo. Newnes, M.P. The
magnitude of the work gave rise to difficulties, and
would have sorely tried the patience of less resolute
men than Mr. Newnes, as will be appreciated when it is
explained that the whole site has been cut out bodily
from a sloping limestone rocky garden, which was ac-
quired as being the finest position in Clifton for the pur-
poses contemplated. It well deserves its name, and
stands out in bold relief upon Sion Hill, reflecting the
greatest credit on the architect and engineers. On this
occasion several speeches were made and an illuminated
address was presented to Mr. Newnes. In the evening,
at the invitation of Mr. Newnes, many persons enjoyed
the dual pleasure of listening to an excellent concert at
the Grand Spa and inspecting the splendidly appointed
Pump room. Lovers of music were also catered for on
several other occasions during the Congress.
On Thursday some five hundred members were enter-
tained at a garden party at Ashton Court, but unfortu-
nately the weather was very unfavorable; happily there
was. a winter garden and museum in which they could
take* refuge. Another garden party was also spoiled, but
here again in door provision was made for such an event,
an organ recital and other entertainments being pro-
vided. During the meeting the National Temperance
League gave a breakfast to a number of the members.
The League has done this for several years, and their
breakfast has become a feature of the annual gathering.
On this occasion the breakfast was presided over for the
first time by the President of the Association, Dr. Long
Fox, who is himself an abstainer, and who in welcoming
the guests said he thought their position as medical
men, with reference to this question of temperance, was
that of medical missionaries. (Hear, hear.) There were
many ways of helping and encouraging die movement,
and it was impossible to say that many of these ideas
were not very useful indeed, because, as the mind of man
was various, so the methods of man were various also.
He was not there to cavil at any of these methods, as
some might say that law was of little practical use unless
the common-sense of the nation had been educated up
to its reception as a national want ; but the great prin-
ciple of the National Temperance League, the good in-
fluence of one person upon another in this temperance
cause, would meet all possible objections. (Hear, hear.)
Great as was the influence exercised by temperate medi-
cal men, with the full knowledge they had of how harm-
ful alcohol was to vitality, and how injurious it was to
many organs of the body, the chance of turning a neigh-
bor from the error of his ways was enhanced a thousand-
fold if the speaker were a total abstainer himself. (Ap-
plause.) They could do something in the way of
removing the stones from the King's highway. Already
one sixth of the population had shaken itself from the
224
MEDICAL RECORD.
[August 1 8, 1894
hideous evil that tended to the destruction of the na-
tion, and in the noble fight against drink, the cause of
Etverty, disease, and crime, the key note of that and all
ndred societies, they might justly boast would include
freedom from all excess. (Loud applause.) The other
night Dr. Annie Cornall wished the cause every success,
and said the movement was especially important in re-
lation to women, because they had such influence in the
home.
Speeches were also delivered by Professor Cameron, of
Glasgow, Dr. Ridge, Dr. Mackenzie, of Belfast, Dr.
Hughes, of Wales, and Dr. Norman Kerr. Mr. Robert
Rae, the Secretary of the League, returned thanks, and
said the work of the League among the members of the
medical profession was the most successful they had ever
undertaken.
I hear that the dinner was well attended, but I did not
fo, having partaken of as many of these entertainments as
care to. For I have found each one very much a replica
of the rest. So also I was unable to take the trip around
the docks, which I hear about a hundred members en-
joyed.
SHORTHAND IN MEDICINE.
To thb Editor or ths Medical Rbcosd.
Sir : In order to promote the use of shorthand in medi-
cine, it is desirable that a list should be compiled of all
who use it. We would, therefore, ask each practitioner
and student who is acquainted with phonetic shorthand,
to send his name and address to Dr. Neil, Warneford
Asylum, Oxford, England.
The preparation of a list of medical phonographers is
intended as a preliminary step to such further measures
for mutual encouragement and help as may appear advis-
able.
W. R. Gowers, M.D., F.R.C.P.,
Edward B. Gray, M.D.,
James Neil, M.D.
NON VOLUIT NOCERE.
To thb Editor or thb Medical Rbcobd.
Sir: In my lecture " Non Noceie," delivered before the
Eleventh International Congress, which you printed in
your issue of May 19th, I referred to a case of idiocy with
premature ossification of the cranial bones kindly reported
to me by Dr. Vander Veer, and used the following words :
"Arthur McKee F , born, 1891. Previous to his
birth, a miscarriage and a still-birth. Mother had al-
buminuria every time [syphilis?].11
About a week ago I received from the father of the un-
fortunate baby a very indignant letter, dated June 9,
1894, in which he says : " I demand an explanation and
insist upon a correction which shall appear in the next
issue of the Medical Record."
Now, Mr. Editor, if after such a long time your space
and your kindness permit you to publish all of this, I
courteously offer the following "explanation" of my
syphilis with interrogation mark in brackets, viz. : Suc-
cessive miscarriages, to a certain extent also persistent al-
buminuria and excessive bone proliferation resulting from
an irritative nutritive process, suggest the presence of
syphilis in a late form. They do not prove it, unless there
be corroboration by the history or the physical exami-
nation of the parents (mostly the father) or the wetnurse.
The interrogation mark means : No certainty at all ; at
all events, justifiable doubt.
The " correction " is that " there was no such intima-
tion whatever in Dr. Vander Veer's report ;" that the
father strenuously denies syphilis, and that, therefore, the
cause of the poor baby's abnormal, both physical and
mental, condition is not explained.
Very sincerely yours,
A. Jacobi, M.D.
New York, August 5, 1894-
PALATABLE AND DIGESTIBLE MILK.
To thb Editor op the Medical Record.
Sir : A brief but suggestive editorial in your issue of
July 28th, on the digestion of milk, prompts me to add
one more to the devices by which the use of this most
essential article of invalid diet may be made more agree-
able to those who cannot, or think they cannot, take it
"straight."
I have never seen it mentioned in any text- book, and
it did not come to me from a professional source, but
from a lady who had been for a long time the patient of
the late Dr. Pease, of Syracuse. Whether it originated
with him I cannot say, but perhaps some of your readers
in Central New York, by whom he is doubtless as pleas-
antly remembered as by myself, can tell me. It is as
follows :
A pint of milk is gently warmed. Into it is dropped,
very slowly and with constant stirring, about twenty
minims of the dilute hydrochloric acid of the United
States Pharmacopoeia. The milk should be stirred until
it cools.
In this way a very fine flocculent coagulum is pro-
duced, floating in the whey, which is easily accessible to
the digestive secretions, while the whole fluid has lost
somewhat of the flat and cloying taste which makes it
unacceptable to so many.
It will be noticed that milk prepared in this way dif-
fers from the various " wheys " in the highly important
particular that the casein is retained and used, instead
of being separated out as a distinct product, while it
avoids the bitterness of pancreatized milk.
I have found it occasionally of great value when other
preparations have been unacceptable either to the palate
or the stomach. Robert T. Edes, M.D.
Boston, Mass.
f^Xedital Stems.
Contagious Diseases— Weekly Statement — Report of
cases and deaths from contagious diseases reported to the
Sanitary Bureau, Health Department, for the week end-
ing August 11, 1894.
Cases. Deaths.
Tuberculosis
Typhoid fever
Scarlet fever. ,........••.
Oerebro-apinai meningitis
Measles
Diphtheria
SmaJl-pox
7°
37
33
o
16
in
X
6
6
6
o
34
1
The True Physician longs for the time when in every
fellow-practitioner he shall find a brother, a counsellor,
a scholar, a gentleman. — W. J. Bell.
Lactate of Cocaine in Tubercular Cystitis.— Dr. Witt-
sack has found benefit from the instillation into the
bladder, once or twice a week, of fifteen drops of a solu-
tion containing twelve grains of lactate of cocaine and
one drachm of lactic acid in one drachm of water. Lac-
tate of cocaine is a white substance the consistency of
honey, readily soluble in water. It has not yet been
obtained in a dry state.
Remarkable Fecundity.— An instance is related in
the Journal de Clinique et de Thirapeutique Infantile*
for May 10, 1894, of a woman, forty-nine years old, who
had given birth to twenty- five children. She had been
married three times and had never had twins. Of the
twenty-five children nineteen were boys, who had all died
in childhood ; the six girls had all lived, the youngest
being five and the eldest twenty-eight years old. The
woman had received a medal at the Sorbonne in recog-
nition of her patriotic efforts to increase the population
of France.
Medical Record
A Weekly yournal of Medicine and Surgery
Vol. 46, No. 8.
Whole No. 1242.
New York, August 25, 1894.
$5.00 Per Annum.
Single Copies, ioc.
Original %x\it\z%.
THE CURE OF CARCINOMA OF THE BREAST
BY RADICAL OPERATION— OBSERVATIONS
IN ONE HUNDRED AND EIGHTEEN CASES.1
By WILLIAM T. BULL, M.D.,
nonssoR of surgery, Columbia college, surgeon to the new York
HOSPITAL.
The following series of cases, occurring between the
years 1880-94, are offered as testimony to the value
of the modern radical operation in cancer of the female
breast. In every instance but one the diagnosis has
been confirmed by microscopical examination, for which
Dr. Frank Ferguson, pathologist to the New York Hos-
pital, has been responsible in the majority. To the
tracing of the cases through this number of years, and
keeping the records up to date, January 1, 1894, Dr.
Charles A. Powers, surgeon to St. Luke's and the New
York Cancer Hospitals, has given much time and enthu-
siasm. He has been associated with me in the care of
many of these patients during the past five years. To
his efforts is due the circumstance that but 3 of the
118 cases have been lost sight of— a smaller percentage
than is noted in any other record. Weir, for instance,
traced but 60 of his 125 patients, Dennis was able to
keep sight of but 33 of 71, and Curtis (Medical Rec-
ord, No. 24, 1894), in collecting the statistics of eight
foreign clinics, gives final results in only 813 of a total
of 1,213 cases.
In the matter of etiology, trauma, previous inflamma-
tion, heredity, and age, are found to play about the
same rdle as is mentioned by other observers. There is
no noteworthy difference from other statistics; and in
these particulars, as well as in such details as the part of
the breast affected, the relative frequency of disease of
the right or left breast, this series gives no information
of practical value. In passing I may, however, note the
fact that of 13 cases in which cancer existed in the pre-
vious generation n were found among the recurrent
and 2 among the cured cases ; and furthermore, that I
have taken no notice of the item of duration of the dis-
ease before operation, because the data in most instances
are so untrustworthy. I have excluded all cases of second-
ary operations (about twenty in number) performed on
patients with whom I had no previous experience, and
have no records of patients in whom no operation was
advised.
The practical value, then, of this record is in its show-
ing as regards the question of cure, to which only a por-
tion of the cases contribute, because not all operations
have been complete or radical in character. As incom-
plete operations, which are ten in number, performed in
the years 1880 to 1884, I include those in which the
breast only was removed primarily ; as complete, those
in which the breast was excised together with a liberal
amount of skin over it, the fascia of the pectoral muscle,
and the glands of the axilla embedded in their fat. This
thorough and admirably planned operation was first sug-
gested by Moore, then advocated by Banks, in England,
popularized by Volkmann in Germany, and warmly sup-
ported by Gross in this country ; and it is now, I believe,
generally adopted. It has been performed in 108 cases
1 Read at a meeting of the Surgical Section of the Massachusetts
Medical Society, June 12, 1894.
without reference to the condition of the glands as de-
termined by examination prior to the operation.
The 10 incomplete operations were all followed by
recovery ; the 108 complete operations include 4 fatal re-
sults, the cause of death being in 2 cases erysipelas ; in i,
chronic nephritis and pneumonia; in 1, acute sepsis and
pneumonia. This is a mortality percentage of 3.6 per
cent. Curtis, above quoted, finds a mortality-rate of
"very nearly six per cent." in 1,213 cases, while Weir
and Dennis have reported series of 125 and 33 cases,
respectively, without death. For so small a mortality it
seems hardly necessary to offer explanations, but it is
worthy of note that all the patients were of the hospital
class, that the two dying of erysipelas undoubtedly were
infected in the hospital, and that the case of acute sepsis
owed its existence to a streptococcus invasion from an
undiscovered source. Curtis's statistics go back as far as
1870. The mortality of the later reporters is much
less than that of the earlier, and in view of several series
without any mortality, I think it may be averred that the
complete operation is attended with but little more risk
than the incomplete, and that in persons otherwise
healthy and in operations unattended with accidents, it
ought not to be greater than three or four per cent. This
is a very slight risk for the patient affected with cancer
to take, especially in view of the prospect of cure.
In order to determine the proportion of cures, we can
utilize of the 108 only those cases which were operated on
prior to 1 89 1. Since that date there have been 30 opera-
tions. Deducting these and the three which have been
lost sight of, I have 75 cases. Of these 75 cases 3 died
from the operation ; 50 died from recurrence or metas-
tasis ; 2 are still living with recurrence ; 4 died of other
diseases after having passed the " three-year limit "
without manifestation of cancerous disease; 16 are alive
and in good health on January 1, 1894.
This gives 20 cured cases out of a total of 75, or 26.6
per cent. This is a higher proportion of cures than has
been previously reported. Curtis gives 20.7 as the per-
centage of cures in the 1,213 cases ne collected. Weir
" nearly twenty," and Dennis twenty-five per cent. The
value of my percentage is increased, I think, by the fact
already mentioned, that but 3 cases of 108 have been
lost sight of.
Regarding these 20 cured cases more in detail, let me
say of the 4 who died of other diseases, after passing the
" three-year limit," that
One died at the end of J years, of pneumonia.
One died at the end of rf years, of chronic bronchitis and emphysema*
One died at the end of 3! years, of acute rheumatism.
One died at the end of 3 years, of chronic nephritis.
The 16 cases still alive and free from recurrence have
lived on an average six years and a few days since the
operation. To be more explicit :
Two are living and well 3 years and 9 months after operation.
Four are living between 4 and 5 years after operation.
Three are living between 5 and 6 years after operation,
One is living between 6 and 7 years after operation.
Three are living between 7 and 8 years after operation.
One is living between 8 and 9 years after operation.
One is living between 9 and 10 years after operation.
One is living 10 years after operation.
These cured cases are all the more significant because~of
the extent of time they have remained cured, the average,
six years, being twice as long as the " three year limit."
Only 2 have undergone secondary operations. Of the
226
MEDICAL RECORD.
[August 25, 1894
4 who died free, 1 had a recurrent'nodule removed at the
end of four months, and died of rheumatism over three
years later. Of the 16 still living, one had three nodules
removed at periods of six months, seven months, and
eighteen months after the primary operation, and is living
five and one half years since the last operation.
In computing the percentage of cases I have included
in the total of seventy-five, the three patients dying from
the operation. This class has been deducted by some
reporters. I have excluded from the " cured " list one
case which died of cancer of the oesophagus nine years
after the operation on the breast and axilla, having been
free meanwhile from recurrence — a case which might be
fairly regarded as an instance of fresh infection, or the
development of a growth entirely independent of the
original disease. Poulsen l has reported an instance of
cancer of the pylorus developing five years after an opera-
tion on the breast, which is capable of a similar explana-
tion. I have accepted the " three-year limit " as evidence
of cure in order to make my statistics to conform to those
of others. It seems to be true, in the majority of cases,
that recurrence takes place in loco, and metastatic de-
posits occur within this, time, though instances of a
later development of both features are not rare. Curtis,
from various sources, records thirty -four recurrences
after three years and up to the seventh year. Weir has
seen one at sixteen, and one at twenty years. I am not
able to give the precise data of recurrence in many cases,
but can say that the average duration of life in cases dy-
ing of recurrence or metastasis was less than three years,
and that I have observed no instances' of reappearance
of the disease after three years. A four-year limit would
be undoubtedly more accurate. Judged by this standard,
my list of cures would be reduced by only 5 cases, mak-
ing 15 cures in 75 cases, or a percentage of twenty, the
same that Curtis's 1,213 cases give with the year limit.
The patients operated on since 1891, not available for
the question of cure, are 30 in number, of whom 10, or
thirty- three and one third per cent., are without recur-
rence and with prospect of cure, though an average of
but fifteen months has elapsed since their operations.
Two died within eighteen months from the time of oper-
ation, free from cancerous disease; 1 died from the
operation, which is already counted in the list of deaths ;
1 1 have died of cancer already, and 6 are living with
recurrent disease.
The record of the incomplete operations emphasizes
the advantage of the complete or radical method of treat-
ment. Of 10 patients in whom only the breast was re-
moved, all died of cancer at the end of an average pe-
riod of thirty-four and one half months, 3 having under-
gone several secondary operations. It is my conviction
that, except as a palliative method, this form of opera-
tion should no longer be countenanced. It is unques-
tionably attended with less risk, as numerous statistics
have shown, but our knowledge of the course of the can-
cerous diseases, and the absence of statistical tacts to sup-
port it, demonstrate that it is an utterly inadequate
method.
< In every case of cancer, whether the glands of the
axilla be felt to be enlarged or not, the complete opera-
tion should be done. It removes not only the diseased
area, but the parts more likely to be affected by recur-
rence, the skin and pectoral fascia, which have been
shown by Heidenhain to be often the seat of deposits
which may escape the naked eye. It clears out the
axilla, the next resting-place of the neoplasm, whose
glands may be enlarged from disease without their pres-
ence being discovered by external examination. Only
in abnormally thin subjects can one be reasonably sure
of the condition of the glands, as many surgeons have
testified. It should do more than this, and that is, re-
move the parts between the axilla and the breast, the
region through which the lymphatics pass. In my opera-
tions, as the accompanying cuts will show, I have been in
the habit of removing the parts in one solid mass from the
1 Arch. fUr Win. Chir., 43, p. 59a.
inner periphery of the breast to the apex of the axilla;
and this detail, which is not generally insisted on, I re-
gard as of great importance.
Without quoting other statistics, it may be safely stated
that the complete operation has been, since its introduc-
tion, attended with a diminishing mortality and an in-
creasing percentage of cures. It has unquestionably
been done in many cases in which it could promise lit-
tle on account of the extent of the disease. One cannot
avoid this conviction in reading the histories of individ-
ual patients, and I know that, in many hospital and some
private patients, I have performed operations under cir-
cumstances which a maturer judgment and larger experi-
ence would now regard as contra- indications to the
operation. If we could expunge from all our lists the
number of these advanced cases, the showing would be a
very much more encouraging one. My notes are not
F10. 1.— Cancer of the Nipple, Fig. 2.— Cancer of Breast and AxiBa, ID
Breast, and Axillary Glands fol- Show Amount of Tissue Removed,
lowing Ulceration of the Nipple
for Eleven Months.
sufficiently full in the matter of extent of the disease to
enable one to make any such distinction. Such points
as adhesion to the wall of the chest, involvement of the
pectoral muscle, fusion of the cancerous glands, and ad-
hesion to the axillary vessels are rarely mentioned,
though all or some of these conditions have been met
with in a considerable number of cases. But in regard
to involvement of the axillary glands I can give some
data.
Of the 20 cured cases the breast alone was affected in
12, while in 8 both glands and breast were involved. Of
55 cases dying (3) of the operation or recurrence (50),
or living with recurrence (2), the glands were involved as
well as the breast in 38, while in 10 the glands were free
from disease. In 7 the condition is not stated. In
other words, of the cured cases forty per cent, had both
breast and axilla affected. It should be stated that the
evidence of involvement of the glands in most cases was
determined by microscopic examination, and that in
August J25, 1894]
MEDICAL RECORD.
227
many the deposits in this region were detected only after
the axillary fat was cut into.
The complete operation, then, is capable of effecting
a core even when the glands are involved, and that in a
considerable proportion of cases ; and if we make a sharp
distinction between the cases according to the condition
of the glands, we shall get the following more encourag-
ing picture of the 75 cases :
This condition was not noted in 17
Breast alone affected in 22
Breast and glands affected in 46
Total 75
Of 22 cases in which the breast alone was diseased, 12,
or about fifty-four per cent., were cured, 10, or forty-five
per cent, died of recurrence. Of 46 cases in which both
breast and glands were involved, 8, or seventeen percent,
were cured, and 38, or eighty- two per cent, died of op-
eration, or a recurrence, or are living with recurrence.
This showing would support the statement that in at
least one-half the cases of cancer limited to the breast
alone the complete method may be expected to effect a
cure. The deaths, it is to be noted, are all among the
cases where both glands and breast are involved. De-
laying the operative treatment, then, not only increases
the death-rate but diminishes the prospect of cure. Pa-
tients ought to be subjected to the complete operation in
the earliest stages of the disease. There is no longer
any excuse for delay on the part of physicians, on the
ground that more time is needed to make a diagnosis,
and the laity, if made aware of the possibilities of cure,
will promptly overcome the dread of operative treatment,
which is another reason for delay. Irregular practi-
tioners furnish the public with the strongest representa-
tions, or misrepresentations, of the success of other
methods which we know to be of less value than the
operative ones. Why should not the regular profession,
through its public representatives — the Boards of Health
—be equally active in informing the people of the dan-
ger of delay, and the promise of cure by early and radi-
cal treatment ?
In a condition, the successful treatment of which de-
pends absolutely on its promptness, exactness in diag-
nosis should play a secondary rdle. A lump in the breast
is never a "nothing," as* it seems occasionally to be
termed by physicians who see it first. It is either an in-
flammatory deposit, or a solid or cystic tumor. Between
the two latter conditions it is often impossible to distin-
guish in large and even small breasts. But the hypoder-
mic syringe and needle, which should be used in all
doubtful cases, clears up this point at once. With its
use I have demonstrated the harmlessness of cases which
have been viewed with suspicion or pronounced malig-
nant by others, and in passing may note that I have en-
countered thirty cases of simple cysts of the mamma in
the past ten years, probably about ten per cent, of all the
cases seen. If a tumor be thus proven to be solid, ex-
ploratory incision should be made the diagnostic test
when its features are doubtful. Naked-eye inspection
will usually suffice, though the freezing microtome and
the nitric acid test of Stiles, or the " punch" devised by
Mixter are unobjectionable. They can be employed
when the incision is not allowed. There is no reason-
able objection to the incision. A benign growth de-
mands operation almost as urgently as a malignant one,
for we have ample testimony of the degeneration of these
tumors into malignant ones at or after the menopause.
Inflammatory deposits can suffer no harm from incision
or renewal. They are liable to be the precursors of can-
cerous disease, and can be looked upon as safe, and en-
titled to be unmolested, only when they are disappear-
ing spontaneously after a recent acute mastitis. I have
two cases bearing on the degeneration of benign tumors
which are worth recording. The first, a woman, aged
forty-five, noticed a rapid growth of a tumor which had
been quiescent in one breast for sixteen years. At the
end of one year the whole breast was transformed into a
typical carcinoma, which was removed without the
glands. Two secondary operations were done, followed
by local recurrence, and she died, at the end of five years
from the beginning of the disease, with cancer of the
liver. The second, aged seventy- five, carried for eighteen
years a small painless tumor, which in one year involved
the greater part of the breast and the axillary glands.
One complete and one secondary operation were fol-
lowed by death from cancer of the lungs and pleura after
twenty months.
A condition of chronic eczema of the nipple (or
Paget's disease) giving rise to cancer, I have met with in
four cases, which are noticeable because the duration of
the ulceration did not exceed one year, being four
months in one, eleven months in a second, and about a
year in the third or fourth. In two the glands as well aa
the breast tumor underlying the ulcer were cancerous.
The ages were forty-eight, sixty, fifty, and forty years.
One patient, operated on a year ago, is still alive and free.
Two died of recurrence within two and a half years.
One lived eighteen months free from trouble, to die of
pneumonia. One patient declined any investigation of
the axilla, and was obliged to undergo a secondary
operation eight months later, which revealed glands
which must have been diseased at the time of the primary
and incomplete operation. The importance of these
cases should not be overlooked. Although it has been
noted that these eczematous conditions often go seven
and even ten years before the development of cancer, it
ii proper to regard them with suspicion, and desirable to
treat them promptly by complete operation so soon as
milder measures fail.
In one of the above cases, where an ulcer had existed —
refusing to remain healed under the application of oint-
ments for a period of eleven months — I had a wedge of
the base of the ulcer removed for examination by the
pathologist, who pronounced it only "chronic inflam-
mation." In view of the duration of the ulceration and
its well-known tendencies, I urged exploratory incision.
A part of the ulcer deeper than the mass removed looked
surely cancerous. The whole breast was removed, ard
the axilla invaded. Subsequent investigation showed
the breast to be cancerous in the neighborhood of the
ulcer, and the glands not to be affected. These might be
considered cases of primary epithelioma of the nipple,
but the fact remains the same, that a persistent ulceration
of the nipple often leads to cancer, and must not be neg-
lected.
It has been generally claimed that the complete and
even the incomplete operation, when it fails to cure,
prolongs life and makes its ending less distressing. I
have not the data at hand to give figures bearing on
these points, because the duration of the disease, as
proven by patients, is so indefinite ; but I can safely say
that, judging by the results so far as the duration of life
is concerned, in those which have undergone secondary
operations, and those which have not, the operated cases
have the advantage. For instance, of ten incomplete
operations all died of cancer at the end of an average
period of 34$ months ; seven of these, without secondary
operation, lived on an average of 234 months ; three, who
had secondary operation, lived an average of 58 J months
after the first operation. Of sixty patients with com-
plete operation I note forty seven who died without any
but the first operative interference, ao-,y^ months; while
thirteen who had ore or several operations subsequent to
the first, died 30 months afterward. But one single case
is worthy of mention. A woman, aged fifty, underwent
the complete operation for a tumor of breast alone of
two years' duration. She died of cancer of liver, lungs,
and pleura, at the end of eight years and eight months
after the operation, ten years and over from the outset
of the disease. In this interval five operations were per
formed, including one on the opposite breast.
Operations, in my opinion, do prolong life, and Ism
quite sure they have a further advantage in regulatirg
the course of the disease, so as to make it more bearable.
228
MEDICAL RECORD.
[August 25, 1894
In a certain number of cases there is no external outbreak,
and the patient dies of internal deposits without know-
ing the nature of her malady. The annoyance of a foul
and bleeding ulcer is avoided, with the pain that comes
from involvement of the walls of the chest. Further-
more, the clean removal of the axilla diminishes the
chance of interference with the venous circulation and
the occasion of that distressing feature— oedema of the
entire arm.
These facts encourage m; to advise secondary opera-
tions when the growths are small and freely movable.
Several such operations may be required without materi-
ally diminishing the prospect of final cure ; but in gen-
eral I have little faith in the value of secondary opera-
tions, except as palliative measures. I believe it is an
excellent measure in dealing with the first occurrence to
give an anaesthetic and inspect thoroughly the whole
line of the cicatrix, rather than to trust to the removal
of the growth with the use of cocaine. This " revision
of the scar," as I have termed it, done at the moment of
the first recurrence, has enabled me to find and remove
nodules that were not felt on palpation. The cocaine
operations, of which I have done a number, have seemed
to me exceedingly unsatisfactory.
In the axilla the removal of recurrent nodules or
glands is often a matter of difficulty, owing to the pres-
ence of cicatricial tissue and the likelihood of finding
deeper masses adherent to the axillary vein. Excision
of a portion of the vein is required in the latter event, a
procedure which I have never known to give rise to un-
pleasant results, but which may in its performance offer
an opportunity of wounding the vein several times un-
awares, with serious hemorrhage. In general, operations
for recurrent masses which are adherent either in the
axillary or breast part of the scar, I have found to be of
no advantage whatsoever.
The operation itself needs no description in detail, but
there are several points which are worthy of emphasis.
The skin incision should in general conform to the oval
type — a widely open oval — and extend from a point near
the sternum to one overlying the axillary vessels. Its
long axis may be at right angles to the direction of the
pectoral fibres, with a second cut in the axillary region,
if the tumor be most conspicuous at the upper and inner,
or outer *nd lower, periphery. Its outline is of little
consequence. Its distance from the neoplasm is of the
greatest importance. When the growth is in the breast
I have usually placed the incision at least one inch from
the borders of the gland, where it is peripherally situated
two inches from the edge on the side affected. The cut
must be made without reference to subsequent approxi-
mation of the edges, though much tissue can be advan-
tageously saved in the axillary part of the incision, and
in the majority of my cases a primary union has been
possible. After separating the mamma itself it is al-
lowed to hang down, still in connection with the axillary
part, till the parts between the breast and axilla and the
contents of the latter have been separated. There is lit-
tle danger of wounding the axillary vessels if the fascia
over the vein is first clearly laid bare and the mass of
vessels and nerves .gently pushed away from the ratty
contents, the vessels crossing the space being clamped
before they are cut. The subscapular nerves must be
avoided, but the intercosto-humeral branches must not
be cut. After the axillary space has been freed of its
contents, search must be made at the very apex, and in
the region between the two pectoral muscles, where out-
lying glands are occasionally found. In closing the
wound I have given up all sorts of relaxation sutures and
come to rely on fine catgut. The edges are brought
only loosely together without any strain, but carefully
approximated to the deeper parts with compresses sup-
ported by adhesive straps. The axillary space must be
obliterated by an additional wad of gauze. If open
wounds are left, it is better, in my opinion, to practise
skin-grafting after granulation has occurred. The opera-
tions have naturally, in the course of these years, run
through the various modifications of antiseptic dressings.
The most recent cases show the most satisfactory results,
and these have been done on aseptic principles, with
sterilized materials and without irrigation or drainage.
Complete primary union without complication has been
obtained in fully two-thirds of the cases, and, where it has
failed, there has been no serious sequelae nor prolonged
suppuration. In two instances erysipelas was fatal.
Operations done in private houses have produced uni-
formly good results as regards wound healing. There
have been no serious after-effects of these operations.
Some patients are much annoyed by a hyperesthesia of
the skin on the inner side of the arm, which gives place
to numbness which gradually disappears. This phenom-
enon has been such a frequent source of complaint when
the dressings are removed that I usually lead patients to
expect it, and promise that it will disappear.
The movements of the arm and shoulder joint have be-
come ultimately perfect in all cases. I usually encourage
motions from the elbow on the fifth day, and those of
the shoulder after the tenth day, and on the average the
slight stiffness yields to natural exercise within three or
four weeks.
In closing, let me say that I have made no distinction
in this series between the different varieties of carcino-
Fig. 3.— Cicatrix, with Free Mobility of Ann, Four Years after Operation.
ma, because of the difficulty of assigning many cases to
an individual class. But I should state that I have uni-
formly advised against operation in the variety known as
" atrophying scirrhus," occurring in old people, and in
the rapidly growing voluminous tumors occurring be-
tween thirty- five and forty-five, and described as en-
cephaloid or medullary carcinoma.
I thank the Massachusetts Medical Society and your-
self, Mr. Chairman, for the privilege of bringing before
you these results of treatment of this most important sur-
gical disease ; and I hope that your experience may be
in line with my own and will serve to strengthen our
convictions, that the modern radical or complete opera-
tion has already cured from twenty to twenty-five per
cent, of all cases of cancer of the breast ; that it may be
expected to cure at least one-half the cases if applied be-
fore the axilla is invaded ; and that it is likely to have
an even better showing if the patients can be brought to
treatment earlier than they manage at present. This can
be effected by less attention to accurate diagnosis, and by
giving up the habit of waiting to see how the tumor will
develop, and by relying on needle exploration and inci-
sion. The incomplete operation should be abandoned,
except as a preventive measure, or for the relief of local
symptoms. Benign neoplasm and inflammatory deposits
August 25, 1894]
MEDICAL RECORD.
229
should be removed, and persistent ulceration of the nip-
ple treated as cancer. Secondary operations are of value
only when the nodules are small and free from adhesions,
and the " revision of the scar " should be performed in
the event of the first recurrence after complete operation.
The risk of the complete operation is slight, and it is fol-
lowed by no undesirable after- effects.
35 Wcst Thirty-fifth Street.
ON THE NEW RELATIONS OF PATHOLOGY
AND PRACTICAL MEDICINE AS BEARING
UPON THE PATHOLOGICAL DEPARTMENTS
OF OUR HOSPITALS.
By JOHN SLADE ELY, M.D.,
PROFESSOR OF PATHOLOGY IN THR WOMAN'S MSDICAL COLLEGE OF THE NRW
YORK INFIRMARY I ASSISTANT IN PATHOLOGY IN THE COLLRGB OF PHYSICIANS
AMD SUBGROMS i PATHOLOGIST TO BELLEVUB HOSPITAL.
In the progress of every science a period of fact accumu-
lation must precede the more strikingly epoch making
one of generalization. Until generalization commences
but little practical application of the facts accumulated is
possible. Pathology affords many examples of the truth
of this great principle of all inductive science. Its clear
perception stimulated Morgagni and his followers to col-
lect the carefully corroborated facts which a century later
suggested the generalizations of the cellular pathology of
Virchow ; and, similarly, the facts accumulated by Pas-
teur in the study of fermentation and putrefaction, made
possible the even greater generalization of the causative
relationship of micro organisms to disease. A glance at
the influence of these generalizations upon the study of
disease and upon the relation of the pathologist to the
clinician is most suggestive.
The enunciation of the fundamental law of the cellular
pathology, omnis cellula e cettula, drew attention to the
cell as the ultimate living factor in the production of the
lesions of disease. The cell and the tissues to which it
gave rise thenceforth became the prime objects of study
to the pathologist. This resulted in the accumulation of
a vast fond of knowledge of the morbid anatomy of dis-
ease. The great usefulness of this study to practical
medicine was evident in the greater accuracy of diag-
nosis, and, secondarily, in the juster appreciation of the
limitations of medication. So long as it was the domi-
nant force in pathology the careful autopsy and subsequent
examination of the tissues met all the absolute require-
ments. They acted as a check upon diagnosis, showing
the clinician his error when it existed, and so helping him
in subsequent cases of the same nature to a more correct
interpretation of the symptoms. From the very nature
of the case the work of the pathologist was largely post
mortem. He was often deplorably ignorant of the
pathology of minor ailments not usually followed by
death, he had but a secondary interest in symptomatology
(in reality an important part of pathology in its broader
sense), and he was rarely called upon to assist the
clinician at the bedside. The position occupied by
pathology during this time wft, then, essentially that of
a pure science ; it had but a limited practical applica-
tion.
But, with the development of the idea of the etiological
relationship of micro-organisms to disease a new epoch
lias opened. We have been taught that many diseases
are the result of the entrance into the body and growth
there of noxious living organisms ; that the changes which
the study of morbid anatomy showed to be characteristic
of these diseases, are the result of the action of these or-
ganisms upon the tissues of the body ; that this action is
produced by poisonous substances elaborated by the
micro-organisms, some of these toxines expending their
energies upon the tissues in the immediate neighborhood
of the growing germs, while others are diffused through-
out the body, giving rise to fever, prostration, etc.,
symptoms more or less common to all diseases of infec-
tious origin.
By these discoveries new interest is awakened in the
alluring field of preventive medicine, for it has been es-
tablished that without the agency of the specific micro-
organism of an infectious disease, that disease can never
originate. Prevent its entrance into the body, and the
disease is prevented. Thus, the interest attaching to the
determination of every detail of the life history of the
microbes of disease becomes immense, many new prob-
lems at once suggesting themselves. What is the path
of entrance of the specific organism into the body ; in
the air inspired, in the food, or through the skin ?
Through what channel does it leave the body of the pa-
tient ? What is the manner of its dissemination, its re-
sistance to drying, sunlight, heat, etc., its habitat during
the interval of its transmission from one person to an.
other ? Without a thorough knowledge of all these
points it may be impossible to institute an efficient plan
of prevention. And, furthermore, we inquire whether,
in certain diseases in which prevention of the entrance
of the infectious material into the body may be imprac-
ticable, it may not be possible nevertheless to induce a
condition of immunity to its action, in this way accom-
plishing the same ultimate result? Thus the influences
inducing a predisposition to, and those inducing an im-
munity from, the action of the contagium of infectious
diseases must receive most careful investigation.
It must be evident, then, that the determination of
the causal relationship of micro organisms to disease has
revolutionized the whole science of pathology, very
greatly widening its scope and increasing its usefulness to
the clinician tenfold. The student of pathology must
in future acquaint himself with subjects which until re-
cently were supposed to have little, if any, bearing upon
disease. It is no longer sufficient for him to confine
himself to the study of morbid anatomy, but he must
now also search for the living causes of disease, he must
study their peculiarities of structure and growth, their
mode of action upon the body, the toxines which they
elaborate, their paths of entrance to and egress from the
body, and the various problems of their destruction and
the prevention of their ravages. In his search for the
cause of a disease he need not wait until death has
brought his victim to the autopsy table, for experiment
has shown that often during life the germs of a disease
are present in the blood and in the various excreta of the
body, as are also the chemical poisons which they pro-
duce. Thus, early in the course of the disease the aid of
the pathologist is sought in diagnosis through examina-
tion of the sputum, vomitus, blood, urine, faeces, and va-
rious inflammatory products. Upon the result of his ex-
amination the subsequent treatment of the case will often
largely depend.
But, besides the changes in pathology wrought by the
study of the causation of disease, the past ten years have
added greatly to our understanding of pathological phys-
iology, if the expression may be allowed, meaning there-
by the perversions of function which are the result of
disease.
Those evidences of disordered function accessible by
the ordinary means of observation, and spoken of as the
symptoms of disease, while really a part of pathology in
its broader sense, have come very properly to belong to
the domain of the clinician, and with them the patholo-
gist has ordinarily but little to do. But a multitude of
evidences of disordered function are inaccessible to or-
dinary observation, and for their detection the services
of the pathologist are required., Foremost among these
at the present time are the changes in the chemistry of
the body which occur as a part of disease, and the im-
mense importance of the study of these changes may be
inferred from the fact that chemical change has been
shown to be a necessary part of all vital process. Ac-
cordingly, with the aid of the facts accumulated by the
study of physiological chemistry, we are beginning to
build up a pathological chemistry which promises to be
of great practical value. During life the study of the
chemical changes indicative of disease is of necessity re-
stricted to the examination of the various secretions and
*3°
MEDICAL RECORD.
[August 25, 1894
excretions of the body ; but as the result of the careful
study which they have received we shall soon be able to
infer with much accuracy, from changes in their chemical
composition in disease, as to the nature of the processes
upon which their abnormalities depend. Already, exam-
inations of stomach contents, of urine, of fseces, of exu-
dates and transudates, and of the blood have become an
important part of the daily routine of the pathologist.
He must be acquainted with the best tests for hydrochloric
acid, for pepsin, and for the abnormal products of diges-
tion in the stomach ; he must be able to determine the
quantity of albumin, sugar, urea, uric acid, sulphates, in-
dican, etc., in the urine; he must kno* how to detect
the results of imperfect intestinal digestion in the faeces;
he must be familiar with th* changes in the composition
of the blood dependent upon diseases of the various or-
gans of the body. But these are only a few of the prob-
lems suggested by the development of pathological chem-
istry. Their immense importance to clinical medicine
cannot but be apparent.
Closely in touch with the new duties imposed upon
the pathologist by the study of the chemistry of disease,
are others which have been suggested by the results of the
investigation of the various problems of immunity. The
self-limited course of the infectious diseases, and the pro-
tection afforded by one attack of many of them against
subsequent attacks of the same disease, have long been
recognized. The recent study of immunity explains this
by the theory that, hand in hand with the production of
the toxines of these diseases, there are produced (by the
cells of the body, presumably) certain antagonistic sub-
stances which neutralize the toxic principles and thus
prevent their action upon the body. These antago-
nistic substances are called " antitoxines," and the ex-
teat of their production is supposed to measure the de-
gree of immunity produced. It has been found that
these antitoxines are present in the blood of animals
rendered immune by artificial means, that the blood of
an animal so immunized possesses the power, when intro-
duced into the body of other animals, of conveying its
immunity to them, and, more important than all, of
ameliorating the symptoms produced by a previous in-
oculation with the infectious material. These facts have
been shown to apply to man as well as to the lower ani-
mals, and thereby has been suggested a plan of treat-
ment of infectious disease by means of the blood serum
of immune animals, which appears most promising from
the reports thus far published. It is to the patholo-
gist that the clinician must look for the induction of im-
munity in animals and the preparation of the blood-
serum necessary for this treatment
Now, it must be evident that the advances in pathol-
ogy which we have sketched demand on the part of the
pathologist a special training for his work, and the devo-
tion to it of an amount of time and labor quite beyond
the possibilities of the clinician. He must now have a
thorough acquaintance with bacteriology, animal chem-
try, and toxicology in addition to his knowledge of path-
ological anatomy. He must have trained powers of ob-
servation and of experimental research, and he must
have at his disposal laboratories equipped with every ap-
pliance necessary for the conduct of his investigations.
And this leads us to speak of the necessity of much
further development than has yet occurred in the way of
providing pathological laboratories in connection with
our hospitals. We are justly proud of the flourishing
laboratories of pathology which have grown up in con-
nection with many of the medical colleges of this coun-
try, and of the careful investigations of the problems of
disease which are being carried on in them. But by the
development of such a wide field of practical applica-
tions pathology has, of necessity, become more or less
divided into two distinct though closely associated de-
partments, that of the pure science of pathology occu-
pied with the theoretical solution of all the problems of
disease, and that of the applied science of pathology oc-
cupied with the application of fill the principles of the
science to the practical uses of the clinician. Though
fulfilling all the requirements ot the first, the laboratories
of our medical schools in only a secondary way meet the
demands of the second. Connected with educational
institutions, they are conducted primarily for educational
purposes ; the time of those connected with them has
many demands upon it for routine work in connection
with large classes of students ; and unless at great ex-
pense of time, the pathologist is never brought into con-
tact with the patient, because of his distance from the
hospital. Thus, the direct usefulness of the pathologist
to the clinician can be but slight.
It is evident, then, that the true ground for the devel-
opment of pathology as applied to clinical medicine is
the hospital and its thoroughly equipped laboratories,
and we would insist again that without these, the clinician
must forego to a very considerable extent the great as-
sistance in his work afforded by the pathologist. It
is surely no unreasonable demand on the part of the pa-
tient, that his physician should be in possession of every
aid afforded by modern science in the treatment of his
case.
What, then, is the equipment which a hospital should
have in order to be abreast of the times in so far as path-
ology is concerned? Besides the thoroughly equipped
autopsy-room, with its adjoining refrigerators for the
storage of bodies, there should be laboratories devoted to
histology, bacteriology, and chemistry. These should
be well lighted and well ventilated, and should be suffi-
ciently large to afford abundant working space, and to
contain all the apparatus required by the most recent ad-
vances in these several branches of science, in so far as
they bear upon pathology. The histological laboratory
should be provided with a good outfit of microscopes,
microtomes, and everything necessary for the minutest
study of the structural changes of the tissues in disease.
It should have the best light obtainable, and should afford
ample shelf room for the storage of the pathological ma-
terial which must be accumulated for study. The bac-
teriological laboratory should afford every facility for the
cultivation and study of the micro-organisms of disease.
It should be removed as far as possible from the possi-
bility of contamination by dust or other disturbing influ-
ences, and for use in connection with it there should be
a room fitted up for the accommodation and observation |
of animals used for the experimental determination of
the pathogenic action of the bacteria. The chemical
laboratory should contain a complete outfit of apparatus
for the examination of the various secretions and excre-
tions of the body, for the separation and study of the
toxines of bacteria, and for the preparation of materials
for preventive inoculation and for the treatment of dis-
ease by means of the blood serum of immune animals.
All this involves a considerable outlay of space and
money on the part of the hospital, but these are more
than counterbalanced by the many advantages to its pa-
tients to be derived from such an equipment. The space
and light may best be obtained in a separate building es-
pecially devoted to the pathological department ; the an-
nual expense incident to the conduct of such a depart-
ment, after the first outlay for building and equipment,
would be relatively small.
And, finally, the hospital should be able to command
the services of a man as director of such a department,,
whose time and energies are entirely devoted to the
scientific development of applied pathology. It is no
longer possible for pathology and practical medicine to
be carried on successfully together, and, since in giving
his services to the hospital the pathologist must be de-
barred from other means of support, he should receive a
salary sufficient for his needs and sufficient to put men of
ability at the command of the hospital.1 The proper
conduction, then, of a pathological department such as
we have endeavored to sketch, demands the payment of
1 It would seem that a fair criterion of the amount necessary for
this purpose might be found in the salaries paid by our universities '
to their professors of pure science.
August 25, 1894]
MEDICAL RECORD.
231
good salaries to its director and his assistants, and the af-
fording them every facility for scientific investigation.
The educational and scientific power of a hospital
equipped as has been suggested is simply inestimable.
Already the Institut ftir Infectionskrankheiten in Berlin
has made its influence felt the world over, and it is to be
hoped that America, by following the lead thus shown,
may come to occupy the same advanced position in the
onward march of scientific medicine which it has long
held in many of the more purely practical branches of
our science.
THE SHADY SIDE OF THE SURGICAL TREAT-
MENT OF TRACHOMA.1
By H. GIFFORD, M.D.,
OMAHA, MSB.
The surgical treatment of trachoma, which dates back at
least to the days of ancient Greece, has had, as you all
know, a most enthusiastic revival during the past few
years; and granulated lids are being treated with all
sorts of inventions and adaptations, from roller forceps
to rasps, tooth-brushes, and pumice stone. It is not my
intention to discuss the merits of these various methods ;
any one of them, properly used, in connection with other
treatment, gives better results than the treatment with
local applications of any kinds of medicines, alone ; but
the praise of them has been so indiscriminate, and the
disadvantages and dangers of the treatment have been
so little dwelt upon, that it is high time for the other
side of the case to receive more attention. That it may
be dear that I have no unfounded prejudice against the
surgical treatment of trachoma, let me state that I have
been chloroforming my trachoma patients and subjecting
their lids to the most vigorous surgical measures, squeez-
ing, cutting, burning, and scraping, according to the case,
for nearly seven years ; several years longer than nearly
all the writers from whom so much has been heard on the
subject. Moreover, as nearly one-fourth of my patients,
bom private and clinical, come to me for trachoma and
its effects, my experience cannot be said to be limited.
Furthermore, I have no idea of belittling the immense
advantage which surgical measures give us in treating the
disease. I should not think of trying to do without
them. I merely wish to point out that the brilliant
results claimed by so many writers are not, as a rule, to
be expected, and that disastrous results may follow their
use in some, if not all, classes of cases. First, as to the
brilliancy of the results. Many writers claim to cure the
great majority of their cases in from four to six weeks ;
these claims, I feel sure, are due to too brief an observa-
tion of the cases. The patients feel well and look com-
paratively well, but if they are kept track of, relapsing
will be found to be the rule ; and in many cases I have
gained the impression that corneal complications are
more apt to occur in the relapses following so called
cures with surgical means, than when medical applica-
tions alone have been employed. Where the diseased
tissue is so localized that it can easily be excised, squeezed,
or scraped out, a cure can sometimes be effected with one
operation ; but, generally, after all the surgical treatment
that is advisable in the course of a month or six weeks, I
find it desirable to have patients continue applications of
sulphate of copper for many months, returning occa-
sionally for such further surgical interference as may be
required.
With regard to the dangers of surgical treatment, the
bad results which I have observed or known to follow it
are, first, suppression of tear-secretion, with resulting
xerophthalmia ; second, ulceration of the cornea, with
partial or complete loss of sight. Respecting the first
of these, I have seen several cases where, after excision
or squeezing out, of the upper retro tarsal folds, the secre-
tion of tears has been decidedly reduced. Most of these
patients experienced no serious inconvenience from this
reduction. In one old case, however, where the tracho-
.. > Read before the Omaha Medical Society, January 10, 1894.
ma in one eye was reduced to a few gelatinous bunches
in the upper fornix, near the outer canthus, these were
squeezed out, and in spite of every precaution to prevent
adhesions, the secretion of tears was almost entirely abol-
ished, so that the patient was obliged constantly to use
vaseline in the eye to keep it comfortable. It is quite
possible that this eye would have become xerophthalmia,
no matter what treatment might have been used, but it
was a very unpleasant experience to have an eye which I
was expecting to make useful and comfortable, made en-
tirely incurable within a few days, as the result of my
treatment.
Slight corneal erosions I have seen develop in seve-
ral cases immediately after surgical treatment of the lids,
but as in most of these cocaine had been used freely, it is
questionable whether the majority of them should not be
laid at the door of the latter. Really dangerous corneal
trouble from surgical trachoma-treatment, I have ob-
served only from the aggravation, by the operation, of
pre-existing corneal affections. Most writers speak of
the rapidity with which corneal complications heal after
the lids have been treated surgically, and in the great
majority of cases this has been my experience also. Tra-
chomatous pannus, in particular, clears up with great
rapidity after proper surgical measures. On the other
hand, I believe that non-vascular ulcerations, whether
superficial or deep, should be considered positive contra-
indications to any extensive surgical interference with the
lids. Not that they too will not, as a rule, be helped by
such interference ; for they generally heal promptly ; but
in rare cases, without our being able to foresee the dan-
gers, they become so rapidly worse after operations for
trachoma that the sight is severely injured, or entirely
destroyed, before they can be checked. I have had two
experiences of this kind and know of three others. The
first of my cases was that of a young man with moderate
trachoma and nearly clear cornese, there being only a
slight superficial ulceration in the upper half of the left
cornea. I excised the upper retro tarsal folds, put in two
stitches on each side, and applied a moist sublimate dress-
ing. On the second day he complained of severe pain
in the left eye, and on examining it I found a nearly cen-
tral ulceration, about one eighth inch in diameter. This
healed slowly, when the stitches were removed and hot
applications used, leaving considerable permanent im-
pairment of vision. The stitches may have been the
cause of the bad result in this case, and since then I have
not used them after excising the folds.
Another case was that of a woman, aged forty-two,
whose right eye had been lost some years before. The
left lids had some trachomatous infiltration ; the upper
three fifths of the cornea was. in a condition of pannus ;
the lower two fifths being clear except for a small super-
ficial ulceration near the lower border. Under chloro-
form, the trachomatous parts of the lids were squeezed
out with ring forceps, after which the conjunctival sac
was washed out every two hours with a boracic-acid solu-
tion. The operation did not involve nearly as much
rough treatment as is often required, and the reaction on
the part of the lids was no greater than common, but the
ulcer became rapidly worse and completely circumscribed
the clear portion of the cornea, before the most vigorous
measures, including a broad Saemisch cut, succeeded in
checking it. As it was, all that portion of the cornea
which had been clear became permanently dimmed, and
until the vessels began to clear off in the upper part of
the cornea, I had a practically blind woman on my
hands. I am convinced that if the pannus had not ex-
isted on the upper part of the cornea, this, too, would
have been involved in the ulceration; but the latter
stopped sharply at the border of the pannus, and when
the vascularization cleared up, as it soon did, useful
vision was restored.
In another case which I have seen, the trachomatous
lids of a man aged thirty- three were squeezed out with
ring forceps by one of the most competent and skilful
oculists of the West, who has had an unusually large ex-
232
MEDICAL RECORD.
[August 25, 1894
perience in the surgical treatment of these cases. Before
the operation, the man could see well with both eyes,
though an ulcer existed in the upper part of the right
cornea. After the operation, this ulcer spread so fast
that the man never saw again with the eye ; almost the
entire cornea sloughed, and when I saw him, some
months afterward, the eye was sightless and had to be
eviscerated, on account of infection of the interior
through the scar.
Another still sadder case, which I have recently seen
was that of a middle aged woman from western Iowa, who
had had trachoma for years. Finally her physician an-
nounced that he had a new and sure cure for her sore
eyes, and proceeded to scarify her lids and apply what
was probably sublimate 1 to 1,000. From her history,
she probably had some moderate corneal complication at
the time of the operation ; at any rate, she never saw
again. Both corneas ulcerated and sloughed, and when
I saw her, five months later, both eyes were hopelessly
blind. How miny similar cases are occurring all over
the country, it is hard to say ; such occurrences are not
the things that one commonly likes to describe from his
own practice, but I have recently noted a case * from the
practice of Abadie, the ardent Parisian advocate of the
tooth brush method of treating trachoma, in which a
woman's conjunctiva (not trachomatous but with a con-
junctivitis of uncertain origin) was brushed vigorously
and the galvano-cautery applied to a granulation tumor
of the conjunctiva ; whereupon, a slight corneal infiltra-
tion which existed at the time of the operation promptly
got so much worse that the whole surface of the cornea
was reduced to a purulent pulp. The patient is said to
have eventually obtained some useful vision of the eye,
but for this she certainly had to thank her good fortune
and not her surgical treatment. [Since this paper was
read, I have learned of a case not included in the above,
in which the scarification of the lids cost the patient his
eye.] : ^
These cases make it plain, I think, that surgical meas-
ures have not simplified the treatment of trachoma ; on
the contrary, they have made it altogether more impera-
tive that he who uses them should be able to examine
the eye with the greatest care and discrimination ; and
should be prepared, if unusual emergencies arise, to treat
them promptly and vigorously. Without these qualifica-
tions, the physician had far better stick to the old blue-
stone and nitrate of silver treatment ; for with these
remedies the disease can always be improved or held in
check, and in many cases cured; whereas, if he uses
surgical measures at all freely, while he may, as a rule,
obtain more brilliant results, he is liable, at any time, to
ruin an eye which otherwise would never be lost.
Medical Practice in Sweden. — In Sweden ten years
of study is incumbent on every medical student. They
are so particular in that enlightened country to have
their medical men thoroughly equipped and " ethically
developed" that the practice of homoeopathy is forbid-
den, and every globule of homoeopathic medicine intro-
duced into the country has to be smuggled in. — New
York Medical Times.
Fruit Eating to Cure All Ills. — A new society of
cranks has been started by a former lieutenant in the
German Army. His name is Boeter. He is the leader
of a new " ism," and as such sailed recently from San
Francisco to Honolulu. The " Fruitarians " is the name
of the new society he represents, and their belief— or
rather notion — is, that modern civilization is full of van-
ities and strange notions, and greatly needs reforming.
The members eat nothing but ripe fruit, eschew cooked
food of any kind, and drink only water. They are to
live in huts, bare of the comforts of civilization, and go
naked. Ex Lieutenant Boeter intends to buy a large tract
of land in the Sandwich Islands, or, perhaps, a small
island outright, for the purpose of founding a colony.
1 Annates d'Oculistique, September, 1893, p. 187.
POST-GRADUATE MEDICAL STUDY ABROAD.1
By ANDREW MacFARLANE, M.D.,
mSTBUCTO* DC PHYSICAL DIAGNOSIS AND CLINICAL MICROSCOPY, ALBANY MfjDf*
CAL COLLBCB.
The student of medicine on the eve of graduation looks
forward eagerly, I am sure, to that crucial and final test
— practice — which demands that he should competently
employ the principles which he has learned, should ex-
hibit the skill of which he claims to be the master, and
which in return offers as a reward an honorable success.
In his student days the mechanism of the human organism
has gradually been spread before him, the mysteries of
diseased conditions have been carefully, step by step, un-
folded to him, and the potentialities of medicine have
been impressed upon him so that all seems simple, clear,
and logical. Unfortunately, the realities of practice bring
their bitter realizations, and what seems plain and simple
when sitting in the amphitheatre often appears dark as
Erebus to the beginner standing by the bedside. Even
that vast storehouse of vaunted remedies becomes at criti-
cal times the charnel house of our hopes, and diseased
processes frequently, much to our surprise and at times
to our chagrin, assume unexpected phases. This inevi-
table result is due to the fact that the mind of the student
has of necessity been impressed with clear-cut pictures of
distinct disease-entities, illustrated by carefully selected
cases exhibiting definite types and none of the vagaries of
disease. Actual practice, however, is very different, and
our patients rarely show the classical pictures of disease.
Mistake after mistake will, therefore, be made, and must
be recognized before that training which is essential to
satisfactory medical work is secured.
The important question, then, is, how is that training
best obtained ? Undoubtedly the best way is by service
in a good hospital, where, under a competent visiting staff,
the house physician has abundant opportunity to see and
examine patients, watch carefully the course of disease,
study closely each individual symptom, and, what is most
important, assumes to a very large extent the responsi-
bility for the care of the patient and meets the many
emergencies which arise during his term of service, all <JF
which is a most valuable preparation for private prac-
tice.
Fortunately our hospitals need no chanticleer to sound
their praises. Each of you has had frequent opportunity
to see the richness of the clinical material and the value
of the services.
To-day, therefore, I shall cursorily speak of the train-
ing secured by special postgraduate study which some of
you may undertake after your hospital work and others
after a few years of private practice. The question natu-
rally arises, where can such work be done most satis*
factorily and at the least cost?
Teachers in the large centres of population have rec-
ognized this need, and to-day there are flourishing schools
for practitioners in New York, Philadelphia, Boston, and
in some of the Western cities. The advantages of these
native post-graduate schools are that they are accessible,
no foreign language must be mastered, the work is espe-
cially arranged to meet the needs of the American practi-
tioner, and the physician can easily, without great loss,
leave his practice for two or three months to brush up on
any special line in which he feels he is weak. The disad-
vantages are that no large hospitals are attached to these
schools, the teaching is to a great extent done with dis-
pensary patients, who are necessarily somewhat unsatis-
factory, and with American patients who do not take
kindly to thorough examinations by classes.
It has been customary, however, for many American
medical students to continue their studies abroad, espe-
cially in German-speaking countries. Little need be said
of the medical work in Great Britain and France, Lon-
don and Paris, though great medical centres offer little to
the American practitioner. As the hospitals are scattered,
much time is lost in going from one to the other, and
1 A talk given to the Senior Class of the Albany Medical College. ;
August 25, 1894]
MEDICAL RECORD.
*33
private instruction, as it exists in Vienna, is practically
unknown. To the specialist who has mastered the ground-
work of his own field, and who is able to fully appreciate
cases without instruction, the abundant clinical material
of London and Paris is of inestimable value.
It will be well, I think, before describing the character
of the medical work in Germany, to consider briefly the
German university, and to note in what respects it differs
from a similar American institution. Nothing in Ger-
many impressed me so much as the large number of great
universities whose fame re3ts not upon huge piles of stone
and mortar, but upon the scholarship and scientific at-
tainments of the men connected with them. Germany,
a country only four times the size of the State of New
York, has twenty universities, any one of which is suffi-
cient to make a nation famous for scholarship. These
universities are state institutions, endowed and controlled
by the Government, having similar requirements for en-
trance, and covering exactly the same ground. The
German university differs essentially from the American
in that it is purely a professional school, and in no sense
of the word " a college." Students before entrance must
have graduated from the gymnasium, where the course of
instruction has been carried to what would be equivalent
to the end of the sophomore year in an average American
college. Here the discipline is most rigid and severe, the
instruction thorough, and the work practically the same
in all the gymnasia. In the university all is changed,
and the greatest latitude is allowed the student in his
course of instruction and in his attendance upon lectures.
The student enters the university to study history, philos-
ophy, letters, theology, medicine, law, etc., because in
Germany all candidates for the higher Government ser-
vice, all teachers in academies, and all professional people,
must have had an university training or its equivalent.
The student is supposed at his age of entrance, twenty,
or more, to know what his life occupation will be, and,
therefore, the line of work he wishes to pursue. He ac-
cordingly matriculates, pays for, and attends lecturers
only upon subjects leading to the end he is seeking.
There are no recitations, no calling of the roll, and it is
usually a matter of supreme indifference to the professor
whether the student attends regularly or not his lectures.
i The student has a lecture-sheet signed at the end of the
term by the professor, and this is the official evidence of
attendance at the requisite number of courses of lectures
when he come3 up for a degree. After having attended
the required number of courses of lectures, as shown by his
lecture-sheet, the student may try the examination for a
degree. For this he has to write a thesis, which he must
defend before a committee of the faculty, and in addition
prove a number of scientific propositions propounded by
them. The severity of the examination is evident from
the fact that outside the professions not more than ten
per cent, of the students take their degrees. This can be
explained, however, to some extent, by the fact that all
mist, in addition, pass state examinations. As the uni-
versity degrees are purely honorary, and somewhat ex-
pensive, many do not seek them.
The teaching body in a German university consists of
the " ordentlicher Professoren," full professors, "aus-
serordentlicher Professoren," somewhat similar to our
adjunct professors, though entirely independent, and the
"privat-docenten." The " privat-docenten " need a
word of description, as they are characteristic of the Ger-
man university and play an important part in the instruc-
tion of the American medical students. They are young
men, thirty to forty years of age, distinguished for schol-
arship, which has been tested by special examinations in-
* volving original research and extensive study. They are
permitted, after having thus shown unusual ability, to de-
liver courses of lectures under the aegis of the university.
They receive no salary from the university except the fees
of the students who attend their lectures. It is therefore
necessary for them either to lecture upon some subject not
covered by a professor, or to deliver lectures more attrac-
tive than those of the professor.
The professors, adjunct professors, and instructors an-
nounce at the beginning of each term (the winter term
extends from October 15th to March 15 th, and the sum-
mer term from April 15th to August 15th) the subjects
of their lectures for the ensuing term, and the student se-
lects those which he wishes to hear.
Each professor and instructor lectures upon the sub-
ject in which he is most interested, and with which he is
therefore most familiar, and regards himself not as one
intended to insist upon attendance, to maintain disci-
pline, or to compel students to work, but as a teacher, i.e.,
one who professes certain opinions, a leader in thought
in his field of work, and who is there to direct, clear the
way, and incite students to earnest effort in the work in
which they are engaged. As there may be, and often are,
lectures delivered by the professors, the adjunct profes-
sors, and the instructors on the same or kindred subjects,
it behooves the professor to keep abreast of the times in
his lectures, making them attractive as well as deeply
scientific, or he will find his lecture-room deserted for the
more brilliant lectures of a young privat-docent.
The adjunct professors and privat-docenten are in-
cited to advanced and original work to attract the at-
tention of that most severe of critics, the scientific
world, and thus receive an .appointment to a higher po-
sition either in their own or in another German univer-
sity. Another factor in stimulating the professors to a
high standard of work is the fact that students rarely
complete their course in one university but study in sev-
eral, courses of lectures taken in one university being
accepted in every other. Thus a medical student might
study histology and pathology in Freiburg where Ziegler
is, obstetrics in Munich under Winckel, medicine in
Heidelberg listening to Erb, in Erlangen to Strilmpell,
or in Berlin under Leyden, Senator, or Gerhardt, and
surgery in the same university or elsewhere. This change
from one university to another is, I believe, more com-
mon among non-medical students, but is still quite fre-
quent among medical students.
The key-note of the German university is freedom in
teaching and liberty in learning. This eternal principle,
which has made Anglo-Saxon governments and civiliza-
tions the most advanced in the world, has given to Ger-
man intellectual life its present pre eminent position and
has elevated its university system to a plane far above
that of any other country.
Briefly, then, what is the effect of this system upon the
university, and what is the result upon the students?
It makes every man completely independent in every-
thing— mode of living, personal behavior, course of in-
struction. It offers the student complete courses of lect-
ures and abundant opportunity for advanced work on
any university subject which he may take or not as he
pleases. The result is that there are the two extremes
among the students — the workers, who avail themselves of
the opportunities afforded, and the others — the dawdlers,
the lazy, and the mentally incompetent, who simply idle
away their time and fritter their opportunities.
The American college contains exactly the same hu-
man elements, as nature is much the same everywhere.
With us, however, the attempt is made to get a fair aver-
age, and the bright, hard working students are to a great
extent held back by the lazy and incompetent, with the
result that the best students do not do as much work as
they might, while, I am afraid, very little good is accom-
plished with the others. All of us, I am sure, know
many men, utterly incompetent, who have received college
degrees for which they did no equivalent work. This
same principle of instruction is carried out in the medi-
cal schools, modified by the special requirements of the
work — laboratory instruction, clinical examination of
patients, surgical technique, etc. It is not necessary to
speak in detail of the German medical schools; that
would require too much time, and in your case is of no
special value except in so far as relates to the work that
American physicians can satisfactorily do in them.
We shall therefore speak only of post-graduate medi-
234
MEDICAL RECORD.
[August 25, 1894
cal work, and shall divide the German medical schools
artificially into the large medical centres, as Vienna and
Berlin, and the smaller, as Heidelberg, Freiburg, WUrz-
burg, etc. The advantages of the smaller university are
that living is cheap, tuition is low, and the student enters
directly into the German life, and thus has an excellent
opportunity to master the German language. The dis-
advantage is that outside of laboratory work you can get
no special instruction, and must take the ordinary lectures
and regular instruction given to the students. This,
while very good, is not quite what is sought by the
American physician, who desires to crowd as much clini-
cal work as possible into a few months. In the laborato-
ries, however, there is always plenty of material, and
much work can be done alone with a little help from the
professor or his assistants. The advantages of the large
medical centres, especially Vienna, are die vast amount
of clinical material which can be used, and the special in-
struction in every subject which can be obtained from
trained and well equipped instructors.
The preeminence of Vienna as a medical centre is due
to its large general hospital. This is, I believe, the
largest hospital in the world, and contains about four
thousand beds. There are within its walls about ten
thousand births a year, and ten to twelve autopsies are
made daily in its pathological institute. With a staff of
twenty-four full professors, thirty-eight adjunct profes-
sors, sixty- two privat docenten, and a large number of
trained assistants, it has a teaching body and clinical ma-
terial unequalled in the world.
The American medical student goes to Vienna not for
the ordinary lecture and laboratory work but to receive
special training, which is to a great extent especially ar-
ranged for him by the privat-docenten and assistants.
The privat-docenten receive nothing, the assistants a
mere pittance from the hospital. They do not engage
in private practice but busy themselves with special in-
vestigations and advanced work in the hospital, with the
hope that some day they may be called to a professor-
ship in Vienna or in one of the smaller Austrian univer-
sities. As they must earn money in some way while
waiting, they are allowed to use the clinical material for
purposes of demonstration in private courses. These
courses are to a great extent arranged to attract the
Americans, as they are the foreigners most lavish with
their money.
Probably the most satisfactory courses given in Vienna
are those on medical diagnosis, and this is due not only
to the instruction, but even more to the vast amount of
clinical material offered for investigation.
There are in the general hospital about fifteen hun-
dred medical patients; of these all the difficult, unusual,
and obscure cases are sent to the wards under the charge
of the teaching professors, who have each about one
hundred and fifty patients in their divisions. The great
mass of ordinary uninteresting cases are placed in wards
under the care of non -teaching professors. Patients also
are frequently transferred from wards under the charge
of a teaching professor to other wards when the disease
has been thoroughly studied and demonstrated.
The assistants of the teaching professors having this
magnificent clinical material are the men who give the
valuable courses in medical diagnosis. The members of
a course, usually limited to six, go to the wards at a
fixed hour, and on a class list find what patient has been
assigned to each member of the class. Every man then
thoroughly examines his patient for an hour, when the
assistant comes and calls on a member of the class to
demonstrate his case. He stands at one side of the head
of the bed, the assistant at the other, while the rest of
the class are grouped about the bed. The demonstrator
must give a complete and exact diagnosis, then make a
thorough, systematic physical examination, the deduc-
tions from which are confirmed, modified, or corrected
in every detail by the assistant. After the examination
the assistant goes rapidly over the case ; grouping to-
gether logically the symptoms, making clear the obscure
points, discussing the differential diagnosis, and speaking
a little about the treatment, though this is usually then-
weak point. Two such cases are demonstrated every
day, and two new cases added, so that each case demon-
strated has been thoroughly examined by every member
of the class. The value of this work depends upon sev-
eral factors. First, the cases are all difficult and inter-
esting, selected from a large number, each one of which
has been carefully studied for the regular lectures of the
professor. Secondly, the patients are exceedingly sub-
missive and rarely object to thorough physical examina-
tions, even when they cause great pain* Thirdly, the
instructor is a splendid diagnostician, one who is seeking
by his work to create such a reputation that he will be
called to a professorship. One of the men under whom
I worked was at that time — 1891-92 — reputed to be
the best diagnostician in Vienna, and since then has been
appointed a professor in the university. Fourth, the men
doing the work are imbued with the true spirit of schol-
arship, seeking knowledge not in order to pass examina-
tions and to receive degrees, but because of its owA in-
trinsic value. In much the same way courses on other
subjects are given, modified by the special character of
the subject.
These courses range in cost from 15 to 30 guldens
for thirty lessons, a gulden being about 43 cents. The
best courses are all about a gulden a lesson, while a very
few courses on diagnostic gynecology and operative
gynecology on the cadaver cost. usually 50 guldens for
twenty-four lessons, but in such cases the class is gener-
ally limited to four.
One rarely takes less than five courses a day, or more
than seven, for which the tuition will range from $9 to
$12 per week. The usual method of living is to hire a
room by the month, where a light breakfast is obtained,
and to take the other meals at a restaurant. One can,
however, if desired, secure a room and full board at a
fixed price in a " pension." The cost of living depends
largely on the personal factor and varies with one's
tastes. Some live decently, with economy, for about £24
per month, while others spend, without extravagance, eas-
ily, twice that amount. Fair limits per month for abso-
lute expenses, tuition, and board, range from $60 to
$ 100. There are, in addition to this sum, the inciden-
tals— Opera, concerts, baths, and personal expenses —
which would increase the cost of living from £75 to £150
per month.
The first amount is low, but not the lowest possible,
though it is as low as it should be, as one should not
neglect to go to the opera and concerts; while the sec-
ond is a fair allowance, but not at all extravagant.
In Berlin there are no courses given which are just the
same as those in Vienna. There are special courses in
the spring vacation and just before the winter semester.
These last four weeks, and often contain very many
members, rendering much individual instruction im-
possible. During the semesters the assistants are not al-
lowed to use the ward patients for private instruction.
The questions now arise as to the knowledge of Ger-
man necessary for satisfactory medical work, whether a
sufficient acquaintance with the language should first be
secured before medical work is begun, or if both may not
be pursued at the same time.
Vienna is the only German city where medical .courses
to any extent are given in English ; but these courses are
generally the poorer ones, while the best are usually given
only in German. Explanations given in English by one
having a meagre knowledge of the language are not, as
a rule, I think, so satisfactory as when given in German,
even if the German of the auditor is decidedly limited. •
It may be well to sketch out, rather vaguely of course,
a stay of a year to a year and a half abroad, and one of
only six or seven months.
In either case as much German as possible should be
learned before starting, and it would be wise to read
some standard German medical work, as that of Striltn-
pell. If an extended stay is planned, it would be best,
August 25, 1894]
MEDICAL RECORD.
*35
I believe, to spend the first three or four months in a
small university town, as Heidelberg, Gttttingen, Frei-
burg, etc. Here the knowledge of the German language
should be the first desideratum, while laboratory work
and attendance upon clinical lectures would be valuable
as German lessons and in teaching German methods of
procedure and examinations.
Then, when German verbs were no longer a night-
mare, and German construction a hopeless labyrinth,
Vienna should be the objective point Here the special-
ist in embryo could spend eight or nine months ; then,
later, two months each in Berlin, Paris, and London,
seeing famous men, studying their methods and examin-
ing their enormous material. For one who can spare
only six or seven months abroad, I believe the result
will be better if he gives the first month exclusively to
Geiman in some small German town, where there are
no temptations to speak English, then go to Vienna,
rather than to proceed directly to Vienna. The thought
no doubt arises why cannot German be studied in
Vienna, the physician taking at first English courses,
then, as his acquaintance with German increases, taking
those given in German. This can be and is done by a
number, but, I believe, not at all successfully.
The temptations to speak English in Vienna are so
great that I doubt if any American medical student, ex-
cept by the greatest self-denial and control, ever learns
in Vienna very much German.
The Americans there are so numerous that they of
themselves form a little society; they have their church
and their social organization, and, as these special
courses are almost entirely taken by Americans, all with
whom they are thrown in contact are American. One
rarely becomes acquainted with the German students in
a large university, and thus has little opportunity of
learning from them.
The cost of a stay for six months need not, with
economy, be more than £450, with $200 additional for
the journey to and fro. For a year it can with economy
be done for $900, including the journey. If a micro-
scope, instruments, books, and clothes should be bought,
or extensive pleasure-trips undertaken, the total would
necessarily be much increased.
The best time to go to Vienna is in the spring, April
and May. Many Americans, who have studied all win-
ter, leave Vienna at this time, either to return home or to
continue work elsewhere ; on this account it is much eas-
ier to get into the best courses, and this is especially the
case if you have a friend in Vienna who will prearrange
work for you. Medical work in Vienna is regulated by
the ordinary commercial laws of supply and demand,
and as the number of Americans is usually very large,
epecially in the fall and winter, and the number of de-
sirable courses limited, there is an eagerness to get for
one's self and one's friends the best, while others have
often to wait for months for the same openings.
It is, however, always an easy thing to start into satis-
factory work in Vienna. The Anglo-American Medical
Association, whose secretary, the Rev. Mr. Gordon, has
done incalculable kindnesses to English-speaking stu-
dents, gives to new-comers most valuable information as
to rooms, board, courses, etc., and introduces them to
the older men, who are usually kind in putting the
new-comer on the right track.
I cannot bring this short and desultory talk to a close
without saying, a word about the German . professor.
You can only become intimate with him in one of the
smaller universities ; but such an acquaintance is of itself
worth a stay at a small university. His kindly welcome
to Americans, his hearty greeting " Herr College," and
his willing assistance to the earnest student make the
stranger feel completely at home. If it be your good
fortune, as it has been mine, to make excursions with
him, you will find a union of unaffected simplicity and
true greatness which will be a remembrance to be cher-
ished, and an ideal to be sought after during the re-
mainder of your lives.
A CASE OF INSANITY DUE TO THE MEN-
STRUAL FUNCTION — OOPHOREC TOMY —
RECOVERY.
By ELIOT GORTON, M.D.,
ASSISTANT PHYSICIAN TO THE NEW JERSEY STATE HOSPITAL, MORK1S PLAINS,
N. J.
In the Medical News of May 20, 1893, appeared an ar-
ticle from the pen of Dr. B. D. Evans, Medical Director
of the New Jersey State Hospital at Morris Plains, on
" Periodic Insanity in which the Exciting Cause Appears
to be the Menstrual Function." The doctor closes the
article by drawing a few deductions from the case he re-
lates, of which the following is a synopsis : " That in
many cases of periodic insanity the exciting cause may
be directly traceable to the menstrual function; and,
when the attacks are coincident with the catameniai flow,
and an apparently normal mental condition prevails be-
tween the menstrual periods, removal of the ovaries is
justifiable even though there be no pathologic lesion."
He cites a case of insanity of eight years1 duration, which
attained to perfect mental and physical health after
oophorectomy, and it is the purpose of this article to add
another case to the literature of the subject, my own
views being in perfect harmony with the sentiments
above elucidated. The following case is interesting and
instructive from every point of view, and not only sup-
ports the above deductions, but in its result contains
much food for reflection.
The case to be related is that of a young school- girl,
aged sixteen, who, when well, was inclined to be very
sociable, lively, and even-tempered. Hereditary history
of a maternal grand-aunt who died insane. Menstrua-
tion had been regular and normal. She was admitted to
this hospital on March 23, 1893, with the following his-
tory:
She had been attending school until the latter part of
September, 1892, when she became very much interested
in her spiritual welfare and became converted. Shortly
after joining the church her mother noticed that she was
not at all like her former self. From a lively, sociable,
bright girl she became moody, irritable, worried, and de-
pressed. When questioned by her mother she admitted
that it was the weight of her sins that was troubling hen
This condition of depression steadily increased until
at Christmas-time, after having on several occasions
threatened suicide, she passed into a semi- stuporous state,
eating but little and sleeping practically not at all. She
remained in this state of stupor for three weeks, when she
suddenly began to improve. The improvement, however,
was but temporary and of short duration. She again
lapsed into a state of depression, but not so profound as
in the preceding attack, and, apparently about to re-
cover, she passed suddenly into so violent a stage of
mania as to render restraint imperative. At this time
she attempted to kill her mother and sister, and suc-
ceeded in wrecking much household furniture. Three
weeks after this maniacal outbreak she was brought to
this hospital.
On admission she was very quiet and lady-like, talked
in a rational and consistent manner, and had the appear-
ance of being a thoroughly well girl, both physically and
mentally. She was, however, placed under careful ob-
servation, but gave no evidence of mental instability un-
til the approach of the menstrual epoch, the latter part
of April. As the flow commenced she became pro-
foundly depressed, refused to talk or eat, and for sev-
eral days was fed with a nasal tube. From this period
of depression she recovered in time to pass into a period
of exaltation as the June menstrual period approached.
She continued in a state of excitement for two weeks, and
it is from this time onward that the regular periodicity
seems to have become established. Every month there-
after, for a few days preceding and following her men-
strual period, she became greatly excited and erotic.
Her language during these periods was offensively ob-
scene and profane; her self control was entirely abol-
236
MEDICAL RECORD.
[August 25, 1894
ishei, and she exhibited many delusions, chiefly of an
erotic character.
These periods usually were of about ten days' duration,
and, as the menstrual flow erased she began to improve,
and in a few days would be apparently well. Then she
was extremely reluctant to discuss her former condition,
and any questioning in regard to it embarrassed her
greatly. She was perfectly cognizant of all that hap-
pened during the cycle through which she had passed,
and the fact that it was a source of much anxiety and
mortification to her, would indicate that she looked back
upon her actions and speech from a comparatively sane
stand point. To her it was incomprehensible, and she
begged to be made well.
In December, 1893, she was subjected to a vaginal ex-
amination, with negative results. The ovaries and tubes
were apparently in a normal condition, but there was a
slight tendency to anteveraion on the part of the uterus.
Daring the examination the absence of tenderness was
especially noted and commented upon.
February 1, 1894, immediately following cessation of
menstruation and consequent return to mental health,
she was removed to the Mount Sinai Hospital in New
York City, and on February 3d was operated upon by
Dr. Brettauer, who removed both ovaries and tubes.
With the exception that the left ovary contained a small
cyst, the appendages were normal. She made a rapid
and uninterrupted recovery from the operation, and at
no time did her temperature .rise above ioo° F.
February 19th she was again returned to our care in
excellent physical and mental condition, quiet, rational,
and with the abdominal wound entirely healed. For
one week after her return she remained quiet and orderly,
with normal pulse and temperature.
February 26th, when she should have menstruated,
she manifested a tendency to exaltation with a decided
erotic impulse. She destroyed a pair of drawers and
threw them down the closet. Her movements were so
abrupt and nervous as to almost simulate chorea. In her
talk she was rational, but inclined to be saucy and irrele-
vant. This period lasted but three days, and was the last
evidence of mental instability she ever presented to us.
At our request she was taken home by her mother on
May 31st last, but before leaving was thoroughly and
carefully examined. The parts were apparently in a per-
fectly normal condition, with no evidence of any adhe-
sions or signs of hernia. The scar on abdomen was not
at all tender and there was no soreness anywhere.
At the present writing, five months after operation,
she has remained perfectly well, mentally and physically,
and has not shown the slightest tendency to a return of
her abnormal mental condition.
In this case the operation was performed as a dernier
ressort, and as embodying the only hope the patient had
of escaping, not only from her periodical paroxysms, but
from that condition from which no mind returns, and
into which she was rapidly drifting— dementia. The
operation intervened, a serious one it is true, but the
patient survived, and is now, and probably will continue
to be, a useful member of society. Still, had she died un-
der the knife of the surgeon, will anyone contend that it
would not have been better so, than that she should have
become a hopelessly demented atom of humanity, and a
life-long charge upon the State or her friends?
This case differs from others which have been reported,
in that the period of excitement seemed to come on as a
result of the preparatory evolution incident to and pre-
ceding the menstrual Mow. Whether this is due to the
congestion which is claimed by competent authorities to
always precede this function, is a point to be determined,
but to my mind it is conclusive. It is also worthy of note
that three days after the flow had become established
there was an appreciable lessening of cerebral and motor
excitement. This in itself would tend to confirm the
opinion that congestion of the parts, concomitant pressure
on nerve-supply, and consequent reflex irritation as a result
of increased blood-pressure, is at least a factor in causation.
We cannot fail to be impressed by the many and
varied psychic disturbances which occur in sane women
at the menstrual period, not alone in the delicate and
sickly, but in the more robust When we take into con-
sideration the intimate relation of the brain with every
other organ in the body by reason of its direct and re-
flex connections, it can readily be appreciated how much
greater must be the strain in those who are afflicted with
a neurotic diathesis. It is, therefore, not a matter of
theory, but a matter of fact, that the menstrual function
exerts a most potent influence upon the nervous system
of woman. Why in some it should be so much more
severe than in others, and become in itself an element
of shock or stress so great as to dethrone reason, can
only be conjectured. No two organizations are precisely
similar, and so many other elements, such as physical
health, environments, heredity, etc., must be taken into
consideration, that in many cases of insanity where
menstruation is normally performed, it is well nigh
impossible to say with any degree of certainty that
this function is the cause, pure and simple, of the
insanity.
Admitting, however, that in the cases under considera-
tion the menstrual function is simply the exciting cause,
where this function exerts so profound an impression
upon the nervous protoplasm as to induce insanity;
where, instead of acting as a "safety-valve" it becomes
the cause of mental explosion ; then it is, in my opinion,
the imperative duty of the physician to advise the artifi-
cial production of the menopause. Especially will this
obtain in those cases in which the cause may be directly
traced to disorders of menstruation, and in which there
is an hereditary taint.
And in this connection let me quote a few lines from
Bsvan-Lewis. He says, " Given an organism predisposed
by inheritance to insanity, such predisposition will tell
with special force at periods of reproduction and develop-
ment."
I am not one of those who hold the sexual organs of
woman responsible for the majority of her ills, and I
deprecate as much as anyone the abuse of abdominal
section. I maintain, however) that death is preferable
to chronic insanity, and in view of the remarkable and
brilliant successes achieved by the surgeon along this
line, I am convinced that we have a field which has been
but little explored, and one which offers bright induce-
ments as regards the cure of insanity by the removal of
the cause ; and I need only add that the consensus of
opinion of many well-known writers confirms the state-
ment that the menstrual function is the cause of insanity
in a large number of cases. Pozzi says "the sexual ap-
paratus is not, so to speak, an accessory wheel in the
female mechanism; it is, on the contrary, the chief
wheel, and it is to secure its proper action that constant
economies and reserves are made by nature."
Dr. George H. Rohe, in an article considering the
legal aspect of this subject, published in the Medical and
Surgical Reporter of July 15, 1893, reports the result of
twenty-two oophorectomies embracing different forms of
insanity. There were twenty physical recoveries and
two deaths. Of this number four made an absolute, and
three a partial, mental recovery. In seven there was de-
cided mental improvement.
I am confident that I have seen several cases become
hopelessly demented, or so deteriorated mentally as to
be beyond medical or surgical aid, which, had ovariotomy
been performed, would have recovered their reason.
There are cases under observation to-day which I am
positive would be greatly benefited, if not permanently
restored mentally, by such an operation.
Under these circumstances it seems to me that it ceases
to be a question of whether or not odphorectomy is justi-
fiable.
I maintain that it should be done in all those cases in
which the menstrual epoch acts as the exciting cause of
insanity, and the earlier the operation is performed the
better for the patient and for posterity.
August 25, 1894]
MEDICAL RECORD.
237
TREPHINING THE FRONTAL BONE FOR
CHRONIC HEADACHE.1
By J. MARSHALL HAWKES, M.D.,
NKW YORK.
Gentlemen : — The case which I am about to present to
you, I am sure will prove interesting ; for while the affection
is rare, when we do find it its incurability is exasperat-
ing. Moreover, it is in a comparatively new field of sur-
gery, and, still more important, the treatment in this and
two other reported cases has been entirely successful.
On June 31, 1891, Mr. M , aged twenty-eight,
applied to the writer for relief from headache of twenty
years' duration.
The history of the case is as follows : When eight years
old, while playing in a yard in the downtown tenement-
house district, he fell on a curbstone and received a cut
in the upper right quadrant of the forehead, about an inch
above the supra-orbital ridge and parallel with it. His
mother took him to the nearest druggist and had the cut
dressed with adhesive plaster, after the manner of the
time. The cut suppurated and healed slowly. He soon
began to suffer from headaches in the upper right frontal
region. They increased in severity during his youth and
young manhood, until they became quite unbearable.
Indeed, he was unfitted for work at least one day in the
week, and frequently for two days. These headaches
were practically continuous. If he awoke in the night he
felt the pain, and it was subject to frequent exacerba-
tions, accompanied by " attacks/' as he termed them.
These attacks consisted of a severe paroxysm of pain,
accompanied by dizziness, making him feel very weak,
so that he would usually, though not always, fall wherever
he happened to be.
At no time during these attacks did he have a convulsion
or even a slight convulsive twitching. He was never un-
conscious, always knowing everyone about him. He
never vomited, nor bit his tongue or cheek; he never
hurt himself when he fell, nor did he ever fall in a dan-
gerous place, though he frequently remarked to his
friends that it was strange that he did not. He always
had a premonition of an attack. No exciting causes were
apparent, though he declares if the wind blew hard in
his face the headache would become worse. He had
them when a boy in school and after he began to work.
Again and again he had to be led home by his fellow-
workmen or sent home in a carriage. He had no more
" attacks " when he was working than when he was not.
He had never had any illness, not even measles.
The treatment of various physicians and attendance at
two of the city hospitals for varying lengths of time, had
not produced any amelioration of his condition, and, at
the time he came to me, his condition so preyed upon
his mind that he feared he would become insane.
On examining his head in the region above indicated, a
small indentation, scarcely an eighth of an inch in length
and of only slight depth, was found, and it was only
after questioning the patient at great length that he re-
membered exactly when he received the injury as above
elicited, though he was positive of his age (eight) at
which the headaches began.
Since the accident had happened so long a time before,
and because the writer could learn so little of his pre-
vious history, it was deemed only prudent to eliminate the
various other causes of headache, such as eye-strain,
stomachic derangement, disease of the kidney, etc. He
was therefore sent to Dr. Knapp, who examined his eyes
and found them both normal. He was dieted most
rigorously on milk and the whites of eggs for some time,
without any relief.
As no trouble could be found and all medical treat-
ment was unavailing, the impression became more and
more fixed that the inner table of the frontal bone had
been fractured, and that the resulting exostosis, or possi-
bly a pacchionian granulation pressing on the brain, was
1 Read at the June, 1894, meeting of the New York County Medical
Association.
the probable cause, and that trephining might give him
relief; certainly nothing else would. He readily con-
sented, and on July 30, 1891, a semicircular incision was4
made surrounding the scar tissue marking the seat of the
accident. When the scalp was turned back there was
seen to be a slight depression in the skull not over half an
inch in length. Following the surgical indication, the
trephine point was placed in the centre of this depression
and a disk of bone, three quarters of.an inch in diameter,
was removed. On examination, this disk was found
slightly thickened at its upper margin, where normally it
should have been slightly thinner. There was, however,
no well-defined mark of fracture. As the dura mater ap-
peared perfectly normal, there was no call for further
search. The trephine hole was carefully burnished,
every rough particle being removed, so as to leave no
possible chance for irritation. The scalp wound was
then carefully sutured with black, iron- dyed silk; no
drainage was deemed necessary.
In five days the stitches in the integument, thirty-
seven in number, were removed. At the first dressing,
on removing the bandage, release of the pressure caused
the patient to have a slight epileptiform seizure; the
twitching of the body was general. Conjecturing that
the sudden removal of pressure was the probable cause of
the trouble, gentle pressure was made upon the area rep-
resenting the uncovered portion of the brain, and at
once the spasm ceased. The wound united promptly and
in seven days the patient was on the street.
From the moment of etherization until now, the patient
has had no headache. He expresses himself as very much
delighted with the result. He goes so far as to say that
he is " beginning life anew."
The hole in the skull has nearly filled with a fairly
dense fibrous tissue, through the centre of which, how-
ever, the pulsation of the brain can still be seen and felt.
On looking over the literature of the subject, I find
only two similar cases reported ; one by Mr. Horseley, of
London, and the other by Dr. Robert F. Weir of this
city. Reference is made to both these cases in Dr. M.
Allen Starr's " Brain Surgery," page 272. In these two
cases there is a history of a blow, but there was no sign
of fracture in either of them.
As to the indications for trephining for chronic head-
ache, Mr. Horseley thinks (and it appears to be the
general consensus of opinion) that " it is justifiable to
trephine in every case where the pain is persistent, local-
ized, and has resisted all medical treatment, whether
there be any fracture or not."
Occasionally, after blows on the head without fracture,
there will develop pacchionian granulations, which in
themselves may cause the persistent headache.
In virtue of the extremely low mortality from a care-
fully performed trephining, there seems to me to be no
contra indication to the operation as a last resort in cases
of the above character.
1343 Lexington Avshuv.
Dr. Eduard Sperk died a short time ago in St.
Petersburg. He was one of the leading physicians of
Russia at the time of his death. The first twelve years
of his professional life were passed in Eastern Siberia,
where he was government physician and afterward medi-
cal inspector. In 1870 he was recalled to the capital to
take charge as physician-in- chief of the Kalinkin Hospi-
tal. He devoted much time to the study of prostitution,
and had written much on the subject.
Spring Knee. — Dr. Delorme describes, in the Gazette
des Hdpitaux, No. 42, 1894, a condition in the knee sim-
ilar in its general features to the well-known spring fin-
ger. Just before full extension of the joint is reached
there is a slight hitch, and then the limb straightens it-
self with a sharp, rather painful jerk. Locomotion is in
consequence rendered uncertain and painful. In the
case observed by the author upon which his description
was based, the interference with free extension occurred
only when the patient was on his feet.
238
MEDICAL RECORD.
[August 25, 1894
The Coexistence of Infectious Diseases.— Dr. Caiger,
at a recent meeting of the Epidemiological Society, pre-
sented a study on the coexistence or close succession of
two or more infectious diseases in the same individual.
His experience at Stockwell, he said, had satisfied him
that such concurrence of infections was as frequent as
mere probabilities would explain, and that, so far from
affording protection against other diseases, some certainly
increased the susceptibility thereto. ( The American Jour-
nal of the Medical Sciences. ) In the last four years he had
seen 362 cases of two and 17 of three diseases running
some parts of their courses concurrently ; in .200 of these
the acute febrile stages of two or three coincided. The
priority of the several diseases was calculated from their
known incubation periods. The primary disease was
scarlatina in 197, which was complicated by diphtheria
in 97 cases, varicella in 43, measles in 31, whooping-
cough in 13, erysipelas in 10, enteric fever in 2, and
typhus in 1. Scarlatina was a complication in no fewer
than 88 among 97 in which the primary disease was
diphtheria; in 20 among 23 of varicella; in 14 of 17 of
whooping cough; in 6 of 9 of enteric, and 9 of 18 of
measles, though here diphtheria accounted for another 7.
Among the 17 triple attacks scarlatina was the primary
disease in 9, and a complication in 4 only, diphtheria
holding the highest place with 9. During the past six
years, 48,367 cases of scarlatina had been admitted into
the hospitals of the Asylums Board ; of these 3,166, or
6.54 per cent., were complicated, 1,094 with'diphtheria,
899 with varicella, 703 with measles, and 404 with
whooping-cough ; the relative numbers of diphtheria and
whooping-cough being probably owing to the fact that
many had already had whooping-cough in infancy, while
diphtheria, though less frequent, might and often did re-
cur; these four diseases accounted for 3,100, or all but
66. The questions suggested by these figures were: 1,
Did any disease render the individual less or more sus-
ceptible to infection by another? 2, Did the primary
disease in any way influence the course or character of
the secondary one as regards (a) incubation, eruption,
etc., periods; (6) severity of the disease; (c) distribu-
tion of local phenomena ; (d) liability to sequelae and
other complications ? The conclusions at which he ar-
rived, after eliminating the influence of age incidence,
seasonal prevalence, actual frequency, etc., were first,
that there was no such thing as antagonism between any,
but rather the reverse, increased susceptibility being
brought about, generally or locally ; that is, first, by the
lessened power of resistance induced by a disease at-
tended with grave constitutional disturbance; and,
secondly, by the local inflammations facilitating the de-
velopment of the contagia of diseases known to affect
the mucous membranes or tissues in question. Thus, an
attack of varicella exerted no influence on any that
might follow, but when scarlet fever was the primary dis-
ease, varicella, favored also by the quasi- dermatitis left
behind, might rival unmitigated smallpox in intensity of
fever and extent of eruption. Scarlatina was frequent
and dangerous after diphtheria, but diphtheria following
scarlatina was still graver, since the scarlatinal throat,
teeming with staphylococci and streptococci, was a perfect
soil for the bacillus of Loeffler. So, too, while the gen-
eral phenomena of measles might be aggravated by pre-
vious diphtheria or scarlatina, and in the latter conjunc-
tion the rash would be intensified, an attack of diphtheria
following on measles was even graver than the post-
scarlatinal, since it inevitably attacked the larynx and
trachea, and tracheotomy was very rarely of any avail.
Measles and whooping-cough were known to follow one
another, or to coexist, mutually increasing the suscepti-
bility of the individual. The author had never found
the incubation period of a disease affected, but the pres-
ence of scarlatina accelerated the appearance of the rash
in measles by a couple of days.
Cystitis in Patients who Have never Had an In-
strument Passed. — Since it has been recognized that all
cases of cystitis are the result of infection, the catheter
has been regarded as the only method by which the in-
fection of the bladder takes place. While this method
ranks first in importance, it is important to bear in mind
that, apart from tuberculosis, cystitis may and does occur
in individuals who have never been catheterized, and who
have never had either a urethritis or infective disease of
the kidney. According to Dr. Reymond, one not un-
commonly meets with cases, usually advanced in life, the
subjects of enlargement of the prostate, who have never
been catheterized, and who have never had symptoms
pointing to infective disease of the kidney ; in whom,
however, there are symptoms of cystitis, and the urine
contains pus and micro organisms. Where does the in-
fection come from ? Whence are the organisms derived ?
Bacteriological examination of the urine in seventeen
cases showed that the bacterium coli commune was pres-
ent in seven, and that other microbes were present in
ten. The latter were such as are normally met with in
the urethra, and it is assumed that they reached the blad-
der by a simple extension backward, the conditions
which enabled them to lodge and give rise to cystitis
being the residual urine in cases of prostatic enlargement.
Those in which the bacterium coli commune was found
were more acute in their clinical features. Of the three
possible routes by which they entered the bladder, the
urethra and ureter were regarded as unlikely. The au-
thor believed that they might have passed from the rec-
tum and through the prostate. — Annates des Maladies
des Organes Genito- Urinaires.
The Dangers of the Long Rectal Tube. — The use
of the long rectal tube in obstruction of the bowel has
never been looked upon with favor by anatomists.
Nothing is more difficult than the successful manoeu-
vring of the rectal tube through the turns of the sigmoid
flexure. Hie question of the value and safety of this
tube having been asked of the British Medical Journal,
the matter was referred to Mr. Harrison Cripps, who re-
plied as follows : Traditions die hard, and notwithstand-
ing the condemnation of the long rectal tube by Brodie,
Treves, and many other eminent authorities, I still find
that in most cases of obstruction or supposed obstruction
the tube has been introduced. Fortunately these tubes
are fairly soft, so that in a capacious rectum, when they
impinge and are arrested about opposite the promontory
of the sacrum, they simply coil up and do no harm. If
stiffer ones are used the patient's life is placed in immi-
nent risk. A patient at St. Bartholomew's Hospital was
to be operated on for ruptured perineum. In order to
increase the supposed efficacy of the injection, a quart of
soap and water, with some ounces of oil, were injected
by means of a long tube. The injection never returned.
A few hours afterward, owing to the acute symptoms of
the patient, I assisted one of my colleagues in opening
the abdomen. The soap and water and oil we found in
the abdominal cavity, and a hole below a reduplicated
fold in the upper part of the rectum. The patient died.
The idea that these tubes can be generally passed into
and beyond the sigmoid flexure is a pure delusion, save
in the rarest circumstances. As a means of diagnosis, or
of treating stricture beyond the reach of the finger, tubes
of any kind are absolutely useless. If a stricture is
actually present it would be 100 to 1 against the long
tube or bougie entering it, for it would almost certainly
catch in the cul-de-sac generally caused by the invagi-
nation of the stricture. If a stricture be not present,
the arrest of the bougie by the sacral promontory leads
to delusive diagnosis. Brodie, in his lectures, alludes to
a case in which a worthy practitioner had spent over 150
hours in dilating a supposed stricture situated high up.
The treatment had extended over a period of a year.
Brodie, who was present at the post- mortem examination,
found there was no sign of a stricture, the bougie be-
coming arrested by a curve of the sacrum.
August 25, 1894]
MEDICAL RECORD.
239
Medical Record:
A Weekly Journal of Medicine and Surgery.
GEORGE F. SHRADY, A.M., M.D., Editor.
Publishers
WM. WOOD & CO., 43, 45, & 47 East Tenth Street
New York, August 25, 1894.
A PLEA FOR PUBLIC ANiESTHETIZERS.
To an observant spectator of operations in our hospitals
ft is a matter for surprise and wonder that fatal accidents
so rarely result during the administration of anaesthetics..
No stronger argument could be furnished to the advocates
of the use of ether in preference to that of chloroform
than the fact that the former is recklessly administered in
hundreds of instances by inexperienced anaesthetizers,
yet without any immediate ill consequences. We use the
word " immediate " advisedly, because we are convinced
that not a few of the fatal cases of acute pulmonary and
renal troubles which have followed ether - anaesthesia
might have been avoided, not by substituting chloroform,
but by administering ether in a proper manner, instead
of saturating the patient with it. Strange as it would
appear to an intelligent layman, hospital surgeons con-
tinue to delegate this important duty to junior assistants,
dressers, and medical students, even in the most serious
operations, in which the constant and skilful surveillance
of the patient is a matter of vital consequence. Occa-
sionally a serious lesson is given, but it is rarely heeded,
until a sudden death on the table leads to a temporary
reform.
We are not exaggerating when we affirm that the aver-
age junior interne does not take the trouble to make a
scientific study of the variations in the pulse and respira-
tion ratio, the changes in the pupils and muscular reflexes,
etc., in a perfectly healthy subject, while the danger sig-
nals in the case of weak patients are often unheeded, or
are not recognized until the close of a long operation,
when the patient is in actual collapse. Then there is a
hasty resort to powerful hypodermatic stimulation,
strychnine, digitaline, or strophanthine, being repeated at
dangerously short intervals, which would have been un-
necessary if a hot saline enema containing whiskey had
been given before or during the operation.
The entire responsibility of watching the pulse de-
volves upon a young fellow, fresh from the medical
school, whose knowledge is almost entirely theoretical,
however great may be his natural aptitude and powers of
observation. The rest of the house- staff are expected to
devote their attention entirely to the operation, and it
must be admitted that the junior's mind is too often ab-
sorbed in its details.
The proper administration of ether is really an art
which few men seem to acquire to perfection. Witness
the annoyance so often experienced by surgeons in pri-
vate operations, when, from courtesy or necessity, the
administration of the anaesthetic is entrusted to the fam-
ily physician, who, with the best of intentions, either
pushes the anaesthetic to the limit of asphyxiation, or
allows the patient to struggle and vomit.
We are far from asserting that the young gentlemen,
who by their zeal and fidelity add so much to the pleas-
ure and profit of our hospital services, do not in many
instances become expert anaesthetizers, but this requires
time, so that, as a rule, they have only become really
proficient when they are replaced by green men. If
this criticism applies to the giving of ether, how much
more forcibly does it apply to the administration of chlo-
roform! Doubtless this valuable anaesthetic would be
employed much more frequently in New York than it is
at present if surgeons had sufficient confidence in the
skill and experience of the anaesthetizer. In our own
experience we have substituted ether in cases in which
chloroform was clearly indicated, simply because we did
not feel justified in entrusting the more dangerous anaes-
thetic to one who was entirely ignorant of its physiolog-
ical action. Personally we would almost prefer to run
the risks of employing ether in a case of suspected renal
or pulmonary trouble, than to incur the equal risks of
having the patient killed by chloroform.
Now this state of things ought not to be allowed to
continue. We believe that the time will come when
every large hospital will have a regular salaried anaes-
thetizer, who will always be available, and who will en-
joy the same confidence in his department as the pathol-
ogist does in his own. Operations will certainly proceed
more smoothly and safely ; we shall hear of fewer deaths
from " heart failure ; " and cases of " ether pneumonia/'
and of "acute uraemia from ether," will be almost un-
known. The advantages to the operator will be im-
mense. Instead of having his mind distracted by the
struggles of a half-anaesthetized patient, or being obliged
to stop his work until she is revived from a condition of
asphyxia, he will be able to give his entire attention to
the operation, relying on the anaesthetizer to note the
danger signals, to administer stimulants when they are
needed, and to keep him informed as to when he must
hasten, or when he can proceed deliberately.
If the expense involved in the employment of a special
anaesthetizer is an objection (and we admit that manag-
ing-boards are apt to prick up their ears at the mention
of any extra outlay in the medical department), we sug-
gest that a subscription-list might be started among the
members of the medical board, all of whom will doubt-
less have, at some time, suffered from the results of the
mal-administration of anaesthetics.
In closing we cannot refrain from alluding to a dan-
gerous practice which we have noticed in some hospitals,
that of allowing a nurse to hold the ether-cone while
another patient is being anaesthetized. This is a dan-
gerous custom (to which we plead guilty), and in the
event of medico-legal investigations would be extremely
difficult to justify in a court of law. As a fact, consid-
erable stress was placed upon this point in the case of
Dr. Mary Dixon-Jones vs. the Brooklyn Eagle.
Habitual good luck engenders carelessness ; but there
is no more striking example of the inconsistency of hu-
man nature than the fact that, while modern surgery de-
mands the most scrupulous attention to details with re-
gard to the preparation of the patient and the technique
240
MEDICAL RECORD.
[August 25, 1894
of the operation, there has been no corresponding im-
provement in this country in respect to the administra-
tion of anaesthetics.
THE CURES OF MUCOUS ENTERITIS.
M. Germain S&e has so many cures for muco-mem-
branous enteritis, that it seems impossible any one suffer-
ing from this usually intractable disease should fail to get
well. First of all, M. Sde gives purgatives, and his pur-
gatives comprise flaxseed, senna and hydrastis, castor-
oil, and olive-oil. As to flaxseed, he tells us that the
patient, immediately after each one of the three principal
meals, should take a tablespoonful of pure flaxseed,
placed for three or four minutes in a quarter of a glassful
of cold water. If the flaxseed is objectionable to the
patient, it can be substituted with psyllium. These
substances are sufficient in themselves, in the majority
of cases, to produce movements of the bowels, without
having to resort to the administration of the various
mineral waters, some of which, owing to the sulphate of
sodium present in them, often give rise to constipation
afterward.
Senna and hydrastis are given according to the follow-
ing formula :
9. Alcoholic extract of hydrastis canadensis gr. xxx.-xxxiv.
Senna leaves bathed in alcohol 3 jss.
M. and make 50 pills. Sig. : 1 pill after each meal.
Every now and then other things are suspended and a
dose of castor-oil is administered.
Olive-oil is given either by itself or in sugared tea, in
doses of from three to four dessertspoonfuls the first day,
morning and evening ; the second day at noon, the same
dose before the second meal ; the third day, a glass at
the same hours ; and the fourth day, a whole glass at
once. After this the patient must rest for four or five
days — that is, the medication should be suspended, to be
again renewed as prescribed. If the first trial shows a
non tolerance of the drug on the part of the patient, the
method must be abandoned. Generally, however, the
oil is well borne, more so than may be supposed, and
"in these cases the rauco- fecal movements produce an
unexpected relief and sometimes a cure, at least for a
considerable time."
Next, M. S6e gives sedatives, and usually in the form
of bromides. But the bromides of calcium or strontium
must be given, and not those of potassium or sodium,
since the latter, he says, irritate the stomach. In our ex-
perience the others do so to just about the same degree.
S6e's formula is :
$ . Bromide of calcium,
Chloride of calcium aa J ij.
Distilled water Oj.
In default of the bromides, he prescribes cannabis in-
dica, as follows :
Q • Solution of gum arabic J iv.
Extract of cannabis indica gr-*j-
M. Sig. : Three tablespoonfuls per day, one before each meal.
If great pain is present, one of the best modes of pro-
ducing relief is the administration of menthol in the fol-
lowing manner :
IJ . Menthol gr. ij.-iij.
Distilled water Oss.
Alcohol q. s. to dissolve the menthol.
M. Sig. : Two tablespoonfuls by the mouth t. i. d.
To diminish fermentation M. S6e knows of three effi-
cacious means only by which to meet this indication,
and he is in the habit of combining them. The first is
the administration of the phosphate of sodium, which
he places above any other antiputrefactive or absorbent
substance. With from forty* five to sixty grains of phos-
phate of sodium a day he obtained "remarkable results.11
The amount of the drug is divided into three parts, each
one of which is ordered to be taken in a little water,
after meals.
For flatulence, the best remedies are salicylic acid in
doses of three grains, and salicylate of sodium associated
with six grains of the phosphate of sodium. These drags
will at the same time diminish the sensibility of the mu-
cous membrane. Borate of sodium or borax is an ex-
cellent substitute for the agents mentioned, and it par-
ticularly aids the digestion of milk.
Yet, M. S^e's salicylic acid surely is irritating to the
stomach, and despite all the remedies mentioned most
cases of the disease, according to text books, do not get
well. However, we present the views of a hopeful thera-
peutist, and trust they may prove useful to our readers.
NAVAL HOSPITALS.
So much interest surrounds the Government hospital
care of the sailors when laid off from disease, but more
particularly when disabled from injuries received in
action, that we pick up with feelings of obligation to the
author a brochure entitled "Notes on Naval Hospitals,
Medical Schools, and Training Schools for Nurses," by
Dr. J. D. Gatewood, Passed Assistant Surgeon, United
States Navy. A sketch of hospital history prefaces a
series of interesting accounts of these special hospitals in
England and France, and then follow descriptions of the
institutions at Portsmouth, Chelsea, Brooklyn, Philadel-
phia, Washington, Annapolis, Norfolk, Pensacola, Mare
Island, and Yokohama, under the care of the medical
department of the United States Navy.
In the absence of a complete treatise upon the subject
these " Notes " are welcome, and aside from their value
for the historical data contained, the plans which are
given of nearly all the structures described make the
architectural feature one to be consulted by those inter-
ested in such matters.
Smuggled Opium. — It is estimated by the Canadian
authorities that at least 100,000 pounds of opium, re-
fined in British Columbia, are annually smuggled into the
United States.
Women Doctors in America. — According to a statis-
tical report drawn up by M. Louis Frank, of Brussels,
there were in 1893 on this side of the Atlantic fully
2,000 women practising medicine in one or other of its
forms and inclusive of 130 homoepathists. The majority
were ordinary practitioners, but among the remainder
were 70 hospital physicians or surgeons ; 95 professors
in the schools ; 610 specialists for the diseases of women ;
70 alienists ; 65 orthopedists ; 40 oculists and aurists ;
and finally 30 electro-therapeutists. In Canada there
is but one medical school exclusively devoted to the
training of medical ladies, but in the United States in
1893 there were ten, one of them being a homoeopathic
establishment
August 25, 1894]
MEDICAL RECORD.
241
%zxo% of tfte WLtzh.
The Plague Bacillus.— In The Lancet of August nth
is a short description, accompanied by illustrations of
preparations made by Drs. Lowson, of Hong Kong, and
Kitasato, of Japan, of the plague bacillus discovered by
the latter. According to Dr. Lowson's description, the
organism — which is a bacterium resembling the bacilli
found in the hemorrhagic septicaemias, except that the
ends are somewhat more rounded — when stained lightly
appears almost like an encapsuled diplococcus, but when
more deeply stained it has the appearance of an ovoid
bacillus with a somewhat lighter centre, especially when
not accurately focussed. When, however, it is focussed
more accurately it is still possible to make out the diplo-
coccus form. It is quite possible that the capsule has been
produced artificially, though in one of the preparations
shown this does not appear to be the case. The positions
in which it is most frequently met with — sometimes appar-
ently in almost pure cultures — are the glandular enlarge-
ments which occur in the groin, in the axilla, and in the
neck, though these enlargements are not always met with
in the rapidly fatal cases. These enlarged glands are
intensely congested, or rather they appear to be infiltrated
with blood. In this blood, which is in a state of disin-
tegration, mixed with the elements of the glandular tissue
which are also broken down, the organisms are exceed-
ingly numerous. They are also met with in considerable
numbers in the spleen and in the other organs, in those
positions where there is a slowing of the circulation as it
passes through capillary networks or sinuses, and are
found even in the blood in the heart and larger vessels.
The British Medical Association in Montreal. — At
the annual banquet of the Association, Dr. Osier, of
Baltimore, speaking for the visitors, suggested that the
Association meet in Montreal in the near future. All
who attended would, he assured them, receive as hearty
a welcome there as did the members of the British Asso-
ciation for the Advancement of Science a few years ago.
The Antitoxin Treatment of Diphtheria. — At a recent
meeting of the Berlin Medical Society, Dr. Katz read a
paper on the antitoxin treatment of diphtheria in the
Kaiser Friedrich Children's Hospital. Since the open-
ing of the hospital there had been treated by the usual
methods 1,081 cases of the disease, with a mortality of
38.9 per cent. Since the middle of March of the present
year 128 cases had been treated by antitoxin injections
with a mortality of but 13.2 per cent. The doses of
antitoxin employed varied from 5 to 20 grammes accord-
ing to the severity of the case. No injurious effects of
the drug upon the heart or kidneys were observed.
The Chinese Fire upon the Bed Cross. — The London
Daily Telegraph says that it is stated on high authority,
that in the recent combats near Seoul the Chinese fired
upon a Japanese ambulance carrying men who wore the
Geneva cross. They killed a doctor and some hospital
attendants.
Discontinuance of Examinations for the Medical
Corps of the Army. — A recent act of Congress has re-
duced the number of assistant surgeons in the Army
from 125 to no. There are now 115 men in this grade,
consequently there are no vacancies to be filled, and no
examining board will be convened until the number is
reduced by casualty or promotion below the limit men-
tioned. In the Navy, on the other hand, several vacan-
cies exist in the Medical Corps, and there are not enough
applicants to fill them. One reason for this is that
assistant surgeons in this branch of the service, when first
appointed, are messed with recent graduates of Annapolis,
their juniors by several years in age and experience, and
it is not until some time has passed that they are eli-
gible for admission to the wardroom.
What Becomes of Old Diplomas ? — An advertisement
in a daily paper of recent date furnishes a partial solution
of the problem as to what becomes of the diplomas of de-
ceased physicians. The advertisement in question offered
for sale the diploma of a physician who had recently died.
The price asked was $50. The advertiser, when he
learned that such a sale would be contrary to law, dis-
creetly withdrew his offer, which he said he had made on
behalf of the widow.
The German Imperial Family and Vaccination.— An
anti-vaccination committee published a report that the
German emperor had refused to allow his children to be
vaccinated. After the report had started on its travel an
inquiry was made, and it was found to be without any
foundation in fact, for all the princes have been vacci-
nated just as any other children.
Sievitia Secandi. — Dr. O'Reilly, of St. Louis, recent-
ly appealed to the Board of Health of that city to exeit
its authority to prevent the wholesale mutilation of wom-
en at the hands of local surgeons. It was stated that
many laparotomies were performed without the shadow
of an excuse, and that these so-called surgical operations
had but the semblance of legality in their performance
to keep them out of the category of attempted or actual
manslaughter. The St. Louis Medical Review admits
that Dr. O'Reilly was justified in his appeal to the
authorities, and that unnecessary operations on the ab-
dominal and generative organs of women are scandal-
ously frequent.
Anthrax in London. — During the past twenty years
118 cases of anthrax have been reported to the sanitary
authorities in London. Of this number, 90 were in per-
sons engaged in the hide and skin trade, 5 in persons
engaged in slaughtering animals,#7 in persons engaged
in the manipulation of horsehair or the manufacture of
brushes, one was employed at a bacteriological labora-
tory, while in 15 instances the source of infection was
not traceable. The number of cases among tanners
shows a progressive decrease, due, it is said, to the fact
that wet hides are taking the place of dry hides in the
trade.
Dr. Cornelius Herz, of Panama Canal notoriety, who
has been living in England since the trial of De Lesseps
and others, has been condemned by default to imprison-
ment for five years, and to pay a fine of 3,000 francs.
The sentence will be executed, if the French authorities
can apprehend him.
Alcohol Free of Duty.— The Senate tariff bill admits
free of duty alcohol to be used in the arts and for medi-
cinal purposes. After its passage another bill was intro-
duced in the House repealing this clause, but it has been
shelved with the bills remitting the duty on sugar and
raw materials.
242
MEDICAL RECORD.
[August 25, 1894
Dengue has been epidemic at Key West, the disease
appearing first among the troops and then spreading to
residents of the island.
Hot a Candidate for Congress.— The editor of this
journal is not a candidate for Congress, as announced in
various contemporaries. His name will not be men-
tioned in the convention which will be held on this date.
The editor, however, cannot refrain from expressing his
sincere thanks to those of his contemporaries who have
kindly and favorably noticed his candidacy as announced
in the secular press.— Journal of the American Medical
Association.
The Woman's Hospital in Seoul.— In this hospital,
the first of its kind in Corea, 2,765 patients were treated
during 1893. Of this number 119 were hospital cases,
2,125 were Ken at the dispensary, and 521 were visited
at their homes. A large number of the outside visits
were upon women of the wealthier classes, as it is not per-
missible for women of high rank to appear upon the
street, although some of them do come in closed sedan-
chairs to the hospital. The work has shown a steady in-
crease during the three years that the hospital has been
in existence. During 1891, in round numbers, 3,000
dispensary visits were made, 4,500 the next year, and
6,500 (representing 2,215 patients) in 1894, a total of
upward of 14,000 visits.
Genius and Degeneration.— Dr. James Weir, Jr., writes
that the sentence beginning, " Henry Clay was addicted
to an over-indulgence in alcohol," in the article with
this title in the Medical Record for August 4th (p.
132), should read : " Daniel Webster was addicted to an
over-indulgence in alcohol."
Sanitary Seienoe in America.— Dr. de Pietra Santa,
editor of the Journal d'Hygiine, says that among the
United States, Michigan, Massachusetts, and Minnesota
rank among the countries of the world in which sanitary
science, both theoretical and practical, has made the
greatest progress.
The Health of the Pope The cable reports that the
Pope had an alarming attack of syncope on Sunday last,
but that he is now in his usual health. His physician,
in an interview with the correspondent of a Berlin paper,
stated not long ago that the aged pontiff has no organic
disease, and suffers only from the weakness incident to
advanced age. His digestion is good and he sleeps like
a child.
The Worm Turns. — Actions for malpraxis are so fre-
quent that it is pleasant to hear occasionally that the
tables are turned and the doctor is able to recover for
slander. Dr. Thorne, an English medical man, has just
been awarded damages for slander upon his professional
skill by one of his patients. The defendant broke his
collar-bone in the hunting- field, and the plaintiff was
called in to attend him professionally. In consequence
of some disagreement, Dr. Thorne gave up attendance,
'and advised his patient to go to another medical man.
Soon afterward he found that the defendant's charges of
malpraxis against him were being freely and publicly dis-
cussed, and brought suit for slander. A number of emi-
nent surgeons gave evidence to the effect that Dr.
Thome's treatment was skilful and proper, and the jury
awarded him ^25 damages.
Treatment of Quinsy.— Dr. S, S. Cartwright writes
that the treatment for tonsillitis, referred to by him in
the issue of July 28th, was first proposed by Dr. A. S.
Hudson, of Stockton, Cal., in an article in the Medical
Record of September 27, 1890.
The Thermogen is an appliance for keeping up the
temperature of patients during an operation, doing away
with the necessity of blankets and hot- water bags. It is
in the form of a quilted cushion with an arrangement of
fine wires inside by which any desired degree of tem-
perature may be maintained by electricity. It was ex-
hibited at the late meeting of the Royal Society in Lon-
don.
A Lift saving Appliance for Miners. — Dr. J. S. Hal-
dane, of England, has invented an apparatus which, it is
asserted, will enable miners to live from one to three,
hours in the after-damp which fills a coal mine after an
explosion of fire damp. The invention consists of a
steel case, holding compressed oxygen and a respirator.
The whole apparatus is no larger than a safety-lamp. It
was shown by its inventor at the meeting of the British
Association for the Advancement of Science in Oxford.
The Cholera persists in Eastern Europe, Southern
France and Holland. The Czar has countermanded the
orders for the holding of the army manoeuvres at Smolensk
owing to the prevalence of cholera in that vicinity. In
Galicia, during the three days ending last Saturday, there
were 237 new cases and 129 deaths, and in Bukowina,
within the same time, 38 new cases and 21 deaths. The
Austrian troops marching through this district to take part
in the annual military manoeuvres have assisted in spread-
ing the disease. The Roumanian Government has estab-
lished a military cordon on the frontier to prevent the in-
troduction of the disease from Bessarabia, but as it cannot
stop the flow of the infected river Pruth, it is difficult to see
what good the cordon will do. Owing to the infection of
the Vistula, and the consequent spread of cholera in the
eastern provinces of Prussia, the orders for the army man-
oeuvres in the neighborhood of Dantzig have been counter-
manded. In many of the towns in these provinces the
authorities have closed the public baths and forbidden
the use of unboiled water and raw fruit. A death from
cholera was reported in Bordeaux on August 10th. The
case was imported from Marseilles, where twenty-one
deaths occurred during the fortnight ending August
17th. Cases are still reported in Amsterdam, Rotter-
dam, Maestricht, and other places in the Netherlands.
A death is said to have taken place from cholera in Chel-
sea, in the southwestern part of London, and several
cases were found among the crew of the steamer Balmore,
which arrived off Gravesend from St. Petersburg, on
August 7th.
11 Intellectual California" is the title of a three vol-
ume report of all the congresses and other " intellectual
events in California contemporaneous with the period of
the Midwinter Fair." The Transactions of the 1894
meeting of the American Medical Association will appear
in one of the volumes, which will be ornamented with
the portraits of some three hundred of the handsome
members of the Association. It is safe to assume that
there will be some three hundred medical subscribers to
the work.
August 25, 1894]'
MEDICAL RECORD.
243
jfcrcietg ^zpovts.
THE BRITISH MEDICAL ASSOCIATION.
Sixty-sccona Annual Meetings held at Bristol, July 31
to August 4, 1894*
Special Report for the Medical Record.
Fourth Day, Friday, August 3D.
(Continued from page ai8.)J
The concluding general meeting was held on Friday
morning, August 3d. There was a good attendance.
The President, who occupied the chair, introduced Sir
Charles A. Cameron, F.R.C.S.I., in a few well-chosen
and appropriate remarks.
Address in Public Medicine. — Sir Charles A. Cam-
eron, who was heartily received, then delivered the ad-
dress in Public Medicine. He said they might claim
that medical men stood pre-eminent among those who
devised means for prolonging life and lessening sickness.
They were the first to show that pure water was indis-
pensable to health, that the efficient drainage of houses
and of towns was a prime requisite to the maintenance
of the health of communities, that overcrowding spread
disease, if it did not develop it, and that the high mor-
tality associated with many industrial occupations might
be lessened by the adoption of certain precautions. The
lives saved by the adoption of Jenner's sublime discovery
of vaccination amounted to millions. In the government
of modern communities the medical man played, even
from a public health point of view, a very subordinate
part, and yet there were many medical men eminently
fitted, by their culture, experience, and ability, to hold
the office of Minister of Public Health, aye, even with a
seat in the cabinet !
Mortality rates in Town and Country. — In 1893 the
mortality rate in the towns was 5.7 per 1,000 in excess
of that in the rest of the country. The difference be-
tween the rural rate and that in some of the towns was
appalling. Why had one British town twice as high a
mortality as another, and why was the average duration
of life so much greater in rural districts than in the
towns ? The causes were no doubt highly complex, and
many of them were local. Among the poor in all towns
birth and death-rates stood highest. Their greater fecund-
ity and high marriage-rates compensated for their
enormous mortality. The poorer a man was the more
likely was he to marry. It was a remarkable but undeni-
able fact that a man's desire for matrimony was in the
inverse proportion to his ability to maintain a family.
Figures showed the appalling mortality of the children
of the poor. If the deaths of children under five years
of age were excluded, there would only be a difference of
about 2 per 1,000 between the town and country death-
rates. A large proportion of the lower classes in the
towns was underfed, insufficiently clothed, and badly
lodged. These unfavorable conditions told most severely
upon the very young. As higher death-rates prevailed
among the poor than obtained in the case of the well-to-
do classes, an undue proportion of very poor people in a
town necessarily caused a higher death-rate than where
the poor were comparatively few. This would be the
case even where the general hygienic conditions of both
towns were much alike. It might be considered that the
comparative poverty of towns might be to some extent
determined by ascertaining the proportion of the popula-
tion who were domestic servants. On the whole, they
found that in the towns where the domestic servants
were very numerous the death-rates were low. The per-
centage of tenements which consisted each of a single
room might, one would suppose, offer an indication of
the poverty of a town. He found, however, the most ex-
traordinary differences in towns, salubrious and other-
wise, as regarded one-room tenements. In the Scotch
towns one-roomed houses were even more common than
in England.
In Dublin one-third of the families lived in single
rooms. The high death-rate which characterized the
denizens of single-room dwellings was largely the result
of the miserable conditions of the people themselves,
apart from the state of their dwellings. If they exchanged
their one-roomed dwellings for four-room tenements,
they would still have a high death-rate by reason of their
poverty and its concomitant evils, and, he feared, from
their intemperance. It was to be regretted that the
local authorities still allowed such houses to be built.
In Dublin they could not be erected, a by-law directly
prohibiting their construction. In Dublin, 2,700 houses
had been de- tenanted and closed — about 1,000 of them
never to be reopened, without any compensation to the
owners. If a municipality were wealthy it could do no
better work than providing good dwellings for the arti-
sans and laborers ; but if its means were limited, it should
look only to the wants of the laboring and still poorer
classes. It was in the dwellings of the very lowest
classes that the seeds of infective disease were nursed as
if in a hotbed. These places were pest spots, and any
amelioration of their condition must be a gain to society
at large. The corporation of Dublin had been able to
provide two room tenements with separate sanitary ac-
commodation of the most modern style, at 2s. per week,
and without loss to the city treasury.
Water Supply. — The disuse of town wells and the fil-
tration of public water-supplies had done much to lessen
the urban mortality. The value of filtration through
mere sand had until recently been under-estimated ; but
the researches of chemists and bacteriologists had shown
that filtration through sand and gravel can be made
almost as perfect as through charcoal. The great impor-
tance of water filtration was painfully demonstrated dur-
ing the last epidemic of cholera at Hamburg. They
had not yet determined, in relation to chemical analysis,
the line which divided a bad from a good water, nor did
he believe that such a line could be drawn. One that
contained very little organic matter might be dangerous
to drink, while, on the contrary, water with a large
amount of organic matter had been drunk with impunity
for years. The number of micro-organisms in water was
regarded by most bacteriologists as a measure of its purity,
regardless of its chemical composition. The epidemic of
enteric fever in the Sees Valley in 1890 and 1891, inves-
tigated by Dr. Barry, of the Local Government Board,
had been held to prove conclusively that this disease was
propagated by water. Dr. Barry's conclusions had, ot
course, been questioned and controverted.
Sewer Air. — The results of recent investigations in
reference to the composition of sewer air showed that it
was superior, bacteriologically at least, to ordinary air.
They could easily understand that in the case of well-
constructed and constantly flushed sewers, the air in
them would not differ from ordinary atmospheric air. It
was the emanations from stagnant sewage in ill-kept sew-
ers that were to be dreaded. The ventilating openings
in the streets were generally objected to by those who
lived opposite to them. Bristol was, perhaps, the only
one of the large towns in which the sewers remained un-
ventilated. As typhoid fever was asserted the most
likely to be produced by sewer emanations, Bristol ought
to have more than an average amount of disease, if the
sewer ventilation theorists were correct. Statistics of
the mean death-rate from enteric fever, in the period
1887 to 1891, showed that five towns had smaller rates
than Bristol, and forty-four had higher. If Bristol had
made a mistake in not ventilating its sewers, it had not
apparently paid any penalty, for in the period 1881 to
1890 only one of the large towns had a lower zymotic
death-rate. He should feel disposed to adopt the Bristol
plan, were it not that there might be some difficulty, in
some towns at least, in cleansing the sewers. Typhoid
fever was not so prevalent in these countries or on the
continent as it formerly was, but in some towns typhoid
fever had not declined, and in a few it had increased.
There was a very general belief that this disease was
244
MEDICAL RECORD.
[August 25, 1894
almost wholly propagated through the media of water,
food, and sewer air ; but he believed that the greater
number of cases arose from the maUrics morbi of the dis-
ease being absorbed from the air. Up to the present,
pathogenic micro organisms had not been frequently de-
tected in the atmosphere, but neither had they been
found, except rarely, in water or milk suspected to have
produced disease. He believed that typhoid fever was a
disease of the miasmatic class, and that it became en*
detnic in certain localities in which the conditions of the
soil were favorable to the development of the micro-or-
ganisms which caused the disease. It had been sug-
gested that the waterlogged condition of Dublin was the
cause of the prevalence of typhoid fever, and that the
obvious remedy was subsoil drainage. It was, however,
a fact that the low lying portion of Dublin, where there
was most typhoid fever, was not damp, and that the
ground- water lay low there, and that in the parts where
the ground-water came much nearer to the surface there
was least typhoid fever. The explanation of this was
not difficult. The cold, wet clays were unfavorable to
the bacillus of the disease, whereas they had better feed-
ing-ground in the loose and well-aerated gravels. It
was stated that typhoid prevailed most among the upper
classes. This was not the case in Dublin.
The Future of Preventive Medicine.— The domain of
public medicine was steadily enlarging in every direc-
tion. Surely the time must come when the results of
these researches would enable man to extirpate some or
all of the diseases which even now were termed " pre-
ventable." England had been described by foreigners
as the birthplace and home of sanitary science, and it
surely deserved the compliment. Never before in the
history of the world were thirty millions of people lo-
cated on fifty thousand square miles, as was the case
with the England of to-day. Of these millions two-
thirds resided in the towns, which yearly had a quarter
of a million added to their teeming population. In
Germany forty-two per cent, of the population lived in
towns containing two thousand and upward. Only
every tenth Russian lived in a town. Notwithstanding
the great and continuous increase in its urban popula-
tion, Great Britain grew healthier and healthier from
decade to decade.
Professor Corfield, of London, moved that the thanks
of the meeting be given to Sir Charles Alexander Cameron
for his able and interesting address. It was due to Sir
Charles that typhus had been so effectually grappled
with in Dublin, for it was through his efforts that the in-
sanitary dwellings which were the hotbeds of the dis-
ease had been swept away by hundreds. The same
reason accounted for the failing power of the disease in
Liverpool. At the same time there was the matter of
the increase of diphtheria. Many causes were attributed
to this, and among those which found most favor with
the officials of the Local Government Board were the
street ventilation of sewers, and the increased aggrega-
tion of children in schools. Alluding to the probable
dispensing with vaccination, the speaker said that the
opposition to this by the medical profession had been at-
tributed to their desire to protect fees, but he prophesied
that if vaccination became non compulsory the public
would require half as many again medical practitioners
as existed to-day.
Dr. Davies (the medical officer of health of Bristol)
seconded the resolution, which was carried by acclama-
tion.
The various formal votes of thanks having been given,
the President of the Council (Dr. Ward Cousins,)
moved a vote of thanks to the President (Dr. E. Long
Fox) for his genial courtesy and marked ability in con-
ducting the business of the congress.
Dr. Winterbotham, of Bridgewater, seconded the re-
solution, which was carried with great enthusiasm.
The President acknowledged this vote with a few cour-
teous remarks, i
A motion on*rthe'agenda in the name of Dr. T. G.
Horder, of Cardiff, advocating an ethical section, was
accepted for consideration in the name of the council.
A very cordial vote of thanks to Dr. Markham Sker-
ritt, who had so well fulfilled the arduous duties of hon-
orary, secretary, terminated the proceedings.
SECTION OF SURGERY.
First Day, Wednesday, August ist.
The proceedings of the section were opened by the
President, Mr. Mitchell Banks, with a few remarks.
President's Address. — He said that no formal address
was needed since Mr. Greig Smith would, on the follow-
ing day, deliver the address on Surgery. Referring to the
progress of modern surgery, he said that in studying the
history of the art it was noticeable that those whose
names were handed down to posterity were not the intro-
ducers or inventors of new methods, nor the brilliant
operators, but the steady, practical observers who were
content to have as their motto " Festina Lente." In
studying of late years modern surgery and its tendencies,
it had sometimes occurred to him that we might be
going too fast, but he was happy to believe that this ten-
dency, which a few years ago seemed to be strong, had
lately been much modified, at any rate in Great Britain.
It was our proud boast that the British surgeon, when he
stood at the bedside, thought only of the sufferer as a
patient, not as so much material for experiment In sur-
gery it was best to be sure that what was new was also
true. Some politician had suggested that it would be an
excellent thing for the country if no new laws were made
for five years. He would similarly suggest that it would
be a good thing for them if no new drugs or new oper-
ations were introduced for five years, so that they might
study and thoroughly estimate the value of those that
they have already. He believed that much time was
wasted in the trial of old methods under new names, be-
cause they had not been thoroughly tried when origi-
nally introduced. He referred to the great harm done
by the non publication of many unsuccessful cases, by
which a false idea was conveyed of the merits of opera-
tions and modes of treatment. There were nowadays
certain misguided sentimentalists who, in the lay press and
elsewhere, abused modern surgery. These people were
antivivisectionists and antivaccinationists, and when their
views were a little more obscure and exalted — anarchists.
The publicity given to surgical work and to hospitals,
managed as they were by charitable and devoted lay-
men, was their best defence.
Operative Treatment of Perforating Ulcer of the
Stomach and Intestines. — Mr. Pearce Gould then
opened the discussion on this subject. He said that a
good many years ago Dr. Marion Sims showed his keen
foresight in prophesying that it would not be long before
perforation of a gastric ulcer would be amenable to
treatment by surgeons, and cease to be a hopeless condi-
tion. Eleven years ago, a distinguished Bristol surgeon
(Mr. Nelson Dobson) read a paper in which he main-
tained that the proper treatment of this complication
should be by abdominal section and suture of the open-
ing in the stomach, or if it proved to be impossible to
close the perforation, that a gastric fistula should be
formed. The reception of these views was not a very
encouraging one, but lately surgeons had more and more
followed Mr. Dobson's advice.
In dealing with the subject, he would exclude all cases
due to malignant disease and disease of the appendix
vermiformis, and would first consider perforating ulcers
of the stomach and duodenum.
The Pathology of the disease was mysterious. It oc-
curred oftenest in anaemic young women, very often of the
domestic-servant class, and less often in middle-aged
men. He described the classical symptoms of gastric
ulcer which, however, unfortunately formed no sure
guide. They were sometimes entirely absent. Statistics
showed that eighty-five per cent, of those in whom the ex-
istence of ulcer was diagnosed recovered. In 6$ per
August 25, 1894]
MEDICAL RECORD.
245
cent, perforation and death occurred ; five per cent,
died from hemorrhage, and the remaining 3$ per
cent, died from exhaustion and other causes. Per-
foration occurred most often in ulcers of the anterior
wall. Duodenal ulcers were most common in men.
Bllroth had recommended that as soon as ulcer was
diagnosed a prophylactic excision should be performed,
bit the speaker did not recommend this treatment.
Among other reasons against it were the facts that so
many cases recovered spontaneously or under treatment,
and that diagnosis was still very uncertain in regard to
the position of the lesion, and some cases were so acute
and perforation occurred so rapidly, that there was no
opportunity of excision. When perforation was followed
by escape of the contents of the viscus into the general
peritoneal cavity, death sometimes occurred almost im-
mediately from shock. In other cases shock might be
almost entirely absent. The success of the operation, he
believed, depended more on the complete and thorough
cleansing of the peritoneal cavity — abdominal toilet —
than on suture of the opening. He related several cases
in illustration of this point.
Time of Operation. — The operation should be under-
taken as soon as possible after reaction from shock set in,
but it was better to wait till proper assistance and ap-
pliances needed for the abdominal toilet were at hand
rather than to proceed without them. For Hushing pur-
poses he preferred boiled water containing one drachm of
common salt to the pint ( 20 § ) to any chemical anti-
septic solution. The solution should be of the tempera-
ture of from no0 to 1120 F, and it exercised a marked
restorative influence on the patient. Flushing should be
done in a regular and systematic manner, and no time
should be spared in making it thorough. It was the one
essential step in the operation. He thought that excision
of the ulcer was a needless and useless proceeding. In
every case where peritonitis was well marked he made an
incision above the pubes and drained the peritoneal cavity.
When from the extent of the disease or size of the opening
it was impossible to close it, the stomach should be drained.
Seven cases were recorded of operation followed by re-
covery.
He cited seventeen cases of perforation from typhoid
ulceration of the intestine which had been operated on.
Of these one recovered. He excluded three cases of
doubtful nature, all of which recovered. The ileum was
the part affected in most cases, and there was often more
than one perforation. It must be borne in mind that
perforation sometimes occurred while cicatrization was in
progress, and even months after the onset of the fever.
Symptoms might be very marked or slight. Spontaneous
recovery was very rare. Operative interference was only
to be recommended when the fever had subsided or nearly
so. With regard to ulcers of the posterior wall of the
stomach which perforated, and sometimes caused sub-
phrenic abscess, such abscesses should be opened and
drained from behind if possible, or if opened in front a
counter-opening should be made for drainage behind;
this was almost essential.
Mr. R. Maclaren, of Carlisle, said that he had personal
experience of four operations in such cases. Of these
three were cases of gastric ulcer, of which two were fatal
and one ended in recovery, and one case of typhoid ulcer
which recovered, operation having been performed thirty-
six hours after the perforation. Simple drainage without
suture was all that was done.
Mr. Rutherford Morrison, of Newcastle, said he
had operated on one case of gastric ulcer. There was
peritonitis limited to the pelvis. The patient died, and
at the necropsy it was found that the sutures held, the
opening was securely closed. The perforation opened
into the lesser sac of the peritoneum. He condemned
excision of the ulcer.
Mr. Gilbert Barling, of Birmingham, gave details of
several cases showing the difficulties of diagnosis and
treatment. He thought that too optimistic a view was
taken generally of these cases. Operations for the cure of
perforating typhoid ulcers were of very doubtful expedi-
ency. If any operation were undertaken it should be as
limited as possible. Opium he thought of great value in
the treatment of the primary shock and after operation.
Suture in typhoid ulcers was not to be advised.
Mr. Ward Cousins, of Southampton, spoke of the
benefits of incision and drainage alone. It was remark-
able how small a quantity of fluid escaped from the stom-
ach in many cases. This was due no doubt partly to
paresis, and hence the value of opium* He believed that
flushing was a much more critical procedure than was
generally thought. He would do it as sparingly as pos-
sible.
Mr. Haslan, of Birmingham, had operated on one
case that ended fatally. He would draw a distinction
between ulcer on the anterior wall of the stomach which
caused general peritonitis, and ulcer of the posterior wall
which often caused only localized inflammation. Un-
fortunately the classical symptoms of ulcer were more
often present in the latter class of cases. Shock often
came on as late as three or four hours after perforation*
The difficulty of the operation was often increased by the
rotation of the anterior surface of the stomach upward so
as to hide the opening. Having once found the ulcer it
was wise not to let it go again, as in his case much time
was lost by neglect of this precaution. The edges of the
ulcer should be inverted and Lembert's suture used. He
would try to empty the viscus through the wound, but
would not waste valuable time over it. He was an ad-
vocate of very free and prolonged flushing.
Mr. Nelson Dobson, of Bristol, said that although
he advocated the operation eleven years ago, he had not
had any opportunity of practising it. It was intensely
interesting to him to find that his suggestion had been
so generally adopted. He hoped, however, that too op-
timistic views would not prevail and cause the operation
to fall into disrepute. He thought it almost futile to wait
for shock to pass off. He would operate as soon as he
was satisfied of the diagnosis.
Mr. Damer Harrisson, of Liverpool, generally
agreed with previous speakers as regarded gastric ulcer.
He doubted the occurrence of spontaneous recovery in
cases of perforating typhoid ulcer. Diagnosis, espe-
cially in the acute stage of the fever, was often very diffi-
cult. He described one case in which two ulcers were
sutured. Death ensued seventeen hours afterward, and
it was found that the sutures still held. He would oper-
ate as soon as the diagnosis was made, and flush freely ;
hot water he believed relieved shock. In one case of
typhoid fever in which perforation was supposed to have
occurred there was distention and loss of the liver dul~
ness. He opened the abdomen and found no perfora-
tion but a kink of the gut. The patient entirely recov-
ered. He preferred to suture the opening in cases of
typhoid ulceration.
Mr. Kendall Franks, of Dublin, had operated on
one case with a fatal result. Much was to be learned from
failures. He would always operate as soon as the pri-
mary shock had passed off, and would remove the diseased
tissue and pass the sutures through healthy tissue. He
thought that the occurrence of a second perforation in
one of the cases cited by Mr. Pearce Gould was a silent
witness to the truth of his view. Flushing was essential
to success, but it was difficult to clear out the lesser
omental cavity and the parts behind the liver and spleen.
Mr. R. O'Callaghan, of London, had operated un-
successfully on two cases. He thought that no other
condition in surgical practice showed such early and
severe collapse. Early operation was imperative without
waiting for reaction from shock. Opium was beneficial'
in case of shock, but not in collapse.
Mr. Pearce Gould said in reply that he was no
advocate for delay, but he would not operate during
primary shock when it was present (it was sometimes
entirely absent). After the shock was rallied from, and
before collapse set in, was the time for operation. As to
the free excision advocated by Mr. Kendal Franks, he
246
MEDICAL RECORD.
[August 25, 1894
said that it was all very well to sacrifice a few inches out
of the twenty feet or so of intestine, but it was a more
serious and difficult matter to remove a large portion of
the stomach-wall and securely suture the remainder,
whereas there was no risk of inversion of the edges caus-
ing trouble in the case of the stomach as it might in the
intestine. As to the actual occurrence of spontaneous
recovery fit>m perforation of a typhoid ulcer it had been
proved to occur sometimes by Cayley and Murchison's
researches. We must beware that, in flushing, septic
materials were not driven from the wound into the dis-
tant parts of the peritoneum and thus disseminated.
Flushing should be begun at the periphery and ended at
the wound.
The President in summing up the discussion said
that the speakers seemed unanimous as to the question of
suture. Washing out of the stomach was needless when
the natural drain by the intestines was open. The ques-
tion of spontaneous recovery was important. It appeared
certain that in some cases it had occurred. Flushing
seemed to be generally approved of, but of course it
might be contraindicated by the patient's condition.
Finally he must congratulate the speakers on the tem-
perate manner of the discussion and the moderation of
their views. He was glad to think that we were aban-
doning the ridiculously optimistic views common a few
years ago in abdominal surgery.
Mammary Tumors. — Mr. Herbert Snow, of London,
read a paper on the dispersal of certain forms of mam-
mary tumor. These were the fibroma of adolescence,
tumors due to inflammatory hyperplasia and certain
tumors due to dilatation of ducts. The inunction of
iodide of lead and mercury ointment four times a day
would cause complete absorption of such in a few weeks,
and so avoid the scars and other drawbacks of operation.
He narrated several cases in point.
There was no discussion on this paper.
Traumatic Delirium Tremens. — Mr. Damer Harris-
son read a short paper on the treatment of traumatic
delirium tremens. He referred to the method popular
in Lancashire among colliers' wives to quiet uproar-
iously drunken husbands. They would send out for
two pennyworth of "Quietner" (three grains of tartar
emetic) and administer it concealed in a pint of beer.
He had adopted a somewhat similar treatment, which
was really almost the same as the old treatment of fever.
After morphine in full doses and chloral hydrate had
failed of any effect whatever, tartar emetic, followed by
chloral or morphine, produced complete cessation of
the delirium, and after its use very small doses of narcot-
ics took full effect. He quoted cases to illustrate this.
Surgery of the Gall-bladder. — Mr. Rutherford
Morrison, of Newcastle, read a paper " On some Points
in the Anatomy of the Right Hypochondriac Region, re-
lating especially to Gall- stones." He demonstrated by
diagrams and drawings the existence of a pouch of perito-
neum behind the right lobe of the liver which was of
importance in the surgery of the gall-bladder. It should
be drained through the parietes immediately below the
kidney.
Hernia in the Aged. — Mr. R O'Callaghan read a
paper on the operation for strangulated hernia in octo-
genarians. He said that old people, especially old
women, bore operation better than those in the prime
of life. He described three cases which were all success-
ful, although in two of them (inguinal hernia) the gut
was almost gangrenous, and it was with great misgivings
that he returned it, but he decided to do so because the
boundary between the congested semigangrenous part
and the healthy gut was ill defined, and after long douch-
ing with water at the temperature of no° F. its appear-
ance improved. He laid great stress on these points, as
of great practical value. The treatment by enterotomy
and the formation of a fistula was unsatisfactory and
fatal. In case of gangrene enterectomy, suture, and re-
turn of the gut was the best treatment. He used no
chemical antiseptics.
Hip-disease in the Aged.— Mr. T. P. Lowe, of Bath,
read a paper on the treatment of senile rheumatic arth-
ritis of the hip joint by forcible movements. He se-
lected the hip joint as typical, and because in old
people it was the first, and often the only, joint attacked.
The symptoms were often mainly those of sciatica. Flex-
ion was generally present, and was maintained by the pres-
ence of adhesions which should be broken through, an
anaesthetic being given, if necessary, and in severe cases
a Thomas's hip- splint should be applied. In mild cases
the recovery was instantaneous and the patient could
walk at once without pain. To break through the adhe-
sions the patient should be laid prone and the thigh for-
cibly raised while the pelvis was held down. His experi-
ence led him unhesitatingly to affirm that synovial fluid
could be restored to a joint which was dry.
Second Day, Thursday, August a©.
Spinal Surgery. — Mr. W. Thorburn introduced the
discussion on " The Surgical Treatment of Injuries
of the Spine and Spinal Cord." To begin with, he
would classify injuries, dividing them into eight classes
as follows: 1, Unilateral dislocation; 2, bilateral dislo-
cation without recoil of the displaced bone; 3, bilateral
dislocation with recoil of the displaced bone ; 4, fract-
ure without recoil (diastasis); 5, fracture with recoil;
6, injury of lamina or processes ; 7, compound fractures ;
8, secondary lesions — hemorrhage, meningitis, etc.
After a careful survey and study of the subject bis con-
clusions were that fracture-dislocation and dislocation
were not difficult to reduce, but that the chances of recov-
ery of the cord were not much improved thereby. A
cord once crushed was incapable of recovery, as was shown
by experiments as well as clinical experience. Any ap-
parent recovery was due to vicarious conduction, some
parts of the cord having escaped damage and being used
instead of those normally employed.
The advantage of reduction simply was that a straight
spine was better than a crooked one should the patient
recover; but, on the other hand, reduction of dislocation
in the cervical region was not without danger to life, and
the more dangerous the higher up the injury. Reduction
might be said to be safe and useful in unilateral and some
bilateral dislocations. When the dorsal region was the
site of injury reduction was not often possible.
As to laminectomy, in most cases of injury it was use-
less because when there was recoil of the bone the lumen
of the canal was restored, and there was no pressure in at
least two-thirds of the cases, and when there was no re-
coil, although laminectomy might be possible, yet there
was not much hope of recovery, for nearly all the cases,
even when there was recoil, ended fatally. When the
continuity of tissue in the cord was once interrupted no
restoration took place. He had found records of two
hundred published cases and had personal experience of
seven. In these seven he had seen no material benefit
from laminectony in any case. Subsequent improvement
was not due to the operation. In compound fractures
(such as those caused by gunshot) he would remove
ragments of lamina or other bone simply as a part of the
wound toilet. When the laminae were primarily injured
operation was useful. There was no natural recoil and
the cord was generally less crushed, and while the frag-
ments of bone were usually small they might be doing
harm by irritating and pressing on the cord. The gyp-
sum corset was, no doubt, useful late in the case, but he
was very doubtful whether it was of use immediately after
the injury, while there was danger of the unseen forma-
tion of pressure sores and extensive sloughing.
Dr. H. L. Burrell, of Boston, U.S.A., said that he
had a basis to go upon of 8 cases of laminectomy of
his own and 4 of his colleague's, besides the collected
records of 178 cases. The hopelessness of the condition
when left to nature was well known and was demon-
strated by him in a paper on the subject published in
1887. He then recommended that in all cases of dis-
August 25, 1894]
MEDICAL RECORD.
247
location and fracture-dislocation an anaesthetic should be
administered with as little delay as possible, for irrepara-
ble damage was done by allowing pressure to continue
even for one hour. The patient should be suspended
and forcible rectification practised, and a gypsum corset
be applied. By the use of this method he had secured
some brilliant results, but since the introduction of oper-
ation he had given it up for laminectomy. The do-noth-
ing treatment should certainly be abandoned.
Immediate reduction had increased the recoveries by
eleven per cent, and if such a blind method did so much
good an operation that enabled the surgeon to see for
himself the exact condition and remedy the displacement
without doing more than needful must certainly do still
more good. He doubted the possibility of an exact dif-
ferential diagnosis, and therefore would operate on all
Mr. C. B. Keetley mentioned a case in his own
practice in which he applied a Sayre's jacket without at-
tempting reduction. The patient entirely recovered.
In another case of cervical fracture- dislocation produced
by diving from a height into a swimming-bath, an aes-
thesia and paralysis were complete in both arms and
legs, but the right arm was somewhat contracted. He
operated, removing the laminae of the third and fourth
cervical vertebrae. The lower margin of the fourth
lamina nearly touched the fifth body. After removing
the laminae the cord seemed to return to its normal
form, and there was afterward some return of power of
movement, but the patient died on the fourth day. At
the necropsy it was found that the cord was cleanly and
completely divided but the dura mater was uninjured.
He thought the operation in general was not a hopeless
one, but that we should not be eager to operate. The
risk of the operation itself was small. The dura mater
need not be opened, and thus it was a little more danger-
ous to operate on a case of simple fracture- dislocation
than of compound. Still it must be admitted that the
operation had its risks. He had operated on another
case of fracture in the cervical region, but the patient
died almost immediately. The necropsy showed fracture
and hemorrhage at the base of the skull.
Mr. Gilbert Barling was quite in accord with Mr.
Thorburn. We should beware of reckless operations
which would only tend to bring laminectomy into con-
tempt. A knowledge of the nature of the accident
would often forbid operation, because we may often be
sore from the extreme violence in indirect injury that the
cord is divided or pulped, and in that case laminectomy
was only " a crude way of administering euthanasia, in
which we are not justified.1' He was quite sure that the
operation had its own risks, and therefore it was wrong
to employ it indiscriminately. He described two cases,
one of direct violence to the side of the neck and arm —
palsy, probably due to hemorrhage, ending in sponta-
neous recovery, and another of great indirect violence
causing displacement of the twelfth dorsal spinous proc-
ess and palsy of the bladder and lower limbs. Now
two years after the accident there was complete recov-
ery except for some patches of anaesthesia. This pa-
tient refused operation. This was one of the most hope-
ful cases for laminectomy, yet the operation would not
have improved the result.
Mr. Barclay, of Bristol, thought that there was a
tendency to be too cautious in these cases, but when
there was a displacement of one vertebra from another,
with recoil, operation was hopeless. When, however,
there was no recoil and obvious displacement we ought
to give the patient the chance afforded by laminectomy,
and if necessary chisel away the projecting edge of the
vertebral body which pressed on the cord. In cases ot
injury and displacement of a process or processes, if
diagnosed, he would operate, but the diagnosis was often
difficult. In cases where hemorrhage was diagnosed he
would also operate.
Mr. Damer Harrisson said that in his opinion opera-
tion was rarely called for; those cases which he had
wished to operate on and had been prevented had gen-
erally recovered. Fixation was the best treatment for
fracture- dislocation. He used a box splint, flexed the
thighs, and drained the bladder, when it was palsied, by a
perineal section, and was thus enabled to prevent decom-
position of urine and cystitis.
Sir William Stokes, of Dublin, did not think that
laminectomy alone could entirely relieve pressure, be-
cause the cord would still be stretched over the project-
ing body in front. He did not think removal of the
projecting body possible without risk of increasing the
injury to the cord ; operation for direct injury was much
more hopeful. He found that these patients did not
bear fixation* well, and there was great risk of sloughing
under the gypsum jacket. He had never found any
need of perineal section, but had succeeded in keeping
the urine and bladder healthy by the use of boric-lotion
injections.
Mr. Reginald Harrison detailed a case showing the
benefit of immediate extension. He agreed with Mr.
Thorburn and others as to the hopeless injury caused by
indirect violence.
Surgeon- Major Hatch was not very sanguine about
the operation. He had had five cases at the Jamsetjee
Hospital in India ; of these one was a case of in-
jury to the cervical region and four of the dorsal
region. In the first case there was meningitis present
at the time of operation. No improvement followed.
The patient died three months afterward. Necropsy
showed that there was no pressure, and only slight
narrowing of the lumen of the canal. Of the four cases
of dorsal injury three died after laminectomy ; in two
the projecting vertebral body was gouged away without
much difficulty and gypsum applied in the prone posi-
tion ; one of these died, the other improved after four-
teen days, and was still improving. Of the other fetal
cases, one was found after death to have an abscess on
the canal below the lesion, the other died at the end of
a week. He thought that reduction of the dislocation
was not at all necessary. The difficulty of diagnosis was
very great, and therefore he would operate to help the
diagnosis, seeing that the prognosis was so bad. He did
not think that secondary operations were hopeful. He
believed there was a future before the operation.
Mr. Jordan Lloyd said that no one surgeon had a
large personal experience of such cases. Fractures of the
spine varied much in severity. Fixation gave good re-
sults. Cases of indirect violence were . best left alone
(except for fixation), and he would not consider opera-
tion in them. Cases of direct injury — generally in the
dorsal region — were, however, amenable to operation.
He had only operated on one case of recent fracture.
The patient died. He would not operate on such a
case to-day. He had, however, removed the laminae of
four or five vertebrae, eight years after the injury, for in-
continence of urine and faeces, and the patient recovered
control of them completely.
Mr. Noble Smith claimed to have benefited a case
of fracture by the application of a spinal support press-
ing on the projecting bone. He had performed lami-
nectomy in one case eight years after the accident. Im-
provement followed.
Mr. Thorburn, in replying, said that there seemed to
be a general agreement as to the facts. There were at least
two hundred cases recorded, and probably many less suc-
cessful cases not recorded, hence, without waiting longer
we were in a position to judge of the value of the opera-
tion. He could fully confirm what Surgeon- Major
Hatch had said as to the feasibility of lateralizing the
cord and gouging away the projecting body. A mistake in
diagnosing the exact site of the injury was not important,
it was easy to extend the incision and go further (gener-
ally higher).
Flat-foot — Sir William Stokes read a paper on
flat-foot and described Gliick's operation of section of
the os calcisand tendo Achillis in order to slide the bone
downward and forward. He preferred to this and to
248
MEDICAL RECORD,
[August 25, 1894
Ogston's operation a cuneiform osteotomy of the astrag-
alus so as to replace that bone within yon Meyer's tri-
angle. He showed casts of a foot before and after oper-
ation.
Mr. Keetley preferred Ogston's operation, but in a
severe case he had had to supplement it by osteotomy of
the tibia and first metatarsal bone, thus producing a well-
shaped foot ; but he was bound to admit that the patient
herself preferred the other foot, which was originally
equally deformed, and had not been operated on. The
pathology of this deformity was most complex.
Traumatic Gangrene. — Mr. Robert Jones, of Liver-
pool, read a paper on a case of acute spreading traumatic
gangrene, treated by amputation and swabbing with pure
liquefied carbolic acid. The patient was thirty-two
years of age, and had a compound fracture of the fore-
arm. The gangrene spread very rapidly, and at the time
of amputation at the shoulder- joint there was swelling
and crackling over the pectoral region and above the
acromion. The soft parts cut through were dark, con-
gested, and gaseous. There were practically no flaps.
The wound and intermuscular spaces were freely swabbed
with carbolic acid, and this was repeated at subsequent
dressings. Recovery followed, hiccough night and day
being the most distressing symptom.
Mr. Jordan Lloyd had a somewhat similar experience
in two cases, aged thirteen and fourteen. After amputa-
tion he plugged the wounds with lint soaked in 1 to
1,000 sublimate solution and made some sixty inch or
half inch incisions into the bronzed and brawny tissues
above. Both patients did well.
(Esophageal Stricture. — Mr. Kendall Franks de-
scribed a case of dysphagia from a stricture of the oesoph-
agus just below the cricoid cartilage. At the opera-
tion (cesophagotomy) it proved to be due to a smooth
double fold of mucous membrane completely closing the
* lumen, except for a slit like aperture (imperceptible from
above) a quarter of an inch long. He excised the dia-
phragm and sutured the edges of the mucous membrane
remaining. The external wound was closed around an
oesophagus tube. The patient recovered. Such cases
were rare, only nine were recorded since the seventeenth
century. The pathology was obscure. The general opin-
ion was that they were congenital, but in this case the
patient (aged forty-six) had only had symptoms for three
years. Could it be the result of prolonged spasm of the
muscularis mucosae and circular fibres? Mr. Franks also
showed a drawing of a case of development of external
piles into fibroid tumors after an operation for internal
piles.
Third Day, Friday, August 3D.
Ovariotomy. — Mr. Mayo Robson read a paper " On
a Consecutive Series of Ovariotomies performed in the
Surgical Clinic at a General Hospital." He brought
forward the details of 216 consecutive cases, without any
selection, as evidence that the claim of obstetricians
to have the monopoly of such cases was unfounded.
General surgeons were the best fitted to succeed ; they
were prepared to deal with any complication that might
arise. He had done 850 abdominal sections with a mor-
tality of twelve percent., including cases of suppurative
peritonitis and one desperate case. Most of his experi-
ence was in the wards of a general hospital.
Of the 216 cases, 14 died. Of these two were cases
of malignant disease, in two there was intestinal obstruc-
tion, one was admitted with peritonitis, in one a fecal
fistula existed and the patient died eight weeks after the
operation, one had a suppurating cyst, one died of bron-
chitis, caused possibly by ether (on this point he held
strong opinions), one from heart disease, one was due to
hemorrhage from slipping of ligature on pedicle of a
sessile tumor caused by vomiting ; one death was traceable
to a collection of sewage under the ward. The mortality
was six and a half per cent.
The risk of sepsis was put forward by obstetric phy-
sicians as an argument against the performance of ovari-
otomy by surgeons who were frequently dealing with
septic wounds, etc.; but he submitted that the obstetri-
cian who might have been attending cases of puerperal
fever, and whose fingers were frequently in contact with
vaginal and other secretions was more likely to convey
infection. He thought further that for these reasons
obstetricians ought to leave ovariotomy to surgeons. As
to diagnosis, the surgeon who was familiar with various
non-gynecological diseases of the abdomen was more
likely to be accurate than the specialist. He was strongly
in favor of the maintenance of the distinction between
the physician and the surgeon. He emphatically pro-
tested against the pretensions of the obstetricians. It
there was to be any specialty let it be that of abdominal
surgery. If a surgeon is fit to operate on the kidney and
the intestinal tract, surely he was fit to operate on the fe-
male organs of generation.
Mr. Ward Cousins warmly congratulated Mr. Rob-
son on his cases. He thought that he scarcely did him-
self justice, however, by including so many complicated
cases.
Mr. Nelson Dobson said that in Bristol ovarian
tumors were operated on as a rule in the general wards,
with results as good as those in special wards elsewhere.
He had seen a case in which ovariotomy was undertaken
by an obstetric physician, which proved to be one of tu-
mor of the kidney ; the mistake was entirely pardon-
able, but it involved the performance of an operation
quite outside the operator's experience, and one he would
not have undertaken had the condition been diagnosed.
Mr. Robson, in reply, said that he could fairly have
separated his cases as Mr. Cousins has suggested, but he
wished to give a table that could not possibly be cavilled
at. If so arranged, his mortality would be only ij4 per
cent. Uncomplicated cases were very rare in his expe-
rience, there were nearly always adhesions or other com-
plications, such as twisted pedicle, which always gave
rise to peritonitis. He used a temporary ligature before
beginning to remove the cyst, when it was possible —
thus lessening the bleeding in dividing adhesions. He
could not agree with one speaker, who claimed that gyn-
ecology was all surgery and should be the surgeon's
province. Many cases were medical, such as those of
slight disease of the uterine appendages, which were best
treated by medical means, such as rest, and it was most
unjustifiable to operate on all these, for, apart from any
risk of operation, it was certainly a disadvantage to a
woman to lose her ovaries.
The President traced the origin of the pretensions of
obstetricians from the days no operations were done on
the abdominal cavity, and the treatment of ovarian tu-
mor was medical. He protested against women's hos-
pitals, officered by men in general practice, who had had
no surgical training since their student days, and were
not fit to suddenly plunge into capital operations any
more than he (Mr. Banks) was to turn a foetus in utero.
He adverted to the recent inquiry at a women's hospital
in London, which had involved the resignation of the
staff.
Papers were also read by Mr. J. Hutchinson, Jr., on
"Injuries of the Elbow-joint," and by Mr. Mansell
Moullin on " Treatment of Enlargement of the Prostate
by Removal of the Testes.1 '
The passing of a cordial vote of thanks to the President,,
moved by Mr. Ward Cousins, closed the proceedings.
SECTION OF MEDICINE.
First Day, Wednesday, August ist.
Dr. F. T. Roberts, as President of this section,
opened it with a few remarks, in which he urged the
necessity of broad views in medicine, deprecated the
tendency to specialize, hoped this section would always
maintain its position, and expressed his pride in being
asked to preside over it this year.
Functional Diseases of the Heart.— Dr. Douglas
August 25, 1894]
MEDICAL RECORD.
249
Powell said that though the term functional had been
objected to, he rather favored it as useful to designate
disorders which were independent of recognizable change
of structure. In the case of the heart, the commonest
causes of such changes were nervous strain, shock, acute
specific diseases, and such like. The result is some im-
pairment of the cardiac mechanism, when the pulse is
affected in its frequency, tension, or rhythm. He depre-
cated the term tachycardia. Many of the cases so
termed resembled angina pectoris. Others were more
like Graves's disease. Pulse tension was most important,
and the recurrent pulse often found with high tension
ought to be carefully distinguished. Abnormal slow-
ness, the so called "bradycardia," is found as a sequel
of typhoid and influenza, and sudden changes from fre-
quency to infrequency, or a normal rate with alternation
to either, have been found. Subjective symptoms are
usually well marked, the patients being often troubled
with a consciousness of such symptoms as irregularity or
intermittence. As to treatment, the causes of mental or
physical over-strain must be removed. Then iron and
arsenic are useful, and sometimes trinitrine may be called
for. Dr. Powell illustrated his paper by the following
tabular statement :
I.
Cardiac Vascular
Hyperesthesia.
Source of
Altered
Innervation.
c. Undue perception CentTal heredi-
of heart's action. . tary neurosis,
normal or altered. I
•a. Oppressed heart's Central,
action with raised
arterial rcsist-
Cardiac plexus.
3. Angina pectoris.
a, Vena;
*, Vera.
Exciting Cause, j Method. Rhythm
I
I
Mental shock,
nervous ex-
haustion.
Mental strain,
nicotine con-
stipation, uric
acid, uraemia.
Mental emotion
peripheral ex-
citement, vis-
ceral.
Variable de- Variable
gree of ar- 1 varicose
terial ten- ' tension,
sion. '
Regular, with t Do.
arhythmic
interludes.
V. M. excit. ' Slow,la-
causing
ondary car-
diac embar-
rassment.
bored,
quick.
II
Heart's Action
Accelerated.
Source of
Altered
Innervation.
Exciting
Cause.
Method. I Rhythn
l_
Xm Paroxysmal palpi-
Central.
Intense voli-
«, Shock ; b,
Regular.
tation under men-
1 tion in emer-
reaction ; c% \
tal excitement.
gencies.
cardiac.
1
pressure ; </,
visceral re-
1
laxation.
a. Paroxysmal palpi-
Central. 1 Vagus inhibi-
Irregular.
tation fiom indi-
tion.
rect vagus excite-
ment.
3. Paroxysmal palpi-
Visceral irrita-
Anaemia.
Irregular.
tation from direct
tion, strain,
vagus excitement.
pericarditis,
endocarditis,
1 nerve strain,
hot bath, men-
tal shock.
4. V. M. relaxation.
Variable.
5. Sustained hurry
Regular.
of heart. 1
Dr. P. M. Chapman could not agree that all causes of
functional derangements of the heart are of nervous ori-
gin, as irritability of muscle undoubtedly has a disturbing
influence, and also fatty degeneration. Slowing of the
pulse may be due to irritation of the vagus, and the best
remedy is faradization of the vagus. Graves's disease is
often looked upon as incurable, but he does not think
so, as he has met with instances of complete cure. The
manometer is indispensable to accurate diagnosis.
Dr. James A. Lindsay was of opinion that the symp-
toms of organic and functional heart derangements are
often identical, but after excitement are more intense
in the former than in the latter. The condition of the
cavity walls affords conclusive evidence.
Dr. Ernest Sansom objected to the term "func-
tional/' and instanced amaurosis, which he defined as a
disease in which the patient saw nothing and the doctor
saw nothing. Similarly, in so-called functional derange-
ments of the heart, the patient often felt a great deal and
the doctor could find nothing wrong. Acute pain might
be present and yet the heart show no sign of disease or
even trouble. " Fatty degeneration " of the heart was a
huge bugbear; but people do not die of it suddenly; in
his opinion it was more frequently associated with per-
nicious progressive anaemia than anything else.
Dr. G. A. Gibson had met with cases of cardiac affec-
tion where the pain was localized in the hands or the
wrists, or in the forearms, and believed these pains to be
due to some profound change in the heart itself, often
proceeding from dilatation, and this was frequently re-
ferred to as proceeding from nervous disturbances.
Dr. Shingleton Smith said there was no test for car-
diac neuritis, and functional could not be separated from
organic disturbances; they were thoroughly mixed in
such diseases as goitre, anaemia, and perhaps in phthisis.
However, the difficulty of diagnosis should not be allowed
to cause hesitation on the part of the medical man. He
found nitrite of amyl act admirably in modifying the
symptoms in cases of functional derangement.
Dr. Watson Williams found cactus grandiflorus a
specific in these cases ; and observed that even in health
the arterial tension was subject to variations.
Dr. Harry Campbell agreed generally with Dr. Pow-
ell, but believes functional cardiac derangements to be
the outcome of nervous disturbance, the result, as often as
not, of heredity. Heart attacks often simulated epi-
lepsy.
Dr. Mandford believed that many cases of functional
derangement were due to vascular tension, and the ef-
fects of mental emotion were often identical with the se
due to fatty degeneration. In such cases mental, as con-
trasted with bodily, rest was of immense importance, and
gave instances. Believed that even moderate doses of
alcohol had the most mischievous effects.
Dr. Tyson said the slow heart of advanced age was
due to organic lesions, and instanced the case of an old
gentleman who always had what was supposed to be an
epileptic fit when the pulse fell to 22. Attacks of " slow
heart " were apt to come on in the night in elderly people
who had partaken freely of supper, and were due to press-
ure by a loaded organ and the recumbent position. He
advised food to be taken in the early rather than a latter
part of the evening, a recommendation that was received
with much applause.
Dr. James Barr said that the cardiac irregularities
were evidenced by variations in the pulse, and that
the right side was stronger than the left. He had
seen the right auricle contract for four hours after the
rest of the heart had ceased to beat. It was the stimula-
tion of the blood that excited the action of the heart,
and as the right side was the first to receive the vital
fluid it was necessarily the stronger of the two ; corres-
pondingly, it was the first to suffer from overwok.
Dr. Rattray related his experience with the one
word paraldehyde, which satisfied both the patient and
the doctor.
Dr. F. T. Roberts, in summing up, said that he be-
lieved in purely functional derangements of the heart,
and they caused much suffering when there was nothing
wrong organically ; he had frequently experienced it in
persons, also in students coming up for examination.
Tobacco was a fertile source of functional cardiac dis-
turbance, and so was alcohol. Many doctors were quite
satisfied when they detected a bruit, but he did not
believe that an apical murmur signified much. He
believed also that application of lanolin to the apical
cardiac region would be vastly more beneficial than drugs
in such cases.
Dr. Powell replied, and alluded to the incompressible
pulse, which he did not deny ; he thought that cardiac
pain was an erroneous expression, as the heart itself felt
no pain. He expressed his great satisfaction that the
discussion on the functional diseases of the heart, which
he had had the honor to open, had been characterized
by so much interest on the part of those who had par-
ticipated in it.
250
MEDICAL RECORD.
[August 25, 1894
Second Day, Thursday, August 2D.
Pyrexia and its Treatment— Dr. Hale White opened
the discussion, giving an able r£sum6 of all that is at
present known of pyrexia and the various means resorted
to to combat it.
Dr. Douglas Powell had seen in influenza a sub-
normal temperature quickly followed by a relapse, and
this because the fall was due to nervous influences.
Pyrexia, he thought, was as normal a feature of disease as
the ordinary temperature of the body was of health, and
he had thought he had seen harm result from lowering it
below the standard of the disease.
Dr. Garrett-Anderson considered that temperature
was' comparatively unimportant, and instanced the case
of relapsing fever. The temperature of children runs up
very easily ; also in the case of women, where there is
more nervous susceptibility than in the case of men.
The temperature of a child might run up to 1010 F. and
above it, without portending anything serious; the human
body was not rigidly bound down to a temperature of
98.40 F. Then there was the high temperature of anae-
mia. Had known good results follow the raising of the
head of the bed, and from the use of the Swiss bath.
Dr. Osler, of Baltimore, mentioned the high temper-
ature of chorea, which was due to the increased muscular
action ; the more violent the muscular contractions, the
higher the temperature, which he had known rise to 1060
and 1070. Cases that present a low temperature at first
may often rise to an abnormal height. Systematic cold
bathing in typhoid fever was as much on account of the
toxaemia that existed as on account of the pyrexia ; was
surprised this plan of treating pyrexia had not found
greater favor than it had in the English-speaking com-
munities of the world. The hydro therapeutic system of
combating disease had certainly decreased the mortality.
Did not believe that the use of the cold bath diminished
the tendency to relapse.
Dr. S. Smith thought it was strange that after
twenty-five years of trial it should still be necessary to
discuss the question of the cold bath in the treatment of
pyrexia; but the introduction into practice of various
antipyretic medicaments has done away with its necessity,
though there were cases in which nothing else would
serve. He thought the bath might be dispensed with
where the fever could be kept under by the use of anti-
pyretics. He had never know any harm to result from
administering a moderate dose of antipyrin every hour,
and if this could be done the patient should not be sub-
jected to the inconvenience and shock of being plunged
into a cold bath ; but where drugs failed the bath was
necessary.
Dr. M. Skerritt rather liked the bath, and preferred
quinine to any other of the antipyretic class of drugs,
but in large doses, say from thirty to forty grains for an
adult. The tendency to relapse was less frequent after
the use of quinine than after the administration of drugs
the action of which was more rapid. As long as there
was breath in the body it was not too late to administer
the cold bath ; he instanced the case of a man who was
actually moribund and recovered from typhus fever after
being placed in a bath of cold water. Had also found it
useful in cases of rheumatic fever.
Dr. Pope queried whether a high temperature was not
an advantage to the subject of a bacterial invasion, other-
wise why should it have been perpetuated? The pro-
duction of heat was due to increase of the heart's action,
and antipyretics act by reducing that action. Found
the injection of cold water into the rectum of great
benefit.
Dr. Tyson did not consider moving a patient, even
when excessive pyrexia was present, to be injurious ; far
more harm was likely to result if the temperature had
fallen below the normal. The high temperature so often
met with in children readily disappeared after the ad-
ministration of an aperient. He deprecated the practice
of permitting young children to paddle in the sea, and
believed it often was the cause of their temperature rising
to an alarming height.
Sir T. Grainger Stewart thought no medical prac-
titioner could be adverse to the cold bath ; much depres-
sion followed the use of drugs. What was the best tem-
perature for the antipyretic bath? 65 ° to 700 F. he
found distressed patients, and would not advocate it ex-
cept in severe cases ; cold or tepid sponging was to be
preferred, or the rapid changing of ice-cloths placed on
the abdomen. The ice-pack, too, was of use. When he
had recourse to the bath he used it warm, and gradually
cooled it by the addition of cold water until the desired
effect was produced ; it was thus a less shock to the system
than plunging the body at once into cold water. In
rheumatism he had not found it so useful as in fever, but
in pneumonia he had seen good results follow its use.
He thought it very likely that climatic influences had a
great deal to do with those varying results.
Dr. Osler thought the bath of primary importance, it
had been carried out successfully at Montreal and Bris-
bane and all intermediate points. It was disagreeable to
the patient and the doctor, and if a better plan could be
devised he would abandon it, but as he saved many lives
by its use he would continue to have recourse to it if it
were to cause as much more inconvenience and trouble
than it did ; his only object was to save life.
Dr. Herbert Snow was surprised that do one should
have mentioned a well known antipyretic formerly much
in vogue, namely, calomel ; it acted, he thought, in a
twofold manner, aperiently and antiaeptically, by its con-
version into bichloride of mercury.
Dr. W. G. Kemp applied heat in the form of hot bottles
to the feet when 'depression followed the administration
of a cold bath. The lecturer had spoken of daily baths.
He advocated one every four hours. The danger of
moving the patient was readily obviated by attention.
He thought doctors lost a great deal by not using aconite
more freely, and recommended that die most prominent
symptom should be first attacked, it was the disease.
When antipyretics failed to produce their effect there was
something beyond pyrexia in the background.
Dr. Heath favored antipyrin, had a case of pneumo-
nia with a temperature of 106. i° in a lad of thirteen
years, gave forty grains of antipyrin in ten -grain doses
every hour, and saved the boy, his own son. Had
found much advantage from the administration of creosote
in the pyrexia and night sweats of phthisis. The suck-
ing of ice was useful and agreeable to the patient, but
cold baths were not applicable in private practice. He
believed that the man who ordered them would soon
find himself without any patients. He believed that the
type of all diseases was much lower to day than a few
years ago.
Dr. Garrett- Anderson said that the relation of idio-
syncracy to pyrexia was too often overlooked.
Dr. Mahomed had no faith in antipyrin, he believed
it killed a relative of his; has faith in quinine and ice-
pack.
Dr. Bently practised for fifteen years in the tropics,
and gave quinine in malarial fever in combination with
sulphate of magnesia. Alone, he found it had no effect.
He found ice and packing of great use in cholera, even
when there was collapse. In cases of influenza he used
antipyrin and salycin combined.
£>r. Roberts, in summing up, thought pyrexia was
often due to unsuspected nerve lesions, and that removal
could be effected with advantage in most cases except
those of typhoid fever. He believed the possession of
a clinical thermometer was not an unmixed blessing-— to
the doctor, yes; to the patient and the patient's friends,
no.
Dr. Hale White, in replying, said he would gladly
take away every clinical thermometer from the patients
and their friends, who were often needlessly alarmed by
its readings ; ten minutes was long enough to keep a
patient in the bath ; a lowering of the temperature was
not necessarily a sign of improvement.
August 25. 1894]
MEDICAL RECORD.
251
Third Day, Friday, August 3D.
The Section met earlier and for a shorter time this
day and not so many were in attendance, and of these
some were anxious to get away by an early train, and
others to attend the concluding general meeting where
the address in Public Medicine was to be given.
Ataxia. — Dr. Ormerod opened the discussion on this
subject. He remarked that swaying about of the body
when the eyes were closed was an indication of the ex-
istence of this disease ; curious to say, a blind ataxic was
affected in the same way when the eyes were shut.
Ataxia was a symptom of disease in various parts of the
body, but especially of cerebellar lesions, and less so of
the cerebral hemispheres, the staggering was due to pa-
ralysis of the muscles of the back and legs. Disease of
the corpora quadrigemina gave rise to a rolling gait.
Disease of the spinal cord was not limited to any set of
transverse fibres, but was most common where disease of
the posterior part of column existed ; it was a late symp-
tom of locomotor ataxy. Motor weakness may exist in
conjunction with ataxia. Toxic influences, expecially
alcoholic, set up ataxia, also follow rheumatism and
gout. Ataxia runs in families and is ranked with tabes,
but he thought wrongly. Hereditary ataxia is of the
cerebellar type, begins in the legs and works up. Fried-
reich's disease is hereditary affection of spinal cord.
Dr. Roberts said he did not know much about ataxia,
except, perhaps, as a subject for examination.
Dr. Andriezen, of India, said forms of ataxia were
due to alcoholism and to insanity, with a rapid breaking
down of the brain tissue ; also to tabes which involved
the nerve cells in posterior tract.
Dr. Waldo thought it was a symptom of brain, spinal
cord, and peripheral nerve lesions, as well as of function-
al disturbances, as in hysteria. Walking backward was
the surest test for ataxia.
Dr. Gordon thought Dr. Ormerod's classification was
pathological, and that a good clinical one was still a
desideratum. The muscles were less paralyzed than not
acting in unison, not backing each other up properly.
In chorea the attempt at voluntary movement provoked
involuntary movements of other muscles. Some thought
it was a functional disease, but there was always hyper-
emia, which had been said only to exist in cases that
went on to a fatal termination.
Dr. Dawson Williams said that ataxia might follow
any of the acute diseases, even malaria. This association
of ataxia with acute diseases lent support to the syphilitic
theory of tabes.
'Hereditary Ataxia.— Dr. Mitchell Clarke pre-
sented a patient, twenty-one years of age, suffering from
Friedreich's disease. The following was the family his-
tory : Father's father died at eighty-three years of age,
he was healthy ; cause of death being old age. Father's
mother died aged seventy-six, of apoplexy. Father's
one brother committed suicide. Father's one sister died
of heart disease. Mother's father living, aged seventy-
t*o, healthy. Mother's mother died of heart disease.
Mother's one brother healthy. Mother's two sisters died
of diabetes within a few months of each other. Patient
has one brother, aged seventeen, affected in same way;
one sister, aged fourteen, strong and well. Three other
children were still born, but no further evidence of syph-
ilis in parents could be obtained. Patient himself has
never had any bad illness. No other case in family ; no
cousins affected with nervous disease. From the age of
eight till thirteen he was continually frightened by his
parents' quarrelling. In both brothers symptoms are
similar. The first symptoms noticed were the difficulty
in standing and walking, especially in the dark, the pe-
culiar gait and inco ordination of movements. Onset
about five years ago; probably early symptoms not no-
ticed ; in brother first came on about the age of twelve.
Course slowly progressive, especially as to muscular
power, but remissions occur.
A second case was that of a pale, pasty-faced man
thirty-five years of age, fairly well nourished. He had
lost the greater part of his hair. He never had any
severe illness ; has had gonorrhoea, but not syphilis. He
never had fits, or any loss of consciousness. He is said,
when aged five years, to have looked "silly" — that is,
he could not stand still, rocked to and fro when stand-
ing, and kept his mouth open ; he had frequent falls,
and appeared to throw himself about when walking. He
worked as an errand-boy till the age of twenty, when he
had to leave off on account of falling frequently and
dropping the things he carried. Since then he had been
unable to work in consequence of growing clumsiness
and weakness, the latter gradually increasing so much
that he has become unable to stand without support.
The father of the patient, a butcher, suffered from heart
disease and dropsy, and died in an asylum, apparently
of melancholia. His parents died of old age, his father
living to be ninety-six ; one of his sisters committed sui-
cide; family healthy. The mother is still living. Her
father's father died at the age of ninety-nice, and her
mother at the age of one hundred and one. Her father
lost all his hair before he was thirty years old, and died
of diabetes; her mother died at the climacteric period.
There were two other sons and another daughter, all of
whom survive. They had fourteen children: 1, Geor-
gina, aged thirty-seven, healthy ; 2, Albert, aged thirty-
five (one of the patients); 3, George (drowned); 4,
Isaac (died of croup) ; 5, a son, aged twenty five (ex-
amined and found healthy) ; 6, William, and 7, Mary
Ann (both died at the age of five months, of " weak-
ness"); 8, Lizzie, aged twenty one (examined and
found healthy) ; 9, a daughter (died at the age of one
month, overlaid) ; 10, Caroline, aged eighteen (one of
the patients) ; n, Isaac (died at the age of three years,
of croup) ; 12, John, aged fourteen (examined and found
healthy) ; 13, Isaac, aged eleven (one of the patients]) ;
14, a child prematurely born at seven months (died in
three days). The father was a heavy drinker; no evi-
dence of syphilis could be obtained. The mother is a
strong, healthy woman, and does hard work. Has never
suffered from fits, from any nervous affection, or any se-
vere illness. She was carefully examined as to state of
reflexes, etc., and found to be normal in every respect.
Tabes Dorsalis. — Dr. Clarke then presented a third
patient with locomotor ataxia.
Symptoms in 1892.— Chas. O , aged fifty-three;
weight, 12 stone 21 pounds; has had syphilis. Illness
began two years ago with lightning pains in legs, diffi-
culty in walking, numbness and loss of power in hands,
girdle-pain, and giddiness increased in the dark.
March 2, 1889. — Ataxy, both of legs and arms, by far
most marked in the latter; there is considerable weak-
ness of leg muscles, with uncertain and high-stepping
gait; movements of hands show great ataxy; he can
only button his coat with difficulty and most clumsily ;
knee-jerk present on the left side, just obtained on tie
right side. Right pupil does not react to light, left re-
acts only over one-third part of circumference on tem-
poral side (no other sign of iritis). Paralysis of right
external rectus; optic disks pale; both fields of vision
irregularly contracted. Static ataxia and Romberg's
symptom well marked. The metatarsal joint of right
great toe is affected with a tabic arthropathy. Pains
five years ; difficulty in micturition two years. His state
in February was as follows: No loss of sensation, gait
extremely ataxic, inability to turn round and to stand
with eyes shut and feet together ; could not walk with-
out a stick ; myosis and inequality of pupils ; Argyll-
Robertson phenomena; loss of sexual power, knee-jerks
absent, gastric and laryngeal crises; rectal pains, and
lightning pains in legs of great severity nearly every day.
Dr. Ormerod, in reply, said he was glad those who had
taken part in the discussion had in the main agreed with him.
Dr. Roberts said that brought the meetings of the
Section to a close. He thanked all for their good be-
havior, and said further that what he had looked for-
ward to with dread had proved a pleasure.
*52
MEDICAL RECORD.
[August 25, 1894
Hero %nstvtxmmts.
A NEW ELECTRODE
APPLICATIONS OF
RENT.
FOR HYDRO- ELECTRIC
THE CONSTANT CUR-
By MARGARET A. CLEAVES, M.D.,
NEW YORK.
INSTRUCTOR IN ELECTRO-THERAPEUTICS, NEW YORK POST- GRADUATE MEDICAL
SCHOOL AND HOSPITAL.
In the treatment of pelvic exudates, ovaritis, vaginitis,
simple and specific, pruritus vulvae, and eczema of the
vulva, I have often felt the need of applying the con-
stant current in such a manner that every part of the
diseased tissue, of whatever nature, would be influenced
by it. This is impossible with any electrode with which
I am familiar. All of the electrodes for the application
of the constant current in these conditions, whether
metal or carbon balls wrapped with absorbent cotton,
or clay and covered with gauze, I have found objection-
able. In the first place, these electrodes can never be
used but for one application without being re-made,
otherwise there is danger of sepsis. Second, because of
the very great danger, even in careful hands, of produc-
ing an eschar, a danger greatly intensified in the hands
of the non-expert. Third, because of the impossibility
of bringing every part of the diseased tissue under the in-
fluence of the current, or of utilizing the cataphoric
property of the current in order to diffuse into the tis-
sues such drugs as would be indicated, especially in dis-
eases of the vulva and in vaginitis, simple and gonor-
rhoea. Some time since I adopted the plan of bringing
masses of pelvic exudates under the influence of the neg-
ative pole by the use of the Baudet de Paris method.
This method was originally intended to be used for con-
stipation and intestinal obstruction. The bowel is dis-
tended, to the toleration of the patient, with salt water,
which serves as the electrolyte, and to the electrode is
attached the negative pole, the indifferent electrode (an
Apostoli pad) being placed over the abdomen of the pa-
tient. It has been possible, in this way, to bring the ex-
udative matter in the pelvis well under the influence of
the constant current, and this without the slightest dan-
ger of producing a caustic action or untoward disturb-
ance of any sort. Rectal applications, however, are
open to serious objection, unless absolutely necessary.
In casting about in my mind for a better method, the
idea occurred to me of a vaginal electrode, constructed
in such a way as to enable me to apply the constant cur-
rent in the form of a douche, either negative or positive,
and at the same time to carry out any indication for
cataphoric medication, or the diffusion of medicated so-
lutions into the diseased tissues.
The external part of the electrode, shown in the cut,
is of hard rubber, the handle of which is filled in with a
brass rod from the point of attaching the rheophore at
A, up to the attachment of the hose of the fountain-
-syringe at B. From B to the end of the tube C, where
the perforated cap, D, screws on, it is lined with a tube
of carbon.
Brass, aluminum, and tin were all tried, but with the
former only the negative pole could be used, with alumi-
num positive currents and diffusion of certain drugs was
possible, but with even mild negative currents this metal
was attacked. Block tin was too readily oxidized to
make it advisable, and the expense of platinum and gold
precluded their use ; therefore, carbon was selected, and
it bids fair to answer every purpose. The electrode
must, of necessity, be straight, and cannot be curved as
it could with a metal tube ; this, however, seems to me
of but little moment. The shield, Et is movable, and
has two rows of perforations through which the surplus
water drains into the tube, F. To this drainage-tube is
affixed a few feet of rubber hose, of less diameter than
that on the fountain syringe through which the water or
the medicated solution gains egress into the vagina, in
order to retard the drainage and keep the vagina dis-
tended during the time of administration of the current
This drainage hose is dropped into a jar at the foot of
the operating- table, the syringe-hose is attached at £,
the rheophore tip at A, and the vagina allowed to be-
come well distended with the water or medicated solu-
tion, before the current is turned on. By firm and even
pressure of the shield over the ostium vaginae, with the
labia folded out, so as to occasion no discomfort to the
patient, it is possible to administer any quantity of the
douche, one to three or more quarts, without getting a
drop upon the patient's clothing.
I have arranged to have a cushion of soft rubber placed
over the edge, as is done in ether inhalers, as will be seen
in the cut. The suction action thus produced will ren-
der it possible at any time that full distention of the vag-
ina is obtained, to maintain the same, by shutting off
the drainage-tube by means of a
clamp. The surplus water, how-
ever, that remains with continuous
drainage is enough to penetrate
every fold and rugae of the vaginal
mucous membrane, as I have de-
monstrated by cutting off the inflow
and taking note of the amount re-
maining as it drained away.
The instrument is made with
three different sizes of perforated
caps, the smallest and largest with
perforations at the side for vaginal
use, while the medium sized cap not
only has the perforations at the side, but at the end
as well, and is to be used for rectal applications. To
convert the instrument into a rectal electrode, the shield
should be withdrawn. It will readily be seen that there
is no point of contact of the conducting material of the
electrode with the mucous membrane in either rectal or
vaginal applications. The salt water or the medicated
solution, whatever its nature, is the electrolyte. As I
have intimated, this method of rectal application origi-
nated with M. Boudet, of Paris.
I have thus far used this douche electrode in cases ol
pelvic exudates, chronic ovaritis, salpingitis, chronic
vaginitis, and in chronic eczema of the vulva. In a case
of chronic vaginitis and eczema of the vulva of twenty
years' standing, with the most intolerable itching, for
which the patient had resorted to various means for re-
lief, and obtained none, I have found this electrode of
the greatest value. In this case the entire mucous mem-
brane of the inner aspect of the labia was thickened,
leathery, and fissured. At the ostium urethra and
vaginae the color was an intense crimson. The same
condition extended into the vagina. There was extreme
sensitiveness upon digital examination, and the patient
was worn and harassed by the continued irritation from
which she had not been free in all these years, despite the
heroic measures that had been used to insure recovery.
After one application of the negative galvanic current in
the form of a douche, there was marked relief from the
constant irritation and a tendency to heal on the part of
the fissures. After four applications had been given, ex-
tending over a period of two weeks, the mucous mem-
brane was found to be as sound and whole as that of a
August 25, 1894]
MEDICAL RECORD.
*53
child, and the congestion at the mouth of the vagina
and urethra had entirely disappeared, the mucous mem-
brane having returned to its normal color and condition.
There was complete cessation of the itching which had
made the patient's life wellnigh intolerable, and a most
marked improvement manifest in her general appearance.
In making the application, the tendency is for the
electrolyzed water to flow out against the shield, and in
that way to come in contact with every part of the mu-
cous membrane of the vulva. Patients find this method
of applying the current exceedingly tolerable, and in the
conditions for which I have used it thus far there has
been an invariable expression of relief following its use.
It is my purpose, in having the electrode constructed
of an unoxidizable medium, to use it not only for the
application of the constant current, but also for the pur-
poses of cataphoric medication. In gonorrhceal vagini-
tis— a condition which is recognized as extremely diffi-
cult to treat — it will be possible by this method to bring
not only the os and cervix uteri, but every interstice of
the vagina as well, under the influence of the medicated
solution and thus combat the specific condition. The
feet that the gonococcus penetrates the submucous struct-
ures, makes it very desirable that we should be able to
apply our remedies in such a manner as to insure their
destruction. By cataphoric medication this is possible,
as the medicament not only comes in contact with the
mucous membrane, but is caused to penetrate more or
less deeply into its structure according to the strength of
the current and the length of the application.
By means of anodal diffusion, a solution of sulphate of
copper of requisite strength could be used to advantage
in gonorrhoeal cases. In the later stages of gonorrhoea,
in conditions of pelvic congestion, uterine catarrh, and
in some leucorrhceas, hydrastine thus diffused would be of
much greater efficacy than in its ordinary administration
by the mouth, or by means of vaginal injections. Bi-
chloride of mercury in solution could also be used accord-
ing to the indications and in strength of from one to
one thousand.
That drugs thus used enter the local and ultimately
the general circulation, no longer admits of doubt. This
diffusion takes place, as a rule, from the positive to the
negative pole, but in some instances from the negative to
the positive.
In the treatment of syphilis, Gartner ' and Ehrmann
obtained not only the specific action of bichloride of
mercury upon the disease, but ascertained its presence in
the urine as well after from fifteen to twenty minutes'
treatment with the galvanic bath, containing from four
to six grammes of the drug. The positive pole was used
and a current strength of 100 milliamp&res. These ex-
periments have been corroborated by Kroneld in Pro-
fessor Lang's clinic in Vienna.
In the treatment of gouty joints with bromide of
lithium cataphoresis, lithium has also been found in the
urine.
By means of the rectal electrode, if the conducting
medium is of an unoxidizable material, cataphoric medi-
cation may be utilized to advantage in the treatment of
chronic intestinal diseases, such as enteritis, simple,
pseudo- membranous, or follicular ; in intestinal catarrh, in
fermentative and putrefactive conditions, and in chronic
thickening of the mucous membrane of the intestines.
Once one is familiar with the properties of the electric
current and the technique of the operation, the therapeu-
tic applications suggest themselves in great abundance.
In all instances we are enabled to avail ourselves, not
only of the electric diffusion of the drugs, but the phy-
siological action of the current as well.
. 68 Madison AvBMUB,lMay 95^1894.
Dr. John Williams, the accoucheur of the Duchess of
York, is a Welshman who was formerly a general prac-
titioner in Swansea.
* Lewandoski : Electro-diagnostik und Therapeutic Wien und
Leipzig, 189a.
A TYPHOID FEVER BED -BATH APPARATUS.
By RUSSELL BELLAMY, M.D.,
HOUSK PHYSICIAH, SECOND MEDICAL DIVISION BBLLEVUB HOSPITAL, NEW YORK.
During the summer and autumn of 1893 many cases
of typhoid fever were admitted to the wards of Bellevue
Hospital, and in the different divisions many methods of
treatment were employed.
Undoubtedly the method that yielded the best results
was that of Brand ; but, unfortunately, it cannot be ex-
tensively used in private practice on account of the great
expense, often five nurses being required, two for night
and two for day work, the fifth assisting at intervals.
In hospitals this treatment can be used to much better
advantage ; but as now practised, and under the most
favorable conditions, it has many drawbacks.
Having superintended and assisted in giving nearly
twelve hundred baths I had an opportunity to note that
the system must be changed in order to lower the mor-
tality, lessen the expense, and cause the patient less men-
tal agitation.
The method of giving a bath in Europe, and as used
in this city by Peabody at the New York Hospital, and
carried out extensively by W. Gilman Thompson at the
Presbyterian Hospital, is used in the second medical
division, under the supervision of visiting physician H. P.
Loomis, and assistant visiting physician C. S. Quimby.
Present Method. — The patient, after being stripped
and covered by a thin sheet, is lowered by three, and
sometimes four, nurses into a bath tub and vigorously
rubbed for fifteen or twenty minutes until the desired
reduction in temperature is secured. He is then re-
turned to bed, usually with considerable difficulty. If he
is stroug, the muscles are stiffened and the weight raised
with ease. If the power of resistance is slight, as is
usually found to be the case by the twelfth day of the
disease, considerable difficulty is experienced in lifting
him to the bed and sometimes a serious traumatism has
occurred. At times the patients complain of pain over
the region of the body where he is handled ; again they
complain of experiencing a tired feeling, and think the
suddenness of being lowered into the water, or roughly
raised, too great a shock and a rather heroic measure.
The close relationship between the visceral and parietal
peritoneum to the abdominal muscles is to be consid-
ered, especially during the period of the disease when
hemorrhage is most likely to occur, since at this time even
a mild traumatism to these muscles could do much harm.
I am inclined to believe that many hemorrhages and
severe attacks of peritonitis will be avoided if the bath
can be given without the least jar or exertion on the
part of the patient.
After going over the literature of typhoid fever and
consulting many of New York's most prominent physi-
cians, I found that some different mechanism for giving
baths is desirable.
The apparatus that Richard Kny & Co. of New
York City, have so thoroughly constructed for mer
consists of a galvanized iron bath-tub — one of any de-
sired material may be substituted — 6 feet 4 inches
long, 22 inches deep, and 20 inches wide. The
supporting frame of this tub is on rubber wheels, and
it is provided with a siphon exhaust - pipe, so that
every drop of water can be removed in a few min-
utes. Supporting a comfortable steel mattress within the
tub are four stout copper chains, passing over pulleys at
either corner of the frame, and over a similar set under
the tub. These chains are connected with an endless
screw by cogs and a bicycle stop-chain. The mechanism
is controlled by a crank, so that the mattress can be
raised or lowered by reversing the wheel. The appara-
tus is so arranged that the mattress can be raised several
inches above the top of the tub, or lowered to the bot-
tom. On one side a piece of galvanized iron, 2 feet-
long by 6 inches wide, is attached by hinges, and is-
used to bridge over the space between the tub and bed.
Method of Using. — The patient, naked, and covered
254
MEDICAL RECORD.
[August 25, 1894
by a linen sheet, is placed upon a heavy rubber blanket,
which is perforated near the centre; the bathtub is
brought to the bedside, and the nurse, standing on the
outer side of the tub and gently drawing the sheet, brings
first the patient's head, then buttocks, and lastly feet, up
on the steel mattress. A comfortable rubber pillow is
placed under the head. The crank is reversed, the
patient lowered into the water suddenly or by degrees,
the bath given*, the mattress raised to the level of the
bed, and the water having escaped through the holes in
the rubber blanket, the patient is transferred to the bed
in the same manner that he was moved to the bath.
The steel mattress can be detached and the whole ap-
paratus thoroughly disinfected. It is painted with white
enamel and is not clumsy. In devising this typhoid
bath-tub I had only hospital cases in view, and the
manufacturer has so constructed this tub that it is
adapted to the average hospital bed. Its height evi-
dently can be modified as desired.
When we consider that a bath can be given by one
attendant, and the patient experience no disturbance,
either mental or physical, we feel that we have done
something toward rendering the famous Brand system
more generally available.
Large Increase of Lunacy in Great Britain. — The
forty- eighth report of the British commissioners in lunacy,
just issued as a Parliamentary paper, says there were in
the kingdom, on January 1st, 92,067 lunatics, idiots, and
persons of unsound mind, according to the various re-
turns to the commissioners. This number is 3,245 in
excess of the corresponding returns from the previous
year, and shows the largest increase in the number of
lunatics yet recorded. The report says: "This large
increase calls the more for some special consideration,
because it follows an increase of 1,974 in the preceding
year, that being far above the average for the ten years
1882 to 1892, which was only 1,300. The increase
seems to have been fairly general throughout England
and Wales, but the predominant feature of the figures is
the great increase shown in the county of London, its
pauper lunatics numbering on January 1st, 800 more
than they did a year previously. It is perhaps right in
this connection to point out that from the administrative
county of Middlesex, which is fast becoming metropoli-
tan, there is shown from last year an excessive increase
of 103, against an average for the previous ten years of
42. From one of the tables attached to the report it
appears this state of affairs, though alarming, is not
quite so serious when considered in conjunction with
the increase of population, the ratio being one insane
person in 326, as against one in 331 for the previous
year."
(&ovrt$vou&zute.
TRANSFER OF THE INSANE TO HOSPITALS.
To the Editor op the Medical Record,
Sir : In a recent number of the Medical Record the
transfer of the insane from their homes to hospitals is dis-
cussed at some length, and the writer of the article criti-
cises severely the system under which such transfers are
made. His remarks are apparently intended to be gen-
eral in their application so as to cover the entire coun-
try, but incidentally, and
I have no doubt inadvert-
ently, unwarranted strict-
ures are made upon an im-
portant feature of the State
Care Law, now in opera-
tion in the State of New
York. The errors can be
easily shown, and I trust
the facts may receive the
publicity they merit in the
columns of the Medical
Record.
That cruelties and in-
human practices were com-
mon a decade ago is only
too true. Indeed the writer
I might easily have found
much more horrible in-
stances of brutality than
those cited. The unfortu-
nate victims of insanity
were often treated like fel-
ons, and it was almost a daily occurrence that they were
brought to hospitals in the strait-jacket, in manacles,
or bound with ropes, and usually in a sad state of bodily
uncleanliness. This terrible state of affairs was one of
the strongest arguments used to secure the passage of
chapter 1 26 of the Laws of 1890, familiarly known as the
State Care Law. Section six of this chapter specifically
made it the duty of the President of the State Commis-
sion in Lunacy " to prescribe regulations governing the
transfer of public insane patients from their homes or
from poor houses to State hospitals by superintendents of
the poor, and concerning the clothing of State patients."
The President of the Commission accordingly, on Sep-
tember 10, 1890, issued the following order :
" 1. That all county superintendents of the poor, or
town, county, or city authorities, before sending a pa-
tient to any State hospital see that said patient is in a
state of bodily cleanliness and provided with the follow-
ing clothing, to wit :
" (a) One full suit of under-clothing. (£) One full
suit of outer clothing, including head- wear, boots, or
shoes.
" Between the months of November and April, both
inclusive, there shall be provided, in addition to the fore-
going, a suitable overcoat for the men patients and a
suitable shawl or cloak for the women patients ; also
gloves or mittens. Considering the great danger always
present of the introduction of contagious or infectious
diseases into institutions where large numbers of people
are congregated, and to avoid so far as possible the in-
troduction of such diseases by means of wearing apparel,
the clothing above provided for must, in all cases, be
new.
"2. In travelling by rail patients must not be com-
pelled to ride in smoking or baggage cars, except in the
case of men patients who may be so violent, profane, or
obscene as to render their presence in ordinary passen-
ger coaches offensive. If any portion of the route is nec-
essary to be traversed by a team a covered conveyance
should, unless impossible, be provided. The shortest
practicable route should be selected ; the hour of de-
parture should be timed, so far as possible, so as to avoid
August 25, 1894]
MEDICAL RECORD.
255
the necessity of stopping over night on the journey, and
so as not to reach the hospital at any unseasonable hour.
Whenever practicable, a notice in advance, by writing or
telegraph, should be sent to the medical superintendent
of the hospital of the coming of the patient. In cases
of violent patients a sufficient number of attendants
should be provided to control their actions without re-
sorting to the use of mechanical restraints, such as straps,
ropes, chains, handcuffs, etc. ; quieting medicines should
not be given to such patients except upon the prescrip-
tion of a physician. If it becomes necessary to remain
over night or for a number of hours at a station on the
route, patients are not to be taken to jail, police station,
or lock- up. Food in proper quantity and quality, and
at intervals not exceeding five hours, should be provided
for patients, but no alcoholic beverages must be given
unless upon prescription of a physician. Opportunity
must be afforded for attention to the calls of nature, and
the rales of decency must be observed. In case of the
employment of extra attendants in conveying violent
patients, care must be taken that they are of adult age
and of good moral character. The provisions of the
statutes which require that a woman attendant shall ac-
company women patients when taken to State hospitals
must be strictly complied with.
" 3. Any violation of the requirements of this order
shall be promptly reported, so far as known to him, by
the Medical Superintendent of the hospital to the State
Commission in Lunacy.
" 4. This order shall take effect on the first day of
October, 1890.
" By tbf President of the Commission,
"T. E. McGarr, Secretary:'
The effect was immediate. The lot of the insane pa-
tient was greatly improved. Mechanical restraint, which
had long been discarded in the hospitals, was thrown aside
by county officials almost entirely, and the whole scheme
of caring for the insane in New York State became more
elevated in character in the letter as well as in the spirit.
The foregoing comprehensive order of the Commission
continued in force for a period of three years, during
which radical reforms were accomplished ; but the best
results were attained only when the State Care Act be-
came wholly operative, October 1, 1893. On that date,
under its provisions, the State Commission in Lunacy
issued the following order : " The authorities of State
hospitals for the insane shall send trained attendants to
transfer insane patients from their homes or from poor-
houses to State hospitals, as provided by section six of
chapter 126 of the Laws of 1890. . . . Whenever
possible, a few days' notice should be given to the hos-
pital authorities of the transfer of the patient, and when
the case is urgent the notice should be sent by telegraph
or telephone."
It will, therefore, be observed that for nearly a year
past the hospital authorities have regularly sent trained
attendants to the homes of patients as soon as notice has
been received that they have been examined and certi-
fied as insane, and have assumed entire charge of the
cases at once. These attendants have been instructed to
see that the orders of die Commission are fully complied
with before starting for the hospital, and to provide for
the patient every possible care and attention during the
transfer, thus securing for him the protection of the hos-
pital at the earliest possible moment. At the Bingham-
ton State Hospital this plan has proved in the highest
degree satisfactory. The attendants employed for this
special work are competent, intelligent, and kind. They
are thoroughly trained in the care of die insane, and in-
variably make their charges as comfortable as possible
during transportation. When women patients are to be
brought to the hospital, women attendants are always
sent to bring them. Cared for in this way they usually
come calmly and are much less disturbed or exhausted
when they arrive at the hospital than was often the
case under the old system. Besides attending to the
patient's physical requirements our attendants succeed
in obtaining good histories of the cases, and thus mate-
rially aid the physicians in deciding upon the proper
course of treatment. All this is accomplished at a cost
to the State rarely exceeding actual travelling expenses.
Surely the reform accomplished in the method of
transporting the insane from their homes to hospitals in
the State of New York, during a period of less than half
a decade, merits stronger commendation than is to be
found in the " undercurrent" which the editorial states
.is now running in the direction of reform.
Charles W. Wagner,
Superintendent Binghamton State Hospital.
Binghamtok, N. V., July 30, 1894.
THE INTRODUCTION OF LEPROSY INTO
JAPAN.
To thb Edith r cf tits Msric/L Rbooid.
Sir : Dr. Beaven Rake, of Trinidad Leper Asylum, re-
cently called my attention to the following passage, to be
found in " Hirsch's Geographical and Historical Pathol-
ogy'1 (translated from the second German edition by
Charles Creighton, M.D. ; London, the New Sydenham
Society, 1885): "In Japan, according to the unani-
mous accounts of the chroniclers, it j(leprosy) must have
appeared as early as the thirteenth century ac (between
1234 and 1250)."
The authority for this statement is given in a footnote
thus : " Schmid, New York Medical Record, July, 1869,
p. i94M
On referring to the Medical Record of 1869, I find
the following passage in "Notes from Japan," by H.
Ernest Schmid, M.D., White Plains, N. Y.: "All rec-
ords on that malady date its first appearance in Japan
only as far back as from about 1234 to 1250."
As Schmid qualifies his statement with the adverb only,
he evidently means a d. and not B.C. Hirsch, there-
fore, seems to me to lean on a broken reed when he
alleges the authority of Schmid.
There is no written evidence in Japan that leprosy was
known there as early as the thirteenth century before
Christ. But there is evidence that it existed before 1234
and 1250 a.d. Under no circumstances could Schmid
mean b.c , there being absolutely no proof for such a date.
It is believed that leprosy existed in Japan as eaily as the
beginning of the eighth century, or even somewhat earlier.
It may have existed there as early as it did in China, that
is 1 1 22 B.c-314 bc* But evidence to this fact there
is none. There are written evidences in Chinese works
of ancient treatments of leprosy which date back, one,
2, 000 years, and the other falls between 618-690 a.d.
Dr. Goto, now in Molokai, is authority for the statement
that the disease was known in Japan in 718 a.d. Ac-
cording to Dr. Baelz, the Etas, the negro element of the
Japanese Islands, are descendants of leper colonies ; they
are to day the leprous element of the outcast population.
The origin of this negroid element is mythical ; it does
not fall in historical times ; neither, as a consequence,
does the origin of leprosy which this element represents.
In this case the disease is supposed, naturally, by leprol-
ogists, to have come from Africa. In the Mongolian
element of the Japanese it is natural to admit that it came
from China, which would carry it back, at all events, to
the epoch of the introduction of Buddhism from China
and Corea, that is, to the sixth century. There can be
no other reasonable theory as to the exact time when
leprosy appeared in Japan.
Dr. Goto, of Honolulu, writes me, under date of July
8, 1894, that since February 8, 1885, to 1894, twenty-
one thousand eight hundred and eighty- one Japanese men,
and five thousand one hundred and ninety- one Japanese
women, emigrated from Japan to the Hawaiian Islands.
In this large number, five men developed the disease after
their arrival, and four were suspected. This is quite the
reverse of what happens at the introduction of Chinese
emigrants. The Chinese seem to take the disease quite
256
MEDICAL RECORD,
[August 25, 1894
naturally, and, indeed, it is they who are believed to have
brought it originally into the Sandwich Islands. This
also would be sufficient to warrant the suspicion that the
disease in Japan came from the Chinese, as well as it did,
if really it did, come through them to the Sandwich
Islands.
Goto remarks that the Japanese made no change in
their diet, and that fish remained prominent therein. We
may remark in passing, that if fish diet was a factor in the
transmission of contagion, there would have been more of
an outbreak in such a large number of Japanese in nine
years (one person a year).
Dr. Basadre, of Lima, Peru, informs me that the only
cases he has observed in Peru were always Chinese, never
Peruvians.
Dr. Mufiiz says that leprosy is very rare in Peru, and
that only a few (Chinese) are affected by it. In 1893
there were only two deaths from leprosy, and at the time
when Dr. Mufiiz wrote to me, there was only one case at
the Hospital del Refugio, and it was a Chinaman.
Hence we may assume confidently that to Japan, the
Sandwich Islands, and to South America, leprosy came
from China.
Albert S. Ashmead, M.D.
45 Macdougal Stkebt, New Yomc
CYANIDE OR FERROCYANIDE OF POTASSIUM?
To the Editor or the Medical Recoed.
Sir : One word about the cyanide of potassium poisoning
case mentioned in the Medical Record of July 7th. It
is evident that some drug was taken, but it could not
have been cyanide of potassium. The patient says : "I
took a solid piece, perfectly smooth on all sides ; " this
fact alone is conclusive, for cyanide of potassium does
not occur in that form, but ferrocyanide of potassium
does, hence it must have been the latter drug. It ap-
pears that the doctor did not see the drug himself, which
renders the case doubtful. Cyanide of potassium is one
of the most formidable poisons known to chemists. It
has destroyed life in a quarter of an hour, and tetanic
spasms occur in a few seconds or minutes, and run
through their course with great rapidity.
J. H. Trent, M.D,
Brooklyn, N. Y.
DOSIMETRIC MEDICATION.
TO THE EOITOK OP THE MEDICAL RECORD.
Sir: Being one who is a believer in the dosimetric
method of administering medicines, I have read Dr.
Mann's article on " A New Cardiac Tonic Dosimetric
Granule'1 with much interest. With the general pur-
port of that article I am thoroughly in accord ; but I
regard it as unfortunate that Dr. Mann uses the term
dosimetric, as his granule is not in reality a dosimetric
granule at all. On the contrary, its composition contra-
venes three of the fundamental principles of dosimetry :
1. Dosimetric granules contain one medicinal prin-
ciple only in each granule.
2. They contain a fixed, usually minute, amount of
the drug. That is to say, for instance, the morphine
granule always contains one milligramme, the strychnine
granule one- half milligramme, and so on.
3. They are made according to the metric system.
It is in the first two of these principles that the strength
of dosimetry lies. The physician adjusts his treatment
to each particular case, giving so many of one kind of
granule and so many of another, and can vary the pro-
portion from time to time, whereas if relying on a num-
ber of ready-made prescriptions like Dr. Mann's, he will
inevitably in many cases give, not what would be the
best prescription for the patient, but the nearest he hap-
pens to have at hand, in his case or office. To my mind
nothing tends so much at the present time to hinder the
progress of scientific therapeutics as the slovenly habit,
which is so wide spread, of using ready-made formulae,
mainly in the form of tablet triturates. Dosimetry aims
among other things at the abolition of this habit.
Perhaps it is hardly necessary to add that Dr. Mann's
prescription can be represented approximately by the
dosimetric granules already in use, thus :
Morphine hydrochlorate. ... 5 granules (5 milligrammes).
Strychnine sulphate I granule (4 milligramme).
Atropine I granule (i milligramme).
Caffeine I granule (1 milligramme).
G. M. Wasse, M.D., M.R C.S. Eng.
Baldwinsvillb, N. Y.
fjfredical Stems.
Contagions Diseases— Weekly Statement— Report of
cases and deaths from contagious diseases reported to the
Sanitary Bureau, Health Department, lor the week end*
ing August 18, 1894.
Tuberculosis
Typhoid ferer
Scarlet ferer
Oerebro-spinal meningitis
Measles
Diphtheria
Small-pox
A Pasteur Institute has been opened in Tunis.
The Monument to Surgeon Parke, the medical officer
of the Emm Pacha relief expedition, which is to be
erected in Dublin, will represent him in the dress worn
in Africa during the expedition, standing with crossed
arms leaning on a gun, resting the left foot upon a
medicine chest.
Hasal Reflexes. — For the diagnosis of "nasal reflex
neurosis " Zarniko requires, 1, that every other possible
explanation should be eliminated ; 2, that there should
be present some local reflex symptoms (for example, fits
of sneezing), such as are known by experience to be fre-
quently associated with remote nasal reflex neuroses ; 3,
that the inspection of the nose should reveal such changes
as frequently set up reflex disturbances ; 4, that artificial
irritation (probing) of some area in the nose should ex-
cite the reflex symptoms ; and 5, that ansesthetization of
that area should put an end to them. In some cases he
considers the last two points sufficient ground for the
diagnosis. — British Medical Journal.
The Value of Our Mistakes.-— It is always a pleasant
thing to be right, but it is generally a much more useful
thing to be wrong. If you are right, all that you do, as
a rule, is to confirm your previous opinion, your previous
habits of reasoning, and your previous self-esteem. But
if you are wrong you generally gain in knowledge and
gain perception of the way in which your method of
diagnosis needs improvement, and the influence on self-
esteem is not likely to do you harm. At least that is my
own experience, and I think I have observed it confirmed
in others. But the result is dependent on deliberate effort.
There is a strong temptation to smooth down error, and
it is very easy not to gain from it its precious lesson. It
is more easy to fancy that there is some accidental cause
for the mistake than frankly to perceive that it is a fault.
But if you make a deliberate effort to realize and to face
in your own mind the mistake you have made, to dis-
cern its cause, and to employ this perception as for as
you can to remove the cause and prevent a like mistake
in the future — if you do this, almost every error becomes
one of the precious experiences of your practical life. —
Dr. W. R. Gowers.1
A Society for the] Suppression of Handshaking, as
leading to an exchange of microbes, has been established
in Baku, Russia.
Medical Record
A Weekly yournal of Medicine and Surgery
Vol. 46, No. 9.
Whole No. 1243.
New York, September i, 1894.
$5.00 Per Annum.
Single Copies, ioc.
i&rigitral Articles.
SEWER GAS A CAUSE OF THROAT DISEASE ;
OR THE EFFECT OF BAD DRAINAGE ON
THE THROAT.1
By BEVERLEY ROBINSON, M.D.,
CLINICAL PROFESSOR OF MKDIC1NR AT TIM BELLEVUE IOSP1TAL MEDICAL COL-
LEGE, NEW YORK.
" A great deal of vague assertion has been made with
regard to the effects of sewer gas, or as it is better called,
sewer air, upon the human system. While some look
upon it as always poisonous, and often virulent, others
consider it usually harmless, though unpleasant. The
good health of workmen engaged constantly upon sewers
is cited in favor of this latter view."'
The opinion just quoted manifestly shows that there
is much of expressed opinion on this subject found in
medical literature which is based upon facts capable of
widely different interpretation. In a tenement house,
let one or more cases of throat disease be suddenly pres-
ent, and the attending physician immediately suspects
the condition of the plumbing. A sanitary inspector
from the Health Board is called. Untrapped, filthy
sinks, malodorous water-closets, a damp cellar containing
accumulations of organic substances, animal or vegetable,
in a state of decomposition and giving off effluvia, will
usually be discovered. Not infrequently, in addition to
these sources of disease, the peppermint or smoke test
properly applied will make known a leaky joint, or a
perforation of the soil pipe, which allows sewer air to
permeate the entire building. Which of these conditions
—or do all combined — occasions the throat affections
which have shown a sudden outbreak, or been present
more or less continuously ? How difficult to decide in a
satisfactory manner !
Whenever, besides the preceding conditions, we find
overcrowding, poor ventilation, bad food, lack of per-
sonal cleanliness, over- fatigue, exposure, anxieties, pov-
erty, excesses— how can we properly estimate the rdle of
each determining or causative factor of the throat disease
in its exact proportion ? Evidently in many instances
the task is very difficult, not to say insuperable. And
yet there are unquestionably numerous examples on
record in which the impure air from sewers and cesspools
has seemingly been the means of propagating diphtheria
and other throat diseases. Instances, indeed, are not
wanting which go to show that the poisonous decompo-
sition of organic matter in sewers is in some way con-
nected with the dissemination of these diseases.
Dr. Chaumont publishes two cases in support of this
opinion. One is that in which a number of children were
attacked with diphtheria, apparently caused by a leakage
of sewage in a part of the house immediately under the
nurseries of the children. The other case was that in
which by a defect in the sewer- ventilating pipe passing
up close to the cupboard in a nursery, there was an escape
of sewer- air into the room occupied by a number of chil-
dren, with the effect of sickening the whole of them.
Dr. Wilson* remarks that " in country districts isolated
outbreaks of diphtheria traceable to cesspool effluvia are
1 Read before the Congress of American Physicians and Surgeons,
Washington, May 30. 1894.
* Medical Record, August, 1888, p. 186
» Handbook of Hygiene, 1877, p. 71.
not at all uncommon. In these cases it is generally
found that there is a water-closet in the house which itself
is badly ventilated, and that the closet drainage dis-
charges into a cesspool which is completely covered up
and only cleaned out at rare intervals. The consequerce
is that any gases generated in the cesspool have no out-
let except through the water closet and into the house,
and hence result attacks of diphtheria, ulcerated sore
throat, and other badly defined ailments."
" From an inquiry instituted by the State Board of
Health of Massachusetts in 1875, respecting the predis-
posing causes of diphtheria, its prevalence, etc., it would
appear that this disease has been most severe in the rural
districts where there are no sewers and where the drain-
age is generally very bad. In some of these places the
level of the ground- water is high, and on this account
when there is high water many cellars are damp or con-
tain standing water. This is probably one of the worst
sanitary conditions in connection with diphtheria. It
helps perpetuate it by furnishing a breeding place for its
disease germs if they become implanted, and it also favors
catarrhs and sore throats, which render persons having
them more susceptible to that disease. Besides the con-
ditions referred to, the soil is often polluted from hcuse
slops and excavated privy- pits." l
"The belief that the propagation of diphtheria is
greatly influenced by contaminated air from sewers,
privies, soils, etc., or, in other words, by filth infection,
seems to be gradually gaining ground ; but at present evi-
dence is not sufficient to justify a decided opinion." 2
" Perhaps these faulty conditions produce a sore throj t
of a benign character which affords a soil suitable for ir-
oculation by the diphtheria germ when present in the
air.
According to other writers, defective sewerage, damp-
ness, and lack of cleanliness, account undoubtedly for
most cases of diphtheria developed in private houses.4
Indeed in some of these instances the presence of the
Loeffler bacillus, the true cause of diphtheria, has been
shown in the gases arising from sinks.6 We owe this de-
monstration to the researches of Dr. Fischer, who has
shown also that these sinks are not properly flushed, and
that for this reason they often become the breeding-place
for these and other bacteria. In commenting upon Dr.
Fischer's researches Koehler states that the portion of
the waste pipe of washstands and sinks between the outer
opening and the first trap is particularly objectionable
for this reason. This portion of the pipe receives vary-
ing amounts of organic matter and water, which is ex-
posed to and warmed by the air of the adjoining room.
These are, of course, suitable conditions to produce an
excellent culture ground for many kinds of microor-
ganisms. The traps of a house may, therefore, be in per-
fect order, and yet we may not be safe from infectious
sore throats. The condition just referred to is usual, and
yet frequently cooks and others escape sore throats, at
least for a time. When they are otherwise well, the
chances are that they will escape ; when they are ailing
for one reason or another, they are more likely to con-
tract a sore throat from habitual contact with the source
of contagion mentioned.
Many people, both adults and children, before con-
1 Report of State Board of Health of New York, 1893, pp. 294, 295.
* Buck : Hygiene and Public Health, vol. i., p. 5fo'
8 Osier : Practice of Medicine, p. 99.
4 Medical Record, September 30, 1893, p. 422.
6 Ibid., January 28, 1893.
^58
MEDICAL RECORD.
[September \, 1894
tracting diphtheria or other affections of the throat have
bsen weak or sickly. The vitality of their body- cells is
already lowered, and they are thus rendered more sus-
ceptible to the action of virulent germs. Many agencies
conspire to bring about this condition ; such are, notably,
wet and cold, hunger, physical or mental depression,
worry, and severe shock. In many instances diphtheria,
follicular tonsillitis, and other forms of sore throat have
been known to follow exposure to some of these causes,
and independently, as far as can be known, of any in-
fection from dirty pipes.
It is an admitted fact that the throat swarms with bac-
teria at all times, and possibly the Loeffler bacillus is
among them occasionally,1 but they are incapable ot
doing much harm to the individual carrying them if he
be in good health. Through the depressing influences
referred to they are capable of multiplying and increas-
ing in virulence, and finally causing infectious sore
throats. The sore throat may be taken indeed by the
individual who first receives or develops the bacillus, or
he may infect other persons without himself having given
evidence of sore throat or other disease.
From what precedes, we should see clearly how im-
portant it is to keep up an excellent condition of general
health ia order to avoid contracting throat diseases. It
is also evident that proper disinfecting washes or gargles
for the mouth and throat are very important to keep it
in a condition where infective bacteria will not de-
velop, or, if present, will not take on virulent proper-
ties. These precautionary measures, which are or may
be useful at all times, and particularly for children, are
likewise specially desirable for the delicate ones, and in
times of epidemic or exposure in any way to the sources
or causes of infectious sore throats.
The aggravating effects upon the condition of the
throat of effluvia from sewers and drains is, then, most
probable. While the distinct connection between the
two conditions cannot always be determined, yet in very
many case3 it is clearly demonstrated. Moreover, rea-
soning by analogy it should be true, inasmuch as sew-
age emanations are known to aggravate the severity of
all the exanthemata, erysipelas, hospital gangrene, and
puerperal fever (Rigby) ; and it would seem that all dis-
eases are more or less affected by these effluvia.9
That many cases of tonsillitis are immediately caused
by the air of sewers and fecal emanations scarcely ad-
mits of reasonable doubt. The evidence in this direc-
tion is very convincing, and I am persuaded that I have
seen these affections dependent to a great extent upon
the polluted air of sewers, cesspools, and of the soil.
We can properly explain the throat affection, it seems to
me, in the same way we do the development of typhoid
fever. "The morbific agent conveyed through the
medium of the air finds its way into the houses from
cesspools improperly located, or from drain pipes imper-
fectly ventilated or badly trapped, or from impure soil
beneath and surrounding the dwellings. With the doc-
trine that the disease is not in the micro-organism itself,
but in its products, we may have floating matter which is
not living and yet which is infective ; so the gases of
certain kinds of decomposition may be sources of con-
tagion without our deciding whether or not they have
been produced through the agency of low forms of
life.1
" In some cases sore throats have been confined to a
particular part of the house, especially exposed to the
effluvia from badly trapped drains; and as the water
supply was unexceptional, and other sources of disease
could not be found, there could be no doubt as to the
source of the infection."
1 That Loeffler bacilli are present at times in considerable number
in the mucous secretions of the tonsils and pharynx of children ap-
parently in good health is now clearly established. This important
and suggestive fact we owe to the researches of Drs. Chappell and
Park Vide Mbdical Record, April 14, 1894.
a Buck : Hygiene and Public Health, vol. i , p. 585 ; quoted from
Parkes.
» Report of the Board of Health of the State of New Jersey, 1893,
p. 76.
Even though we might be inclined to give a different
interpretation to some facts of an analogous kind, yet
what we can say is that in many instances in which the
bad sewerage has been partially, or more or less thor-
oughly remedied, the throat affections have notably les-
sened, or disappeared almost entirely for a while. In
this direction we have the unbiassed and careful testi-
mony of many judicious observers. Thus Dr. Billing toD,
of New York, writes in regard to the etiology of diph-
theria : " The relation of cause to effect has been demon-
strated by the fact that in some buildings which had
come to be looked upon by me as diphtheria nests, there
has been no recurrence of the disease for quite a number
of years since the evils referred to, viz., foul cellars,
neglected cesspools, bad plumbing, untrapped sinks, no
air-shafts, were removed through the efforts of the Board
of Health. It is probable, moreover, that it is, in some
degree at least, a result of the removal of these foci of the
disease that the mortality from diphtheria in the ward
of which Dr. Billington was an out-door visiting physi-
cian, has become very much less.1 The experience of
Billington is corroborated by that of others. Thus " the
persistent attacks of enteric fever (and also diphtheria?)
which formerly occurred at Eastney Barracks in England
were due to sewer-air being forced back by the tide, no
traps or ventilating openings being supplied ; since this
was remedied and ventilation carried out, no case of fe-
ver has occurred." *
On the other hand, I have known diphtheria and folli-
cular tonsillitis to occur, and not infrequently, in houses
where the closest investigation could show no defect
whatever in the sewerage of the house, where the cellar
was clean and dry, where ventilation was excellent, and
where, indeed, no discoverable and satisfactory cause
of the kind referred to could account for the develop-
ment of these diseases. At first thought this fact would
appear to support those observers who claim that insan-
itary conditions, due especially to defective plumbing
and drainage, have very little to do in occasioning an
outbreak of throat disease. This statement I can only
admit in so far as to say that imperfect sewerage is only
one of the efficient causes of diphtheria and other throat
diseases, and that numerous other causes of these affec-
tions may and do exist These other causes, already re-
ferred to, are especially active, no doubt, in times of epi-
demics. In cases of diphtheria and other throat diseases
due to endemic causes, it is quite clear at times that the
bad sewerage of the house acts in one of two ways : First,
in causing a condition of the throat upon which the
specific bacillus of diphtheria, or other micro organism,
can graft itself more readily ; second, in developing, per-
petuating, or perhaps in originating, the specific bacillus
or other microbe which is frequently present in the air
of a certain house or locality.
Again, in estimating the influence of drainage in pro-
ducing throat disease in certain houses of the rich, and
even though no visible defect can always be discovered,
it must be remembered that in view of the complicated
and multiform appliances of modern plumbing, they
" have seemed to multiply rather than to obviate the in-
sidious dangers from noxious miasms." a
Be it observed, also, that American houses, as a rule,
have no other way of changing the air than by opening
the windows. Water-closets oftentimes are found with
no connection with the outer air, located in the middle
of the house, and what ventilation there is, is into the
rooms of the house.4
According to Jacobi * cases of diphtheria which are
traceable to sewers are very frequent. Yet he shows how
in the same house one may see cases of dysentery, ty-
1 Diphtheria and Croup, p. 22. New York : William Wood & Co.
1889.
8 Stevenson & Murphy : Hygiene and Public Health, vol. L, p. 11.
London, 1802.
8 Billington, p. 23.
4 Parkes Hygiene, with Am. Supplement. Wood & Co., 1884, p.
526 (Appendix).
• Treatise on Diphtheria, p. 34. Wm. Wood & Co. New York,
1880.
September i, 1894]
MEDICAL RECORD.
259
phoid fever, and diphtheritic sore throats, all due appar-
ently to a common poison.
This should be admitted, says Jacobi, unless we as-
sign a triple character to the poison, or banishing the
belief in specific influences, simply attribute the causa-
tion of these diseases to the lowered tone of the system,
and after this manner affording to morbid influences an
opportunity to exercise their power.
The following case, in my personal experience, has in
this connection some interest. I was called to see a
case of diphtheria in the practice of Dr. Smith Ely,
New York. In regard to this case Dr. Ely in a letter
dated March 12, 1894, reports as follows: " In a per-
sistent search for a cause of diphtheria in the C
children, some of the casing enclosing the drain pipe in
the water close* being removed, a piece of the pipe
below the trap was found to be broken out, so that, of
course, the sewer gas mingled freely with the air of the
house. This state of things might have existed for a
long time. There was another slight case of diphtheria
in one of the other children at the same time. In Sep-
tember, 1 89 1, the same child who had diphtheria so
badly had typhoid fever. There were other cases in the
neighborhood, however."
As is so frequent in similar cases, the possibilities of
causation in infectious diseases are rarely single, or
always definitely separated from one another.
In certain families, diphtheria and follicular tonsillitis
show a tendency to spread even though the sanitary
conditions are of the best.1 The connection, moreover,
between diphtheria and preceding throat affections is oc-
casionally most marked. This is probably the most im-
portant link between various insanitary conditions and
the diphtheria which sometimes breaks out amid them.
In this sense defective house sanitation is often a cause
of diphtheria by producing a morbid condition of the mu-
cous membrane which favors the development of the
specific bacillus, though in other instances there is reason
to believe that the specific bacillus might be present in the
sewers of a district, and thence gain access to a house.2
Moreover, now " many are entertaining the view that
different microphytes may produce the same disease, or
that the same microphyte is subject to modification in
virulence and in its products, and that disease may be in-
fluenced by the quality, as well as by the quantity, of the
invading irritant." '
Once the sewers have become infected they may per-
haps continue to be so for an indefinite period. If, then,
for any reason, the plumbing fixtures of a particular
domicile are defective, it is readily appreciable how sewer-
air laden with disease germs finds access to it.4
Observation and experience have further taught us
that sewers, if not properly constructed and carefully
attended to, are more detrimental to health than if there
were none at all.6
On the other hand, it is certain that in many instances
diphtheria does not require for its development any ot
the ordinarily considered an ti hygienic conditions. So
far as we can determine accurately, the growth of the in-
fectious element of the disease is not invariably favored by
bad air or imperfect ventilation. Witness the facts re-
ported by Jenner/ who states that he has seen more cases
of this disease in hospital than in private practice ; and
again, as showing how little the untoward course of diph-
theria is thus influenced, we note that whilst half of
Jenner's hospital cases died, more than half of his private
cases died.
These opinions of Jenner are in a measure corrobo-
rated by the results of .a careful comparison of a large
number of cases of diphtheria, reported in Massachusetts
(Jacobi). Among the conclusions of the official report
we find that " The contamination of the atmosphere of
1 Tenner : Lectures on Fevers and Diphtheria. New York, 1893.
* British Medical Journal, February 24, 1894, p. 430.
* Report of Board of Health of State of New Jersey, 1893, P- 8a«
* Vide Report of State Board of Health of New York, 1893, p. 516.
* Report of State Board of Health of New Jersey, 1893, p. 282,
* Jenner : Loc. cit.
the bed chamber by the emanations from sewers requires
further study.1 '
In this connection Dr. Arthur Newsholme, Medical
Officer of Health for Brighton, England, states that
diphtheria had increased in England latterly, and more
particularly in urban districts.
" In this particular it differed greatly from other dis-
eases of zymotic type, which had been much mitigated
in severity by sanitary improvements." 1
If this fact be admitted, it is additional proof perhaps
that diphtheria depends for its spread on contagion
direct from infected materials. The presence of sewers
favors its continued existence. Closely inhabited local-
ities do the same thing also, by furnishing ready means
for communication of the disease. Thus in most cities
it has become endemic.2
Elsewhere8 in speaking of tonsillitis, I have said : " It
is perhaps a less familiar fact that exposure to a vitiated
atmosphere will occasion the development of tonsillitis
in children. Septic causes of tonsillitis are also often
met with, and I am constantly advised of the fact that
defective drainage may give rise to recurrent attacks of
tonsillitis in children."
This statement seems to receive corroboration from
Osier,4 who writes, " Bad hygienic surroundings appear
to have a direct etiological connection with the disease."
In so many instances defective drainage has been found
associated with outbreaks of follicular tonsillitis that
sewer-gas is regarded as a common exciting cause. Ber-
nabei has also found that in many cases of acute angina
streptococci are discovered, and that these cases are epi-
demic and contagious.
Rendu and Bulloche are even of the opinion that all
acute anginas are of bacterial origin, and similar opinions
are held of late by many other observers.5
In many of these cases, according to Kingston Fox,6
and Browne, the differential diagnosis from acute tonsil-
litis due to cold or other causes is made by the fact that
the septic cases are bilateral in the beginning.
No doubt, as I have observed frequently, some chil-
dren are rendered more susceptible to septic causes by
the presence at the same time of a rheumatic habit or a
strumous constitution . Nevertheless, whenever recurren t
attacks of tonsillitis occur in a child, or among children
in the same family, it becomes a duty to see to it that
the basins, sinks, lavatories, drains, and pipes shall be
examined as carefully as possible, to discover if there be
any defect in the plumbing through which sewer gas
may gain entrance to the house. It is important again
to observe that frequently no doubt what is recognized
as sewer- gas in our houses is the result of decomposition
which takes place in the house-drains themselves, rather
than the result of decomposition in the distant sewer
forced into our houses through the connecting drain
(Waring). It is doubtless a fact that in many instances
the gases formed within the drain of a house are far
more hurtful to health than the gases which circulate in
the main sewers. This is frequently explained by the
fact that pipes and drains of the house have become
coated over with slimy deposits which in time are con-
siderable, and because many of these soil pipes are never
properly ventilated by a proper circulation of air.
A considerable degree of doubt exists in the minds of
some practitioners about the evil effects of sewer-air on the
throat. This arises probably from " the notorious fact
that workers in sewers are remarkably free from disease,
and particularly from affections of the throat." Indeed,
in the numerous citations which I have referred to per-
sonally, I have found no case in which one of these men
is said to have suffered from diphtheria or tonsillitis. In
many of the cases of disease which have been reported,
1 British Medical Journal, February 24, 1894, p. 430.
a Vide Report of State Board of Health of New York, 1893, p. 516.
8 Cyclopaedia of Diseases of Children, Keating, vol. ii., p. 33a.
4 Practice of Medicine p. 332. «
• Burnett : System of Diseases of the Ear, Throat , and Nose, vol.
ii., pp. 250,251.
•Transactions of the Medical Society of London, vol ix., p. 255.
26o
MEDICAL RECORD.
[September i, 1894
the illness may have been only a coincidence,1 and in
no manner connected with their profession. It may
also be said in regard to these cases of immunity that
these men have become gradually acclimatized to their
usual surroundings, and that the others who were un-
favorably affected by the work in the sewers, had aban-
doned it and taken up employment of a different kind.
Whenever cases of diphtheria, follicular tonsillitis, or
erythematous sore throat occur in a house where the
plumbing is found to be defective, we should be careful
not to ascribe these diseases necessarily to this cause.
In what precedes it has been shown that throat diseases
may, and often do, occur where the drainage is bad ; they
also occur where the sewerage is in perfect condition ; they
likewise appear where there is no sewerage at all to ac-
count for the outbreak. If the sanitary appliances are
defective, we are naturally inclined to hold them respon-
sible for the throat disease. And yet, as a fact, few of
our city, or country houses, even of those owned by
wealthy people, come up in their plumbing arrange-
ments to the requirements of a careful sanitary engineer.
Despite this fact, the throat condition of the majority of
people remains tolerably good, and the percentage of those
who suffer from diphtheria, or less severe disorders of the
throat, is comparatively small. Again, there may be
some cause of throat disease other than that of breathing
sewer-air, which has been overlooked, and yet ultimately
is proven to be the occasion of the outbreak. In illus-
tration of this statement I would cite an outbreak of
diphtheria in the village of Upchurch, England, which
was finally attributed to the dust from the collections of
refuse from London dustbins accumulated in the neigh-
borhood, and when the utter absence of any other
source of infection was affirmed.3
The chronic poisoning with sewer-air, especially in
its relation with diseases of the throat, is, as we have seen,
a subject to which considerable thought has been given,
and yet the conclusions arrived at are uncertain. Still
it would seem to be fairly well established by repeated
observations that the breathing of sewer-air for any con-
siderable length of time, and even though largely di-
luted, will occasion many of the throat affections. The
clinical experience of numerous physicians, the evidence
of sanitarians, all point strongly to this fact. It is also
proven that evil effects of breathing sewer gas on the
throat depend not so much on the quantity as on the
quality of the gas. If the sewer- air contain the specific
germs of diphtheria, it may become the carrier of this dis-
ease. At another time, when the sewer-air contains no
such specific germs, it will be the bearer only of follicu-
lar or erythematous tonsillitis.
It is probable that sewer-air may at times be inhaled
quite a long period without developing any symptoms of
throat disease. At a later period, when the sewer-air
becomes laden with harmful germs, a throat affection of
infectious type may occur with certainty. In children,
when no specific disease germs are at work, the symp-
toms of chronic sewer-air poisoning are frequently those
of catarrhal tonsillitis. In times of epidemics the catar-
rhal tonsillitis is apt to assume a severe or malignant type,8
and a simple sore throat may, under the influence of
sewer- air, assume a very serious and aggravated form. In
children, particularly, the susceptibility to the influence
of air polluted by sewage emanations appears to be
greatest. They easily become languid, and may suffer
from sore throat connected or not with diarrhoea or some
other manifest disturbance of the digestive tract4
People are more apt to suffer from the evil effects of
sewer-gas during the night than during the day, when the
body is undergoing active exercise, and when the rooms
are better ventilated. This is the reason why we hear
patients say so frequently that they have gone to bed
perfectly well and have awakened during the night or in
1 Osier : Practice of Medicine, p. 261.
9 The Journal of Laryngology, March, 1894, p. 124.
3 Reference Hand-book of the Medical Sciences, vol. vi. , p. 435.
4 Bartley : Ibid , vol. vi., p. 436.
the early morning suffering from sore throat. It is quite
possible that the ordinary putrefactive bacteria, when
germinating in pent-up sewerage, may be the cause of
the catarrhal sore throats produced by sewer-air.1
Finally, it must be obvious " that the effect oftentimes
is practically the same whether the fermenting sewage is
contained in sewers, or has soaked into the ground about
the house. Both may pollute the air with the sajne gases
and may produce like effects upon the throat. When
furnace fires are used in the house, the gases from a sewer-
soaked soil may be drawn into the rooms above, giving
rise to all the injurious effects of sewer-air.M * " Or the
position of the air inlet of a furnace near a drain-opening
or other source of contamination may allow foul air to
pass into the heating chamber of the furnace and be
distributed through the house," thus tfbcoming the effi-
cient cause of diphtheria, follicular tonsillitis, or other
throat disease.
The following communication I am indebted for to the
courtesy of Dr. A. Campbell White, House Physician at
the Willard Parker Hospital, N. Y. Dr. White's report
appears to me very interesting and instructive. Miss
Graf, the nurse from St. Luke's Hospital, referred to by
Dr. Campbell, was seen by me both during and subse-
quent to her attack of diphtheria.
" I believe the impression is or has been quite univer-
sal that the origin of epidemics or of individual cases of
this disease could be traced to faulty plumbing or some
other condition giving rise to escape of sewer-gas. That
such a condition can be the primary cause of diphtheria
we are now quite safe in denying.
" We are very positive in asserting that the Klebs-Loef-
fler bacillus is the organism at the foundation of every
case of diphtheria, and we can be almost equally positive
in saying that this germ cannot be found in sewer gas.
"If the drain- pipes are in a moist condition, as they
almost invariably are, it is justifiable to believe that even
though these pipes may be loaded with the bacilli of
diphtheria, the gases escaping will not carry the infection
necessary to produce this disease.
" We can take for an example, and I think it is a good
one, the wards in our hospital. Here we have some fifty
patients, every one of whom has the bacillus of Klebs
and Loeffler in the throat or nasal passages. We can
compare, for sake of argument, these throats to the sewer
pipes, and the air these patients are constantly exhaling
to the sewer gases. Now the ward, of course, in spite
of good ventilation, is constantly filled with the expired
air of patients suffering, some of them, from the very
worst forms of diphtheria, yet we have never succeeded
in obtaining any Klebs Loeffler bacilli in the air exam-
ined, nor have any of the attendants, who live twelve
hours out of twenty- four in these same wards, contracted
the disease.
" We are very firmly convinced that to contract this
disease direct contact is absolutely necessary. Therefore
sewerage (containing the diphtheria bacillus) must come
in direct contact with the patient by contaminating the
water, or some other such manner, in order to be held
responsible for an attack of diphtheria."
Nevertheless I do not hesitate in saying that constant
exposure to sewer-gas is a very important element in
determining the severity of an attack of diphtheria, and
that in many cases it is the most important factor in
bringing on a fatal result.
At the annual meeting of the Public Health Associa-
tion, held in Baltimore in 1875, ^r- Noel, after citing
many cases in his own practice to bear out his statement,
said : " We do not say that this gas is the direct cause
of diphtheria, croup, etc., in the sense of being the one
and only efficient cause, but we do contend, and we
defy criticism here, that in Baltimore City it has most
assuredly been the one constant factor invariably present
in the most malignant and well defined house epidem-
1 Loc. cit , p. 436.
■ Parkes : Hygiene, with American Supplement p. 5«6 (Appendix).
Wm Wood & Co., 1884.
September i, 1894]
MEDICAL RECORD.
261
ics." We can give an excellent example in our own
recent experience. I refer to the case of Miss Graf from
St. Luke's Hospital, and the other two nurses who at-
tended the family in Pennsylvania, a family of seven or
eight members, living in a house where the plumbing is
exceptionally poor, and, as the nurses testify, where there
is a constant odor of sewer-gas penetrating the entire
place. Now every member of this family, ranging in ages
from under five years to twenty-seven years, contracted
the disease, and every one died after a comparatively
short illness. This is a most frightful mortality. The
three nurses who attended these cases also contracted
the disease, but immediately came to our hospital for
treatment. Not one of them died, and only one devel-
oped into anything like the malignant form assumed
undoubtedly by the cases in Pennsylvania. We can
hardly attribute this difference entirely to treatment, nor
can we say they did not have the same exposure, but I
think we are justified in believing that this marked dif-
ference in mortality was more than a little influenced by
the fact that the former cases were treated in a sewer-
poisoned atmosphere, while the more fortunate nurses
were cared for in a clean, well-ventilated ward in our
hospital, where there is no taint of sewer -gas.
Another important point to remember is that we are
now finding many people in the very best of health
walking around with the Klebs- Loeffler bacilli in their
throats displaying no signs whatever of diphtheria.
Some of these people later develop the disease, in others
the Loeffler bacilli disappear without having caused any
trouble or inconvenience. The former have been exposed
to cold, have developed a catarrhal inflammation of the
respiratory passages, or in some such way the throat,
previously immune, is rendered susceptible to the ba-
cillus. Now such a person, with the necessary bacilli in
his throat, breathing in from day to day the atmosphere
laden with sewer-gas, is almost certain to develop diph-
theria, and we can readily see how easy it is to say (not
knowing that the patient had previously the bacilli in
his throat) that such a person contracted his diphtheria
from the gas escaping from a defective sewer-pipe, while,
on the contrary, if he had not already the bacilli in his
throat, he might have gone on indefinitely breathing
this vitiated air without even developing the disease.
We have ample reason to believe that sewer- gas attacks
the weak spots of the patient. Dr. F. Gordon Morrill
mentions this point in the Boston Medical and Surgical
Journal of 1884. Among the diseases brought on by
sewer-gas in this way he mentions, besides those affect-
ing the throat, rheumatism, gout, asthma, pneumonia,
and even neurasthenia.
The influence of sewer gas upon diseases of the throat
can be summarized as follows: 1. Given a patient with
a so-called weak throat, subject to frequent attacks of
quinsy, etc., expose him to sewer-gas, he will probably
develop amygdalitis. 2. Given a patient in good health,
with a throat containing Klebs Loeffler bacilli, expose
him for any time to sewer-gas, and he will probably de-
velop diphtheria ; or 3. Given a mild case of diphtheria,
expose him to sewer-gas, and the disease will assume a
more malignant type.
Therefore, although sewer- gas plays an important part
in the etiology of some throat diseases, it can by no means
be held responsible as the primary all-efficient cause.
The following letter is also of considerable interest. I
saw the last boy who died, in consultation with Dr.
Chandler, and agreed entirely with him in regard to the
diagnosis:
•'South Orangjb, May 26, 1894.
" Dear Doctor : The history you desire is in brief as
follows: In April, 1888, Mr. C built and occupied
a house on Avenue, Orange, N. J. In April, 1890,
his oldest son was very sick with diphtheria, but recov-
ered. No unusual amount of sickness affected his family
for two years later in this house. He then moved to
another town.
" A Mr. G occupied the same house after Mr.
C-
vacated. He had a family of three children. All
had been previously well. They soon sickened of vari-
ous disorders of no especial name or magnitude. After
living in the house about one year one child developed
diphtheria, and after a week's sickness died.1 About a
month later, a third child was attacked with the same
disease. By the advice of their physician they left the
house on the third day of the child's sickness, but that
child also died.
" The plumbing and draining of the house were found
to be defective, the wash tray in the butler's pantry was
without a trap. Mr. C , who first lived in the house
used the tray, but always kept the plug in the outlet and
there was no overflow. Mr. G did not use the tray,
and the plug was often out, and a * bad odor ' was no-
ticed from the tray.
" An outlet pipe, to remove surface water which might
collect in the cellar, ran directly to the cesspool andVas
also without a trap. Thus there were two vents from the
cesspool directly into the house.
" These are, briefly, the facts without comment. They
speak for themselves.
" Very truly yours,
" William J. Chandler."
THE PHONOGRAPH : ITS PHYSICS, PHYSIOL-
OGY, AND CLINICAL IMPORT.2
By J. MOUNT BLEYER, M.D.,
NKW YORK.
VISITING SURGEON TO THE NEW YORK THROAT, NOSK, AND CHBST HOSPITAL \
LARYNGOLOGIST GERMAN WBST-SIOB CLINIC; MEMBER ROYAL ACADEMY,
NAPLES, ITALY, ETC.
Before I enter upon a demonstration of the under-
lying principles and the action of the phonograph, let
me occupy a moment of your time by recalling those
special characteristics of the human voice, the dis-
tinguishing qualities of musical tones, etc., which it is
necessary to keep before us in order to thoroughly
understand the instrument I intend to dissect, both
anatomically and physiologically before you.
You are all more or less familiar with the phonograph.
Five years ago it was a closed book to us. To-day we
presume to know it from preface to appendix. I fancy
there are many here in this section who casually know
me from the few years of work I have done in experi-
menting with the machine and the fragments that from
time to time have gone forth to the profession from my
pen and workshop. I can almost hear them say : " Here
he is again ; what can he have to tell us now ?" My an-
swer is simply to let you know the further stage of per-
fection to which I have been able to carry the recording
and reproducing with integrity the sounds and tones
which, aside from their general scientific importance,
must soon become a valuable assistant to us in the posi-
tive recognition of disease.
All sound begins in those collisions and attractions
among material things by which their parts are thrown
into tremors. These are almost as various in quality as
the properties of material substances. The sounds we
hear are but indices to the vibrations of bodies from
which they proceed, and the multitude of such terms
as splash, roar, ring, thud, crack, whiz, squeak, crash, il-
lustrate the marvellous diversity of characters which
material vibrations may take. In the production of
noise the thrills of matter are transient and irregular,
but when prolonged and regular they give rise to
musical sounds. Vibration depends upon elasticity, and
bodies which are capable of the protracted and measured
pulsations of music must, of course, be highly elastic.
All bodies vibrate differently, and this depends upon the
nature, form, and magnitude of the mass in motion. The
vibrations of bells differ with their sizes and the metals
and alfbys which compose them ; while wooden and me-
» Another child was stricken with a light attack of the same character
before the first child died, but recovered.
» Read before the International Medical Congress, Rome, 1894,
262
MEDICAL RECORD.
[September i, 1894
tallic tubes, strained strings, and stretched membranes,
illustrate the same thing.
Take a tuning-fork and set it into vibration by draw-
ing a violoncello string across its prongs ; the fork yields
its own characteristic note, which will be loud or soft in
harmony with the manner in which the fork has been set
into vibration ; so long as we use one fork only, it is
obvious that ihe only vibration which can be produced
in the sounds confines itself to a vibration of their in-
tensity. If the extent of the vibrations be small, the
sound resulting is feeble ; its loudness increasing with
the excursion of the prongs. What is true of the tun-
ing-fork is true of any musical instrument, and hence the
loudness of musical sounds depends upon the amplitude
of the vibratory space of that which produces it. Now
take two tuning forks, differing in the pitch, and let us
presume that one is just an octave above the other.
They may be excited in such a way that the notes emit-
ted are of equal loudness, the only point in which they
differ being in pitch.
We all know that the pitch of a fork depends upon
its rate of vibration, which we can readily measure with
suitable apparatus, and thus it is comparatively easy for
us to accurately determine the pitch of a tuning-fork,
and should we so test the two tuning-forks in question we
would find that the notes of the one of increased pitch
would vibrate twice as fast as the other. If the one, say,
makes one hundred oscillations per second, the other, an
octave higher, would make two hundred in the same inter-
val of time, thus we may be assured that the pitch of any
note depends upon its rate of vibration and nothing else.
So having accounted for two characteristics of a musi-
cal note, let ms come to the third, which is of equal, if
■ T» ■J__JJ*A
\ \ \ \
Fig. x. — A stretched firing showing a pendulum motion which makes only a given number of vibrations in a fixed time.
not greater, importance, and by no means so easy of ex-
planation. I refer to what we generally term the "quality. ' '
The French have the more comprehensive term for it ;
they call it " timbre, " while the Germans have the
most exact defining word in the term " klang-farbe."
Klang-farbe is that which constitutes the difference be-
tween a violin or an organ and a piano forte, or between
two human voices; indeed we may say between any
sounds, musical or otherwise, which are of the same pitch
and loudness, but readily distinguishable from each other.
To explain the physical cause of quality let us suppose
we have a thin metallic wire stretched between two
points over a sounding board (Fig. 1 ). When plucked
at the centre the wire vibrates over its entire
length, a loop being formed between the two points.
The note emitted by the wire when vibrating in this
manner is called the fundamental note. If we should
dampen the wire at the centre by laying across it a
feather or quill pen, and pluck it at a point midway
between the centre and one end, both halves would
vibrate in the same manner and independently of each
other. That is to say, there will be two vibrating seg-
ments and a point of rest or node at the centre. But
the rapidity of vibration of each segment will be twice as
great as that of the wire when vibrating as a whole, and
consequently the note emitted will be the octave of the
fundamental.
When damped at a point one-third of the length from
either extremity, and plucked half-way between that
point and the nearer extremity, the wire will vibrate in
three equal divisions, just as it vibrated before in two
divisions; but now the rate of vibration will be "three
times as great as at first, and the note produced will be
a twelfth above the fundamental. Similarly, by dampen-
ing and plucking it at suitable points, the wire may be
made to vibrate in four parts, five parts, six parts, etc.,
the rate of vibration increasing to four, five, six, etc.,
times what it was at first. For example, let us assume
that when the wire was swinging as a whole, and sound-
ing its fundamental note, the number of oscillations
performed in a second was 100. Then we see that,
by taking suitable precautions, the wire can be made
to break up into two, three, four, five, six, etc., vibrat-
ing segments, the rates of vibrations being respectively
200, 300, 400, 500, 600, etc., and the series of notes
emitted being the octave above the fundamental, the
fifth above the octave, the double octave, the third and
fifth above the double octave, and so on. We now
come to an important point, which is this — that, the
wire being free, it is practically impossible to strike or
pluck it in such a way as to make it vibrate according to
one of the above systems alone. It will vibrate as a
whole, wherever and however it is struck; but this
mode has always associated with it or superposed upon
it some of the other modes of vibration to which we
have just referred. In other words, the fundamental
note is never heard alone, but always in combination
with a certain number of its overtones, as they are called.
Each form of vibration called into existence sings as it
were its own song, without heeding what is being done
by its followers, and the consequence is that the sound
which reaches the ears is not simple but highly com-
posite in its character. The word " clang " has been sug-
gested to denote such composite sound, the constituent
simple sounds of which it is the aggregate being called
its first, second, third, etc., partial tones. All the pos-
sible partial tones are not necessarily present in a clang,
nor of those which are present are the intensities all
the same. For in-
stance, if the wire
be struck at the
centre, that point
cannot be a note,
but must be a point
of maximum dis-
turbance ; hence all
the even partial
tones are excluded, and only the off ones, the first, third,
fifth, and so on are heard.
That characteristic of a musical note or clang which is
called its quality depends upon the number and relative
intensities of the partial tones which go to form it. The
tone of a tuning fork is approximately simple ; so is that
of a stopped wooden organ- pipe of large aperture blown
by only a slight pressure of wind. Such tones sound
sweet and mild, but they are tame and spiritless. In the
clang of the violin, on the other hand, a large number of
partial tones are represented ; hence the vivacious and
brilliant character of this instrument. The sounds of the
human voice are produced by the vibrations of vocal
bands, aided by the resonance of the mouth. The size
and shape of -the cavity of the mouth may be altered by
opening and closing the jaws and by tightening and
loosening the lips. We should expect that these move-
ments would not be without effect on the resonance of
the contained air, and such proves upon experiment to
be the fact. Hence, when the vocal bands have origi-
nated a clang containing numerous well- developed partial
tones, the mouth cavity, by successively throwing itself
into different postures, can favor by its resonance first
one overtone and then another, at one moment this group
of partial tones, at another that. In this manner endless
varieties of quality are rendered possible. Any one may
prove it himself by making the experiments, that when
singing on a given note he can only change from one
vowel sound to another by altering the shape and size of
his mouth cavity.
The Propagation of Sound. — Having thus briefly in-
dicated the physical causes of the various differences in
musical notes and the production of sounds by the organ
of voice, I will now devote a few moments to consider
how these sounds are propagated through the air and
September i, 1894]
MEDICAL RECORD.
263
reach the delicate diaphragm of the phonograph, while
recording any kind of sounds.
Now, in order that all these multifarious and diversified
tremblings of natural objects may be brought into rela-
tion with animate creatures, a common medium of com-
munication is necessary. The air around us is such a
medium. It possesses the marvellous power of taking up
the numberless and ever-varying thrills of material ob-
jects and conveying them through space with all their
peculiarities. The sensitiveness of the air (if I may so
speak) to the faintest tremors in material objects, and its
power of transmitting their individual qualities, are most
wonderful. It drinks up the infinitesimal motions of
things and diffuses them swiftly, simultaneously, and in
countless myriads in all directions around.
That air is the medium of sound is proved by the fact
that when vibrations occur in space void of air the
silence is not broken. If a bell suspended by a string in
a vacuum be struck, nothing is heard, although, if it is in
contact with the jar, the vibrations are communicated to
the outer air and sound produced. That air transmits
the kind of motion that it receives is also proved by the
fact that it will take up vibrations at one point and com-
municate them to a distant object that is capable of
vibrating in the same way.
The velocity of impulses in the air which produces
sound has been well established, and all kinds of shocks
— the firing of a gun, notes of a musical instrument, or
the voice, whether high or low, harsh or soft — all move
at the same rate. The velocity is not affected by
changes in atmospheric pressure or moisture, or by rain
or snow, but it is affected by wind and by tempera-
ture.
The speed of-sound is 1.090 feet per second at the
freezing-point, and increases about one foot per second
for each degree of ascent on the Fahrenheit scale.
Sound moves in air with about the speed of a cannon-
ball, and at a rate ten times greater than the swiftest
motion of air in a hurricane. The sound produced in
the open air tends to move in all directions with equal
speed, but this tendency may be disturbed by various
conditions. If the whole mass of air is moving in one
direction, sound will travel faster with it than against it.
In still air the sound of a musket-shot will be heard
farthest in the direction of the impulse. Experiments
have shown that a person speaking in the open air can
be heard about equally well at a distance of 100 feet in
front, 75 feet on each side, and 30 feet behind. When
an obstacle checks a sound in one direction it can be
heard farther in others, because, as a given amount of
force produces a given amount of motion if the mo-
tion is arrested in some directions it is increased in
others.
We have now seen that air is the common vehicle of
sound, and that the sound- impulses move in all directions
at a high speed. But what is it that actually moves ?
The particles of air certainly not shot from the vibrating
body to the ear, for then we should live in the midst of
storms ten times more violent than tropical cyclones.
The wonderful elastic properties of gases here come into
play. The vibrations of bodies produce waves or pulses
in the air. When a disturbance is produced at any point
in an aerial at rest, sonorous undulations spread out from
that point in all directions. These undulations are the
effect of the rapid vibratory motion of the air particles.
The analogy of water waves will help us to understand
what is taking place under these circumstances. If a
stone be dropped into the still surface of a pond, a
series of concentric circular waves are produced, each
wave consisting of a crest and a hollow. The waves
travel from the centre of disturbance, while the drops of
water which constitute them have an oscillatory motion
in a vertical direction. That is to say, following any
radical line, the water particles vibrate in a direction at
right angles to that in which the wave is propagated.
The distance between two successive crests or two suc-
cessive hollows is called the length of the wave ; the
amplitude of vibration is the vertical distance through
which an individual drop moves. In a similar manner
sonorous undulations are propagated through air by the
oscillatory motion of the air- particles. But there is this
important difference between the two cases, that in the
latter the vibrating particles move in the same direction
in which the sound is being propagated. Consequently
such waves are not distinguished by alternate crests and
hollows, but by alternate condensations and rarefactions
of the air, the transmission of which constitutes the
transmission of sound. The wave length is the distance
between two consecutive condensations or rarefactions.
It depends upon the pitch of the transmitted sound be-
ing shortened as the sound is more acute, while the ex-
tent of vibration of the air- particles increases with the
loudness. Such are the peculiarities of the vibratory
motion in air corresponding to the pitch and loudness of
the transmitted sound. But what is there in the char-
acter of the motion to account for the difference in qual-
ity ? A little reflection will show that there is only one
thing left to account for these, and that is the form of
the vibration. Let us mentally isolate a particle of air,
and follow its movements as the sound passes. If the
disturbance is a simple one, produced, say, by the vibra-
tion of a tuning-fork, the motion of the air- particle will
be simple also, that is, it will vibrate to and fro like the
bob of a pendulum, coming to rest at each end of its ex-
cursion, and from these points increasing in velocity un-
til it passes its neutral point. Such, however, is clearly
not the only mode of vibration possible. If the disturb-
ance be produced by a clang comprising a number of
partial tones of various intensities, all excited simultane-
ously, it is obvious that the air- particle must vibrate in
obedience to everyone of these tones. Its motion will
be the resultant of all the motions due to the separate
partial tones. We may imagine it starting from its
position of rest to move forward, then stop short, and
turn back for an instant, then on again until it reaches
the end of its excursion. In returning it may perform
the same series of to and- fro motions in the opposite di-
rection, or it may move in a totally different way.
Nevertheless, however complex its motion may be — and
as a rule it will be exceedingly complex — its periodic
character will be maintained. All the tremors and per-
turbations in one wave will recur in all the others.
Could we see what takes place in a room when a tun-
ing-fork is in vibration, giving out a "single note," we
should behold all the particles of the air agitated in
tremulous sympathy, and filling the space with swiftly
expanding spheres of spectral beauty. Or were the effect
produced by several instruments played, we should see
forms in countless variety carving the air into ever-
changing figures of geometrical harmony, and creating
the perfect music of geometrical forms. Such a revela-
tion is impossible from the swiftness of movement, which
would baffle the eye ; but it would be also impossible,
because the complications of movement would confuse it.
But where the optical sense fails the auditory sense suc-
ceeds. The membrane of the ear receives the torrent of
motion and transmits it with all its harmonies. In an
orchestra, where scores of instruments are playing through
the whole compass of the scale, the air is cut into waves
or pulses by every complexity of vibration — grave tones
mingle with shrill, soft with harsh, fundamentals are
merged in overtones, and the storm of impulses is shot
with the speed of rifle bullets against the diaphragm of
the phonograph as against the tympanum ; and yet there
is no confusion. In all their infinite diversity of qual-
ities the waves are graven upon the little membranes.
In order to complete the physics in this paper, I can-
not pass over it without paying some attention to visible
sound.
The idea of getting a visual expression for musical vi-
brations occurred to Chladni, a physician of the last cen-
tury. He fastened a plate of glass by its centre, and
then, having scattered some sand over the surface, threw
it into sonorous vibration by means of a violin bow
264
MEDICAL RECORD.
[September i, 1894
(Fig. 2). The plate when thus set in vibration, the sand
was tossed away from certain parts of the surface and
collected in other parts, forming regular geometrical fig-
ures. The plate, like a string, has one rate of vibrations
which belongs to it ; but again, like a string, by " damp-
ening1' it with a touch of the finger or fingers in differ-
ent points along the edge the note changes, and with it
the figure made by the sand. The lines on the plate
waere the sand settles are nodes, the lines of comparative
rest. The violent agitation in the parts left bare can be
shown by mixing a little lycopodium powder with the
sand ; this is excessively light, and is caught in the little
whirlwinds of air generated about the vibrating segments.
Fig. a.— Showing the to-antl-fro excursion of a plucked string.
A little instrument invented by Professor Sedley Tay-
lor, and called the phoneidoscope, gives a most exquisite
illustration of music made visible. He says that by this
contrivance it is possible, by msans of a soap film, to get
different figures for different pitches, for different inten-
sities, and for different qualities of tone. I did not find
this instrument to answer in practice.
We are now upon the very threshold of Mrs. Hughes's
voice figures of which I have spoken in cxtinso in a
previous communication, but for the sake of complete-
ness I will recapitulate some of the important points
set forth therein. She has reached the path which
brought her to them by the phoneidoscope. Her eido-
phone is constructed on the same principle as the pho-
neidoscope ; in eidophone, instead of the frail lamina of
soap-suds, she has a stretched membrane of india-rubber
to receive the vibrations, and on this is spread a thin
layer of some pasty substance which will retain the record
made by the vibrations of the membrane. These voice-
flo/rcrs are not the simple, visual forms corresponding
with the vibrations of the air set in motion by the voice.
The waves generated in the closed bowl of the eidophone
are reflected again and again from the sides of the vessel.
The volume of air inclosed has its own rate of vibration ;
the stretched membrane has also its own rate, which in
turn is modified by the character and thickness of the
paste spread upon it. Added to these are molecular
forces of cohesion and adhesion between the particles of
paste, and again between the paste and the membrane.
The form which grows into shape is the resultant of all
these complicated forces, and, in some instances, new
elements of change have been added. A glass plate is
placed on top of the vibrating membrane and moved
over it. We have a new body introduced with its proper
rate of vibration, besides a mechanical motion further to
complicate the problem.
The results are very wonderful and beautiful, and open
up a field for investigation which is most interesting ; but
so far we have the resultant of many forces, not one of
which has been weighed and measured. In a letter,
Mrs. Hughes, replying to some questions asked in the
hope of greater accuracy, says: "The notes producing
the figures vary necessarily with the weight of material
used and the tension of the membrane, so that any one
note may, under different circumstances, produce differ-
ent figures, and conversely, different notes may, under
different circumstances, produce similar figures."
The daisy f jrms (Fig. 3 ) were sung into shape, she
says, by extremely low notes, very softly sounded, some
of them by A in the first space of the bass clef— a won-
derful note to be reached by a woman's voice, whose
highest note is the B flat above the treble clef, a compass
of over three octaves. Sometimes geometrical foims,
not given in the illustrations, were produced by the
highest notes of her voice, while the serpent, fern, and
tree forms were made by singing her middle notes with
great intensity.
Among some of the first experimenters of hearing with
the eyes, were Messrs. Lissajous and Duhamel, whose re-
searches in that line are known to all of us. The more
recent men who worked in this field are Leon Scott and
Dr. Koenig. The first is the inventor of the phonauto-
graph, whose instrument gave a more comprehensive
sound-writing ; and the latter for making sound visible
by a compound series of flames produced by a single
burning jet connected with two or more tubes, and com-
bined with a series of resonators. This has been ex-
ceedingly serviceable in the elucidation of those obscure
qualities of sounds, of which he was enabled to distin-
guish different voices and instruments, even when the
pitch and intensity of the notes are the same.
It is useless to dive into the minute description of
those apparatuses, etc., as they may be found in all works
on modern physics.
Early last April I had occasion to apply the principles
demonstrated by the work of Chladni and^Mrs. Hughes to
another and highly important branch of our science. The
result of these experiments will probably be made known
to the members of this Congress by my colleague, the
distinguished American physician, Dr. George Engle-
man, of St. Louis, with whom I was engaged in the task
of bridling the faradic current and accurately measur-
ing and calculating the number of interruptions of the
faradic machines used by our electro-therapeutists, and
observing the physiological action at the various rates of
interruptions. Dr. Engleman, as I understand, will detail
the exhaustive research he and I have made in this direc-
tion in the section of electro therapeutics or physiology.
By means of sensitive diaphragms and a dry powder,
like lycopodium, I obtained visual pictures of regular
geometric shape corresponding accurately to the number
of breaks in the current. In this instance I employed a
hollow cylinder about three inches in diameter and about
six inches long, over which I stretched an elastic mem-
brane. Upon the centre of this membrane a small part
of dry lycopodium was dropped and the cylinder was
placed upon the diaphragm of a telephone receiver, the
open end next the diaphragm. With each change in the
number of interruptions in the faradic current, the pow-
der assumed a different geometric form, and we were thus
enabled to calculate the number of interruptions with
absolute accuracy as they ranged from 3,000 to 50,000,
and as I have since learned, up to 102,000 per minute.
Some of the figures resembling those of Hughes and
Chladni.
When sonorous undulations impinge upon the delicate
diaphragm of a phonograph the latter is set in vibration.
Its particles move to and fro in some way or other. The
complexity of their motion will depend upon that of the
air from which it was derived. This brings me to what
I have to say of the phonograph itself.
In the annals of modern inventions the phonograph
(Figs. 4 and 5) and its inventor, Thomas A. Edison,
will always occupy a foremost place. Years ago, had
a scientist had the temerity to proclaim that he could
record and reproduce human speech, the sounds of
music, and other living tones, and preserve them for
ages just as the pathologist guards his specimens from
the ravages of time, he would have been proclaimed a
September i, 1894]
MEDICAL RECORD.
265
Seaweed or Landscape Form.
sorcerer and perhaps burned at the stake, as were the accomplished was so wonderful that inventors were
so-called witches in my own country only two centuries tempted to work over it.
ago. How times have changed ! I need not rehearse But the phonograph of to-day, the novel and remark-
the early trials and tribulations of the
illustrious gentleman, whose ideas
crystallized in tangible form are be-
fore you. It would simply be a rep-
etition of the fortunes of all the great
observers whose work has become his-
toric. He fought against almost in-
surmountable obstacles and overcame
them. Let me briefly recount the
story of the discovery of the phono-
graph.
Edison's early phonograph was
founded upon the discovery, that if a
delicate diaphragm or sounding-board
is provided with a sharp point of steel,
its vibrations under the sound of the
humin voice will cause the sharp point
or stylus to make a series of impres-
sions or indentations upon a sheet of
wax or other analogous material passed
beneath it. Such indentations, though
microscopic, are sufficiently defined to
cause similar vibrations in the dia-
phragm, if the stylus is again passed
over the furrow of indentations, and
this reproduction is loud enough to
be distinctly heard. Thus, the pho-
nograph, in its primitive form, con-
sists of a little sounding-board carry-
ing on its under surface a needle point,
and a sheet of wax so held as just to
touch the needle. The sound-waves
of the voice cause the sounding board
or diaphragm to vibrate with a rapid-
ity varying with the pitch of the note.
If the wax sheet was made to move
slowly along while the sound-waves of
music, talking, or singing were allowed
to impinge upon the sounding-board,
the result was found to be a continu-
ous line of minute indentations, corre
sponding in depth and geometric form
to the outline of the original sound
waves.
These lines were continued side by
side, until the smooth surface of the
sheet was covered over with indenta-
tions.
This done, on raising the stylus and
the diaphragm and again placing it in
the first furrow of indentations, the
stylus, as it travelled through the series
of lines, caused the sounding-board
again to vibrate, sending out an exact
repetition of the sounds as they were
originally impressed in the wax; al-
though somewhat changed in pitch,
intensity, and quality, they were yet
of sufficient accuracy to demonstrate
the possibility of recording and re-
producing living sounds.
Photographs and measurements of
these tracings of the sound waves on
the wax cylinders, etc., were recently
made by Hermann, of the Konigsberg
physiological institute, and are of
great interest in the study of the phys
ics of sound.
The defects of the first phonograph
were so great that Edison found it
impossible to interest capitalists in _ Jh ™*' *■ ,M w v p a ,k m^T™ .
perfecting it. At the Same time emi- F,G' >-*h0™* VulCC F«™ of Mrs' Hughes-Produced by Means of the E.dophone.
nent men in Europe were not wanting, who predicted able instrument, has passed much of its experimental
great things for the phonograph of the future. What it stage. It is now practically successful in every respect,
Serpent Form.
Cross-vibration Figure.
266
MEDICAL RECORD.
[September i, 1894
and must be regarded as instrumental in opening up a
new field for scientific research, and making one more
application of science to industry. Its aim is to record
and reproduce speech ; to make a permanent record of
vocal or other sonorous vibrations ; to recreate these vi-
brations in such manner that the original vibrations may
be again imparted to the air as sounds.
Notwithstanding all that has been said against the
properties of the sounds reproduced by the phonograph,
there is 110 doubt but that they are reflected in absolute
integrity, but somewhat decreased in volume. In other
effects, begged M. Paskos to repeat the experiment before
them again, under such conditions as they laid down fcr
him. M. Paskos complied with this request, and they
were absolutely satisfied with the result. Others still re-
mained incredulous, and it was necessary before they ac-
cepted the fact that speech should be reproduced in to
simple a way.
Fig. 4*
words, I mean to say that the record of a sound, as it is
given out or as we hear it coming from the phonograph,
is an exact miniature of the original. And this is easily
explained if we bear in mind the fact that the diaphragm
can only record those wave-pulses which are caught up
and encompassed by the recording trumpet. The others
lose themselves in space, yet the pitch and quality re-
main unchanged.
The phonograph is really a natural outcome of the
telephone ; but unlike any form of telephone, it is me-
chanical and not electrical in its action.
The following anecdote is told by M. Paskos, Mr. Edi-
son's agent, who presented the first phonograph for exhi-
bition before the academicians of Paris. It was a curi-
ous spectacle to witness the expression of the faces of
these academicians when M. Paskos caused the wonder-
ful instrument to speak. A murmur of admiration was
heard from all parts of the hall, a murmur succeeded by
repeated applause. The learned Academy, generally so
cold, had never before abandoned itself to such enthusi-
asm, yet some members of a sceptical turn of mind, in-
stead of examining the physical fact, ascribed it to moral
causes, and a report soon ran through the room which
seemed to accuse the Academy of having been mystified
by a clever ventriloquist. Certainly the spirit of ancient
Gaul is still to be found among the French, even in the
Academy. One said that the sounds emitted by the in-
strument were precisely those of a ventriloquist. An-
other asked if M. Paskos's face and lips, as he turned the
instrument, did not resemble the grimaces of a ventrilo-
quist. A third admitted that the phonograph might emit
sounds, but believed it was much helped by the manipu-
lator. Finally, the Academy requested M. du Moncel to
try the experiment, and as he was not accustomed to speak
into the instrument it was unsuccessful, to the great
joy of the incredulous. Some members of the Academy,
however, desirous of ascertaining the real nature of the
The anecdote I have just related cannot be
interpreted to the discredit of the Academic ties
Sciences, since ihe Academy is bound to j re-
serve the true principles of science intact, acd
to accept startling facts only after careful ex-
amination. ( >wing to this attitude, all that
emanates from the Academy can be received
with complete confidence; and we cannot ap
prove too highly of reserve which does not give
way to the first impulse of enthusiasm and ad-
miration*
Its present achievements in recording music
are wonderful. The phonograph will reproduce
any kind of music — singing, the piano, violin,
cornet, oboe, etc. — with a beauty of tone and accuracy
astonishing to the musician. It is possible also to mag-
nify musical sounds without distorting them, as often
happens where speech is concerned. Thus, when a
musical* is arranged, the phonograph is put up to as to
be heard one hundred feet away. Even should the pho-
nograph never reach greater perfection than its present
stage, which is hardly possible in this age, it is and will
Fig. 5-
continue to be of the greatest use to musicians, elocu-
tionists, authors, editors, and physicians. To this last-
named profession, of which I am a member, I have been
the means of directing their attention to the practical
use of the phonograph in medicine.
For several years past I have devoted considerable time
to studying the uses to which as a recorder of the sounds
of disease and organs in health, upon which the physician
September i, 1894]
MEDICAL RECORD.
267
depends so much for the accuracy of his diagnosis. Al-
ready I can say, notwithstanding its many imperfections,
the phonograph is made to record many of the character-
istic sounds of disease of the respiratory apparatus. For
example, when in good voice the vocal expression of
singers may be recorded and kept for comparison with
the sound produced in case the vocal bands are affected.
Time and again have I realized great benefit from the
phonograph of tenors, baritones, and bassos among my
patients, and not only have thus been able to recognize
the difference in shade of tone and quality, and thus
direct my attention to remedying the defect, but patients
have also been able to recognize the deterioration of their
voices from the normal standard themselves. This is one
of the reasons why I desire to forcibly place before you
the possible advantage the phonograph possesses in the
perfection of elocution and singing, and to laryngologists
in particular.
- As a specialist in the department of medicine involving
diseases of the throat, nose, and chest, I owe much of
what little success I have had to the phonograph. Nat-
urally, my practice brings me into direct contact with
celebrated people of high vocal culture, many with al-
ready fully trained voices, and so from the outset the
phonograph which I made as standards of singing, speak-
ing, etc., represented a condition very near the standard
of perfection which both teachers of singing and elocution
are striving to attain. The excellent artists whose re-
cords I have taken, and treasure very much, were those
educated in singing in the various methods of the Ger-
man, Italian, and French schools, and representing over
and over again these phonographs, I have been able to
detect readily any change or oncoming change in the
normal action of the vocal bands. It is astonishing to
hear the difference in the methods that the special train-
ing of one of these schools gives to singers, to actors, and
elocutionists; and more astonishing it is to compare singers
of a mixed school with those whose singing is simply a
natural exponent of fine vocal organs plus the training.
The music that is in the well-trained artist rings forth its
melody in pure musical sound from out of the indented
pulse waves imprinted on the cylinder of wax. By util-
izing these for a comparative study with the lesser nat-
ural and other voices, I have reached much profit in the
study of the different shading of tones and quality pos-
sessed by their vocal organs.
Mr. Edison's intention is now nearly fulfilled in being
able to manufacture a quantity of instruments as perfect
as the best of the present experimental machines, and to
make them so automatic in action and so easily adjusted
that everyone who uses a sewing machine or typewriter
or a telephone, can use the phonograph ; we concede at
once what wonderful field is before it.
The price of phonographs is nominal, and the new wax
cylinders upon them cost scarcely more than writing-
paper. Once a cylinder has been engraved or has had a
message recorded upon it, it can be passed through the
phonograph any number of times apparently without de-
terioration. I possess some valuable phonograms which
have been read, sung, and played thousands of times by
the phonograph, and no special indication of wear is ob-
servable. Finally, bear in mind that having once ob-
tained a good phonogram, it can be multiplied and dupli-
cated at small cost. What a wonderful prospect opens
before us. This duplication of phonograms is not known
to us as yet, but no doubt experiment will give it to the
public, and duplication will be as common as in pho-
tography.
Imagine what the phonograph will do for the man on
the borders of civilization. It will supply him with books
in a far more welcome shape than print, for phonographs
will read themselves. The mail will bring him the latest
play from London, or opera from Vienna. If he cares
for political speeches, he can have the Congressional Rec-
ord in the shape of phonograms. It is possible even to
imagine that many books and stories may not see print
at all ; they will go into the hands of their readers or
hearers rather as phonograms. But think what a musical
critic can do for his public. He can give whole arias
from an opera or entire movements from a symphony, by
way of proof or illustration. The veiy tones of an actor's
or singer's voice might be reproduced in the morning
notice of last night's important dramatic or musical
event.
In music, as already hinted, the value of the phot ograph
in its present stage is indisputable. Musicians are di-
vided, probably always will be, as to the manner in which
certain famous symphonies ought to be conducted.
The metronome marks used by Beethoven are at best
but uncertain guides; while no written directions as to
dynamic values, expression, etc., are worth much. The
phonograph will make it possible for the musician of the
future to know exactly how our composers wished their
music given, for it will repeat that music as played to-
day, with every shade of expression, with all its infinite
changes of time. Moreover, the phonograph offers to
the composer that long sought instrument, an automatic
recorder of improvisation upon the piano or other instru-
ment. In the far off future, when our descendants *ish
to compare our simple little Wagner operas with the
complex productions of their own times, requiring, per-
haps, a dozen orchestras playing in half a dozen differ-
ent keys at once, they will have an accurate phono-
graphic record of our harmonic simplicity. In logic we
say, that where a premise is established the deduction is
evident. So what can be done in one instance can be
done in all other similar instances. Those persons who
smile incredulously when it is said that the perfected
phonograph will do away with letter- wiiting, will read
to us, sing to us, teach us foreign languages with their
proper accents, teach us different methods of singing,
elocution, give us books, music, plays, speeches, at al-
most no cost, become a constant source of instruction
and amusement, must have forgotten the ridicule they
heaped upon the rumor that an American inventor
proposed to talk from New York to Chicago. The
achievements of the phonograph will be no less wonder-
ful than those of the telephone.
Marvellous as this instrument is, it is still quite new,
and it is impossible to say to what degree of perfection
it may yet be carried. It has already opened the door
to an entirely new and untiied field in the realm of
sound. It is a new instrument in the hands of science,
wherewith to search out laws in nature yet unknown.
Already it has suggested many valuable uses. Un-
doubtedly it is the most remarkable invention of this
century.
If time permitted I should talk more in detail regard-
ing the use of the phonograph as a teacher of singing,
elocution, etc., but from the demonstration of phono-
grams one must be satisfied of the truth and of the value
of the phonograph.
I am still in hopes, and notwithstanding the fact that
at present the microphone is very unsatisfactory in its
workings in many respects, to be able to record the
sounds of the heart and respiratory tract both in health
and disease. The value of such record, I need not tell
you, would go a great way toward the practical education
of our medical students in the groundwork of physical
diagnosis.
I have already made several records of pathognomonic
sounds, but my work, owing to the pressure of time and
the responsibilities of a large practice, is still so in-
complete that I hesitate to present it to such an august
body of distinguished medical men.
At the next Congress I may show you the cabinet of
records, which will demonstrate aurally the sounds of
disease of the air- passages and heart just as we hear them
in the hospital wards, and as we recognize them from
the descriptions in otr books, of lessened or intensified
pitch and changed quality.
In my own specialty the phonograph has been of
much service. In all diseases affecting the vocal bands
we are sure to have a change in the character of the
268
MEDICAL RECORD.
[September i, 1894
vocal sounds. These sounds in not a few instances are
pathognomonic, but as one.
Experience and observation have not been extensive
enough, we have as yet no accepted classification, without
which phonographic records would signify little. With
a competent microphone, as I hope and feel it can be
perfected, both the classification and recording of these
sounds will be made so that all of us, even the general
practitioner, will be able to make his diagnosis more
positive.
To my American colleagues, and to those of other coun-
tries who may chance to come to my city, I extend a
cordial invitation to visit my workshop, which unfortu-
nately I could not carry with me, and see the work as it
has progressed up to this time.
I shall be ever ready to demonstrate and show you how
far I have succeeded, and so give you the ocular proof
of what I have laid claim to in this paper.
460 Lf.XINGTON AVENUE.
OBSERVATIONS ON PHYSIOLOGICAL PULMO
NARY ATELECTASIS.
Being Part of a Report of the Committee on Clini-
cal Medicine of The Medical Society of the
State of California.
By ALBERT ABRAMS, A.lVf., M.D., F.R.M.S., Chairman of
the Committer.
SAN FRANCISCO, CAL.
PBOPSSSOK OP PATHOLOGY, COOPER MKOICAL COLLKGt; PRESIDENT OP THE SAN
FRANCISCO MEOICO-CHIRURGICAL SOCIETY J YICS-PRBSIDENT OP THE MEDICAL
SOCIETY OP THE STATE OP CALIFORNIA.
Mr. President and Fellow Members : At a previous
meeting of this Society I presented a paper on " Pul-
monary Atelectasis as a cause of Anaemia'1 (" Transac-
tions of The Medical Society of the State of California,
1892 "). I will succinctly recount the essential facts of
that paper.
There are present over the thorax of apparently normal
individuals constant areas of diminished lung resonance,
varying from dulness to flatness as obtained by percus-
sion. These areas vary in number and situation as far as
the individual case is concerned, but they admit in the
Aggregate of definite localization. The areas of dulness or
atelectatic zones, as I will call them, are no longer demon-
strable by percussion after repeated forced inspirations.
The atelectatic zones are dependent on circumscribed pul-
monary atelectasis, or collapse of limited portions of the
lung. I have referred to this form of atelectasis as physio-
logical, with the object of employing the term for differen-
tiation only. The physiological atelectasis under consid-
eration is an eradicable condition dissociated with anv
demonstrable lesion. When the atelectatic zones are mul ti-
plied or augmented in area, especially in young people,
they are associated with the symptomatic complex of
anaemia, and finally, when the atelectatic zones are dis-
pelled by respiratory gymnastics, the syndrome of anaemia
disappears, while its recrudescence is always associated
with a reappearance of the atelectatic zones.
My observations have been extended since the publi-
cation of my original paper, and the results attained con-
firm my primary conclusions. While it is true, from the
stand-point of the physiologist, that the lungs during life
are in a stretched condition, it is equally true, from the
stand-point of the clinician, that certain portions of the
lung are collapsed and deprived of sufficient air to yield
a dulness, or in some instances a flatness, on percussion.
These areas of dulness vary, as determined by linear per-
cussion, from a twenty- five cent piece to a dollar in size,
or even more.
The atelectatic zones are only permanently absent when
the lungs are emphysematous, and temporarily so after
repeated deep inspirations. I have noted in my investiga-
tions that after forced inspirations are made the atelec-
tatic zones, in adults as well as in children, can be dis-
pelled, reappearing in a few minutes when tranquil
breathing is resumed, and continuing so until an in-
creased demand is again made on the capacity of the
lungs.
The facts just enunciated do not refer to the areas of
lung tissue intermediary to the atelectatic zones, for we
already know from the observations of others, especially
Da Costa,, that when percussion is made over the lungs
by respiratory percussion, as it is called, at the end of
full inspiration, a sound of higher pitch and vesiculo-
tympanitic quality is obtained ; whereas a held expiration
diminishes the resonance.
In the accompanying illustrations (Figs. 1 and 2) I
have projected a composite picture defining the situation
Fig. i.— Showing Atelectatic Zones on the Anterior Surface of the ChesL
of the atelectatic zones, based on examination of over one
hundred apparently healthy individuals, children as weD
as adults.
It may be remarked that the atelectatic zones on the
posterior surface of the chest- wall are more frequent, and
admit of more definite localization, than those on the
anterior surface of the thoracic wall.
The atelectatic zones, as shown in the illustrations, do
not represent the only areas of lung tissue that are nor-
mally incapacitated, for aside from the fact that collapsed
lung remote from the chest-wall will elude percussion,
there are other superficial areas of too limited an extent
to yield a dulness on percussion. The practical conclu-
F:g. 2.— Showing Atelectatic Zones on the Posterior Surface of the ChesL
sions that can be formulated as a result of these observa-
tions may be summarized under the following groupings :
1. The relation that pulmonary atelectasis bears to
anaemia.
2. The mistakes that may accrue from misinterpreta-
tion of the physical signs in the examination of the
chest, and the correction of the conventional errors of
topographical percussion.
3. The relation that pulmonary atelectasis -bears to
tuberculosis.
4. The aid afforded to auscultation by the elimination
of atelectasis.
1. I have already shown in my previous paper that
September i, 1894]
MEDICAL RECORD.
269
anaemia of pulmonary origin exists, and fui thermore,
that this anaemia is associated with extensive areas of
lung dulness. That when this latter is corrected,
amelioration and recovery from the anaemia occur. I
have also referred in my original paper to the fact that
increased respiratory activity is of great therapeutic
value in anaemia from any cause.
2. The mistakes that may accrue from misinterpreta-
tion of the physical signs of atelectatic dulness, from
dulness caused by lung consolidation, are many, and in
consequence of mistakes occurring in my own practice
and in the practice of other physicians, I invariably
adopt the expedient of having the patient practise forced
breathing before making an examination of the chest.
If inflation of the lung cannot be secured with the
patient in the erect posture, I place him in the right or
left lateral posture, according to whether an examination
of the left or right lung is desired.
I have often found that dulness produced by lung
consolidation will frequently disappear, to be supplanted
by resonance after forced deep breathing.
This fact may, to the novitiate in physical diagnosis,
be mistaken for atelectatic dulness. Taken altogether,
percussion of the lungs is an untrustworthy method of
diagnosis unless it is controlled by auscultation. I hold
that topographical percussion, as obtained ordinarily, is
of inconstant value. The limitation of organs by per-
cussion, especially of the heart, will vary from day to
day, and the percussional area of dulness in the same
case, and at the same time, will be variously obtained by
different diagnosticians. The borders of the heart, liver,
and spleen are dependent on the degree of lung inflation,
and must vary according to the activity of respiration.
Topographical percussion must always be based upon
the state of pulmonary inflation, and the results governed
accordingly.
3. The relation that atelectasis bears to pulmonary
tuberculosis is an important one. A properly inflated
lung affords adequate protection against pulmonary tu-
berculosis. A collapsed area of lung affords a nidus for
the specific microbes. The facultative anaerobins thrive
best in an illy-ventilated lung. The foregoing state-
ments are borne out by theory and statistical evidence.
Pulmonary tuberculosis is frequently initiated by the
symptomatic picture of anaemia. This anaemia is un-
questionably of pulmonary origin, and is associated with
demonstrable atelectatic zones.
The atelectatic zones correspond with the destructive
routes followed by incipient pulmonary tuberculosis.
4. The aid afforded auscultation by elimination of
atelectasis is obvious. Auscultation of the lungs should
always be conducted with the patient in different post-
ures, the object being to utilize the actual respiratory
capacity of the lungs, thus eliminating the auscultatory
phenomena of atelectasis and accentuating abnormal
sounds which may be present.
I have recourse to the following manoeuvre for elicit-
ing pleural friction-sounds when absent, and accentuating
them when present, by having the patient lie on the sus-
pected side or region for half a minute or longer, after
having taken a deep inspiration. This position favors
the approximation of the two pleural la>ers.
Now, when the patient adopts the sitting posture and
attempts forced expiration, a friction -sound is heard
which is usually intensified during the subsequent
inspiration.
Unless a deep inspiration is taken before the patient
lies on the suspected side, crepitant rales, concomitants
of atelectasis, will be heard. I consider the foregoing
manoeuvre of more value for diagnosis than any of the
methods usually described for eliciting and differentiating
the same phenomena.
Low Temperature. — Dr. George R. Dean, writing in
the Medical and Surgical Reporter of June 30, 1894, re-
lates a case of cystitis in which the temperature fell on
several occasions to 920 F.
A CASE OF LYMPHADENOMA (HODGKIN'S
DISEASE) ACCOMPANIED BY FEATURES
CHARACTERISTIC OF MYXCEDEMA, AND
OTHERS SUGGESTIVE OF ACROMEGALY.
By W. A. CROSS, M.D.,
JEMCINION, PA.
I desire to put the following case on record on account
of its unusual complications, and the manner of their de-
velopment.
Mrs. H , aged thirty-four, American. A person
of more than ordinary intelligence, of good family his-
tory, and in the enjoyment of exceptionally good health
until the commencement of her last illness. She was a
happy wife and mother. Menstruation appeared at four-
teen years, and was always normally performed. She
gave birth to five children, two boys and three girls, and
had no miscarriages. There was no inherited predispo-
sition to glandular troubles.
In July, 1892, there developed a very troublesome
cough of a spasmodic character ; the paroxysms occurred
both day and night, and greatly interfered with her
sleep and rest. I could not discover any lesion which
would account for its origin and persistency. I made
use of all sorts of means for its relief, with very poor suc-
cess. Antispasmodics made some impression, but the
best results were obtained from the administiation of an
emulsion of cod liver oil; this gave her considerable
relief for a time.
Her good constitution enabled her to resist the evil
effects of these frequent paroxysms, with the attendant
loss of sleep and rest, for a long while. She remained
under my care for one year, and then, as I had failed to
afford her any adequate relief, and had not discovered
the nature of her disease, she proposed putting herself
under the observation of some other physician.
In July, 1893, she consulted Dr. Louis Jurist, of Phila-
delphia. By this time her general health had begun to
fail ; she had a cachectic appearance suggestive of tuber-
culosis, or some malignant disease. I knew Dr. Jurist
to be a careful observer, and tiusted that he might te
more successful than I in getting at the cause of her
trouble, and waited patiently for his judgment of the
case.
I did not see the patient again for a period of six
weeks, and then, while visiting another member of the
family I had the opportunity of observing her carefully.
She still had her cough, had lost much flesh, and was
very anaemic. My attention was called to a swelling on
the right side of the sternum, high up. I believed this to
be connected with her disease in some way, but I did not
imagine its significance at that time.
The next time I saw the patient was October 22, 1893.
By this time her condition was such that she could not
visit Dr. Jurist at his office in the city, and, at his ie-
quest, I took charge of her at her home.
I do not know when the myxoedematous features fust
became apparent, but when I saw her at this time my
attention was attracted to them immediately. Her phy-
sician did not write me fully in regard to the sequence
of development of the various features, but said " Mrs.
H 's case interests me very much, and I am obliged
to you for your willingness to study it with me. Many
things have passed through my mind regarding her con-
dition: tubercle, myxoedtma, acromegaly, and malig-
nant disease have all had fair consideration. I do not
quite understand the bony protrusion on the right of her
sternum. Is the growth in her neck secondary ? Her
wasting would indicate a serious encroachment on her
vitality. Might she not have a mediastinal tumor ? I
would gladly hear from you."
My examination of the patient at this time discovered
the following conditions : She presented many of the
characteristic features of myxoedema. The physiognomy
was dull and mask like, but not to an exaggerated degree ;
the face was not enlarged to the extent that is usual in
these cases ; the skin was dry and of a peculiar yellow-
270
MEDICAL RECORD.
[September 1, 1894
ish white color; both upper and lower eyelids were
swollen, with a puffiness of the tissues below the lower
lids ; the nose was thin, having a pinched appearance ;
the mouth wa* natural, excepting the deep lines on either
side of it ; the pendulous lower lip was absent ; the
tongue was a little thickened ; there was a slight hesi-
tancy in her speech, and articulation was not perfectly
distinct ; the scalp was dry, the hair scanty, dry, and
brittle ; the hair which is usually found on the .forearms
and legs hid disappeared, also that in the axilla and
about the pubes; the forearm* were enlarged and thtck-
e. led, particularly at the wrists, indicating an enlarge-
ment of the bony tissues ; the hands were large and
puffy, with a remarkable clubbing of the finger-tips; the
finger- nails were thickened and curved to an unusual
degree ; the hands and fingers were so swollen that they
were clumsy, and the patient could not make use of
either needle or pen ; the legs and feet showed the same
aba or mil features as were present in the upper extremi-
ties. A pro nine at peculiarity of the foot was the pro-
jection of the calcaneum and a welt of hard tissue along
the outer aspect of the foot.
Tnere was an enlarged gland about the size of a hen's
egg on the left side of the neck, just above the clavicle,
and posterior to the sterno-mastoid muscle. The mind
was clear, memory apparently unimpaired. She con-
versed intelligently, had poor appetite, digestion was not
good, the bowels moved twice daily, the kidneys acted
all right. She would have slept will if it had not been
for the cough ; vision was normal ; had no pain ; felt
weak; heart's action was rapid and impaired; com-
pla'ned of shortness of breath. There was some diffi
cilty ia swallowing. The temperature ranged from 980
F. in the morning to 990 F. in the evening; pulse, 105
in the morning; 120 in the evening. Complained of
not feeling warm; there was no perspiration. Passed
forty-six ounces of urine in twenty-four hours, of low
specific gravity, containing no albumin, no casts, no
sugar, phosphates in abundance, urates below normal;
reaction acid ; menstruation normal.
The patient, although weak, was up and about, over-
seeing her household affairs ; locomotion was impaired,
and she tired easily, but she still possessed a considera-
ble amount of will power.
A pondered extract of thyroid gland was administered
three times per day for about four weeks, with appar-
ently no improvement ; the raw glands finely minced
and taken with her other food, were tried for a while, but
these were so distasteful to her that their use was soon
discontinued.
From the lart week in November to the middle of De-
cember no active treatment was employed ; during this
period she grew rapidly worse, the myxedematous feat-
ures became more pronounced, the cough was persist-
ent, there was no desire for food, and there was a scanty
secretion of urine ; for a number of days she did not pass
more than one pint in twenty-four hours. The lower
limbs became ©edematous, she was dull looking and act-
ing, slept the most of her time day and night. The
sleep was a restless one, disturbed not only by the cough,
but by ugly dreams which really amounted to hallucina-
tions. She could not lie down, neither could she lean
back in her chair, owing to the dyspnoea occasioned by
s ich positions. The only way in which she could get
rest wa3 by sitting in her chair, leaning forward with her
h»ad resting upon a pillow placed upon a table in front
of her. In such a posture she sat and slept the most of
her time. Lymphoid tumors developed on the right
side of the neck, and in the right axilla. Menstruation
was missed for the first time in November, and did not
occur again.
Dr. J. C. Wilson, of Philadelphia, saw the patient, in
consultation, November 22, 1893. His diagnosis was
lymphadenoma accompanied by features suggestive of
both myxoedema and acromegaly. He advised the use
of the thyroid extract, and also Fowler's solution to the
point of toleration.
A thyroid extract prepared by Dr. George W. Crary,
of New York City, was obtained. As an initial dose we
gave two drops three times per day, this was gradually
increased until we reached eight drops t.Ld. ; at this
point the dyspnoea and disturbed heart's action became
so great that it was necessary to discontinue its use for
a couple of days. We resumed with a two-drop dose, and
added a drop to the dose each day, until fifteen drops
t i.d. were taken, without any inconvenience whatever..
As we advanced the second time, her condition im-
proved rapidly ; her paroxysms of coughing became less
frequent and distressing. She did not sleep so much
through the day, and her rest was less disturbed at night.
She could lean back in her chair, and could lie down in
bed. The appetite improved. She could swallow solids
without difficulty, and any reasonable article of food
could be taken without discomfort
I must not neglect to state that the arsenic occasioned
so much gastric distress that we were obliged to discon-
tinue its use ; the appetite did not improve until after
the arsenic was dropped.
The quantity of urine secreted steadily increased until
it reached seventy-two ounces daily; it was analyzed
frequently, the urates remained a little below normal in
quantity, phosphates in abundance, no albumin, no casts,
no sugar, specific gravity 1.020 to 1.025.
After the thyroid extract had been used for about three
weeks the swellings in the various parts of the body
showed signs of decrease. The face was the first to lose
its puffiness. The enlargement of the right forearm,
wrist, and hand became reduced in size. One week later
the same process took place in the left upper extremity,
next followed the right, and then the left lower ex-
tremity.
As the oedema decreased the skin lost its glazed ap-
pearance and commenced scaling, the new skin was soft,
and was often moist with perspiration ; a new hairy
growth appeared upon the arms, legs, and head. The
clubbed condition of the fingers was less apparent, and
she was able to use her needle once more.
That which interested and astonished me most was
the attempt to correct the exaggerated curve of the fin-
ger-nails ; they rapidly changed their shape, and two of
them on the right hand became almost normal in ap-
pearance.
Tne oedema of the legs and feet became so much re-
duced that the patient was able once more to wear her
shoes, to walk about her room, then to go up and down
stairs, to walk out upon the piazza, and finally to take a
sleigh- ride.
Tne glandular trouble did not improve, but went from
bad to worse. About the middle of February a retro-
grade change commenced, the cough became more an-
noying, the heart's action more feeble, the appetite
failed. Swallowing became a distressing act, soft food
could be gotten down fairly well, but the attempt to
swallow liquids occasioned a paroxysm of coughing and
strangling which was painful to witness ; the taking of a
meal was dreaded, and consumed a great deal of time.
Liquids were taken through a tube, and by certain ma-
noeuvring were finally swallowed. A stomach tube was
passed without much difficulty, but the patient preferred
not to use it, and persisted in her own way of getting
food and drink down her oesophagus.
The weakened action of the heart and the accompany-
ing dyspnoea necessitated the withdrawal of the thyroid
extract for a few days. As no relief was experienced
from its discontinuance we again resumed its administra-
tion, but it had no further control— the oedema, dysp-
noea, dysphagia, drowsiness, hallucinations, and bodily
weakness increased steadily, and she died March 15,
1894.
Dr. Jurist continued to see the case at intervals durirg
her illness, and Dr. Wharton Sinkler, of Philadelphia,
saw her in consultation a few days before her death.
Dr. Boyer, of Philadelphia, made an examination ot
the blood ; the result was very interesting. There were
September i, 1894]
MEDICAL RECORD.
271
five million eight hundred thousand red corpuscles to the
cubic millimetre, and forty eight thousand white corpus-
cles to the cubic millimetre, or a proportion of about
one white to one hundred and twenty red. The per-
centage of haemoglobin was about sixty.
It is greatly to be regretted that a post mortem could
not be had ; it would have been exceedingly interesting,
and would most likely have thrown some light on the
pathology of the disease. It would have indicated the
condition of the spleen and internal lymphatics, and would
have determined whether there was present a mediastinal
tumor, and would also have shown the condition of the
bronchial glands.
In summing up the case, we notice first the persistent
spasmodic cough. This cough was evidently dependent
upon either the pressure of a mediastinal tumor or en-
larged bronchial glands, perhaps both. The probability
of the existence of a mediastinal growth early in the
trouble is enhanced by the development of the embar-
rassed breathing and difficult deglutition among the first
features in the disease.
The cough had existed for very nearly a year before
the patient showed signs of cachexia. During this pe-
riod she was to all outward appearances well. She at-
tended to her household and social duties, was cheerful,
had a good appetite the most of the time, the bowels
moved regularly, and she menstruated normally.
We have next the increasing signs of cachexia, which
for a long time could not be accounted for. Then came
the tumor on the right side of the sternum, followed soon
by the enlarged gland on the left side of the neck, and
the apparent disappearance of the thyroid gland.
With these changes came the development of the char-
acteristic features of myxoedema — the multiplication of
the lymphoid growths in different parts of the body.
We have the remarkable clubbing of the finger-tips, the
curve of the finger- and toe-nails, the apparent projection
of the calcaneum, and the welt along the outer edge of
the feet, suggestive of acromegaly.
The effect of the thyroid extract upon the myxede-
matous features was for a time most remarkable, followed
in a short while by its failure of control, with increasing
weakness, stupidity, hallucinations, dyspnoea, cardiac
palpitation, suffocation, and death.
Drs. J. C. Wilson and Wharton Sinkler concur in the
opinion that the case was originally one of Hodgkin's
disease, and that the myxoedema occurred symptomatic
cally, as a result of involvement of the thyroid gland due
to the lymphadenoma.
I am inclined to the belief that there existed a medi
astinal tumor, as was insisted on by Dr. Jurist, and that
this growth was directly or indirectly the cause of the
cough and of the dyspnoea. Why the paroxysms of
coughing should have become less frequent and severe,
and the ability to swallow should have improved under
the use of the extract, I am unable to understand.
The case, from any stand-point, was an exceedingly in-
teresting one, and worthy of putting on record.
Seventeen-Year Locusts. — The newspapers have re-
ported several cases of death following bites from these
insects.
A Haw Location for the Soul— The champion title
of the year must surely be " A New Systematic Treat-
ment of All Diseased Conditions, from Strict Elec-
trical Polarization, Adapted Particularly for Examina-
tions and the Treatment of Disease. Embracing Some
Entirely New Principles Concerning Portions of Oar
Organism. Also, An Entirely New Motive Power
Regarding the Cleansing and Circulation of the Blood
by Strict Electrical Polarization, Locating Exactly the
Ssat or Throne of that Eternal, Immortal, and Ever-Con-
trolling Principle Denominated the Soul or Mind, To-
gether with Very Many Other New and Important
Facts and Principles. By A. H. Stevens, M.D , E.D."
Dr. Stevens locates the Soul in the corpus callosum.
Where Our Drugs Come From. — " Principal Exports
to the United States'1 is the title of a pamphlet lately
issued by the State Department, which is of especial in-
terest from the fact that it gives the value of our imports,
and the names of the products, and the countries from
which they are derived. The report is compiled from
the reports of the various consuls of this country, and
the figures bearing upon the extent of the drug and chemi-
cal imports are interesting both on account of the mag-
nitude of the commercial interests involved in the trade,
and the fact that they show that the most remote por-
tions of the earth are called upon to supply our demand
for drugs and medicines. The figures given, with a few
exceptions, cover the calendar year 1892, and the report
is arranged to show the value of goods as " declared for
export" in the various consular districts. From the
Buda Pesth and Vienna districts of Austria Hungary we
receive drugs and chemicals amounting to £122,758. From
Trieste insect powder and flowers amounting to £71,884.
From France our imports included olive oil, drugs,
chemicals, argols, dyestuffs, toilet articles, and perfumery,
and amounted to £2,564,000. Germany furnished us
with drugs, chemicals, dyes, colors, and essential oils to
the amount of £9,193,849. Greece sent us £24,108 worth
of sponges. From Italy we received olive oil, brimstone,
canary seed, crude glycerine, soap, argols, onis root,
almonds, licorice, sumac, and essential oils, valued at
£4909,704. The Netherlands sent us cacao butter,
drugs, and dyestufTs amounting to £366,470. Corkwood
worth £1,069,057, and argols worth £131,805, came from
Portugal. The Batoum district, Russia, furnished us
licorice root valued at £624,363. Spain furnished us
cream of tartar, glycerine, licorice, saffron, corkwood,
olive oil, and canary seed worth £1,505,505. Sweden
and Norway sent us £82,055 worth of cod-liver oil and
oxalic acid worth £18,090. Little Switzerland sent us
anilines, dyestufTs, and chemicals worth £439,518, and
enough argols and beef extract to make the total £475 r
760. We received from Turkey, in Europe, £403,013 ;
attar of roses, £141,929; gum tragacanth, £55,620.
From the United Kingdom, which seems to be a sort of
clearing-house for the world, we received drugs and
chemicals amounting to £12,570,180. British North
America sent us £22,003 worth of senega root and £12,-
664 worth of sulphur. Sarsapariila worth £67,577 ; va-
nilla, £710,580 ; fustic, £130,913 ; gum chicle, £475>665>
and silver dollars, which are apparently a drug on the
market, to the amount of £454.03* > came to us from
Mexico. China furnished cassia, £164,497; gall nuts,
£5,730, and rhubarb, £16,454. Dutch India, gum damar, .
£64.729 ; gum copal, £30,452 ; cassia, £26,593. Japan,
sulphur, £226,025 ; menthol, £23 391 ; camphor, £522,.
152. Philippine Islands, indigo, £16,369 ; ylang ylang
oil, £10,002. Turkey, in Asia, licorice root, £1,023,-
710; opium, £451,431. New Zealand, kauri gum, £1,-
997,607. Tahiti (Society Is'ands), vanilla, £36,698.
Honduras, sarsapariila, £30,951 ; chicle, £4.604. Brazil,
copaiba, £28,958; guarana, £8,078; castor beans, £22,-
774. Chili, nitrate of soda, £2,880,643; iodine, £57?,-
313. Peru, coca leaves and elixir, £5,329. British
•West Indies, sponges, £236,555 ; dyewoods, £186,842 ;
ginger, £40,734; pimento, £126,400. Dutch West
Indies (Curasao), aloes, £3,047. Guadeloupe, va-
nilla, £c,66o. San Domingo, dyewoofs, £38,307.
Porto Rico, bay rum and oil, £3,494- Canary Islands,
cochineal, £17,382; almonds, £3,877. British Africa,
argols, £10,088; palm oil, £1,892. Egypt, senna,
£36,627. Algiers, corkwood, £22,159. Morocco,
canary, cumin, and coriander seeds, £4>735- Zanzibar,
cloves, £289,688; clove stems, £4.058; gum copal,
£51,836. British Asia, Aden, civet, £4,898. Calcutta,
drugs, £4,272,076 ; saltpetre, £518,845. Ceylon, cocoa-
nut oil, £937,331; cinchona, £73»l85> essential oils,
£73,015. Hong Kong, opium, prepared, £543»°9I y
cassia, £79,170; medicines, £51,418. Singapore, gam-
bier, £733,855 ; gum copal, £119,493 —Pharmaceutical
Era.
2/2
MEDICAL RECORD.
[September if 1894
Medical Record:
A Weekly Journal of Medicine and Surgery.
GEORGE F. SHRADY, A.M., M.D., Editor.
Publishers
WM. WOOD & CO., 43, 45, & 47 East Tenth Street
New York, September 1, 1894.
THE CONFIDENTIAL RELATIONS OF THE
PHYSICIAN.
The recent decision of Judge Cole, of the Supreme
Court of the District of Columbia, holding that physi-
cians and lawyers are not exempted from giving testi-
mony when called upon in court, on the ground that
such information was professionally confidential, will
strike everyone who learns of it with becoming surprise.
The ruling, wise as it may appear to the learned judge,
will be viewed by the community at large in a widely
different light. Were it not that this opinion has been
deliberately rendered in a high court of justice by one of
its officers, it might be looked upon as an attempt to
create a cheap sensation, or a foolish bid for personal
notoriety. Fortunately, however, its very absurdity is
its death-blow. Physicians have heretofore gone to
prison rather than abuse their patients' confidences, and
they will do so again when opportunities force them to
such extremities, in spite of judges' edicts or juries1 find-
ings. The opinion of the learned judge is contrary to
that of all wise and good men since civilization began
or social relations were in any way respected. It has
been the bulwark of the Hippocratic oath, the funda-
mental principle of legal pleading, and the corner-stone
of the Christian religion, to respect and hold sacred the
privileged communications of such as come to their con-
fessors for sympathy, forgiveness, and help. The very
stability of society, the preservation of social relations,
the maintenance of honorable intercourse, the most
sacred obligations existing between members of the hu-
man family, rest upon the uncompromising integrity of
those principles which even in heathen ages have made
us trust one another. And yet for the sake of obtaining
some evidence in a divorce suit an expounder of the law
makes bold to insult the higher instincts of our humanity
by aiming a blow at the honor of every man who hears a
confession. If we mistake not, the learned judge will
stand alone in his opinion, which is in itself a distinc-
tion sufficiently gratifying to him, perhaps, as opposed
to that of the rest of mankind, and is worthy of remark
on that account. It is difficult to imagine the great
harm that would ensue if the professions of law and medi-
cine, forgettiog all their time-honored customs, their
treasured traditions, and their sacred rights, should be
compelled to abide by the absurd, illogical, and damag-
ing decision of our learned interpreter of legal obliga-
tions. Let any practitioner of medicine think for him-
self of the disastrous consequences which would result
from the disclosure in court of those family secrets which
he has been forced to know, even within the circle of
his own'practice. And how much more for the profes-
sion at large !
Fortunately, however, the remarkable ruling will not
affect any medical or legal gentleman outside the juris-
diction of the court in question, and will doubtless be
very properly overruled in the next test- case. In any
event, with the medical profession the opinion will al-
ways be, as it has always been, that no physician or sur-
geon must, directly or indirectly, under any circum-
stances or conditions, at no time or place, abuse the
confidence of anyone who has trusted to his personal
honor in the dire extremities of sickness and suffering.
The man who would do otherwise, judge or no judge,
would disgrace his calling, would prostitute the highest
obligation of his profession, and outrage the most sacred
trust that could be imposed.
THE DANGER OF THE COMMUNION CUP.
We are pleased to know that the frequent discussion in
these columns as to the danger of the communion cup in
propagating disease is bearing fruit by transference to
the columns of the daily press. The public is thus be-
ing educated to the necessities of the situation, and
there is a reasonable hope that the claims of preventive
medicine will be vindicated even against those whose
faith in old forms have failed to listen to reason before.
The following telling experience, detailed by Dr. Al-
bert S. Ashmead in a recent letter to the Sun, points
its own moral :
" The last time I knelt at the communion altar of the
Episcopal Church there knelt at one side of me a pa-
tient whom I knew, as I was treating him at the time,
to be a syphilitic; his mouth had mucous patches,
which make the disease especially contagious. This
person took the cup before it came to me. Of course,
•I let the cup pass.
" At another time the person next to me, but follow-
ing me in the use of the cup, was also a patient of mine,
in an advanced stage of tuberculosis. The mouth of
this person was in a condition dangerous to his neighbor.
" Of course, no man who is not a complete survival of
the Middle Ages can assert that, under these circum-
stances, a man (if he knew) should apply his lips to a
probably dangerously contaminated cup, trusting in
the protection of the Lord, who has allowed hundreds,
a hundred times, to perish in burning or earth shaken
churches, while they were in the very act of worshipping
Him.M
Verily a little sermon in itself, and from a churchman
and a physician, who views both sides reverently for
Christianity's sake, and candidly for the vindication of
truth.
The Sun, with its usual vigor of diction and direct-
ness of aim, thus valiantly takes sides with science and
fact as against tradition and prejudice :
" When a physician writes to a newspaper, as one
wrote to the Sun the other day, that he refrained from
drinking from the chalice at a recent celebration of the
Eucharist in the Episcopal Church, because before him
two patients of his had sipped from the cup, the one
afflicted with an odious and the other with a destructive
September i, 1894]
MEDICAL RECORD.
273
communicable disease, reasonable fears of the danger of
the hallowed practice are excited even among the most
devout of communicants ; and such fears, thus justified,
are quickly and widely diffused. Is it unlikely, then, is
it not probable, that this alarm will become so extensive
and so great that all churches whose doctrines require
that both elements shall be administered to the whole
body of communicants will be compelled to imitate the
Rochester example, or adopt some other method devised
for the same purpose, in order to save the communion
in both kinds from perilous disease ? "
The fact of danger is indisputable, and the conclusion
for safety is irresistible. We are confident that it is only
a question of time when, as the Sun says, all churches
will be compelled to imitate the Rochester example.
Contagion is no respecter of cups, men, or place, when
the essential conditions of its propagation are present.
The Christian will never yield up the cup ; why should
he object to its being clean and free from danger?
Why one contaminated chalice against many safe ones ?
OPHTHALMIC HEMICRANIA.
Under this title in // Raccoglitore medico, January 10,
1894, Dr. Palombi gives an interesting account of hered-
itary ophthalmic hemicraaia, together with a considera-
tion of the subject at large. The patient whose case is
cited belonged to a neuropathic family, his particular
trouble originating with the great grandfather and being
regularly transmitted for three generations, only one
person in the entire family escaping. From his earliest
recollection, the patient had suffered from migraine;
bat like his own father and grandfather, the intensity of
the trouble reached its maximum between the ages of
fifteen and thirty. The author very justly criticises the
term ophthalmic migraine, or hemicrania, to describe an
idiopathic affection in which ocular phenomena are con-
tingents, like the agraphia, aphasia, paresis, etc., that
sometimes accompany it. The chief phenomenon is the
onesided headache. The work of Galezowski and of
Charcot is passed in brief review, the history of the
particular case in this migrainous family seeming to
challenge a little the views held by these two ob-
servers: viz., that hemicrania is allied to epilepsy, and
is an affection with an anatomical substratum of chronic
progressive basilar meningitis, with secondary neuritis
resulting from compression. Errors have been made in
regard to migraine by confounding it with the various
pathological states with which it may be associated. It
is a protopathic affection that may develop in persons
otherwise healthy. In the case cited there had never
been any premonitory symptoms.
The author notes two periods in hemicrania : the pe-
riod of invasion, and the period during which appear,
but not always, the following symptoms, enumerated in
their order of frequency: lateral or horizontal hemi-
anopsia, scintillating scotomata, migrainous amaurosis,
amblyopia, tingling and paretic aching, aphasia, and
agraphia. In the same proportion that ocular phenom-
ena disappear, just as a curtain on the stage is drawn
apart laterally, tingling and heaviness begin in the fin-
gers, the forearm, the arm, and one-half of the face.
These last-named symptoms are usually confined to one
upper extremity, but the hemianopsia and scotomata are
ordinarily sjmmetrical. When the tingling begins, the
various painful symptoms disappear, and then, if present
at all, different forms of aphasia come on, of which the
rarest are agraphia and word-blindness. The symptoms
of the first period succeed each other singly. This is
their special characteristic. After a few moments of
apathetic repose, the second period is ushered in by its
unique symptom, headache. This pain has a special
quality of its own, and can never be confounded by the
patient with any other. It is indescribable. Its inten-
sity is in proportion to those of the other symptoms and
to the duration of the attack. Cerebral impotence is
absolute while it lasts. The periodicity varies. Palombi
admits but one cause for hemicrania : heredity. Excit-
ing causes are numerous, of which the principal are at-
mospheric pressure, cold, constipation, and glaring light.
Often the exciting cause is apparently wanting, and the
attacks appear spontaneously.
Hemicrania, or migraine, is a vasomotor neurosis.
Hypothetically, it is possible to admit a capillary apo-
plexy as the anatomical basis of the disorder. As pre-
ventive measures, the Italian observer finds quinine and
bromides of value ; and advises antifebrin during the
attacks. To sum up : Hemicrania is a distinct neurosis,
of which the pathogenesis and anatomical seat are un-
known ; it has characteristic clinical features that estab-
lish its identity, and it is analogous to hysteria and
epilepsy, though it presents no traits in common with
them other than heredity.
Concerning remedies, Hirt speaks of citrate of caffeine,
two grains three times a day, for those cases in which the
conditions of the circulation (increased tension, vaso-
dilatation) give no suggestion. Efforts must be directed
toward building up the general health by cold-water
treatment, general faradization according to Beard and
Rockwell's method, franklinization with the Holtz
machine, and systematic gymnastic exercise at home.
Sometimes lasting advantage has been obtained by
change of climate, travelling, and by a stay at the moun-
tains or seaside. Gray recommends twenty or thirty
grains of bromide during the attack, and cannabis indi-
ca at other times. For anaemia, peptonate of iron in
three grain doses, three times daily, is to be given when
the condition is not specially marked; when pro-
nounced general physical depression exists, quinine is to
be added. In some cases of anaemia in which there are
hepatic symptoms a sixtieth to a thirty second of a grain
of bichloride three times a day should be added to the
iron, or the iron and quinine. Dana considers bromide
of potassium, nitro glycerin, cannabis indica, and arsenic
the best remedies for continued internal use. Cannabis
indica, either with or without arsenic, is the most trust-
worthy, and the bromides the least to be depended upon.
To relieve the attacks, salicylate of soda, caffeine, anti-
pyrine, powdered guarana, menthol, muriate of ammonia,
and bromide of potassium are reliable remedies for a
time, but lose their effect as do almost all other drugs.
Rest is the most important element in the management
of an attack, rest and perfect seclusion from the world
and affairs.
Naming Streets after Hedical Ken.— The Parisian
Municipal Council has named three streets in that city
after Charcot, Tr61at, and Trousseau.
274
MEDICAL RECORD.
[September i, 1894
llcxus of tfoe IS&eefe.
French Association for the Advancement of Science.
— The twenty-third annual meeting of this association was
held at Caen during the week commencing August 9th,
under the presidency of Professor Mascait. Among the
papers read in the Section of Natural and Medical
Sciences was a report by Dr. Le Genole " On the Dangers
of Athletic Sports in the Case of Children. ' ' Dr. F. Reg-
nault contributed a paper " On the Causes of the Atti-
tude Assumed by Women during Parturition ; ' ' Dr. Cartaz
one " On a Special Variety of Stenosis of the (Esoph-
agus; " Dr. Galliard one "On the Treatment of Cer-
tain Non-syphilitic Headaches by Calomel ; " and Dr.
Raphael Dubois one " On the Mechanism of Sleep.11
Professor Billroth' s Widow has been granted a yearly
pension of 2,000 florins. The law allows a pension of
600 florins only to the widows of professors, and the
grant of a larger sum is a mark of especial favor from the
Emperor of Austria.
The British Hedical Association will hold its next an-
nual meeting in London. Dr. J. Russell Reynolds is
the President-elect, and Sir William Priestly will be
Chairman of the Reception Committee. The last meet-
ing of the Association in London was in 1873, under the
presidency of Sir William Fergusson.
The Tailors of Gratz not long since presented a peti-
tion to the Rector Magnificus of the University, praying
that in future no student receive his doctorate diploma
until he has furnished proof that he owes his tailor noth-
ing.
The Shah of Persia, who sent for Dr. Galezowski, of
Paris, to examine his eyes, has been found to have no or-
ganic disease. His general health was poor' and the
ocular trouble was purely functional.
The German Public Health Association will hold its
nineteenth annual meeting in Magdeburg, on September
19-22, 1894. The managers of the Association have
been subjected to some adverse criticism for calling a
meeting so soon after the International Congress of Hy-
giene and Demography in Buda Pesth, especially as many
of the subjects to be discussed are the same as those to
come before the congress.
Dr. Daniel Cornelius Danielssen died recently at
Bergen, Norway, at the age of seventy-nine years. He
was well known as an authority on leprosy, to the study
of which disease he had devoted his entire life. The
wotk which gained for him his reputation was written
conjointly with W. Boeck, and contained the result of
an investigation undertaken at the instance of the Nor-
wegian Government. It was published in 1847. It was
those observers who established the identity of leprosy, as
seen in Norway, with elephantiasis Graecorum. Dr. Dan-
ielssen was born in Christiania, and at the time of his death
was physician in -chief to the Leper Hospital in Bergen.
Dr. Philip Lonsdale died in Cos Cob, Conn., on
August 2 1st, at the age of seventy- seven years. Dr. Lons •
dale entered the United States Navy about fifty years ago,
and served as surgeon on Admiral Farragut's flagship
Hartford, during the civil war. He was medical director
in the navy at the time of his retirement, which took place
several years ago.
The American Association for the Advancement of
Science will hold its next annual meeting in San Fran-
cisco. The officers for the coming year are : President,
E. W. Morley, of Cleveland, O.; Secretary, F. W. Put-
nam, of Cambridge, Mass.; General Secretary > James
Lewis Howe, of Louisville, Ky ; Secretary of the Coun
cil, Charles R. Barnes, of Morris an, Wis. The vice-
presidents are the chairmen of the various sections.
Typhoid Fever in Hontclair. — It has been ascertained
that the cause of the recent epidemic of typhoid fever in
Montclair, N. J., was due to contaminated wells. Four
wells, the water of which was examined and found to con-
tain typhoid bacilli, have been ordered to be closed.
The wells are all on Bloomfield Avenue, in the most
thickly populated part of the town, and the pumps are
of easy access to the public.
The Anatomical Congress will hold its next meeting
at Basel, Switzerland, on April, 17, 18, and 19, 1895.
The Bottling of Mineral Waters in France. — The
question of the artificial aeration of natural mineral
waters was recently up for discussion before the Paris
Academy of Medicine. The methods of bottling in use
at certain springs were condemned, and the Government
was urged to adopt the following precautionary regula-
tions: 1. The sale of mineral waters which have been
decanted, or artificially rendered gaseous, shall be pro-
hibited. 2. Every application to the ministry for author-
ization must be accompanied by the certificate of a com-
petent official that the water has not thus been already
manipulated, and by the written promise of the propri-
etor not to resort to these processes. 3. Reservoirs must
be hermetically closed, and should be emptied at least
every twenty-four hours. They are to be so placed that
the spring flows direct into the reservoir. 4. Bottles
must be thoroughly sterilized before being filled, and all
causes of pollution during bottling are to be most care-
fully avoided.
The Prize of the Accademia dei Lincei. — The royal
prize of one thouiand lire has been divided equally be-
tween Professors Tizzoni and Luciani for meritorious
work in the fields of pathology and experimental physi-
ology.
The Origin of Typhoid Fever. — Dr. Kenwood read a
paper before the Section on Public Health at the Bristol
meeting of the British Medical Association, in which
he advanced the opinion that typhoid fever might be
developed from simple diarrhoea, the specific bacillus
springing by a process of evolution from the bacterium
coli commune. He believed that dogs might be carriers
of the disease, and cited four cases in support of this
view. In one case an examination of the stools passed
by a dog, prior and subsequent to the appearance of ty-
phoid fever in a household in which there was no other
discoverable cause, revealed the presence of typhoid
germs.
Science Ignored. — " Whatever water the water- works
furnishes has to be taken as it is, and we must trust to
God for the rest,11 is a pious sentiment attributed to the
Director of the Department of Public Works of Pitts-
burgh, who is also quoted as saying : "I don't put much
trust in scientists anyway. A theory is nowhere besides
practice anyway." The faith, to say nothing of the
grammar, of this worthy director must be of a very high
September i, 1894]
MEDICAL RECORD.
275
order, such as to move microbes, if not mountains ; for a
more efficient method of pouring the contagia of ty-
phoid and other water-borne diseases down the throats
of the Pittsburghers than that afforded by the city water-
works could hardly be imagined. This is explained
very clearly by a diagram published in the August issue
of the Pittsburgh Medical Review, The water of the
Alleghany River, polluted by sewage from the Work-
house and the Alleghany City Poor Farm, and by the
surface drainage of the village of Hoboken, is deflected
by means of a dam directly into the intake- pipe of the
Pittsburgh water-works. Comment is needless.
The Mississippi Valley Hedical Association will hold
its twentieth annual meeting in Hot Springs, Ark., on
November 20-23, 1894. The President of the Asso-
ciation is Dr. Xenophon C. Scott, of Cleveland, and the
Secretary, Dr. Frederick C. Woodburn, of Indianapolis.
Dr. Bernhard OrSnhut, of this city, was lost at sea
from the steamship Bothnia, which arrived last Sunday
in Boston from Liverpool. It is not known whether he
jamped or accidentally fell overboard. He was a gradu-
ate of the College of Physicians and Surgeons, but re-
tired from practice four years ago to devote himself to
the real estate business. He was forty- eight years of age.
The Antitoxin Treatment of Diphtheria.— The Board
of Health of this city proposes to ask for an appropria-
tion from the Board of Estimate and Apportionment to
enable it to manufacture diphtheria antitoxin in large
quantities. Dr. Biggs, the bacteriologist of the depart-
ment, has recently returned from Berlin, *here he went
to study the method of manufacture and the results ob-
tained by the use of this remedy. His report is very
strongly in favor of the new method, and it is upon the
strength of this report that the Board has determined to
undertake the production of antitoxin at a cost suffi-
ciently low to bring it within the means of poor people.
A Conflict between State and National Health Au-
thorities.— The Surgeon-General of the Marine Hospital
Service ordered that all vessels arriving in New Orleans
from Central and South American ports during August
and September be detained five days after inspection in-
stead of three days, as has been the rule hitherto. The
Louisiana Board of Health regarded the execution of
this rule as an unnecessary obstruction to commerce, and
an appeal was made to the Secretary of the Treasury to
have the order rescinded. The Secretary, however, has
refused to interfere.
The Cholera is believed to be decreasing in Europe.
No new districts have been invaded during the past
week, and the number of new cjses in already infected
regions is slowly diminishing. It is hoped that, with
the advent of cooler weather, the danger of any further
spread of the disease will be averted.
Dr. Joseph Bancroft, one of the leading physicians of
Brisbane, Queensland, died in that city a few weeks ago
at the age of fifty- eight. He was born in Manchester,
but had practised in Brisbane for the past thirty years.
Opposition to a Health Officer.— A petition is in cir-
culation in Brooklyn praying for the removal of the
Health Commissioner of that city. The opposition to
him appears to have been excited by the firm stand which
he took relative to quarantine regulations and vaccina-
tion during the small-pox alarm last winter and spring.
1 1 Dr. Oliver Wendell Holmes passed his eighty-fifth
birthday on Wednesday of this week at his summer home
at Beverley Farms, Mass. He is in excellent health,
walks a mile every pleasant morning, and takes a long
drive every afternoon. In an interview in the Boston
Advertiser the poet said, in reply to the question
whether he was writing an autobiography : " I am in the
habit of dictating many of my recollections, some of my
thoughts and opinions to my secretary, who has in this
way accumulated a considerable mass of notes. Many
of these will be interesting to my family and intimates,
some of them, perhaps, to a wider public if I should see
fit to make use of them, or leave them to be made use of
by others. It is the one thing a person long past the
active period of life can do with ease and pleasure ; and
in the midst of much that might as well, perhaps, perish
with the writer, will, not improbably, be found memo-
randa deserving of permanent record. " Concerning his
age he said, that the twelfth septennial period had always
seemed to him .as one of the natural boundaries of life.
One who has lived to complete his eighty fifth year has
had his full share, even of an old man's allowance.
Whatever is granted over that is a prodigal indulgence
on the part of nature.
K. Paquelin's name is familiar to medical mankind in
connection with his thermo-cautery ; he is, perhaps, less
known as the possessor of a mental heat-producing ap-
paratus which manifests its working by an occasional out-
pouring of verse, glowing, as might be expected, with
" words that burn." The French journals have recently
published a poetic -effusion of his in which the origin of
percussion is told in classic style as an accidental discov-
ery (Have not most great discoveries in medicine been
more or less accidental ?) of Bacchus. When Semele
was dying, with the future god of wine still in her womb,
Vulcan performed Caesarean section, and delivered the
child, whom he incontinently inserted into his father's
thigh. Here the lusty youngster kicked about so vigor-
ously that he gave his parent sciatica. On escaping
from his prison he was naturally thirsty, and he soon be-
gan to suffer from alcoholic tremor. When sitting on
his favorite seat, a wine-cask, he was constantly drum-
ming on it with his fingers, and hammering it with his
restless feet. The difference of resonance attracted his
attention, and he soon learnt
du son dit a^rique
A discerner lc sens de celui dit hydrique ;
II sut en mcme temps tracer sur son tonneau
Exactement la ligne cm siegeait le niveau.
Man, we gather, soon learnt by Bacchus's example .to
diagnose the internal condition of a wine- cask, and Hip-
pocrates by and by bettered the instruction by deter-
mining the limits of the spleen by percussion. Is it too
much to hope that M. Paquelin's centre of poetic ther-
raogenesis may hold out till he has found a divine origin
for auscultation, inspection of the tongue, and the other
esoteric mysteries of the medical art ? — British Medical
Journal,
University Befonns in Italy. — The Italian Govern-
ment proposes to suppress twenty- three universities in the
peninsula and to convert them into preparatory schools,
creating in place of them large and thoroughly well ap-
pointed state universities in Rome, Naples, and two or
three other of the larger cities.
276
MEDICAL RECORD.
[September if 1894
%txitws and ^otitis of §0joks*
An American Text-Book of the Diseases of Chil-
dren. Including Special Chapters on Essential Sur-
gical Subjects : Diseases of the Eye, Ear, Nose, and
Throat ; Diseases of the Skin ; on the Diet, Hygiene,
and General Management of Children. By American
Teachers. Edited by Louis Starr, M.D. Physician
to the Children's Hospital and Consulting Pediatrist
to the Maternity Hospital, Philadelphia. Assisted by
Thompson S. Westcott, M.D., Attending Physician to
the Dispensary for Diseases of Children, Hospital of
the University of Pennsylvania, Philadelphia. W. B.
Saunders. 1894.
This is a comprehensive treatise on a highly important
branch of practical medicine. The treatment of the va-
rious subjects by the sixty-three contributors is very un-
even, four minor topics being unduly expanded at the
expense of more important subjects. Nevertheless the
work will be found useful as one of reference for all those
interested in pediatrics.
America may well be proud of her recent contribu-
tions to the better knowledge of diseases of children,
and the work before us fittingly attests the growing sig-
nificance attached to this branch of general medicine.
The illustrations are in the main good, and will be found
especially helpful by those who have not made a special
study of paedology. The colored plates are, however,
exceptionally poor and misleading.
Dermatologische Zeitschrift. Herausgegeben von
Dr. O. Lassar; Bd. I., Heft L Berlin: Verlag von
S. Karger. 1894.
The first number of this new and promising skin journal,
contains contributions from the editor, Dr. Lassar, and
such other well-known men as Saalfeld, Kromayer,
Joseph, Unna, etc. The prospectus for succeeding num-
bers is so rich in original articles that this department
will prove of much interest to dermatologist?.
A number of fairly good illustrations are bound in at
the end of the volume, making over 120 pages.
Zur Behandlung der Lungentuberculose mittels
Koch'scher Injectionen. Von Dr. E. Thorner,
Sanitatsrath in Berlin. Berlin: S. Karger. 1894.
This is a brief history and critical study of tuberculin as
employed in the treatment of pulmonary tuberculosis.
The author regards this substance as a valuable remedy,
capable of curing the disease in its early stages, and of
bringing about, very marked improvement in more ad-
vanced cases. " It is," he says, " the most important
remedy we have for the treatment of tuberculosis, and it
is the duty of every physician, even if not to employ the
remedy himself, at least to study impartially the results
of its administration."
Biography of Eminent American Physicians and
Surgeons. Edited by R. French Stone, M.D.,
author of " Elements of Modern Medicine," Surgeon-
General National Guard State of Indiana, Consulting
Physician to Indianapolis City Hospital, etc. Royal
8vo, pp. 751. Indianapolis: Carlan & Hollenbeck.
1894.
This work contains seven hundred and fifty double-
columned pages of biography, with photo-engraved por-
traits of hundreds of medical men. The editor has evi-
dently done his best to give an impartial record of the
subjects treated, and due credit must be accorded him for
honesty of purpose and purity of motive. It is obviously
impossible to make a work ot this character beyond criti-
cism. The most difficult of all undertakings is to please
every great man who may be entitled to go down in his-
tory. Hence it is generally prudent to wait until they
are dead and cannot talk back. It is true the world over
that " many are called but few are chosen," but the dif-
ficulty is in drawing the line between the two. The edi-
tor has succeeded fairly well in this line, although a great
many of the eminent men are heard of for the first time.
Some partiality is shown for immediate neighbors in In-
dianapolis, but this can be explained naturally by a better
knowledge of their merits than those of other eminent
men in larger cities. As must inevitably happen in the
best regulated family, wondrous distinctions will thrust
themselves upon general notice. In New York, Philadel-
phia, and Chicago, the selections are not such as would
be made by one having a large acquaintance with medi-
cal men of reputation. Almost as a rule the best men
have the shortest notices and the fewest pictures, but
they have themselves to blame in not furnishing the nec-
essary data. The accounts of distinguished deceased
members of the profession are singularly good, and add
important and interesting chapters to the history of
medical achievements in America. The photo-engrav-
ures are not well printed, although the plates have evi-
dently been carefully made. The book will be interest-
ing to a wide circle of curious readers, but best of all, will
furnish valuable and trustworthy data for obituary no-
tices.
The Etiology of Osseous Deformities of the Head,
Face, Jaws, and Teeth. By Eugene S. Talbot,
M.D., D.D.S., Professor Dental Surgery Woman's
Medical College; Lecturer on Dental Surgery and
Pathology, Rush Medical College, Chicago, etc. Third
Edition. 8vo, pp. 484. Chicago: The W. T.
Keener Co. 1894.
The third edition of this interesting work represents a
revision and enlargement of the previous ones, and
is in so much an improvement of them. The new field
of inquiry, as to the relation of deformities of head, face,
jaws, and teeth, to those of other foims of the degenerate
type, is discussed with singular clearness, with a pains-
taking examination of scientific data, and with the result
of formulating very instructive, interesting, and valuable
data for the prosecution of this important department of
anthropology. It is thus shown that the variations from
the normal type of cranial, facial, and maxillary develop-
ments are in keeping with those associated with asym-
metry in other organs, and for the most part are depend-
ent upon the like causes of hereditary taint, racial
peculiarities, climate, and environment. The subject —
from the focal point of interest, the mouth— compasses a
wide range of collateral observations, proving a remark-
able and instructive association of these forms of defective
development with those of the brain, the nervous centres,
the bones, and incidentally with the character, tempera-
ment, and hereditary proclivities of the individual. The
illustrations, over four hundred in number, are mostly
original and represent in an excellent and striking man-
ner the leading types discussed. The work as a whole is
carefully done, is thoroughly scientific in tone, and adds
some very important and original data to the literature
of an intensely interesting study.
Prompt Aid to the Injured. A Manual of Instruction
designed for Military and Civil Use. By Alva H.
Doty, M D., Major and Surgeon of Ninth Regiment,
N.G.S.N.Y. Second Edition. i2mo, pp. 304.
New York : D. Appleton & Co. 1894.
The second edition of this useful manual has been en-
larged by a practical chapter on hygiene, and the addi-
tion of the recently adopted drill regulations for the Am-
bulance Corps of the United States Aimy. All the
subjects are treated in a thoroughly practical manner,
and the book will prove indispensable to all who follow
camp life.
Jahresberichte Cber die Fortschritte der Anatomie
und Physiologie. XX. Band, Literatem, 1891. II.
Abtheilung. Phvsiologie mit General Register zu
Band XI.-XX. Leipzig : Verlag von F. C. W. Vogel.
1893.
With the present volume and its very complete index,
this valuable publication ceases to appear.
September i, 1894]
MEDICAL RECORD.
27;
Department of the Interior, Census Office. — Vital
Statistics of New York and Brooklyn, Covering the Pe-
riod of Six Years ending May 30, 1890. By John S.
Billings, Surgeon United States Army, Expert Spe-
cial Agent. Quarto, pp. 529. Washington, D. C. 1894.
This exhaustive report presents a number of interesting
features which are quite novel in the line of census work,
notably such as the subdivision of the city into sanitary
districts, and the analyzation of the immediate surround-
ings of stated conditions upon the death rates of differ-
ent races and classes of people. The influence of hered-
ity, as derived from the mother is also shown. Aside
from an almost bewildering array of figures, their analy-
sis as bearing upon the conditions and influences named,
a number of finely executed full-paged maps of New York
and Brooklyn, are given, with the subdivision of sanitary
districts proportionately shaded to illustrate the different
degrees of death-rate from different diseases, accidents,
suicides, etc. Age appears to be one of the most im-
portant factors. Deaths of the very young and very old
take the lead. Of the male population in both cities over
fifteen, over one half are married. The death-rate was
greatest in the widowed and least among the single.
The death rate of consumption was nearly equal in both
sexes, being most fatal among the accountants and clerks,
dressmakers and seamstresses, while suicide was most fre-
quent among the school teachers in New York. Statis-
tics are also presented of all other diseases in their varied
and complex relations, affording an amount of instructive
and valuable information which reflects the highest credit
upon the minute and painstaking methods of the talent-
ed and accomplished compiler. The work can be stud-
ied with the greatest profit by the sanitarian and econo-
mist.
Hydatid Disease, Vol. II. By the late John Davies
Thomas, M.D. (London), F.R.C.S. Eng., etc. Ed-
ited by Alfred Austin Lendon, M D. (London),
Lecturer on Forensic Medical and Clinical Medicine,
University of Adelaide. 8vo, pp. 166. London :
Bailltere, Tindall & Cox. 1894.
This volume consists of a collection of papers on hy-
datid disease by the late Dr. Thomas, and presents a well-
arranged account of the affection as related to the ab-
dominal organs, thoracic viscera, nervous system, bones,
muscles, etc. The clinical phenomena are also clearly
presented, and the treatment by operative procedure is
clearly detailed. The first volume of the series was the
introductory one by the editor, while the present one
contains wholly the views of Dr. Thomas.
Transactions of the Fifteenth Annual Meeting of
the American Laryngological Association, held in
New York, May, 1893. 8vo, pp. 165. New York :
D. Appleton & Co. 1894.
This volume contains much that is interesting to the
laryngologists. The papers of Dr. Delavan on neglect in
reporting cancer operations, of Dr. Lefferts on intubation
in the adult, of Dr. Lincoln on recurrence at a new site
of a laryngeal growth, and of Dr. Jonathan Wright on
the structure of oedematous nasal polypi, are worthy of
special note.
Manual of Practical Anatomy, in Two Volumes. By
D. J. Cunningham, M.D., Professor of Anatomy, Uni-
versity of Dublin. Edinburgh and London : Young
J. Pentland. i2mo, pp. 647. Philadelphia: J. B.
Lippincott.
This is a well-arranged, carefully written, and well il-
lustrated work on practical anatomy. The author proves
himself to be a good teacher in his very natural method,
and in the thorough appreciation of the wants of the stu-
dent. In many parts of the work will be found most
valuable suggestions for an easier and more direct man-
ner of study than is usual with works of its kind. Much
attention is deservedly given to topographical anatomy,
particularly as applied to the abdominal organs. Many
of the illustrations are entirely new, while all are good
and to the point. It is exceedingly difficult to give any-
thing strikingly new in a dissection manual, but the
author has done a good part in infusing an individuality
in the work which will commend itself to the reader.
Braithwaite's Retrospect, Vol. CIX., January to June,
1894.
This well-known volume contains the usual amount of
valuable selections for reference which have given it such
a well-deserved reputation among students and practi-
tioners.
A Retrospect of Surgery, January, 1890, to January
1894. Prepared by Francis J. Shepherd, M.D. , CM.,
Surgeon to the Montreal General Hospital. 8vo, pp.
259. Montreal.
This is a little book of abstracts of the progress of sur-
gery, reprinted from the Montreal Medical Journal, and
contains a fair selection of the notable things done in
that line during the past four years.
Die neuesten Untersuchungen Ober die Patholog-
ische Anatomie und Physiologie der Tabes Dor-
salis. Zwei Vortrage, von E. Leyden. Berlin.
1894.
This is a small monograph written to show that the
author, first and many years ago, demonstrated the initial
lesion of tabes to be in the posterior spinal roots. This
is getting to be the modern view, but it is not yet entirely
proven to be the true one.
Lehrbuch der Nervenkrankheiten fOr Aerzte und
Studirende, von Professor Dr. H. Oppenheim, mit
220 Abbildungen. Pp. 870. Berlin : Verlag von S.
Karger. 1894.
The reputation of Professor Oppenheim as a careful ob-
server and writer, and his long experience in Charity
wards and the clinics of Berlin, lead one to expect a
valuable treatise from him. There are a good many
treatises on nervous diseases now, each having some
special merits. Perhaps the special merit of Oppen-
heim's is the care and detail which are given to the
interesting but relatively rare diseases. Thus syringo-
myelia gets nearly as much space as cerebral hemorrhage.
Brain parasites and sinus thrombosis get more than
myelitis. The chapters on cerebral syphilis and loco-
motor ataxia are particularly good.
Turning to the practical side, we find absolutely no
new suggestions or helpful advice. For epilepsy, neu-
ralgia, tabes, etc., the same list of drugs, the same ad-
vice about diet, baths, and potash is given. The author
shows himself keenly alert to every clinical phenomenon
or pathological process, but he does not take % human
and curative interest. This is the Teutonic way, and
Americans who do like to help their patients as well as
to make a local and pathological diagnosis, are accused
of being shallow and credulous. Despite of our criticism
in this respect, however, we do not hesitate to say that
Oppenheim's work is the most systematic treatise which
any German has written since the ancient days of Rom-
berg. It is well and copiously illustrated.
Les Nouvelles Id£es sur la Structure du Syst£me ner-
veux chez l'Homme et chez les Vert£br£s. Par
le Dr. S. R. Cajal. Edition fran^aise revue et
augments par l'auteur. Traduite de l'espagnol par
le Dr. L. Azoulay, Preface de M. Mathias Duval. Avec
49 figures dans le texte. Small 8vo. Pp. 200.
Paris : C. Reinwald et Cie. 1894.
Professor Cajal' s name is identified with some of the
most important of the recent advances in the anatomy of
the nervous system obtained by the application of me-
tallic stains. Cajal himself is one of the very few mod-
ern Spaniards who have obtained an international
reputation. No one could better present the new ideas
of the structure of the nervous system, and the present
work fulfils its purpose admirably, being clear and ex-
plicit without being cumbersome. The author adds
descriptions of various new methods of staining.
278
MEDICAL RECORD.
[September I, 1894
£0ci*tg Reports.
THE BRITISH MEDICAL ASSOCIATION.
Sixty-second Annual Meeting, held at Bristol, July ji
to August 4, 1894.
Special Report for the Medical Rkcoka.
(Continued from page 351.)
SECTION OF OBSTETRIC MEDICINE AND GYNECOL-
. OGY.
First Day, Wednesday, August ist.
Dr. J. G. Swayne, the President, delivered a short in-
troductory address. He reviewed, historically, previous
meetings of the Association at Bristol, and referred to his
address in 1883, when he insisted on the importance of
midwifery, and that it should stand next to medicine and
surgery, and not be considered a specialty. Since then a
new race of gynecologists and abdominal operators had
sprung up.
He drew attention to the fact that medicine and sur-
gery formed the subject of an address each year, but that
obstetric medicine only occasionally did so, and thought
that that was wrong.
Induced Labor in the Absence of Dystocia. — Dr.
Robert Barnes, of London, opened a discussion on
" The Necessity of Inducing Labor in Certain Con-
ditions of the Mothers not Obstructing Delivery." He
said that as medical science advanced this was a matter
which needed revision. We should study the methods
of nature in adopting this means of relief; the safety of
the mother should be our first consideration, and of the
child the second, but frequently the two conditions ran
together.
The duty of the physician when the pregnant woman
was in difficulty was to consider the means of safety for
both mother and child, and no problem in medicine was
more difficult.
The most remarkable phenomena of pregnancy were
increase in the excitability of the nervous system and in-
crease in the blood and in the blood-pressure. We must
recognize that the struggle between pregnancy and the
coexisting disease was strictly physiological.
We must keep a strict watch over each organ, but be
careful not to press expectant treatment too far. Sev-
eral of the conditions were those which attended exces-
sive nerve tension, and were of a convulsive character, of
these the first one was vomiting ; this was like other con-
vulsive attacks and tended to be rendered chronic, each
attack helping to graft a habit of vomiting.
Vomirmg, in his experience, was most severe in cases
where there was nerve shock or depression ; rapid disin-
tegration of tissue followed persistent vomiting, and this
tended to cause a condition of toxaemia, ending in coma
and death. Vomiting may throw excessive strain on the
brain and cause cerebral hemorrhage. When rapid ema-
ciation with toxaemic symptoms occurs, the induction
of labor may .prove too late. In cases in which the
vomiting is due to excessive distention of the uterus,
labor should be induced early.
Tetanus was a strong indication for the induction of
labor. In chorea he thought that pregnancy should be
terminated, and, as a general rule, one should not allow
pregnancy in any convulsive disorder to continue. In
insanity he would induce labor, though Dr. Savage was
of a different opinion.
Vascular disorders, the excessive blood pressure found
in pregnancy, was sometimes relieved by external hem-
orrhage as epistaxis, by serous effusion, or by vomiting,
throwing off some fluid, or by dropsical effusion, or might
result in cerebral hemorrhage. For the excessive blood-
pressure we should purge, and in some cases venesection
was strongly indicated, and, as a last resource, we might
induce labor.
Extreme anaemia might render induction necessary, or
it might be required when valvular disease of the heart
or aneurism was present. We should carefully watch
these cases and induce labor when distress supervened.
He believed that pregnancy aggravated phthisis, but the
question of inducing labor was a difficult one. When
tumors coexisted, as a general rule it was safer to let
pregnancy go on. Repeated labors with a dead child
suggested the bringing on of labor in a succeeding one
before death occurred, and he believed that carrying a
dead child was injurious to a woman. In scarlet fever
he would induce labor if albuminuria were present.
In conclusion, he would urge the rule laid down by
Denman, never to perform the operation without a con-
sultation beforehand.
The President said that in an experience of fifty-two
years he had induced labor 37 times ; in 24 of these
cases it was done for contracted pelvis. In the re-
maining 13, 5 times for persistent vomiting, 3 for ana-
sarca and albuminuria, 2 for hydramnios, 1 for vaginal
hemorrhage, 1 for severe irritability of bladder, 1 for dis-
eased placenta.
Dr. More Madden, of Dublin, said that where the
child had died in previous pregnancies he would induce
labor as early as the sixth month, and he believed that
at that time the child would be viable. As regards
method, he preferred that of dilating the cervix by the
ringer.
Dr. Murphy, of Sunderland, thought the most fre-
quent of the cases under discussion were those of grave
albuminuria. As regards method, where no hurry, he
would rupture the membranes; where rapid delivery was
required, he would use Barnes's bags. Where the bag
could not be introduced he would start with a lent.
Dr. Murdoch Cameron, of Glasgow, would take ex-
ception to the induction of labor in fevers. With re-
spect to uterine tumors he would not be inclined to in-
terfere, unless the tumor were likely to obstruct labor.
You may remove the tumor without interfering with the
pregnancy. He did not think the child was viable before
the seventh month, and the nearer the eighth month the
labor was induced, the better. In ascites it was some-
times necessary to induce labor. In hemorrhage and
eclampsia he had no hesitation in inducing it, although
some were still disinclined to induce it in eclampsia.
He thought some cases of violent vomiting were lost by
delay.
Dr. Heywood Smith, of London, would not induce
labor in cases of fibroid tumor.
Mr. J. W. Taylor, of Birmingham, called attention to
cases of dropsy and albuminuria before the child was via-
ble, and thought that these were the cases in which it
was most desirable to have some settled rule laid down.
Dr. Massey, of Bournemouth, related a case of severe
dropsy in which he had induced labor by passing a cath-
eter between the membranes and uterine wall with good
result.
Dr. Byers, of Belfast, agreed in inducing labor in
cases of vomiting which persisted in spite of treatment,
but thought that all were not agreed that, given albu-
minuria in pregnancy, induction cf labor should be de-
cided upon.
He related three cases of primiparae all with albuminuria
and dropsy : 1. Dead foetus, no interference, good re-
covery ; he did not interfere because the foetus was dead
and there was no high-tension pulse. 2. Primipara,
sixth month, one- fourth col. albumin, no high-tension
pulse, no marked oedema; treated by warm baths and
milk diet; living child at term; good recovery. 3.
Much headache, high-tension pulse, labor induced.
Cases like the third were more troublesome because
eclampsia was likely to follow. Recently Smyly, at the
Rotunda, had found that in a large number of cases of
eclampsia equally good results were obtained by leaving
pregnancy alone and injecting morphia hypodermically.
Dr. Wright, of Leeds, had in one case been obliged
to induce labor for severe ptyalism. In ovarian tumors
would remove tumor and leave pregnancy. Would use
solid bougie instead of catheter.
September i, 1894]
MEDICAL RECORD.
279
Dr. Aust Lawrence, of Bristol, urged necessity of
first inquiring if vomiting were due to any other cause ;
had seen cases in which it was due to acute yellow
atrophy of liver. Urged importance of giving a good
trial of other treatment, especially of moral suasion ;
would be very chary of inducing labor in fever.
Dr. Tweedy, of Dublin, said that in the Rotunda Hos-
pital the induction of labor was looked upon as a danger-
ous proceeding only to be resorted to in extreme cases,
and it was seldom done except for contracted pelvis.
Recently a woman was admitted with fibroid tumors at
the seventh month ; a Porro's operation was done at term.
He believed that in only two per cent, of cases of albu-
minuria did eclampsia follow, and they did not induce
labor at the Rotunda in cases of eclampsia in pregnancy,
but treated the condition by hypodermic injection of
morphia, one-half grain every half hour, with very good
results.
He had never seen a case of death from vomiting in
pregnancy. In ovarian tumor in pregnancy he would
open abdomen and remove tumors.
Dr. M. A. Scharlieb, of London, had twice done ova-
riotomy in pregnancy with good results.
Dr. Boxall, of London, had induced labor in one case,
because of varicose veins in vulva which threatened to
burst Would be very diffident in interfering in cases
where fibroid tumor complicated pregnancy.
Dr. Pearse, of Southsea, thought that a mistake was
often made in waiting for a viable child, and that the
condition of the mother should alone decide the neces-
sity.
Dr. Barnes, in reply, said that he had seen cases of
vomiting prove fatal. As regarded method, preferred
bougie to catheter. He did not think digital dilatation de-
sirable. There was no class of cases in which the indue-
tion of labor was always necessary, and he did not advo-
cate it in all cases of albuminuria. In convulsions, he
thought inhalation of nitrite of amyl the best treatment.
He would retract now an opinion he expressed years ago,
and would say that when there was ovarian tumor and
pregnancy, you should remove the tumor and not the
pregnancy.
Uterine Fibroids. — Dr. M. A. Scharlieb, of London,
then read a paper on " The Treatment of Uterine Myo-
mata." She gave an account of the operative proceed-
ings in nineteen cases. In six she removed the appen-
dages, and all recovered. In thirteen she removed uterine
tumor and appendages, and two proved fatal. In one
she removed tumor only. In the first six cases she
removed the tubes as close to the cornua as she could.
In the cases of hysterectomy she first ligated the bread
ligaments outside the appendages, then ligated the uter-
ine artery. She made flaps of the peritoneum on ante-
rior and posterior surfaces of uterus, and she carefully
disinfected the cervix with pure phenol. She closed the
abdominal wall with three separate layers of stitches.
In four she used a temporary elastic ligature, and in all
these she drained. In the remainder she tied all bleed-
ing points and did not drain.
The lessons she drew were : First, the importance ot
thorough surgical cleanliness.
In her cases the patient had repeated hot baths first,
then the skin was disinfected by washing with soap and
water, alcohol, solution of permanganate of potash, fol-
lowed by oxalic acid. Then 1 to 2, coo corrosive subli-
mate, and lastly a carbolic compress was left on for
twenty four hours. The clothes worn by the patient
were also sterilized. The operator and assistants
cleansed their arms and hands in the same way as the
patient's abdomen was done, and wore sterilized linen
overalls. The instruments were boiled and laid in 1 to
20 carbolic, which was diluted with boiling water at the
time of operation, and they were put down during opera-
tion in a shallow dish containing carbolic. The sponges
were cleansed with sulphurous acid and kept in carbolic.
The second lesson to be learnt was the importance of
handling the peritoneum as little as possible ; she did not
believe in sponging or mopping the peritoneum, and
thought that doing so encouraged hemorrhage. She
avoided the temporary elastic ligature as much as possible,
because she thought that there was more oozing after-
ward. She avoided drainage as much as possible.
The third lesson was to tie the arteries, both uterine
and ovarian, carefully ; and the fourth, to treat the stump
intra peritoneally.
In all cases there was no sepsis, and the two which
proved fatal died from shock. She did not leave a lig-
ature on the stump; because it caused death of tissue.
She drew attention to the fact that only one of the cases
was the mother of children, the remainder being unmar-
ried or sterile.
Resection of the Uterus. — Dr. J. Stuart Nairne read
a paper on " Resection of the Uterus for Fibroid Tumors
and other Diseases." He pointed out that removing
the appendages did not always restore to health, that
enucleation of the tumor per vaginam or by abdominal
incision was dangerous and the results not always satis-
factory. He would propose what he called resection,
namely, to split the uterus, remove the tumor, and stitch
the remains of the uterus together, tying the vessels as
he met with them. He had treated three cases in that
way, they had recovered and one had since had a child.
Extirpation of the Uterus for Myomata. —Dr. Smyly,
of Dublin, read a paper on " Total Extirpation of the
Myomatous Uterus. ' ' He said that the treatment of uter-
ine myoma was still one of the burning questions of the
day, but that he in this paper would deal only with the
last resource ot surgery. He would advise, however, that
those who were beginning to do hysterectomy should
adopt the extra peritoneal treatment of the pedicle ; this
was the only method he adopted up to 1892, since then
he had only done one case in that way. What he did
now was to perform total extirpation in one of three
ways : By abdominal section, per vaginam, by a combi-
nation of the two, or the " mixed method." The dangers
of hysterectomy depended on the stump, and by adopting
this method these dangers were removed. He had done
fifteen cases with two deaths. By the mixed methed,
eleven cases with one death. By the abdominal method,
two cases with one death. By the vaginal methed, cne
case, no death. Some very large tumors among them.
One where the uterus was as large as a full* term preg-
nancy and contained several myomata was removed in
this way. He opened the abdomen, ligatured the broad
ligaments, then divided the pouch of Douglas, and lastly
separated uterus from bladder.
In small tumors he had removed the uterus per vaginam
by morcellement, and in one case the fragments weighed
two and a half pounds; for two days beforehand the
vagina was packed with antiseptic gauze, patient was
placed in lithotomy position, and cervix drawn down and
separated from bladder. Pouch of Douglas then opened
and cervix cut away, and then uterus attacked.
Dr. Heywood Smith, of London, congratulated Mrs.
Scharlieb on her success; he thought that soon all cases
would be treated by the intra peritoneal method or by
complete extirpation. Vaginal . hysterectomy showed a
less mortality than any other method, but the best way
of dealing with these tumors was not yet determined.
Dr. Rabagliati, of Bradford, related a case in which
a large fibroid disappeared after pregnancy, and thought
that now too much attention was directed to surgical
treatment, and too little to dietetic and medicinal.
Dr. Cullingworth, of London, drew attention to the
extreme care which Mrs. Scharlieb paid to the prevention
of sepsis, and said that the method resembled that
adopted in the Johns Hopkins University Hospital, as
published by Dr. Howard Kelly ; and the same precau-
tions had been adopted in a maternity at Clapham, car-
ried on by ladies, with excellent results. He complained
that there were not sufficient statistics at present to en-
able one to decide whether hysterectomy was justifiable
or not, and that what we really want is an authentic his-
tory of a number of cases not treated surgically ; opera
280
MEDICAL RECORD.
[September i, 1894
tions were more frequent now because we know that these
tumors sometimes kill, but many disappear without
operation.
Dr. Travers, of London, thought that cases after
hysterectomy were never so well able to work for their
living as after other abdominal operations.
Dr. Aust Lawrence, of Bristol, thought that the sta-
tion of life of the patient often determined the treatment.
Thus hysterectomy was required in the poor woman,
whereas a well to do one who could lay up might avoid
the operation.
Dr. Barnes, of London, would like an authoritative
opinion as to whether a fibroid tumor ever killed, as it had
recently been stated by a prominent London physician
that they never did so.
Mrs. Scharlieb, in reply, said that one seldom found
the appendages healthy in cases of myoma; in nearly all
her cases the ovaries were enlarged and cystic. The
question of removal of the appendages of the tumor de-
pended on the nature of the growth. Thus in large,
smooth, uninodular tumors removing the appendages did
not check the growth ; also multinodular tumors, when of
large size, needed the major operation, though in two or
three of her cases the electrical treatment had been used
and had proved futile. She thought that there was no
doubt that fibroids did sometimes kill by the hemorrhage
and pain, or by pressure on the ureters. Her patients
had been able to return to hard work after the operation!
and no hernia had resulted in any of her cases.
Second Day, Thursday, August 2D.
Hemorrhage in Late Pregnancy. — Dr. Smyly, ot
Dublin, opened a discussion on "The Treatment of
Hemorrhage during the last Two Months of Pregnancy."
He said that in the great majority of cases this was due to
separation of the placenta ; the uterus was divided into
two distinct portions, and this difference which existed in
pregnancy was most apparent after parturition. The
upper thick portion received its blood-supply directly from
the uterine and ovarian arteries, and the lower thinned
portion, to which the blood vessels passed, from the upper
segment. The limiting line was called the retraction
ring ; the placenta was sometimes situated in the lower
segment, bat wherever its situation premature separation
of it caused hemorrhage. It was not possible always to
draw a line between accidental and unavoidable hemor-
rhage.
Placenta praevia occurred in women who had borne
several children rapidly, also in connection with an en-
larged and diseased uterus. The placenta was seldom
normal in these cases. It was thinned. There were often
spaces in which its tissue was deficient, and placenta
succenturiata occurred. He thought that an abnor-
mally low attachment of the placenta might be attributed
to four causes : 1. When there was a very large placenta
which could not find room in the uterus. 2. When the
uterine walls were concave inward, instead of convex, as
they should be, and there was an actual instead of a po-
tential cavity. 3. The stretching of the cilia in endome-
tritis. 4. The placenta being developed from decidua
reflexa.
The diagnosis was made from the hemorrhage and
from feeling the placenta. He did not believe that aus-
cultation was of any value for diagnostic purposes. The
hemorrhage before labor may be due to a disproportion
between the placenta and the area of its site. Hemor-
rhage during labor was due to the distention of the
lower uterine segment, and its being drawn up by the
action of the longitudinal fibres, and the detachment of
the placenta miy cease with the rupture of the mem-
branes.
Treatment. — In almost all cases the os will admit two
fingers ; if so, bring down a leg and then leave the case
to nature. If further hemorrhage occurs, gentle pulling
on the leg will arrest it. There were two conditions in
which this treatment was inapplicable : 1. When the os
would not admit the finger ; in these he would plug the
vagina. 2. When the labor was advanced and turning
impossible. In these he would rupture the membranes.
He did not recommend any other methods, and disap-
proved of accouchement forc£ and separation of the pla-
centa by the finger. The method which was common was
bad, viz., to plug the vagina until the whole hand could
be introduced, and then to do internal version. This was
attended by many dangers, among which he would
mention sepsis, entrance of air into veins causing sudden
death, and laceration of the cervix.
The mortality of the method he had described had
been seven per cent. Of twenty cases lately treated two
had died.
Accidental Hemorrhage. — He did not think that an
accident would cause separation of a healthy placenta.
The commonest cause of this condition was disease of the
endometrium, and this was frequently associated with
syphilis and renal disease. The blood vessels were dis-
eased and caused hemorrhage, and this went on if the
blood had not free escape until the pressure to which it
was subjected equalled the blood-pressure in the maternal
vessels. He thought that concealed accidental hemor-
rhage was due to some disease of the uterine wall, which
rendered it unable to resist the pressure of the effused
blood, and on that account he looked upon it as danger-
ous because it always betokened a diseased atonic uterus.
Treatment — It was impossible to lay down a routine
treatment, and he thought that the importance of ruptur-
ing the membranes had been overestimated, and this was
only useful when labor was somewhat advanced. Some
cases required nothing to be done. When the os was
small he thought that rupturing was bad, as it reduced the
pressure in the uterus and so favored further hemorrhage.
It does not always induce pains, and so blood flowed into
the partially emptied uterus. It is better in severe cases
to combat shock, and where blood is escaping from the
uterus to use vaginal douches of hot water, followed by a
vaginal tampon. He did not think that the tampon
favored concealed hemorrhage. After rupturing the
membranes he would never use tampons. In very bad
cases he believed that Porro's operation would be better
than accouchement ford.
He epitomized his treatment thus : When os small, pre-
serve membranes; when hemorrhage appeared exter-
nally, plug ; when labor advanced, rupture membranes
and deliver by the best method possible.
Dr. Robert Barnes, of London, believed that disease
of the uterus was the most common cause of hemorrhages ;
but that disease of the placenta was also a cause. In
placenta praevia he would not use accouchement forc6.
He described the retraction ring long before Bandl. He
looked upon placenta praevia as resembling ectopic ges-
tation, in that the placenta was fixed to a part which was
not adapted to receive it. When the os was small he
used his own bags. He always preferred forceps to ver-
sion, where possible, as it gave a better chance to the
child. He did not like the use of the vaginal plug.
Dr. Byers, of Belfast, had met with cases of placenta
praevia in which the os would not admit the fingers, and in
three such cases he had tried De Ribes's bag with good re-
sults. After introducing the bag, if labor did not come on,
he had found that gently pulling on the bag would hasten
it, and would anvst any hemorrhage. He had found
that he could introduce De Ribes's bag when the os was
the size of a shilling. In accidental hemorrhage rupture
of the membranes only did harm when pains did not
quickly follow.
Dr. More Madden, of Dublin, was opposed to a good
deal that Dr. Smyly had said, and he advocated ac-
couchement forc£ and the vaginal plug ; for the latter
purpose he used a clean sponge soaked in terebene. Af-
ter sufficient dilatation had been obtained he performed
internal version, never using bipolar method. In acci-
dental hemorrhage he saw no objection to rupturing the
membranes.
Dr. Murphy, of Sunderland, said that we should rec-
September if 1894]
MEDICAL RECORD.
281
ognize the danger of placenta previa, and if the seventh
month had passed take the case in hand at once. He had
always found in cases of placenta previa that the finger
could be introduced into the cervix. He then separated
the placenta for a short distance around the os and put in
a Barnes bag, and as soon as sufficient dilatation had been
obtained he delivered. He thought that the place to put
in a plug was the cervix, and not the vagina.
Dr. Murdock Cameron, of Glasgow, entirely disap-
proved of Porro's operation in any case of accidental
hemorrhage. He advocated the vaginal plug. He had
never seen a case of concealed accidental hemorrhage.
When the placenta was central he always pushed his
fingers straight through its substance.
Dr. Scharlieb, of London, believed in plugging with
iodoform gauze.
Dr. Robert Boxall, of London, had investigated the
point on the membranes which presented over the os by
touching it with eosine at an early stage of labor, and
locating the stained spot afterward. He found that in
many of these cases the placenta must have encroached
on the dangerous zone, though there were no symptoms of
placenta previa, and the latter was especially the case
when the membranes ruptured early. In some cases ex-
ternal version was possible. He drew attention to the
fact that an accident was sometimes the cause of hemor-
rhage in placenta previa marginalis. He had examined
a large number of placentae, and in several cases had found
evidence of hemorrhage having occurred a month or two
previously, when there had been no symptoms. He im-
pressed the necessity of inducing labor when hemorrhage
had once occurred. In cases where there was no dilata-
tion of the os, the hot douche proved useful. In some
cases he plugged the vagina, using wool soaked in sub-
limate solution. He had seen cases in which the placenta
covered the greater part of the interior of the uterus.
Dr. Aust Lawrence, of Bristol, said that when the
cervix would not admit the finger he was in the habit of
plugging the cervix with iodoform gauze. He thought
cases in which there were repeated small bleedings were
more dangerous than those in which the hemorrhage
was at once alarming. He would never leave the woman
until labor was finished when once bleeding had set in.
Vaginal Hysterectomy for Cancer of the Uterus.—
Mr. F. B. Jessett, of London, then read a paper en-
titled, " On Thirty Cases of Vaginal Hysterectomy for
Carcinoma Uteri, with Two Deaths. " He said that vag-
inal hysterectomy was now a well- recognized operation,
and was done in three ways : 1, using ligatures ; 2, using
clamp ; 3, combined abdominal and vaginal method.
He laid great stress on the importance of suitable prepa-
ration of the patient beforehand. He would have her
kept in bed three or four days, and syringe vagina fre-
quently. He dusted iodoform of cervix through a Fergu-
son speculum, especially if there was ulceration. Tlie
diet should be light.
Details of Operation. — Patient in lithotomy position,
using Clover's coutelL Two Sims specula were passed,
one in front and one behind. A sharp hook seized the
anterior lip of cervix and pulled it down, and cervix was
seized by two vulsella. A sound was passed into the
bladder to determine its limits. Strong scissors then di-
vided the mucous membrane around the os. The blad-
der and ureters were separated by the fingers, special
care being taken to free thoroughly at the sides.
The utero - vesical fold of peritoneum was opened.
Then Douglas's pouch was opened and the fore-fin-
ger of the left hand passed behind and the thumb
in front of the broad ligament, and the uterine artery on
each side recognized. A special strong curved needle
was passed up at the front of the broad ligament and
pushed through above where the uterine artery was
felt, threaded, and withdrawn, and ligature tied. A pair
of pressure forceps was applied between the uterus and
the ligature and the broad ligament divided with scis-
sors. The fundus was anteverted or retroverted so as
to bring the ovaries into view, and the remainder of
the broad ligament transfixed and tied in two sections,
the ends of the ligatures being left long and brought
down through the vagina. The anterior and posterioi
peritoneal flaps were seized with catch^forceps and
brought down. A glass drainage-tube was passed into
the peritoneal cavity and the vagina plugged. The
plugs being removed on the second day.
In two cases the uterus was so large that it could not
be removed through the vagina entire. In these cases
it had been advised to divide the uterus in half, but he
preferred to treat them by the combined method. The
patient being in the same position, the operator stands
between her legs to make the abdominal incision. The
uterus was then drawn up and the broad ligaments
tied.
As to the question of clamp and ligature, he preferred
ligature, but he thought that in cases where the patient
was very exhausted the clamp might be used, as it took
a shorter time. He had invented a special clamp for the
purpose.
Apex Treatment. — If prolapse of omentum or intestine
occurred, he used the speculum ; packed the vagina daily,
and used douching. He had the bowels open on the
third day. He found it necessary to tie a catheter in the
bladder for at least two days.
As regards the results, cases only were fit for this oper-
ation in which the disease was limited to the uterus, and
the latter was freely movable.
The advantages of the clamp were that the operation
was more rapid. Its disadvantages were that the end
projected into the peritoneal cavity and might convey
septic matter. That it inevitably led to necrosis of the
tissues it grasped. That intestinal obstruction was more
frequent after its use, and that the ureters might be
caught between its blades. Also, that the weight and
discomfort to the patient occasioned by its use were con-
siderable.
As regards silk and catgut for ligatures, he preferred
silk for the uterine artery, but for the remainder of the
broad ligament catgut might be used. He did not
stitch the peritoneal flaps, but drew them down into the
vagina and carefully packed around them.
As regards drainage, he thought that if there was much
oozing it was safer to use a glass drainage-tube. If gauze
were used, the omentum might be entangled in it and
drawn out. Flushing the peritoneum was useful.
The dangers of the operation were sepsis, hemorrhage,
and injury to ureters. This might be avoided by being care-
ful to thoroughly separate bladder, and by taking care to
pass the needle from before backward. Vesico- vaginal
fistula might result, or recto-vaginal fistula in virginal
narrow vaginae. In cases of cauliflower growth he would
remove the growth before doing hysterectomy. He did
not think it necessary to remove the ovaries and tubes.
Dr. Smyly, of Dublin, had sometimes had occasion to
regret having performed the operation when the disease
had been too extensive. The principal guides as to the
amount of extension of the growth were that the uterus
should be mobile and the broad ligaments not invaded
by the growth, as shown by examination per rectum. He
preferred the method of Dr. Doyen, of Rheims. Both
flushing and suturing of the peritoneum were usually un-
necessary.
Dr. Heywood Smith, of London, drew attention to
the danger of inverting the uterus when the disease was
in the cervix, as being likely to infect the peritoneum ;
and said that ligature was almost impossible when the
vagina was narrow. He would use the catheter as little
as possible.
Dr. Aust Lawrence, of Bristol, drew attention to the
importance of recognizing that cancer in an early stage
is curable, and of making an early diagnosis.
Dr. Scharlieb had found the clamp cause much pain
and discomfort, and was of opinion that it retarded
recovery.
Dr. Jessett, in reply, said that in cases which had ex-
tended too far for operation, he would use the curette and
282
MEDICAL RECORD.
[September i, 1894
pack the cavity with chloride of zinc, which brought away
a slough of the diseased tissue.
Dr. More Madden, of Dublin, read a paper " On
Primitive and other Hyper«sthetic Conditions of the
Vulva and Vagina. ' ' The paper was devoted almost entire-
ly to the treatment of these conditions. He advised par-
ticularly cleanliness ; the use of germicides, as corrosive
sublimate, and the application of methylene blue to the
parts. He had found this latter do much good, but the
disadvantage was the coloration produced, which was
difficult to remove. In dyspareunia he advocated forci-
ble stretching under ether.
HaBmatometra. — Dr. Murphy, of Sunderland, read a
paper entitled " Notes of a Case of Haematometra suc-
cessfully Treated by Hysterectomy/ '
Patient, aged forty- two, married ; never menstruated ;
tumor reaching two inches above umbilicus; has been
forming some months. On vaginal examination finger
passed two inches and was then stopped by a septum,
which was found to be the hymen unruptured. No
swelling could be felt above this, and no uterus could be
made out on rectal examination. The tumor in the ab-
domen was thought to be ovarian. On opening the ab-
domen the tumor was found to be uterus distended with
menstrual blood and with os occluded.
Menstruation.— Mr. E. T. Collins, of Cardiff, read a
paper on "The Nervous Impulses Controlling Menstru-
ation and Uterine Hemorrhage." His observations
went to prove that there was a nerve-centre, but that its
action was reflex and not automatic, and depended on
irritation from the uterus.
Third Day, Friday, August 3D.
Separation of the After-coming Head. — Dr. Purslow,
of Birmingham, read a paper entitled " An Account of
Four Cases in which Separation of the After-coming
Head had Occurred during Delivery, and of the Means
used to Extract the Head." He narrated the cases : The
first three occurred in connection with premature de-
livery before the sixth month, and the head came off
owing to obstruction from a tight cervix. In none of
the cases was there any sign of life in the child. One
of the heads was extracted by the finger, and the other
two by ovum forceps. In the fourth case the child was
fully developed, but decomposed, and there was some
narrowing of the pelvic brim; the child had presented by
the breech, and in endeavoring to extract the head came
off and was left in utero.
Dr. Purslow saw the case four hours later, after several
attempts had been made to extract by forceps and
crotchet. He extracted by the cephalotribe after very
considerable difficulty, the difficulty arising from the
tendency of the blades to slip off, owing to the difficulty
of applying them over the centre of the head, and from
the fact that when they were applied the lock was one
and one-half to two inches within the vulva. The pa-
tient made an excellent recovery. He reviewed the
methods of extraction advocated by ancient and modern
authors, and concluded by advising recourse to the ceph-
alotribe as the best means of delivery. Some of the
other methods advocated involved bringing the head
down in such a position that the jagged protruding ends
of the fractured cervical vertebrae were apt to seriously
injure the vaginal or uterine wall.
Ectopic Gestation.— Dr. Cullingworth, of London,
read a paper "Ona Case of Advanced Extrauterine Ges-
tation in which a Living Child was removed, the placen-
ta left Undisturbed, and the Abdominal Wound entirely
Closed/' He said that it was sometimes advised in
these cases to wait for the death of the child before
operating, so as to allow the placental circulation to
diminish. It had been advised at the operation to leave
the placenta with the cord protruding from the abdom-
inal wound. It had been proposed by Lawson Tait to
leave the placenta to undergo absorption; the attach*
ment of the placenta at the operation was dangerous,
because the attachment of the placenta differed from
that found in the uterus, and in ectopic gestation there
was no mechanism for arresting hemorrhage when it was
detached. That absorption could occur was proved by
those cases in which the foetus had died. No operation
had been performed and everything, with the exception
of the bones, had disappeared.
In his case the child was alive at operation, the open-
ing in the membranes was sutured, and the cord cut
short. There was satisfactory progress for three weeks,
on the twenty-fourth day a rigor occurred, and on the
twenty-sixth day he opened the abdomen. He found
purulent fluid in the remains of the amniotic sac, he
washed out, but the patient died the same day.
Autopsy. — No suppuration in substance of placenta;
child still alive and well. In future operations he would
allow bleeding from the divided end of the cord, so as to
lessen size of placenta ; would divide cord quite close to
placenta ; would remove all the amnion possible, strip-
ping it off from the placental surface, as the sepsis in this
case arose from the remains of the amniotic sac ; and it
would teach him to remove parts not likely to cause
hemorrhage in their removal, but likely from their non-
vascular^ to decompose.
Dr. Aust Lawrence narrated two cases in which
he had operated ; in one the placenta was absorbed and
patient recovered ; in the other there was septicaemia
and death on the twenty fourth day. He would leave the
placenta, and if there were symptoms would reopen the
wound.
Dr. Cullingworth, in reply, said he would be on
guard for septic symptoms and reopen abdomen at once.
It was a difficult matter to decide, in cases in which the
foetus had died, how soon afterward to operate. He
had operated four weeks after and removed the placenta
with perfect ease. Drainage should not be used if any
hope were entertained that the placenta would absorb.
He would strip off amnion right up to margin of cord
and cut the latter off as close as was possible.
Pseudo-ovarian Disease. — Dr. Rabagliati, of Brad-
ford, read a paper on " Some Obscure Ailments which
Simulate Ovarian Disease ; their Causes and Treatment."
The cases he described were often called ovarian neu-
ralgia. There was pain in ilio lumbar region, pain in
head, menstruation tending to be profuse, slight leucor-
rhcea, and these symptoms persisted for years. On mak-
ing an examination the tissues were flabby ; they were
suffering from "diseases of a lax fibre" and deficient
nutrition of the affected parts, and the essential cause of
these sufferings was rheumatism of the muscle sheaths of
the fibres of the abdominal and pelvic muscles.
The affected muscles, especially the rectus, were tender
to pressure. On passing the finger into the umbilicus, a
slight opening was felt, the edges of which were sharp
and very tender. There was tenderness on pressure over
the erector spinae muscle and over the sacro-iliac syn-
chondroses. The pectoral muscles and those at the back
of the neck were also tender. The causes of the condi-
tion were malnutrition, especially too little nitrogene-
ous food. The symptoms were not due to hysteria.
Treatment consisted in feeding and movements of the
muscles under pressure ; these latter the patient was in-
structed to do herself, and photographs were exhibited
to show how the movements were performed. Cold
baths were also used, and by these means Dr. Rabagliati
said he had cured cases for whom removal of the ovaries
had been advised.
The Section was then adjourned.
Curiosities of Cholera. — It is a fact of the various
cholera epidemics that have swept Europe, that in every
one the mortality at Rome and Madrid was greatest on
Sundays, at London and Berlin on Wednesdays, and at
Paris on Saturdays. At present, in St. Petersburg,
where the death rate is upward of one hundred daily, the
mortality list is increased one-fourth on Saturdays. —
Medical Age.
September i, 1894]
MEDICAL RECORD.
283
THE PRACTITIONERS' SOCIETY OF NEW
YORK.
Siatea Meeting, April 6, 1894.
George L. Peabodv, M.D., Chairman, pro tern.
Chronic Double Parotiditis — Two Cases. — Dr. Rob
ert Abbe presented a man and photographs of this and
another case of chronic double parotiditis. The first
case, of which photographs alone were shown, occurred
some years ago in a man whom he had first seen, as he
was reminded later, in the practice of Dr. Weir. The
enlargement of the parotid glands had persisted during
the entire time the patient remained under Dr. Abbe's
observation, perhaps a year and a half. Had at no time
been attended by very acute symptoms ; no suppuration.
The man presented was the only other similar case which
had come under his observation. The glandular en-
largement had existed over a year, and had come on
without apparent cause, although on account of the ra-
pidity of its development Dr. Abbe had at first supposed
it was due to mumps, a view which proved to be incor-
rect. Last summer the man had had an attack of appen-
dicitis, but recovered after about two weeks, and was able
to res'ime business in Wall Street until about two months
ago, when he had another attack of appendicitis, for
which Dr. Abbe operated and removed the suppurative
appendix. Since that date the man had felt better than
at any time for two years, had gained about twenty-five
pounds in weight ; but there had been no change in the
parotid glands except that the swelling was a little more
diffuse and a little softer, but contained no fluid.
In the first case the entire parotid had been involved ;
in the second only the upper portion in front of the
tragus and lobule.
Dr. Weir remembered the first case, of which he said
Dr. Abbe took the photograph for him. The swelling
was harder than in the case of the man presented, was of
the entire parotids, which were swollen in equal degree.
Surgical interference was not considered necessary. The
present case reminded him of one recently seen in a
patient from Montreal, in which, however, the suspicion
of symmetrical fatty tumors was confirmed by the pres-
ence of fatty growths in the neck.
Dr. McBurnby was disposed to think, from the soft-
ness of the tumors, the presence of at least the greater
portion of the parotid at a lower situation, and the fact
that the man had been growing fat, that the case was one
of lipomata symmetrical on the two sides.
Dr. Abbe said he had had in mind the possibility of
fatty tumors, but the growths had not been so soft in the
first place; they had developed when the man was in his
poorest health, before he had begun to take on flesh, and
had remained of the same size since the first month.
Dr. Andrew H. Smith remarked, incidentally to the
question of symmetrical lipomatous tumors, that about
seven years ago a patient entered the Presbyterian Hos-
pital with seven or eight symmetrical lipomata in differ-
ent parts of the body, there being two on the forehead,
two on the neck, and others located symmetrically else-
where.
Cholecystenterostomy by Murphy's Button — Recov-
ery.— Dr. Robert Abbe related the case. In October
last Mrs. M , aged forty five, had entered her fourth
month of profound jaundice, with entire loss of appetite,
emaciation, and exhaustion.
She had never had biliary colic, and the onset of this
attack was unaccompanied by other symptoms.
Examination showed her to be very thin and deeply
jaundiced. The gall bladder could be felt well distended.
No other tumor was apparent.
Drs. C. W. Packard, Archibald Campbell, of Mt.
Vernon, and I agreed that there was probably present ob-
structive pressure from cancer. As the patient's condi-
tion was critical I operated on the chance of finding stone
obstruction, and to establish a new channel for the bile
under any circumstances.
I found the common duct the site of a small hard mass
no larger than the end joint of one's thumb. The gall-
bladder was distended with a pint of black viscid bile ;
there were no stones in it.
The tumor was movable and could be pinched up be-
tween the thumb and fingers. It was hard enough to be
a stone bedded in an inflamed duct, but needling and
knife puncture showed it to be a small, hard neoplasm.
Further operation of any sort was prevented by the
extremely low condition of the patient at this juncture,
and an external bile fistula was quickly established.
With assiduous care the patient rallied well under Dr.
Campbell's attendance, and made an excellent convales-
cence. The jaundice quickly disappeared, strength and
appetite came back, and she gained flesh. The duct ob-
struction remained absolute. Stools continued white,
and a daily discharge of from fourteen to sixteen ounces of
bile was caught in a thin rubber bag secured to the drain-
age-tube.
At the end of three months she was in good condition,
and I operated to divert the bile into the duodenum.
The gall-bladder was atrophied, but readily separated
from the under side of the liver. Half a Murphy's button
was put into a slit in the gall-bladder, and half in the
duodenum six inches below the pylorus. The two were
united and the abdomen closed. The purse-string suture
of the thickened gall bladder made it a little difficult to
draw the slit within the grasp of the button, but an out-
side stitch perfected the union.
Examination of the small tumor of the duct showed
slight enlargement during the three months since first
operation.
Uninterrupted convalescence ensued. The button
was passed on the twelfth day.
Dr. Abbe also presented two specimens from the dog's
intestine, one illustrating end- to end union after resection
and the use of Murphy's button, the other long opening
formed by lateral anastomosis. There was no doubt, he
thought, but that the button could be used in the human
intestine with greater security and a more perfect result
than could be obtained by any other method with which
he was acquainted. The rim of the button cut out a
clean section of the gut, which did not show the tendency
to contract which was observed after making a broad
suture line.
Dr. Weir said fear had been expressed that some time
one of the buttons might fail to pass and constitute an
obstruction. It seemed, however, that experience had
proven this objection unfounded in the end-to-end anas-
tomosis. But it had been proposed to employ an elon-
gated button for lateral anastomosis. In the speaker's
opinion, the one shown and intended to accomplish this
end would prove a failure, as it did not provide for long
enough an opening. He inquired of Dr. McBurney
what had been the result in the case at Roosevelt Hospi-
tal in which Dr. Murphy had himself made end-to end
anastomosis with his button.
Dr. McBurney said the result had been successful,
but other operations would have to be performed, as had
been intended, before the patient could be dismissed
from the hospital.
In reply to an interrogatory, Dr. Abbe said the but-
ton came away in from seven to fifteen days. The quick-
ness of the operation and security obtained by thus sand-
wiching together the ends of the intestine, recommended
the method particularly to those who had not had great
experience with the technique of abdominal surgery.
Cases in Genito-urinary Surgery. — Dr. R. F. Weir
read a paper bearing this title. (See p. 161.)
A Medical Syndicate. — We read in one of the relig-
ious weeklies an enthusiastic notice of the adoption, by
two churches, in a town in Iowa, of a plan of assessing
every church member fifty cents a month; and in return
offering free medical attendance and three dollars a week
during illness, with the entire funeral expense in case of
death. — Polyclinic.
284
MEDICAL RECORD.
[September 1, 1894
<&otx*Bpou&sncz.
DR. EASTMAN'S METHOD OF SUPRAPUBIC
HYSTERECTOMY.
To ths Editor op the Medical Record.
Sir : In the current volume of the Medical Record,
page 147* you speak of my address before the Gyneco-
logical Section of the American Medical Association, and
say that my method consists of tying the uterine arteries
in the broad ligaments close to the corner of the uterus.
While the ligature in a given case may include the uter-
ine artery, the whole point of originality which I claim
was that the coiling arteries given off from the uterine
artery nourished the uterus by a plexus, and not by pen-
etrating the uterus ; therefore, instead of ligating the
uterine arteries at all, I go between them and the uterus,
peeling out even the entire cervix, and only perhaps oc-
casionally ligating some little spurting twig which has
been abnormally enlarged.
If I had said anywhere that I ligated the uterine
arteries, then there would have been nothing in my meth-
od to claim originality for. There may not be now, as
others had already gone from below upward, peeling
out the uterine cervix without clamp or ligature — notably
Sauter, of Constance, Germany, three quarters of a cen-
tury ago.
I repeat, the whole spirit of my essay, Section in San
Francisco, read before the Michigan State Medical Society,
was to prove that the coiling arteries of the uterus do not
penetrate that organ, but are spread out over it in a cap-
illary net-work, and that the uterine cervix can be peeled
out from above downward without clamp or ligature to
control hemorrhage.
Joseph Eastman, M.D.
Indianapolis- August 13, 1894.
BATHS IN INFLAMMATORY AFFECTIONS OF
CHILDREN.
To the Editor of tub Medical Record.
Sir : More than fifteen years ago you published an ar-
ticle of mine on the efficacy of balneotherapy in acute
bowel affections seen so frequently, and so deadly, in the
congested areas of ciiies during the heated term of sum-
mer. I have found this method as reliable as ever in my
experience since that time. I first wrote on this subject
in a report made to the Philadelphia Medical Times, in
July, 1875, then edited by Professor H. C. Wood (where
it appears under the head of " Correspondence "), and
subsequently I made reports once or twice for the Medi-
cal Record.
The tropical heat of this summer, and the fearful rate
of mortality in children under three years of age from
entero-colitis, leads me briefly to recall my original pub-
lications. Dr. Wood, after a most successul use of
baths in the Children's Hospital on the grounds of
the Centennial Exposition, 1876, did me the honor to
say (editorially), in 1877, » the Philadelphia Medical
Times: " It must be granted to Dr. Comegys the credit
of having introduced the most life-saving improvements
in modern therapeutics.' '
The application of these baths is so simple that they
can readily be applied in any house. We are summoned
usually to see a child who has already been sick some
time and undergone household treatment, and we find a
hot skin]; temperature, 1020 to 1040 F.; rapid pulse, 130
to 150 ; respirations, 30 to 40 ; with frequent vomiting
and purging ; tongue and mouth dry, intense thirst, in-
somnia, rolling of the head, and uttering distressing
cries.
I direct an immersion bath in hydrant water, which
with us in summer is about 750 F., and over the forehead
and scalp, the head being held in the hand, is poured a
stream of cistern water, 65 ° F. This operation is kept
up for several minutes — eight to ten. In a little while
the child ceases to cry and struggle, and it will drink
greedily of water. Often the lips become bluish and
the jaw trembles. After the bath, the patient should be
put unwiped in a blanket. The sedative effects of the
cold bath will speedily disappear, reaction is established,
and the child goes to sleep promptly ; the fever disap-
pears, the pulse has lost its frequency, the breathing is
slower and more natural, the vomiting and diarrhoea
cease.
For several years past I have ceased to use cold water
and rely entirely on hot bathing, always using a water
two or three degrees above the fever temperature of the
body, and keeping the patient submerged from six to ten
minutes; still, however, pouring cold water over the
head. I have made this change because the use of cold
water is so much more painful or distressing to the little
sufferers. When they are withdrawn from the bath they
are wrapped in a soft and warm blanket, where they will
sweat like a rain, and in this way the toxines which have
accumulated in the blood, and so depress the cardiac,
arterial, and capillary circulation, are eliminated and
convalescent conditions are promptly established. In
short, I have ceased to use cold baths in inflammatory
affections of any form in young children.
I will not discuss internal medication, but barely men-
tion small doses — one eighth grain — of calomel are very
useful ; or, what I like better, blue pill mixed with syr.
rhu. aromat. ; either remedy given in small doses every
three hours. Food: Good milk and cream in equal
parts and a certain amount of brandy every three hours.
If a fresh air location can be obtained, there is very little
danger of a relapse.
C. G. Comegys, M.D.
Cincinnati, O., August 13, 1894.
HYGIENIC TREATMENT VS. "EAR-RUBBING,"
FOR "HAY FEVER."
To tub Editor or the Mbdicai. Record.
Sir : A Hamburg physician (according to the Deutsche
Med. Zeitung), whose condition from hay fever had been
so severe as to necessitate his using a closed carriage all
through the summer (sic !) has for the past three years
" been able to lead an endurable existence during the hay-
fever season," by means of roasting his own ears, so to
say, "rubbing them till they became red and hot"
" As soon as the least sensation of fulness in the nose ap-
pears, there is recognized a certain amount of pallor in
the ears. A thorough rubbing of the ears, at times even
to contusion, has always succeeded in freeing the nasal
mucous membrane from its congestion. The rubbing
must be thorough and repeated as often as the least symp-
tom of congestion returns to the nose." The doctor
declares that several patients have also been relieved by
this method, and he hopes that some other physician may
be able to give his patients some relief ! This is indeed
a worthy ambition. But from the writer's point of view,
after years of the most complete success in the manage-
ment of the disease by a perfectly rational method, Dr.
Ferber's plan of relieving congestion of the nose by
means of counter-irritation, getting up a congestion of
the ears by rasping them till they are raw, seems pitifully
absurd.
In view of all that we hear and see of this terrible
enemy of the human race, it would seem that any remedy
that will enable a victim of hay fever to " lead an endur-
able existence " in summer should be widely published ;
but any doctor who recognizes this disorder as a local
fever, and does not directly cool his head instead of
warming his ears, ought to have the latter soundly boxed —
which, by the way, would answer in place of rubbing. (I
should be sorry to have my prescription misinterpreted.)
Hundreds of hay-fever victims spend the summer at
the White Mountains every year, where it is said the
majority find great relief, and some, indeed, complete
immunity from the disorder, in spite of the contin-
uance of the very practices which provoke the dis-
ease further south, viz., winter dress and diet. At
September i, 1894]
MEDICAL RECORD.
285
the North Pole we may guzzle blubber and wear several
layers of clothing without fear of fever, and so long as
anyone is ignorant or foolish enough to stick to his win-
ter dress and diet, as do, practically, all the hay- fever
fiends the writer has known, he must go far enough
north to give him something like winter atmospheric
conditions.
The disorder under consideration is without doubt
one of surfeit and skin smothering. A frugivorous
and abstemious diet, plenty of air-bathing, and the
abandonment of all superfluous clothing — every fibre
of clothing beyond a respectable covering of the body
should be regarded as superfluous — under- flannels worn
while the sweltering wretch prays for a cold wave, what
language can sufficiently emphasise such stupidity?
This principle applied to the limit makes hay fever
practically impossible. The same plan will speed the
core of an acute attack; proper head cooling and a
East day will do the rest.
The head is to be cooled in and in, moderately but
persistently, till marked relief is felt, and repeated as
often as the local fever returns. " I was wonderfully re-
lieved in two hours, and completely cured the second
day/' was the report from a distant patient to
whom I had wired the details of treatment. The fact
of the matter is, we may all not only " lead an endurable
existence" during the summer, but we may even be
aggressively happy in spite of torrid waves, if we keep
cool, as the artist mixed his colors, " with brains."
Charles E. Page, M.D.
8*7 Boylston Strut. Boston, Mass.
tion of the brain, and never remain in the water after a
feeling of chilliness supervenes.
Harvey Bashore, M.D.
W»st Fair vip w, Pa., August 33, 1P94.
BATHERS' "CRAMP."
Is it a Popular Fallacy?
To the Editor of the Mpdical Record.
Sir : We hear so much during the summer months of
cases of drowning caused by so called "cramp," that
even an experienced swimmer must almost be afraid to
venture beyond his depth. The newspaper article, com-
menting on a drowning case, generally begins with the
fact that the bather was a good swimmer, but that he
suddenly, when some distance from help, stopped his
exertions and sank; the case is labelled "death from
drowning caused by cramp."
Now, is this really so ? Is the bather — an adept per-
haps— liable to be struck down so quickly and without
warning ? If it is true, the danger from bathing in deep
water is so great that one is hardly justified in running
the risk.
I have not had the good fortune to analyze any case
of so-called " cramp," but I have knowledge of a case
of a young physician which, had it resulted fatally, would
probably have been so called ; as it was, the case did
not end fatally and the young man lived to tell the tale :
It was within two hours after eating a very hearty
dinner, and after considerable exercise, that the bather,
an excellent swimmer, took a plunge, feet first into the
cool (700 F.) water of Hell Gate ; immediately he arose
to the surface, an inconceivable feeling of nausea came
on, and everything before his eyes became hazy; he
remembers that in a mechanical way he kept his arms
and feet moving until help arrived, but during the whole
procedure he was in a dazed condition — in street par-
lance, he had " lost his head " — the result of the nausea
and possible congestion of the brain. Emesis was quickly
followed by return to health. Now, this I take as an ex-
ample of the danger which may befall anyone ; exhaus-
tion and cold are others ; spasmodic contraction of the
glottis from inhalation of water might be another ; in
fact, we have causes enough without calling everything
" cramp ; " and these causes may be reduced to a mini-
mum by following some of the well known hygienic rules
for bathing, as (see Rohe) : Never bathe within two
hour3 after eating ; never plunge in cold water feet first,
but always head first, so as to avoid tendency to conges
CONCERNING THE TABLET TRITURATE.
To the Editor or the Medical Record.
Sir : I believe there is a pretty general agreement among
physicians that the tablet triturate is one of the best
methods of dispensing medicines. Of the absolute re-
liability of these goods, as made by the best manufactu-
rers, there can be no doubt. They are inexpensive. They
are easily carried in the ordinary pocket case. The sub-
division of dosage in the case of children and others, by
crushing the tablet, is convenient. Not the least of the
valuable features of the tablet triturate is that it enables
the physician, by dispensing his own medicine, to limit,
in a measure, the tendency on the part of some druggists
to counter-prescribing. I believe, therefore, that one
point in their manufacture is worthy of attention. I re-
fer to stamping each tablet with a number. This has al-
ways been the custom of one large manufacturer. I
learn that another leading firm is about to introduce the
custom. This does not seem to me to be in the interest
of the physician. I know of some instances where pa-
tients, who have had tablet triturates prescribed for them
by a physician, have carefully preserved a numbered
sample, and gone to a druggist with the request to
" match " it ; something after the manner in which la-
dies match ribbons at the bargain counter. The only
reason I have ever seen given for numbering tablets is
that of one manufacturer, that if a physician breaks a
bottle, or if they become mixed in any manner, he could
identify and sort out the tablets by their number. This
is hardly a practical point, and breakage is little apt to
occur. I believe the tablet triturate has come to stay,
and I would like to see it manufactured exactly right in
every particular.
Geo. W. Milks, M.D.
xi Chiriy Stbbst, Oneida, N. Y.
THE SOCIETY OF RUSSIAN PHYSICIANS.
To the Editor of thb M«nc al Record.
Sir : In the Novoe Vremya, the popular Russian daily
newspaper, there lately appeared an account of the pro-
ceedings of the Medical Association which was founded
in memory of N. I. PirogofT.
In connection with an interesting report on juridical
medicine, it was said that the professional expert could
be viewed as merely a part of the legal machinery, under
direction of the judge, as a simple witness, and as a per-
son competent to value the significance of scientific facts,
and to determine, through special experiences, the anat-
omical changes brought about by an injury, or the ac-
companying psychological results (" data ").
As critique of the foregoing, and of the whole subject,
the reviewer stated that the sphere of the medico legal
testifier should be enlarged ; he should be empowered by
law, together with the judge, to give conclusions, thus
being able to show the necessary effects of the acts in
question ; and to keep apart all malevolent words or in-
sinuations. Before the lawmakers lies the problem : i.
The relations of the physician to the court, in the field
of medical jurisprudence. 2. The peculiarity and limits
of his activity. 3. The method of action as to expert
testimony ; especially the bearing of all these on peda-
gogic instruction, which is continually changing with the
advance of science.
After a discussion on disinfectants which had lasted
two hours, one of the delegates summed up the matter,
by saying: "The Zemtsvo (provincial legislature) sent
me here to find out what capable experimenters would
say — to learn something. I have listened long, and, I
regret to say, have not obtained anything of value ; I shall
have to go home with empty hands." *«—• '- ;- ~~* ♦*»-
Russia is not the
286
MEDICAL RECORD.
[September i, 1894
only country where vain words become wearisome to the
hungry mind.
The unhygienic condition of houses and villages was
said to be largely due to the fact that their location is
determined for the convenience of governmental admin-
istration, leaving out of view the topographical sanitary
relations. The question of making legally obligatory
the participation of medical men in the choice of build-
ing sites was considered by the society. The section in
re decided that a medical inspection of new buildings
was desirable. On account of extensive infectious dis-
eases of the eyes, in villages scattered over the land, it
was determined to recommend the use of preventive
means at the time of birth.
The psychological division of the congress adopted a
resolution for the appointment of a committee to take
statistics of those showing evidence of mental infirmity
and of the insane. They hoped, by this means, to re-
lieve many now suffering in chains and hovels. Inter-
esting demonstrations of nervous phenomena, in the
perception of sensation, were given by the section de-
voted to psychiatrics. One physician stated that the in-
dications of mental disease in Western Europe and in
Russia were not identical.
An address was read advocating the systematic regis-
tration of sickness and death from tuberculosis, the same
as in cases of infectious diseases.
From the remarks of one surgeon we learn that his
recent microscopic observations, experiments, etc., make
probable the parasitic origin of tumors, especially malig-
nant ones. This tends to corroborate statements made
by other investigators.
The next meeting of the society is arranged for the
spring of 1896, in the heart of Old Russia, at the sacred
city of Kiev.
F. B. Stephenson, M.D., U. S. N.
Boston, Mass., August 13, 1894.
OUR LONDON LETTER.
(From our Special Correspondent.)
the british scientific congress at oxford — lord
Salisbury's address as president — the outbreak
of small-pox — arrival op a case of cholera on
A STEAMER — THE BACILLUS OF PLAGUE — DR. GRIF-
FITHS— DR. WIGLESWORTH — SIR JOSEPH FAYRER.
London, August tx, 1894.
No sooner have we finished our trip to Bristol for the
British Medical Association, than we must hasten to
Oxford to attend the meeting of its parent — the British
Association for the Advancement of Science. This year
is somewhat exceptional, as a great political leader has
consented to preside, and there are rumors that his ad-
dress will deal with the unsolved problems of science.
The President is no other than the Marquis of Salisbury,
who is Chancellor of the University of Oxford, but who
appears on this occasion rather in the character of his
F.R.S. It is known well enough to a few that his
Lordship's studies have been by no means confined to
the ancient learning or dimmed by his ardor in politics,
but have extended so far in scientific directions as to
entitle him to a high place among practical scientists.
In some points his researches have been greatly appre-
ciated, but no little curiosity was felt and expressed as to
what he would say in his presidential address. Let me
say at once that this address would have been no disap-
pointment had it come from one of the masters whose
whole life had been devoted to science, and when we
remember the other directions in which Lord Salisbury's
mind has been engaged, it is very remarkable. He
showed himself at home in the theories of the chemi-
cal elements, in the discoveries of the spectroscope, and
the problems of the ether. From these unsolved enig-
mas he passed to the riddle of life and sketched with
a master-hand the controversy that has raged since
Darwin's " Origin of Species " appeared. The effect of
this work was shown and its proved results admitted,
while the differences of view existing were also stated.
The differences between the mathematicians and biolo-
gists were touched upon, but his Lordship said he would
not get into the line of fire between them by intervening,
and until the differences are adjusted laymen are justified
in giving a verdict of " not proven " on the tremendous
issues raised by the most advanced Darwinians. Then
came a caveat against the " great danger scientific re-
search is running at the present time, the acceptance of
mere conjecture in the name and place of knowledge, in
preference to making frankly the admission that no cer-
tain knowledge can be attained." This point was illus-
trated by a reference to Professor Weismann's dictum,
that we must accept natural selection because, if not, we
must fall back on the agency of design, which the pro-
fessor seems to look upon as an inadmissible conclusion,
or even a heresy. But Lord Salisbury's statement will
not easily be met by Professor Weismann, especially as
he reinforced his logic by falling back on the judgment
of Lord Kelvin, " the greatest living master of natural
science among us," and quoting the peroration of that
master's address from the same chair, more than twenty
years ago, these significant words :
" I have always felt that the hypothesis of natural selec-
tion does not contain the true theory of evolution, if
evolution there has been in biology. ... I feel
profoundly convinced that the argument of design has
been greatly too much lost sight of in recent zoological
speculations. Overpoweringly strong proofs of intelli-
gent and benevolent design lie around us, and if ever
perplexities, whether metaphysical or scientific, turn us
away from them for a time, they come back to us with
irresistible force, showing to us through nature the in-
fluence of a free-will, and teaching us that all living
things depend on one everlasting Creator and Ruler."
Small-pox is still with us. The outbreak at St. John's
Wood, which I reported, is the most serious we have had
since 1885, DUt ** appears to have been conquered by the
determined and active intervention of the sanitary
authorities. But for the energy displayed, we might
have found it extending to the whole metropolis.
A steamer arrived off Gravesend, from St. Petersburg,
bringing cholera, one of the crew having died on the
short voyage. The vessel was visited at once by the
medical officer of health, and one or two suspicious cases
removed for observation. The bacteriological diagnosis
is cholera. We may probably have other importations,
but if all are as carefully segregated we may perhaps es-
cape an epidemic.
The bacillus of the bubonic plague has been sent to
London, and was exhibited at Bristol also, where a very
fine collection of cultivations of bacteria was shown by
the Institute of Preventive Medicine ; all sorts of micro-
organisms were exhibited growing on various media,
and would give the opportunity of acquiring or extend-
ing knowledge to most people, could time be afforded for
serious study. Of course, in a crowd at such an exhibi-
tion this is impracticable.
Dr. Griffiths, of Swansea, to whose cruel case of slan-
der I have alluded in previous letters, has received ^500
from the fund started in his defence, with an illuminated
address of sympathy.
The medical superintendent of Rainhill Asylum, Dr.
Wiglesworth, has been stabbed by one of the lunatics
who had concealed a knife in his sleeve. The wound is
serious, and the doctor not yet out of danger.
Sir Joseph Fayrer is about to retire from the service in
which he has done such admirable work.
Double Pay for Twins. — A man in Ohio was arrested
not long ago at the instance of a woman who claimed
that he was the father of her unborn child. He was re
leased on payment of #300. But when the time came it
was found that there were twins, and the poor man was
arrested again, and the penalty for his misdoing was
promptly doubled by a sympathetic jury.
September i, 1894]
MEDICAL RECORD.
2S7
f^ero %xi&txximzntB.
A LID ELEVATOR FOR CATARACT OPERA-
TION.
By EDWARD SWASEY, M.D.,
WORCESTER, MASS.
OCULIST AND AURIST TO WORCESTER CITY HOSPITAL
The most troublesome instrument that is used about the
eye in removal of cataract, and in all operations in which
the globe is opened, is undoubtedly the speculum. And
moreover, it is always a possible means of injury to the
eye, for the patient may at any moment forcibly press it
down upon the globe by the strong action of the orbic-
ularis muscle, and if the corneal section has been com-
pleted, he will almost surely force the lens out pre-
maturely, and not infrequently some ot the vitreous will
follow it.
Because of this danger, some of our best operators care-
fully remove the speculum as soon as the lens capsule
r:zz^:^3
has been opened, and thus avoid this possible dangerous
compression of the incised globe. Others do away with
the speculum entirely, and elevate the upper lid by means
of the lid elevator, held by an assistant But the arm of
an assistant is unavoidably more or less in the operator's
way, and must be worked around, even if a trained and
trustworthy hand of an assistant could always be at com-
mand to hold the elevator. But an instrument which
securely holds the lid open, and has its point of anchor-
age outside the lids, is much freer from the danger of this
compression of the eye than is the speculum, which sim-
ply rests within the lids. And at best, the speculum is
an awkward instrument to unlock and remove from un-
der the two lids, at a time when the utmost gentleness is
necessary in every step of the operation. At least I have
found it so, and seeing the simplicity of the lid elevator,
I have tried to make use of it, and yet be free from an
assistant. The little device shown in these drawings ac-
complishes the object. The lid-hook of the elevator is
carved into the shape shown at A, and it then holds se-
curely under the lid ; the ordinary form is at once tilted
from under the lid at the first attempt to close the lid.
This is attached by a flat-linked chain to a small, blunt,
shallow hook on a forehead piece which is securely held
in place by the ordinary head-band. The chain is two
and a half inches in length, and has eleven open links,
which admit of fine adjustment of the lid elevation ; the
hook gives an additional length of half an inch. The
shallow hook allows the quick and easy removal of the
chain without forcibly drawing on the lid, and once de-
tached the lid hook is as readily slipped from under the
lid as any elevator. The flat links adjust themselves to
any angles that are found from the lid piece to the head-
band, and the whole field of view is unobstructed for
the operator. The patient cannot even begin to close
his eye with this in place.
The chief objections I find to the Pyle instrument1 are
that it projects forward from the brow so far that it se-
1 Medical Record, August i, 1891, p. 139.
riously obstructs the operator's view, and the adjustments
are so many, too much mechanism is required. I have
made use of the instrument here described in cataract
operations, and it certainly has advantages over the or-
dinary speculum ; it is so quickly and easily removed.
George Tiemann & Co., of New York, made the instru-
ment for me.
A POCKET PELVIMETER.
By HERMAN L. COLLYER, M.D.,
NEW YORK.
GYNECOLOGIST TO THE WEST SIDE GERMAN CLINIC, ASSISTANT GYNECOLOGIST TO
THE FRENCH HOSPITAL, El C.
The measurements of the female pelvis are so great a
necessity in obstetrics that I feel a simply constructed,
inexpensive instrument, within the reach of every physi-
cian, would be very acceptable, and would tend to en-
courage pelvimetry in the profession generally.
It is a frequent occurrence that a contracted pelvis is
unrecognized until the labor has become tedious, at a
time when symphyseotomy is made difficult by the delay.
In my first case of elective symphyseotomy, performed
successfully June 5, 1894, I was led to devise some ac-
curate, inexpensive pelvimeter, possessing all the advan-
tages of the expensive instruments, and correcting some
of their disadvantages. As the idea is purely original, I
may say, I hope by the insertion of this article my read-
ers will derive benefit from my endeavors and be encour-
aged to practise pelvimetry more extensively.
The instrument is twelve inches long, elliptical in
shape, capable of measuring to the extent of fourteen
inches, with a pivot hinge and thumb-screw attached to
one end. At this end there is a semicircular plate,
marked legibly with the metric system on the one side,
and the English system of measurement on the other, in
a convenient position to be read easily. The advantage
of having the two systems together is very great, as it
admits of ready comparison and reference.
Through the kindness of Mr. J. Welker, instrument-
maker, of this city, I am able to present to the profession
a portable and inexpensive pelvimeter, which will, I
think, commend itself to everyone.
109 East Fifty-fourth Street.
Salines operate in three or four hours. Croton-oil in
one or two hours. Jalap, gamboge, and senna in three
or four hours. Rhubarb and castor-oil in from four to
six hours. Aloes and mandrake in from ten to fourteen
hours. — Louisville Medical Monthly.
288
MEDICAL RECORD.
[September I, 1894
IJfcedical Sterna
Contagions Diseases— Weekly Statement— Report of
cases and deaths from contagious diseases reported to the
Sanitary Bureau, Health Department, for the week end-
ing August 25, 1894.
Tuberculosis
Typhoid fever
Scarlet fever
Cerebro-fpinal meningitis
Measles
Diphtheria
SmaH-poi
Caies. Deaths.
86
"5
26
7
22
X
O
2
IX
2
"3
36
7
0
To Increase the Birth-rate of France. — Stringent
laws have recently been enacted by the French Govern-
ment, which, despairing of obtaining any increase in the
birth- rate of the land, is endeavoring to save the few
children that are born. One of these regulations forbids,
under a severe penalty, anyone to give infants under
one year any form of solid food, unless such be ordered
by a written prescription, signed by a legally qualified
medical man. Other regulations are equally restricting,
and, as the French have a knack of enforcing their en-
actments, down to the most trifling ones, as American
visitors to Paris often find to their cost, it is probable
that many childish lives will be saved. One could wish,
on seeing an East-Side tenement mother feeding her few
months' old baby with a peach or banana bought from
the curb fruit-stall, after half a day's exposure to the
August sun, that the municipality of New York would
copy a few of these French regulations. It would vastly
lessen the work of the dispensaries and visiting tenement
physicians.
The Treatment of Diphtheria with Immunizing Se-
rum.— Professors Ehrlich, Kossel, and Dr. Wasserman,
in Berlin, have published a paper on the application
of curing serum, as invented by Professor Behring, as-
sistant of Professor Koch. Behring had undertaken to
give an immunity from the diphtheritic poison, and
after that to get a serum from the blood of those
animals, by which he hoped to protect individuals of
the human race against the results of diphtheria, as
well as to cure the disease when already developed in an
individual. Ehrlich, Kossel, and Wasserman have fol-
lowed Behring in his experiments. They always had in
view to use the results of their experiments for curative
purposes. They experimented on goats. We will say
nothing of the technical dates for giving the serum.
Two hundred and twenty patients with diphtheria were
treated with the serum. Of these there were cured 168,
or 76.4 per cent.; 52 died. Tracheotomy was performed
in 67 cases, of which 30 died ; the rest recovered. But
a true insight of the curing effects of the injections is
gathered only by grouping the number of the diseased
people by the days after the infection on which the
treatment was begun :
Day after be-
gt fining of
Treated.
First day 6
Second day ... 66 (9 tracheot-
omies.)
Third day ao (8 tracheot-
omies.)
Fourth day ... 39 (14 tracheot-
omies. )
Fifth day 23 (10 tracheot-
omies. )
Cured.
64 (7 tracheot-
omies. )
25 (7 tracheot-
omies. )
30 (10 tracheot-
omies.)
13 (4 tracheot-
omies.)
Died.
a (a tracheot-
omies. )
4 (1 tracheot-
omy.)
9 (4 tracheot-
omies.)
10 (6 tracheot-
omies. )
Percentage
of cures.
100
97
86
77
56-5
It is to be seen by this table of dates that the safety of
the serum treatment depends essentially upon the date
on which the treatment of the children is begun, and
that on the first day results were had never seen before.
Of 72 children received at the hospital during the first
two days of the disease, there were only 2 deaths ; of 72
cases treated without serum after statistics reaching over
twenty five years, there were 25 deaths, or 34. 7 per cent
The above- named experimenters give the following
points of view for the treatment with their serum of those
children sick of diphtheria : 1. The fate of the children
depends upon the treatment during the first three days 0/
the sickness. Therefore the serum should be injected as
soon as possible after the beginning of the disease. 2.
As there must be a surplus of antitoxine in the sick body,
the dose of commencement should be, in light cases, at
least 200 unities of immunization. In cases of gravity
and in those tracheotomized, 400 unities were needed.
The treatment with serum should be continued some
time after ceasing of rise of temperature and of the local
inflammation. The total amount of dispensed serum
may reach in a single case (in correspondence with the
gravity of the symptoms) 500, 1,000, 1,500 unities of im-
munization.— Berlin Correspondent Journal of American
Medical Association.
A Revival of Hindu Medicine. — The educated na-
tives of India intermittently advocate, through the native
press, the resuscitation of indigenous and time-honored
methods of treating disease which have' fallen into disre-
pute and disuse. The merits of ancient drugs and of
primitive practices and practitioners are on such oc-
casions vaunted as being better in themselves and better
adapted to the people and circumstances of Hindustan
than exotic systems and medicines. It appears that dis-
pensaries have been established in the native states of
Travancore and Mysore, for the purpose of giving the
natives of these territories the benefits of Hindu medi-
cines, which are considered more congenial, cheap, and
efficacious than foreign medicines. Foreign surgery is
allowed to be infinitely superior to native, and no at-
tempt is made to compete with that. It is recognized
that native doctors are, with few exceptions, ignorant
and uneducated, and it is proposed to teach them
"chemistry, physiology, hygiene, and other kindred
subjects. *
Worse than " Pidgin."— Dr. W. P. Noble, of Pao
Ting Foo, China, sends us the following letter, addressed
to him by a native in government employ in that city :
" I am deject indeed for I got a kind of measles and
cannot come to your Hospital because on duty this
noon; I not know whether you can come to my office
or not, I hope you come and let you know what measles
it is. If you allow me well much hosanna recieve from
you. I cannot conceal my sickness from you. When I
make water the water come to the end and stop there
until a little while, then meander out in that time of
which I speak that is very painful. I hope you excuse
me at once.
"Yours respectifully,
" P. S. W."
The Difference.— When a lawyer defends a man for
his life, and by some technicality or shrewdness he gains
his case that lawyer is often spoken of as " that man
who saved my life." When a person is stricken down,
we will say with strangulated hernia, just as sure death
as hanging unless relieved, he sends for the physician,
who understands this technicality of nature, and relieves
him, saves him not from the gallows, but death. He
does not say "that physician saved my life," but
"through the providence of God I escaped death." —
Charlotte Medical Journal.
Lively Apothecaries and Deadly Consequences. — In
Stendal, not long since, the police forcibly closed a drug-
store where they found the proprietor away, and the two
clerks intoxicated. Before their condition was discovered
they had compounded a number of prescriptions, mixing
up various drugs without any regard to directions or
dosage.
The Plague in London in 1664, with which the pres-
ent epidemic in China is believed to be identical, caused
69,000 deaths out of a total population of 460,000.
Medical Record
A Weekly yournal of Medicine and Surgery
Vol. 46, No, 10.
Whole No. 1244.
New York, September 8, 1894.
$5.00 Per Annum.
Single Copies, ioc.
<&ri0ttrat Qxtitlts.
SOME CONSIDERATIONS ON DIFFERENT TYPES
OF EXUDATIVE INFLAMMATION.*
A Study Based on Bacterial Examinations from One
Hundred and Thirty-five Surgical Cases.
By CHARLES N. DOWD, M.D.,
NEW YORK.
ASSISTANT SURGEON TO THK NEW YORK CANCKR HOSPITAL.
It is evident that all inflammations which call for sur-
gical treatment are not alike : some spread in the tissues
rapidly and persistently; some remain localized, but
cause necrosis of the involved tissues; others neither
spread far nor cause severe injury to the affected parts.
Again, some cause profound constitutional disturbance
with very slight local effect, while others produce
extensive local disturbance with slight constitutional
effect. Some cause discharges of greenish, odorous pus,
so profuse as to quickly saturate bulky dressings; others
give only a small amount of thin, sero purulent effusion.
These differences are largely due to the particular species
of bacteria which cause the inflammation, and to varia-
tions in virulence which bacteria of the same species may
show, although the site of the infection and the condi-
tion of the patient may have much influence.
In the effort to investigate the subject, we have in the
past year made bacterial studies from 135 cases which
were seen in the Vanderbilt Clinic, the New York Can-
cer Hospital, and in two instances in the practice of other
surgeons who gave us the opportunity of studying cases
of pyaemia.
Those seen at the Vanderbilt Clinic were ambulant
cases ; a large number of them had acute forms of sup-
purative inflammation, which had originated from small
wounds or had extended into the subcutaneous tissues, so
as to cause cellulitis of greater or less extent. Some had
fresh wounds with little inflammation about them ; some
granulating and healing wounds, and some furuncles
and abscesses of a less acute type.
Those seen at the Cancer Hospital were operative
cases. In some of them ulcerating growths were exam-
ined before operation ; in others wound discharges and
stitches were examined after operation.
The cases may be clinically grouped as follows :
Cases.
Cellulitis 51
Fresh infected wounds 17
Granulating wounds. 18
Healing wounds (stitches). 5
Furuncles 7
Abscesses 37
The material for study was obtained on the sterile
swabs which have been described by Dr. Park.1 They
are made by twisting bits of cotton on the ends of pieces
of stiff wire. They were inserted into the depths of the
wounds so as to avoid surface contamination, and were
immediately streaked across agar Petri's plates. The
plates were then put into the thermostat and the
growths studied in the ordinary way with the microscope,
and by further gelatine and beef- tea cultures ; also by
animal inoculations in certain instances. In a large pro-
• Read before the Surgical Section of the New York Academy of
Medicine, March 12, 1894.
portion of the cases morphological studies of cover-glass
preparations of the pus were also made.
The bacterial work was done, with the collaboration
of Dr. William H. Park, in the Bacterial La t oratory of
the College of Physicians of New York City, or in con-
nection with that laboratory.
The following table indicates in a diagrammatic way
the results of the examinations :
ii
Streptococcus pyogenes alone . 9
Streptococcus pyogenes predominant 23 1
Streptococcus pyogenes relatively few 3
Staph, pyogenes aureus alone z z 1
Staph, pyogenes aureus predominant 8
Staph, pyogenes aureus relatively few Z3
Staph, pyogenes or epidermis albus alone x
Staph, pyogenes or epidermis albus predominant
Staph, pyogenes or epidermis albus relatively few.. J zo
Staph, cereus albus 3
Staph, citreus z
No growths on agar
Very few growths on agar
Bacillus pyocyanus .. '
Bacillus coli com muni
Overgrown 4:
Few undetermined colonies za
fflju.srj
'3 ' -
3
v
u
In those instances in which streptococcus pyogenes
are recorded " predominant," the associated forms were
mostly staphylococci, and in those instances in which
staphylococci are recorded predominant, the associated
forms were mostly streptococci.
Analysis of the Tabulated Besults. — From all the
cases in which there was acute inflammation accompa-
nied by severe constitutional symptoms, abundant cultures
of streptococcus pyogenes or of staphylococcus pyogenes
aureus were obtained; frequently both existed in the
same case. These two organisms were by far the most
important ones found, and as there were well-marked pe-
culiarities in many of the inflammations which they
caused, it may be well to give a somewhat detailed ac-
count of the conditions in which they occurred. To
this we add a description of the conditions in which cer-
tain other forms were found.
Streptococcus Pyogenes. — Among the fifty one c*ses
of cellulitis studied there were eight which showed a per-
sistent tendency to spreading inflammation with under-
mining of the tissues, which continued in spite of free
incision, careful packing, and mcist dressing, and in all
of these streptococci were found.
As an example of this group we may note one in
which an inflammation which involved the entire fore-
arm spread rapidly from a small butcher- knife cut on the
back of the hand ; free incisions were promptly made,
the wounds were carefully packed with gauze, and moist
antiseptic dressings were applied, much of the time daily.
Still fiie inflammation continued for more than three
months, the fascia sloughed away in large pieces, and
there was a continual undermining of the tissues, with
the formation of pus pockets even when healing was pro-
gressing at the margins of the incisions; and finally the
patient was left with a stiffened hand and wrist. Re-
peated bacterial examinations of the pus showed only
streptococci pyogenes in the depths of the wound, while
a few staphylococci were also twice found on the sur-
face.
290
MEDICAL RECORD.
[September 8f 1894
The two cases of pyaemia illustrated the same charac-
teristic spreading, undermining streptococcus inflamma-
tion. In bov.h; the streptococcus and staphylococcus
pyogenes aureus were found in the original wounds,9
while in the metastatic abscesses the streptococci were
found without the staphylococcus pyogenes aureus. In
the first a phlegmon of the arm appeared a week after
the operation, and progressed until it involved the
entire arm and hand ; a little later there was a similar
phlegm Dn in the back; there was also inflammation
in several of the joints. Incisions were made at differ-
ent times in five separate places in the back and arm,
and pure cultures of streptococci were obtained from the
pus found at each incision; the abscesses were persist-
ent ; the one in the back remained open six months, un-
til the patient's death. In the other case the metastatic
abscesses were of a similar character, but less extensive.
This spreading, undermining characteristic of strepto-
coccus inflammation has been often described and is well
established. Inflammations of this variety were the most
virulent which we had to deal with ; no available treat-
ment seemed sufficient to promptly limit the growth of
the streptococci in the tissues; cultures could be ob-
tained from the walls of the pockets after washing them
with a 1 to 1,000 solution of bichloride of mercury, and
free and early incision and packing did not prevent the
undermining process of the inflammation.
There was a group of cases closely allied to these in
which streptococci were always found; cases which
represent an intermediary phase between typical cellu-
litis and typical erysipelas. In the skin there was indu-
ration and an inflammation somewhat less distinctly mar-
ginated than in typical erysipelas ; in the subcutaneous
tissue a little pus was found.
The condition is illustrated by the following case : A
healthy man scratched his hand on a dry-goods box one
week before admission to the clinic. Three days later
he began to have pain on the anterior surface of the arm
j 1st above the elbow, and at the same time he had a chill.
Oa admission there was an indurated area on the anterior
surface of the arm about 5x6 inches in extent. The
skin was oeiematous and red. On the outer side the
redness was marginated and extended half way down the
forearm. Oa the inner side it was not marginated.
Temperature, ioo° F. ; pulse, 80. There was hardly any
axillary tenderness or enlargement of lymph nodes.
There was no distinct fluctuation, but an aspirating needle
inserted just above the elbow withdrew pus from which a
pure culture of streptococcus was obtained.
Most surgeons would not call this erysipelas, but in
the seven cases which were of this general type we were
much puzzled to know whether we were dealing with ery-
sipelas or cellulitis, and in one instance a patient who
had diffuse induration and inflammation about an infected
wound, which seemed far less like erysipelas than the
above, returned on the second day with typical erysipelas
so well marked that no one would question the diag-
nosis.
Cases like these make a chain of union between erysip-
elas and cellulitis, which would lead us to believe that
there is no absolute and fundamental distinction between
the two phases of inflammation. This is practically the
same ground which bacteriologists have taken.
Passet.2 Rosenbach,8 Prudden,4 Biondi,5 Fraenkel,6
Roger,7 Welch,3 Baumgarten,* Kirchner,10 Crookshank,11
and many others, have studied the relationship between the
streptococcus pyogenes and streptococcus erysipelatis,
and the weight of authority indicates that there are no
constant differences between them, and that the varia-
tions are no greater than are frequently seen in individuals
of the same species.
It is, however, a point of considerable importance, that
infection from one type of streptococcus inflammation is
likely to reproduce the same type. Infection from erysip-
elas is likely to cause erysipelas, as all surgeons know and
as Fehleisen n proved by a series of inoculations. Just
how likely it is to produce other forms of inflammation
we do not know, but Coley" in making 120 inoculations
to produce erysipelas, only caused two abscesses, and
these he thought were due to contaminations of staphy-
lococci Hajek 14 found that the original type of strepto-
coccus inflammation was usually reproduced in inoculated
animals.
This close alliance between erysipelas and phlegmonous
inflammation is a matter of much practical importance.
We fear erysipelas and avoid all contact with it when
engaged in operative work. The man who would care
for a case of erysipelas and then do an operation or at-
tend an obstetric case, would be considered very culpable.
Yet the same precautions are not taken in regard to other
kinds of streptococcus inflammation. A suppurating
wound in which the pus teems with streptococci is cer-
tainly more likely to contaminate the surgeon's hands
than a case of erysipelas is, and this contamination may
well be followed by suppuration, phlegmonous inflamma-
tion, or perhaps by pyaemia, in the patient whom he oper-
ates upon soon afterward. But such an occurrence would
be considered an unavoidable wound accident, while the
erysipelas, which is more characteristic, would be traced
to its true source. The danger of transmitting erysipelas
has long been guarded against, because the infecting case
and the infected case so closely resemble each other.
But when we remember that in any case of streptococcus
inflammation we are dealing with a germ which is not to
be distinguished from that which causes erysipelas, and
furthermore, that it is often capable of causing an inflam-
mation more virulent than erysipelas, it is obvious that
the greatest care is necessary to avoid transmitting in-
fection.
Beside these groups of cases, streptococci were fre-
quently found where there was nothing particularly char-
acteristic. They were present in 65 out of the 135
cases examined. They were found in almost all the cases
of severe inflammation, but they were also present in
many of the mild ones, and they did not always cause a
spreading inflammation. In one instance they were
found in almost pure culture in a finger bleb which
seemed hardly more than a large blister, and which had
existed for several days without showing acute inflamma-
tion. Whether these differences depend on the varie-
ties of streptococci and their variations in virulence
on the constitution of the patient, or on the thorough-
ness of the inoculation, one can hardly state. Probably
all these factors have their influence. The condition
finds its parallel in other forms of infection ; for example,
the bacillus typhosus sometimes causes only a slight fever
and sometimes causes death, and Loeffler's bacillus some
times causes a slight sore throat, and sometimes a diph-
theria which is quickly fataL
Variations in the growth of the streptococci were no-
ticeable. Some grew in long chains and some in short
ones ; and the colonies differed in their general appear-
ance microscopically and macroscopically, also in the
quality of imparting cloudiness to the beef-tea in which
they grew. In view of the work of v. Lingelsheim 15 on
the subject, we noted the relationship between the length
of the chains and the virulence of the infection, and
found that in certain instances the short- as well as the
long-chained varieties were virulent.
Staphylococcus Pyogenes Aureus. — In the entire series
of 135 cases it was found in pure cultures 26 times,
and in no one of these cases was there a spreading in-
flammation. The cases of cellulitis of the hand illustrate
this well — there were 1 1 of them in which staphylococcus
pyogenes aureus alone was found, and in no instance did
the inflammation extend upward so as to make incision
above the wrist necessary ; while in the 23 cases in which
streptococci were the predominant bacteria, there were 5
in which incision was necessary at some point above the
wrist, and streptococci were found in these incisions.
A boil illustrates in a limited way the type of inflam-
mation which these staphylococci cause : a severe in-
flammation producing necrosis of tissue and giving a
comparatively severe constitutional reaction, but not
September 8, 1894]
MEDICAL RECORD.
291
spreading widely by direct extension. Seven boils were
examined, and all had them in pure culture.
- The following case also illustrates this kind of inflam-
mation : The patient sustained a compound fracture of
the middle phalanx of the ring-finger, which was followed
by inflammation in the soft parts and in the bones.
Three weeks after the injury amputation was done through
the proximal phalanx, in the hope of preserving a part of
the ringer, but suppuration continued in the soft parts of
this stump for more than two months. The inflamma-
tion, however, never extended above the finger. It was
severe enough to destroy the bone before the amputation
and to keep up a most tedious suppuration after it, but
it did not show any tendency to extend upward.
Cultures were made from this wound at six different
times, and unmixed growths of staphylococcus pyogenes
aureus were obtained in all instances excepting one ; in
that one a contamination — presumably saprophytic — was
also found. We are well aware that these staphylococci
may enter the blood current and cause a fatal pyaemia,
and that they have been found in many cases of osteo-
myelitis,16 but in this series of cases they remained loca-
lized even when the streptococci which accompanied
them in the original wound caused metastatic abscesses.
These staphylococci have frequently been considered
more important than the streptococci, but the recent bac-
terial studies indicate that the streptococci are the more
important and the more common ; in this series of cases
they were certainly so. It is to be remembered that the
staphylococci grow in large thick colonies on the agar,
while the streptococci grow in small thin colonies;
hence it is possible that in some cases which have been
reported the streptococci may have been covered by the
large colonies of staphylococci. One of the cases here
recorded shows how easily such an error could be made.
An infected wound was surrounded by an inflammation
which had the appearance of a streptococcus inflamma-
tion, but the first culture showed abundant staphylococci
and very few streptococci; a second culture, however,
taken on another day from an undermining part of the
wound, showed streptococci almost alone. It would ob-
viously have been an error to conclude from the first ex-
amination that this was an instance of staphylococcus
inflammation. The difficulties of finding the colonies of
streptococci are greater where roll tubes are used than
with Petri's plates.
Staphylococcus pyogenes aureus was also found in cer-
tain instances in mild inflammations in which there was
nothing particularly characteristic.
The inflammations caused by staphylococcus pyogenes
aureus were much more easily controlled than those
caused by streptococci. Moderate- sized incisions with
gauze packing and moist, mild antiseptic dressing, were
usually quickly efficient.
Staphylococcus Pyogenes Aldus — Staphylococcus Epi-
dermis Albus.— Besides those mild cases already referred
to there was a group of cases which showed a mild
form of inflammation and gave cultures of white staphy-
lococci, or in certain instances of lemon-colored staphy-
lococci. One could not say that in all mild cases only
these staphylococci were to be found, but where they
alone were present the inflammation was always of a
mild type.
The white staphylococci were found in pure culture in
thirteen cases. Only one of these was a case of cellulitis,
and that was sufficiently interesting to merit particular
attention. The point of infection was apparently a pal-
mar blister at the base of the middle-finger ; the inflam-
mation extended into the palm and between the fingers,
and caused considerable swelling and superficial fluctua-
tion. There was, however, little pain or constitutional
disturbance, and on incision the pus was found to lie
mostly just below the epidermis, which was raised from
the true skin. After incision the inflammation subsided
very quickly. Bacterial examinations were made four
different times, and white staphylococci were found in
pure culture each time.
This was manifestly a very mild form of inflammation,
and the other conditions in which the white staphylococci
were found indicated an equally mild action. Five
times stitches were examined from wounds which healed
aseptically or with only slight moisture, and from four
of them pure cultures of the white staphylococci were
obtained. They were also found alone from a needle
used in the skin of a clean wound and from a clean
drainage opening. Once they were found in pure cult-
ure in a blood- clot under which a resected finger- joint
had healed; twice in old sinuses which led to dead
bone ; and they were almost always found in superficial
granulating wounds.
Hence we see that in all instances they were so found
as to indicate that they had a very mild infective power.
They were found in association with other bacteria very
frequently in wounds which had been opened. In these
instances it is believed that they were carried in from the
skin, and that usually they were not the cause of the
original inflammation.
In 1884-85, when the classical articles of Rosenbach n
and Passet 18 appeared, describing the pyogenic cocci
which they found in acute inflammations, the staphy-
lococcus pyogenes albus was believed to be of practically
the same pyogenic power as the staphylococcus pyogenes
aureus with which it was usually associated. This belief
was based largely on animal inoculations.
In the only case, however, in which Rosenbach found
the albus in pure culture, the inflammation was of so mild
a type as to have been clinically considered gonorrhoea!
rheumatism of the knee.
Passet did not record the clinical histories of his
cases. Since that time numerous observations have been
recorded which indicate that they are usually of very
mild pyogenic power.
Welch8 has made a very extensive study of the subject,
and has found white staphylococci regularly present in
the skin, and frequently present at the margin of healing
wounds. He found that they usually did not interfere
with the healing of wounds if the tissues were in good
condition. Although they might occasion stitch ab-
scesses or a little suppuration along drainage openings, or
where the tissues were strangulated, they might cause
severe inflammation. Their pyogenic power was so
slight that he considered the term staphylococcus epi-
dermis albus preferable to staphylococcus pyogenes albus.
Whether staphylococcus epidermis albus and staphy-
lococcus pyogenes albus are the same organism, is not
entirely settled, but Welch's suggestion that the former
may be a modified form of the latter, certainly meets the
requirements of the present stage of the investigation.
In this series of cases no effort has been made to
separate them. Those colonies which remained white
on the agar for several days, which were morphologically
like the pyogenic staphylococci, and which fluidified
gelatine, were recorded simply as white staphylococci.
Among the other observers who have found white
staphylococci of mild infective power, we may mention
the following :
Grisky and Robbw found them in nineteen out of
forty- five laparotomy wounds, and they did not prevent
prompt healing.
Bossowski20 found them in wounds which were treated
aseptically, but they did not interfere with the healing in
any marked degree.
Lanz and Flach,2i in examining wound discharges,
found that where staphylococci pyogenes aurii were
present there was severe suppuration in all the cases but
one, and that where the white staphylococci alone were
present the wounds regularly healed well.
Many cases of serous effusion have been reported
which contained the white staphylococci. Levy22 pro-
duced suppuration in rabbits in two instances from white
staphylococci so obtained. For further literature on the
subject, the reader is referred to Jordan w and Sternberg.28
These observations indicate that the white staphy-
lococci usually cause a much milder type of inflammation
292
MEDICAL RECORD,
[September 8, 1894
than the golden ones. We say usually, because we must
recognize the variations in virulence which are shown by
all the forms of bacteria which we are studying.
The question is one of much practical importance :
here is a form of suppuration which need not be feared
as the severer forms are ; for instance, it is possible for a
wound to heal well under a blood clot when these cocci
alone are present. It seems reasonable that granulating
wounds which have only this form of infection should
have their edges brought together and only a very small
allowance for drainage made, and that all wounds which
have only this form of infection should be treated with
little fear of serious inflammation — staphylococcus pyogenes
citrcus.
In four instances, staphylococci were found which
appeared identical with the white staphylococci in all re-
spects, excepting that after eight or ten days they turned
to a lemon color on agar.
They were found in a superficial abscess and in heal-
ing wounds, and produced very slight constitutional
reaction. They fluidified gelatine slowly, and when in-
jected under rabbits' skins in beef-tea cultures, they pro-
duced only a little induration and congestion.
They are much slower in turning to a lemon color than
the staphylococci pyogenes citrei described in the text-
books.
Cases from which no Bacterial Growths Could be
Obtained on Agar. — There was a group of eleven cases
from which the pus gave no growths on agar. They
were abscesses presumably tubercular, or buboes, and the
courses which they ran bear decidedly on the question
of injection versus incision for these conditions. A case
of large tubercular abscess shows the point of issue. It
was so situated as to make the diagnosis obscure until in-
cision was made. The incision liberated a large amount
of pus which was sterile, in the sense that no bacteria
grew from it on agar. A few days later, however, the pus
in the wound contained streptococci and the symptoms
changed accordingly. There was the febrile reaction
and the constitutional symptoms which accompany
the streptococcus infection. It had been impossible
to keep infection from the open discharging wound,
and the patient had suffered accordingly. When the
diagnosis can be made in such cases, it is manifestly wiser
not to open the abscess in such a way as to allow the en-
trance of the streptococci.
Some of the tubercular cervical abscesses showed a sim-
ilar course. There is one under observation at the time
of writing, which was incised and curetted three and a half
months ago, which has discharged thin pus and formed
unhealthy granulations ever since and is still open ; while
others of a similar nature which were aspirated, and in-
jected with a ten per cent, mixture of iodoform in vaseline,
show only a little hardening at the site of the abscess.
Buboes show a similar condition. They frequently re-
main open and suppurate for many weeks when they are
incised and curetted ; yet we have seen two heal promptly
and well under aspiration and injection of iodoform and
vaseline, and Otis34 has reported many such cases.
The reported cases of pyosalpinx in which the pus is
found to be sterile, illustrate the same condition of pus
without infective power, and such are not to be treated
as those cases are where there is acute purulent inflam-
mation.
It is possible that some of the cases examined had
abscesses which had become sterile through the dying
out of the bacteria which had caused the original suppu-
ration. Further studies are needed on this point. There
certainly were many cases which were almost sterile, in
which only very a few bacteria grew along a heavy streak
of pus ; perhaps a dozen colonies where hundreds of colo-
nies would be expected if the process had been an acute
one ; hence it is evident that bacteria inclosed in an
abscess may show a tendency to die out.
Cases in which the Bacteria which Caused the Orig-
inal Inflammation were Replaced by Others. — Some
of the cases already referred to, in which the white
staphylococci were found, belong to this group, since they
were evidently carried into the wounds from the skin.
In other cases, particularly old ulcers, the bacteria of
decomposition were found in such numbers as to cover
all other forms on the agar. In others, the bacillus pyo-
cyaneus was found. In a recent monograph, Schimmel-
busch,35 called attention to some interesting facts con-
cerning these bacilli.
1. They are regular inhabitants of the skin, particu-
larly in the axilla, the groin, and the anal furrow.
2. They are capable of infecting wounds which occur
where they exist.
3. They usually cause profuse suppuration with little
constitutional disturbance.
These characteristics were shown in the four cases in
which we found these bacilli. In two of them axillary
abscesses which at first contained streptococci, afterward
had the bacilli pyocyanii ; a third case showed the growth
from a mastoid abscess ; the plain gauze dressing in this
instance became bright green over a considerable area ;
in the fourth case the patient had a severe burn of the
hand, the discharge in this case was so profuse as to
quickly penetrate a gauze dressing an inch or two in
thickness ; yet when some of the metacarpal bones were
removed the wounds healed well, the patient seemed to
suffer only from the exhausting effect of so much pus
production.
Healing occurred in all the cases within a resonably
short time, and in all suppuration was free but the con-
stitutional symptoms were slight.
Bacillus Coli Communis. — It may be mentioned that
in three cases of ischeo-rectal abscesses the bacillus coli
communis was found. Neither of the cases were partic-
ularly virulent. In both the bacillus grew in pure cult-
ure on the agar plates. No particular importance is
ascribed to these cases as their number is so small.
Summary. — In review we may say that in the ordinary
cases which we have seen, at least five fairly distinct types
of inflammation have been recognized.
x. A severe form of inflammation which showed a ten-
dency to spread through the tissues, and which was caused
by the streptococcus pyogenes.
2. A severe form of inflammation, more localized than
the above, caused by the staphylococcus pyogenes
aureus.
3. A mild form of inflammation, caused by staphylo-
coccus pyogenes or epidermis albus, or in certain in-
stances by the staphylococcus pyogenes citreus.
4. Slowly progressing inflammation, in which the
ordinary pyogenic cocci were not found; such as cold
abscesses and buboes.
5. Inflammation in which the bacteria which caused
the original infection had been replaced by other bac-
teria ; particularly by the bacillus pyocyaneus and the
bacteria of decomposition.
The inflammations of these groups call for different
treatment. The acute streptococcus inflammations should
have early and extensive incisions, packing of the wounds,
and continual moist dressing. The staphylococcus pyo-
genes aureus inflammations call for similar, but somewhat
less vigorous, treatment.
The inflammations caused by the white and lemon-
colored staphylococci need only small incision, and
wounds which contain only these cocci are favorable ones
for secondary suture.
Abscesses which contain no pyogenic .cocci (such as
tubercular abscess and buboes) should not be so opened
and dressed as to allow the entrance of these coed ; aspi-
ration and injection of a ten-percent mixture of iodo-
form in vaseline is frequently good treatment for them.
Cleansing of the wounds and the application of non-
irritating absorbent dressings, are the means to be used
against the bacilli pyocyanii and the bacteria of decom-
position.
In a large proportion of cases the bacterial examina-
tion can be made in time to guide the treatment ; in very
many cases, however, the characteristics of the inflamma-
September 8, 1894]
MEDICAL RECORD.
293
tions are sufficiently well marked to make this unneces-
sary.
It is to be remembered that bacteria of the same species
show marked variations in virulence, and that those of
slight virulence do not always show plainly the peculiari-
ties which characterize the virulent ones.
1 Park : New York Mbdical Record, No. 6, 1893, p. 163.
* Passet : Baumgartens Jahresbericht, 1885, p. 24.
* Rosenbach : Ibid., 1885, p. 24.
* Prudden : American Journal of the Medical Sciences, April, 1889.
* Biondi : Deutsch. Med. Woch., 1886. No. viii., p. 132.
* Fraenkel: Centralblatt Bakt. u. Parasit., iii., 1889, p. 691.
1 Roger: Revue de Medecine, xii., 02.
* Welch : American Journal of the Medical Sciences, x. , 1891.
* Baumgarten : Lehrbuch der Path. Mykologie, p. 329.
10 Kirchner: Centralblatt Bakt. u. Parasit., 1892. p. 749.
11 Crookshank : Seventh International Congress of Hygiene and
Demography, 1891.
" Fehleisen : Archiv f. Klin. Chir.
11 Coley : American Journal of the Medical Sciences, May, 1893.
" Hajek: Wien Med Jahrb., 1887.
14 ▼. Lingelsheim : Zeitschr. f. Hygiene, 1891, Bd. x.
»• Jordan : BeitrJl^e z. Klin. Chir. , Bd. x. , p. 587.
17 Rosenbach : Die Mikroorganismen bei den Wund infections,
Krank heiten des Menschen, 1884.
»* Passet : l'ortschritte der Medicin, 1885.
'• Grisky and Robb : American Journal of Obstetrics and Diseases
of Women and Children, December, 1892.
* Bossowski : Wien Med. Woch., 1887, Nos. 8 and 9.
" Lanz and Flach : Archiv I Klin. Chir , 1892. Bd. 44.
n Levy : Archiv. f. experiment. Pathol, und Pharmakol , Bd. 27,
. 1890.
"Sternberg: Manual of Bacteriology, New York, 1892.
»< Otis : Journal of Cutaneous and Genito- Urinary Diseases, May,
1893-
*• Schimmelbusch : Sammlung Klin. V or tag, No. 62, 1893.
METHODS OF ESTIMATING THE HEIGHT
FROM PARTS OF THE SKELETON.1
By THOMAS D WIGHT, M.D., LL.D.,
NAHANT, MASS.
PARKMAN PJtOPttSSOR OF ANATOMY AT HARVARD UNIVERSITY.
This is an anatomical problem which of late has been
coming into more and more prominent notice, and is
applied both to the determination of the heights of ex-
tinct tribes and nations of which the skeletons have been
found, and also to the identification of individuals. It
is evident that the process is not necessarily the same
for these two purposes. In the case of races individual
peculiarities are of little account, and reliance may be
■placed upon averages. This cannot be done when the
question is of the identification of a certain skeleton.
The purpose of this paper is chiefly to discuss the
methods to be used for single cases, more particularly in
medico-legal practice.
The process of estimating the height from the more or
less detached pieces of the skeleton may be done accord-
ing to either of two very different plans, which under cer-
tain circumstances may be profitably combined. These
plans are the anatomical and the mathematical. The
former consists simply in putting the bones together, in
reproducing the curves of the spine, in making due al-
lowance for the soft jMirts, and in measuring the height.
In an essay on the " Identification of the Human
Skeleton," published in 1878, 1 gave certain rules for
this process. Since then I have endeavored to perfect
them, and by means of many measurements have obtained
original data for disputed points. I have also studied
individual variations to ascertain what weight should be
given to them.
The first step in what I call the anatomical method is
to place the spine correctly, which had best be done by
putting the.vertebrae, supposing them to be completely
separate, in a bed of clay or of putty which will admit
of their being moved until properly adjusted.
Three points call for consideration — the amount of
cartilage to be represented in each region, the propor-
tions of the different regions, and the curves ; but in
practice the first two are closely connected. Instead,
therefore, of giving the statements of the amount of gris-
tle to be represented in each region, I should proceed to
1 Read before the Association of American Anatomists at Washing-
Con, May 31, 1894.
give each region the proper proportionate length accord-
ing to my measurements. I have made measurements
following the curve of the spine from the atlas to the
promontory on fifty male and on twenty-three female
subjects with the following results, showing both the ac-
tual length of these regions and their percentages, the
movable part of the spine being reckoned as too.
Male. Per cent. Female. Per cent.
Ctm. Ctm.
Cervical 13.3 21.5 12. 1 21.2
Thoracic l 28.7 46.3 26.5 46. 1
Lumbar 19.9 32.2 18.7 32.7
Total 61.9 100.0 57.4 100.0
It is interesting to compare these results with those of
others. Ravenel measured the spines of eleven men and
eleven women and Aeby of eight men and eight women.
Combining their results we have for nineteen of each sex
the following proportions :
Male. Female.
Cervical 21.7 21.7
Thoracic 46.7 46.5
Lumbar 31 .4 32.4
Total 99.8 100.6
In my measurements, as well as in these, the disks at
the junction of two regions are reckoned with the upper
one. It appears from this, and especially from my fig-
ures, that these proportions are essentially the same in
the two sexes, though I agree with other authorities in
finding the lumbar region a little longer in woman, rela-
tively. It is clear that if the vertebrae are arranged so as
to make the regions correspond to these proportions, the
more intricate question of the amount of gristle belong-
ing to each will take care of itself. The question of the
curves is more difficult, and one which does not admit of
a definite solution, for the reason that they vary in young
people, at all events, with the time of day, and in all,
except, perhaps, the very old, with the position of the
body. Individual variations are also endless. It might
be of use to follow Humphry's suggestion that a line
dropped from the middle of the odontoid passes through
the middle of the body of the second and twelfth thoracic
vertebrae and through the anterior inferior edge of the
fifth lumbar. Should a few vertebrae be wanting this
system of proportions is all the more valuable. In case
of an extra vertebra, which mopt frequently occurs in the
lumbar region, I have found that the whole length of the
spine is not necessarily increased beyond the average,
nor always longer in proportion to the height, but that
the proportion of the lumbar region is invariably so. In
cases of only eleven thoracic vertebrae it is presumable
that the thoracic region is short, but though I have several
such specimens in my collection, unfortunately I have no
measurements taken when the parts were fresh. I have
records of a female spine with thirteen thoracic vertebrae
in which the percentages were : cervical, 19.9 ; thoracic,
50.6; lumbar, 29.4; the length being 61.6 ctm., very
long for a woman.
If it be asked whether anomalies of number in the
spine are sufficiently numerous to be taken into account,
I would say that in so far as this affects the proportion of
the spine to the height it shall be considered later, that
as far as it concerns putting the bones together it obliges
the expert to disregard the arbitrary rules of proportions
and to arrange the vertebrae as best he can. If there are
no complications he should find this no insuperable diffi-
culty.
It is to be observed that I disregard entirely the lower
portion of the spine, as it is very liable to vary and has,
moreover, no influence on the height.
The spine being settled, the next step is to put it on
the pelvis. Of course the inclination of the latter has a
great influence on the height, and unfortunately this is
just the point which is most difficult to settle. As I
stated in 1878, what Hermann von Meyer calls the nor-
1 In accordance with a vote of the Association of American Anato-
mists, I have adopted the term " thoracic " in place of " dorsal."
294
MEDICAL RECORD.
[September 8, 1894
mal conjugate is probably a more trustworthy guide than
the conventional angle. This is a line passing from the
top of the symphysis to the middle of the third sacral
vertebra, on which a transverse line can usually be seen.
This imaginary line forms an angle of thirty degrees with
the horizon. We may, moreover, strive to make the
notch of the acetabulum look directly downward and to
bring the anterior superior spines of the ilia into the
same vertical plane as the spines of the pubes. Never-
theless, many pelves will occur, especially those of which
the first vertebra is transitional, for which the anatomist
must rely on his general knowledge and good judgment
rather than on rule.
The pelvis being then in place, the bones of the leg
are to be added and due allowance made for the soft
parts. In putting the thigh-bone into the socket care
must be taken that it does not touch the upper border,
from which it is separated by cartilage. The lateral in-
clination must also be borne in mind — in other words,
the condyles must rest on a level The very slight an-
teroposterior slant may be disregarded.
At the knee about 6 mm. may be added and about as
much more for the two joints of the ankle. The addi-
tion of 12 mm. for the soft parts of the sole of the foot is
not far off, though of course it is liable to variation.
The skull is then to be placed, allowing 3 mm. for the
joint between it and the spine, and about six for the
scalp. According to Topinard 35 mm. are to be added
to the skeleton for all these soft parts, a statement not
materially different from mine. It is probably equally
correct.
I shall now consider the application of the mathemat-
ical method, and later, cases in which the two may be
profitably combined. The mathematical method rests
on the proportion of certain bones to the height, and it
is obvious that even if these proportions were collected
from thousands of specimens, as Manouvrier remarks,
these would give us no certainty. There are persons
with short legs and persons with long legs, and there-
fore no single rule of proportion can be true for both.
This method, therefore, is to be used when we can do no
better. Ishallshowlaterwhatthepossibleerroramountsto.
In medico-legal works some very insufficient tables
are still quoted ; but of late years this matter has received
particular attention, especially in France, which has at
last set this department of science on a comparatively
stable basis. Three observers especially concern us.
They are Topinard, Rollet, and Manouvrier.
Topinard calculates proportions based on observations
giving the following ratios of certain bones to the
height = 100 : humerus, 20; radius, 14.3; femur, 27.3 ;
tibia, 22.1. Thus, knowing the length of one of these
bones, we have only to multiply it by 100, and divide it
by the corresponding ratio. This should give the
height of the skeleton, to which he adds 3.5 ctm. for the
soft parts.
Rollet went further. He measured fifty male and fifty
female bodies before dissection and measured the three
long bones of each arm and leg. He then constructed
tables, reckoned proportions, and gave five different
methods of finding the height. Any one of the six chief
long bones may be used, or the average result of calcu-
lation from each. His favorite method is by means of
tables, one for each sex, and a simple rule of three.
He proceeds thus : the length (L) of a bone being
known, we find the length of the bone nearest to it in the
table (B) and the average height (H) corresponding to
B. Then weknow thatasB : L = H : X or X = - - •
He gives also a rapid method, which consists simply in
multiplying the length of the bones by certain numbers.
Thus multiplying the male humerus by 5.06, the female
by 5.22, the radius by 6.86 or 7.16, the femur by 3.66
or 3.71, the tibia by 4.53 or 4.61, gives the person's
height in centimetres.
The most recent paper is that of Manouvrier. He
criticised Rollet's tables because of his hundred subjects
fifty- one were sixty years or more. Their spines, there-
fore, had probably become shorter than normal, thus in-
juring their proportions. He formed, therefore, new
tables from Rollet's by rejecting these fifty-one senile
cases, which happily were divided as evenly as possible
between the sexes, and by rearranging the tables so as
to make the scale of the length of each bone the basis ot
calculation instead of the scale of the heights ; obviously
the proper course. He, moreover, measured the femur in
its normal position instead of taking its greatest: length,
as Rollet, following Topinard, had done. Further, as
these bones had been measured when fresh, he pointed
out that in the case of dry bones 2 mm. should be added
to their length. Finally, he claims that as the recum-
bent body, and the dead body presumably still more,
gains in length, at least 2 ctm. should be deducted
from the result in calculating the height of the living
person. His method was then to look for the length of
the known bone in his tables which gave the correspond-
ing height. If the precise length was not there, to find
its distance from the nearest and to make a suitable al-
lowance in the height Such is the mathematical
method as applied to the long bones.
In a previous paper I attempted to find the ratio of
the length of the sternum, excluding the ensiform carti-
lage, to the height of the body. My measurements em-
braced seventy men and thirty-nine women. I found
that the average ratio in men was 9.65 per cent- By
subdividing tins set into groups I found that in the short-
est men the sternum was relatively a little longer and in
the tallest a little shorter, but the extreme variations of
groups (not of individuals) was only from 9.56 per cent, to
9 98 per cent. The average of the thirty-nine women was
9.22 per cent. After the exclusion of a small number
of cases the range of variation was remarkably small.
Since then I have observations on seventy-nine men and
thirty-one women which bring the totals to one hun-
dred and forty-nine men and seventy women. The to-
tal average is 9.59 per cent, for the men and 9.08 per
cent, for the women, showing that on the average the
male sternum is distinctly longer relatively to the height.
None the less this cannot be commended as a method of
estimating the height in individual cases. The obvious
reason is the very common occurrence of very peculiar
sterna. It is one of the least stable parts of the skeleton.
While I believe that a typical sternum has a fairly con-
stant ratio to the height in each sex, variations are so
numerous that this method must be discarded.
I have added a new method of my own, namely, the
estimation of the height from the length of the spine
measured in a straight line from the top of the atlas to
the promontory of the sacrum, thus excluding the most
variable regions, the sacral and coccygeal. The tables
which I have used were constructed from measurements
of fifty-six male and twenty-one female spines made after
the completion of dissection, the basis being, according
to Manouvrier's plan, the length of the spines, not the
scale of heights. Instead of dividing the number of ob-
servations into equal parts, I have thought it better to
arrange them in groups containing all the observations
of every 3 ctm. Thus my fifty- six male spines comprised
three of less than 57 ctm. (the shortest being 56.4), four-
teen from 57 to 60, twenty-four from 60 to 63, twelve
from 63 to 66f and three longer ones (the longest being
69.8). I then reckoned the average ratio of each group
to the height and found the coefficient by which to
multiply any spine falling within any group. It is evi-
dent that this method, while giving very good data for
the lengths represented by large groups, must be of little
value for the extremes, represented by few bones. Still
it seems to me more trustworthy on the whole than the
plan of dividing the fifty-six spines into four groups of
fourteen or into eight groups of seven. It makes all
but the extreme groups more homogeneous. The weak-
ness of these may be frankly admitted. As to the age of
the subjects, several old ones have been admitted, thus
twenty among the males were sixty or more and seven
September 8, 1894]
MEDICAL RECORD.
295
among the women. Here I give simply the coefficients
by which to multiply the length of spine. All that is
needed is to find the group in which it belongs and mul-
tiply by the given coefficient.
Malhs. Fbmalp.
Length of Spine Coefficient Length of Spine Coefficient.
Under 57 ctm 2.93 Under 54 ctm ... 2.94
From 57 to 60 2. 84 From 54 to 57 2.82
From 60 to 63 2.78 From 57 to 60 2.79
From 63 to 66 2. 79 Above 60 2.76
Above 66 2.65
As the spines grow longer the coefficient decreases,
excepting that in the male table it is practically the same
for two groups.
For several years it has been my custom to measure
the height and certain other dimensions of subjects be-
fore dissection, and later to measure the length of hu-
merus, radius, femur, and tibia, and that of the spine both
in a straight line and following the curves. Anyone
who has had experience in the dissecting-room will
understand that for various reasons I often did not get
all these measurements on both sides, nor of all these
bones. Instead of constructing new tables of my own
for the long bones I have chosen twenty male and
twenty female subjects, with few exceptions under sixty
years old. In all every humerus, radius, femur, and tibia
had been measured on both sides and the average length
taken as a starting-point. From this the height has been
calculated from every one of the four bones and the
average of the four results taken as the answer, accord-
ing to the methods of Topinard, Rollet, and Manouvrier
successively.
I have added in using Topinard's method the 3. 5 ctm.
which it requires. Perhaps I have been somewhat un-
just to Rollet by using his rapid method instead of the
one which is his first choice, but as presumably Manou-
vrier's modifications of Rollet's tables must be considered
an improvement, the method I have followed permits us
to judge whether this more complicated process, for
which tables are necessary, has any marked advantage
over Rollet's very simple rapid one.
I do not find any striking difference between the value
of humerus, radius, femur, and tibia as a basis of calcula-
tion. Naturally, as I believe Manouvrier remarks, we
should choose the longer bones as having the smaller co-
efficients by which therefore any error is multiplied a
smaller number of times than if the bones were shorter
and the coefficient larger.
Female.
Malf.
i
I-
?
s
g
:J
I
8
4
754
470
100
7i
7^7 I 5*
S*> . 36
556 37
15 67
A9 54
Aiz »?
747 56
Ac 40
557 , 37
5*x 34
653 *4
755 42
<t 38
547 47
53* 68
i'o.9
16c. a
163.0
163.5
163.6
168.4
169.0
169. 1
169.2
17a. 1
172.6
173.6
173.1
174.4
«74-9
178-0
181. 3
18S.7
188. a
i9i-5
157.7
j *58.8 ,
165.0 I
«6i.3 I
I75.a
172.0
I 171.7 !
172 2
• 173. 1 ,
1751 .
, 1745
I 174.8
1 1743
1 1758
! 167 9
176.3
183.2
185.6
199.0
Average error.
—3-a
—2-4
+ 1.7
+ 1-5
—2.3
+ 6.8
+ 3.0
+ 2.6
+ 3.0
+ x.o
*-2.S
+1.9
+ 1.7
— O.I
+ 0.9
— XO.I
—50
—2.5
—2.6
-1-8.5
316
1539
154-9
159.6
161. 1
1575
172. 1
1679
167 8
168.3
169.3
171.3
170.6
171. o
170.4
172.0
164.9
172-5
179-2
187.8
195 o
—7 o
-6-3
—2.4
! —2.4
—0.1
+ 3-7
— x.x
—13
l —0.9
■ —2.8 .
—i-3 ■
— 2.0 I
— 2.x ;
. —40
—2.9
— 131
—8.8
-6.5
—0.4
_ + 3-5
3-93
160.3
> 160.9
163.8
164.6
162.5
1677
167.2
I 167.7
, 168.1
, 168. x
I 168.8
1692
168.7
168.5
166.x
170.0
175.x
177.0
188.3
— 1.8
+ I.X
— I.I
+ 1.5
—1.3
— 1.9
—1.5
—4.0
—4.5
-3.8
—3.9
—5.7
-6.4
— xi.9
— 10.6
—11. a 1
—3-2
4.38
170. 1 +8.9
X61.8 ;
167.5 '
165.8 I
167.2
I 164.7 '
I i69-5
168.6
I 173.7
! 1757
1743
168.7
1 168.7
175-9 I
»79 9 !
! iSt-3 I
1 183. 1
—1.7
+ 39
—a.6
—1.8
—4-5
—a.6
—4.0
+ X.I
+ a.6
—6.2
-9-3
-H
-6.9
-8-4
4-45
N.H. — The numbers in the first column are solely for the identification of the
body in my notes.
Topi-
nard.
Number of errors not over 1 ctm ... 3
Total number not over a. 5 ctm x 1
Errors from 2.5 to 5 ctm 6
Errors above 5 ctm 3
Rollet
Manou-
Spine.
83
C8
<
60
20
63
ax 23
47i 33
729 a6
566 41
746 23
461 51
450 51
A6 41
733 19
583 30
565 3i
646
I *
481
in
SI
32)
50
24
12 55
619 ao
563 26
149.0
140 2
-8.8
no. 1
-89
M4- 4
-4.6
1*2.0
+ 3 0
151 .°
148.6
—2.4
148 6
—2.4
151 7
+ 0.7
152.2
+ 1.2
152.2
154 6
+ 2.4
154.8
+ 2.6
1 55 7
+ 3-5
150.8
— 1 4
154- 4
M5-3
—9.1
145.2
—9.2
148.8
-5-6
159 ©
+ 4-5
155 .0
158.1
+ 3 1
158.2
+ 3 2
1570
+a.o
155-7
154-2
— 1 5
153.6
— 2.1
155.6
— O.l
1559
+0.3
156.2
157-8
+ 1 6
158.2
+ 2.0
157.5
+ 13
158.2
+ 3.0
156.3
154 9
—1.4
155.2
— l 1
155-7
-0.6
156.5
+ 0.2
1566
163.7
+ 7.1
164. 1
+ 7-5
160.5
+ 3-9
153-6
—3.0
157-1
160.8
+ 3-7
161. 1
+ 4.0
158.2
+ 1.1
156.7
-O.4
158.7
1550
-3-7
155.3
-3 4
156. 1
— a.6
1595
+ O.8
1590
146.4
— 12.6
146.4
—12.6
M9-3
-9.7
166.8
+ 7-8
160.0
1557
-4-3
156.2
-38
156.1
—3.9
159 3
-O.7
160.8
1569
—3 9
1571
-37
156.9
—3-9
1579
-2.9
161.9
166.9
+ 5.0
168.3
+ 6.4
163.0
+ i.i
1590
-2.9
162.9
157 9
—5.0
i~59°
—39
157.8
-Si
163.8
1594
—4-4
159.4
—4-4
158.4
-5-4
160.4
~3i
165.3
164.9
—0.4
165.4
+ 0.1
161. 2
—4 1
166.9
+ 1.6
168.0
164. 1
—3-9
164.6
—3-4
163.3
—4-7
166.4
— 1.6
171.2
164.6
-6.6
164.9
--6.3
161. a
— 10. 0
— -
-
—
Average error 4-54, , 4-55
3.69 '
Number of errors not over x ctm
Total number not over 2.5 ctm. . .
Errors from 2.5 to 5 ctm
Errors above 5 ctm
Topi-
nard*
Rollet. I
Manou-
Spine.
3
10
6
In seventeen of each sex I have also the length of the
spine. The tables are arranged according to heights.
After each column is one of errors, showing whether the
result was too great or too little. It is evident that the
errors on the minus side very much predominate, the
exceptions being by Topinard's method and by the spine
in the male table. It is also seen at a glance that the
worst results by all methods, and especially by that of
the spine, are in the male table. The summing up at the
foot of the tables is particularly instructive and curious.
It shows that for the males, if we take the average error
as the criterion, the methods rank in order of merit as
follows: Topinard, Rollet, Manouvrier, spine; for the
women the order is spine first, Manouvrier second,
Topinard and Rollet practically even for third place.
If we judge by the number of results within 2.5 ctm. the
standing is materially the same. Comparing the results
of the two tables, Topinard's method seems the best.
In seventeen of forty cases his error is less than 2.5 ctm.,
and in thirty- two not over 5 ctm. There is little to
choose between Rollet and Manouvrier, but as the lat-
ter's results for the most part err by defect I should not
deduct 2 ctm. to make up for lengthening in the recum-
bent position.
On the whole it seems that in about one quarter of
the cases the error is likely to exceed 5 ctm. or two inches.
Conversely that in three-quarters of the cases it is possi-
ble to reckon the height reasonably closely. When we
consider that the height is a variable quantity at different
times of day and according to position, that moreover
the accurate height of comparatively few people is known,
we must feel that to come within one inch (as occurs in
about one-half the cases) is very satisfactory, and with-
in two inches is not bad. The fact must be frankly ad-
mitted, however, that a greater error than two inches is
bad, and that this occurs about once in four times.
In studying the tables we find that the error from the
spine is by no means always on the opposite side from
the error from the long bones, as one would expect. In
one case (653) the error by every method is very consid-
erable, and all are by defect. I can only suggest by way
of explanation (the possibility of some blunder being al-
ways admitted) that there may have been uncommon
thickness of the soft parts, a large head, and great in-
clination of the pelvis. After writing these words I find
in point of fact that the top of the trochanter is on the
average of the two sides about 9 ctm. above the symphy-s
sis. This seems incredible ; but an error in transcribing
296
MEDICAL RECORD.
[September 8, 1894
these figures before dissection could have no connection
with the subsequent measurements. I am inclined to be-
lieve, therefore, that the subject must have been a pecul-
iar one. In some cases in these tables all the results are
wonderfully concurrent, thus on a man (100, aged 31)
the errors of the four results range from 2.4 ctm. to 1.5
and in a woman (746, aged 23) from 1.4 ctm. to 0.2.
As to whether the occurrence of anomalies of number
of the vertebrae is so frequent as to throw discredit on the
spine as a basis of calculation, the reply is somewhat un-
certain. Since I have looked for such anomalies I have
found them with a frequency which is surprising, though
1 am not able to express it in figures. I question, how-
ever, whether they give rise to any greater variation than
comes from the uncertain length of the legs.
We have now to consider cases in which certain parts
are wanting by supplying which we should be able not to
rely solely on proportions. Let us suppose that the pel-
vis is wanting, or so shattered as to be useless, though
we have both the legs and the spine. The problem is
evidently how high to place the promontory above the
trochanters. The height of the promontory above the
symphysis is often stated as from about 3^ to 4 inches
(say from 9 to 10 ctm.). This, I believe, came originally
from Naegele's statement that in well-formed women it
is about 3^4 inches. From my own observations I should
giro the distance at about 9.5 ctm. for man and 10.5 ctm.
for woman. We need, therefore, to know the relation of
the height of the symphysis to that of the great trochan-
ter. I find from measurements before dissection from
118 male and 37 female white bodies that in the males
the trochanter is on the average 1.1 ctm. higher than the
symphysis, and 3 mm. in females. Having in view the
greater height of the promontory above the symphysis in
women, we may without serious error reckon that the
promontory id 10.5 ctm. above the trochanter in either
sex.
Topinard , gives provisionally the following distances
on a vertical line of landmarks above the hip in the male
of medium height : From the anterior superior spine of
the ilium to the head of the femur, 6 ctm.; from the head
to the greater trochanter, 2 ctm. ; thence to the pubes,
2 cm.
In certain cases we may have recourse to the propor-
tionate height of the symphysis, which is admittedly not
far from the middle in both sexes, although there are dif-
ferences of opinion on certain points, as in particularly
tall or short persons. From dissecting-room measure-
ments of no males and 32 females I find that the pubic
height equals in men 51.4 per cent, and in women 50.3
per cent. ; the differences obtained by dividing like meas
urements of each sex into a longer and shorter half were
absolutely insignificant, none reaching a half of one per
cent. None the less I should esteem this proportion of
most value in medium heights. Quetelet, it may be
mentioned, puts the pubic height at .508 of the whole in
man, and .498 in woman. Practically, considering the
vagueness of the height and the insignificance of one-
thousandth of it, we may for persons of medium height
call the symphysis the middle point in women and a lit-
tle (say 1 ctm.) above it in men.
Should the head be wanting we must make a suitable
addition to the height of the spine. Sappey gives 13 3
ctm. as the average male height from the front of the
foramen magnum to the vertex of the skull, and 12.5 ctm.
for the female. To this 1 ctm. more should be added for
the space between the top of the spine and the border of
the foramen magnum and for the scalp, reckoned to-
gether.
Perhaps it might be useful to remember that the top of
the spine is on a level with the anterior nasal spine and
with the lower border of the auditory meatus.
Should the foot be wanting we might add for astrag-
alus, os calds, and soft parts 9 ctm. for man, and 8 ctm.
for woman. I cannot, however, claim any great accuracy
for this procedure.
1 L' Anthropologic, fourth edition, 1884, p. 341.
By these methods it is, I believe, possible to estimate
the height to within 5 ctm. in three-quarters of the cases
when it is done solely by the method of proportions.
When the most important parts of the skeleton are pres-
ent there seems no reason why the error should ever
reach that amount. Indeed the only reason why so large
a margin should be allowed is the difficulty of knowing
what the true height may have been, and the further fact
that as it is not a constant quantity, it never can be
known certainly.
CRIMINAL PSYCHOLOGY.
Bv J AS. WEIR, Jr., M.D.,
OWMNSBOBOUGH, KY.
In an article which appeared in the Medical Rec-
ord, January 13th, entitled " Criminal Anthropol-
ogy," I showed by photographs and original sketches
that the criminal was, anatomically and physiologically,
an abnormal man, and also that he was, unquestion-
ably, an atavism. With the permission of the reader I
will quote some of the closing sentences of the above-
mentioned article, and they shall form the text from
which the present paper will be elaborated. " Atavism
has hurled him" (the congenital criminal) "back thou-
sands of years, and has placed him beside his pithecoid
ancestor. He is a savage in the midst of civilization.
His customs and desires, his responsibilities and religion
are those of a savage, born and dead centuries and dec-
ades of centuries ago. . . . Poor unfortunates!
Are they to be held responsible for Nature's vagaries ?
Enlightened humanity has a difficult problem to solve
when asked the question, ' What will you do with the
criminal? ' " Ethics, concrete and abstract, are the re-
sult of psychical evolution. Abstract ethics, pure and
refined, have reached a high point in civilized man,
while concrete ethics, ethics necessary for the preserva-
tion of species living in communities (social law), have
reached an equally high point among savages, and some
of the lower animals, e.g., the social hymenoptera and
some of the birds and mammals. Most savages are
purely animal in their natures, and have none of the re-
fined psychical emotions which ennoble the possessor
of abstract ethics, civilized man. Parental love, conju-
gal affection, fraternal love such as civilized man experi-
ences, are unknown to the savage. Even the love of
God is, with him, material and concrete. The love of
the beautiful in Nature is, in the savage entirely absent,
or, if present at all, it is only so in its material sense.
His love of the beautiful (ornament) is rude and uncul-
tivated, and, in its gratification he scarcely excels the
rude decorative attempts of some of the lower animals,
e.g., the bower-bird, humming-bird, spider, etc. His ass-
theticism is coarse and unrefined, and, in truth, is not
elevated above his gross animal desires. His drama, his
poetry, and his art appeal to his carnal nature. He is
essentially an animal devoid of every refined psychical
emotion. I hold that the congenital criminal not only
resembles the savage anatomically and physiologically,
but that, psychically, the savage is also his archetype.
It will be necessary, in order to prove this, to discuss
the ethics and aesthetics of savages and compare them
with the ethics and aesthetics of congenital criminals.
Personally I am not acquainted with the psychology of
the savage except for that knowledge derived from read-
ing the observations of others, but with the psychology
of the criminal I am thoroughly conversant, having
lived with him in two of the largest cities in the United
States.
In the following description of the savage and his
habits, I have borrowed freely from the works of Hall,
De Quatrefages, Nares, Lubbock, Markham, Lyons,
Ross, Reclus, Day, and Bancroft. I will not, however,
distract the reader's attention by sprinkling my text with
references. The Eskimos or Inoits are a primitive race
inhabiting the most northerly habitable portions of the
globe ; and it was in these people, before contact with civ-
September 8, 1894]
MEDICAL RECORD,
297
ilized man had contaminated them, that we found evi-
dences of concrete ethics and aesthetics, such as we have
every reason to believe existed in all primitive races of
men at, or, a short time after, the inception of psychi-
cal evolution. The Inoit habitation is communal ; a
whole community may dwell in one house. The central
part of this house, where the ever-burning lamp is placed,
is common to all. Cords are stretched across the other
portions of the house dividing it into imaginary stalls or
boxes, and these stalls are occupied by one or more fami-
lies. There is no other fire save that of the lamp, which
serves to melt the ice and snow for drinking-water.
There is an utter absence of that which we term mod-
esty. The inhabitants of the " kachim," owing to the
great heat generated by so many bodies in one small
room, strip off their clothes and go about entirely
naked. "There is no natural want or physiological
function which they hesitate about satisfying in public."
They are dirty, squalid, ill- smelling. They are un-
washed, though fond of the vapor-bath ; this they in-
dulge in for the same reason that hogs will indulge in
mud-baths, for the gratification it affords. They some-
times bathe their faces in decomposed urine, but this
they do for a religious, or, rather medico-religious fe-
tisch, for they regard the bladder as the seat of the soul.
The use of urine as an emollescent and a medicine is al-
most universal among savage races. The Wahabis and
Ugoyos of East Africa, the Banians of the Momba,
the Chewsures of the Caucasus, the Silesians, the Be-
douins, and the Arabs all use it. Even in France and
Spain it is used by certain people as an emollescent and
a dentifrice. We will see, at the proper time, what a
prominent place it occupies in the materia medica of the
congenital criminal.
" In Aleutia those most nearly related to each other
contract a union, the brother with the sister, and some-
times the father with the daughter." Langsdorf re-
proached an Aleutian for so doing; he replied, "Why
not? the otters do it! " Between husband and wife
there is no conjugal affection. They are not at all
jealous. The Aleutian offers his wife to the guest as
freely as he offers the chunk of seal-blubber. His
friends are welcome to enjoy her if they arc mar-
ried and are in a position to return the favor. Im-
moral ! Wrong ! Not a bit of it. Remember that these
people are mere animals and have no knowledge of ab-
stract ethics; they see nothing wrong in a woman de
daring that one husband is not enough for her. It used
to be the custom in Florence for the women to demand
in their marriage contracts the right to take a lover.
The Aleutian girls, enjoying full liberty during their
girlhood, demand at their espousals the right of the ei-
eisbeat. During the absence of the legitimate husband
the cicisbeo takes his place. Brothers frequently marry
the same woman; in fact, among the Thlinkets and
Koloshes, adelphogamy is the rule. The Nair girl calls
in any man who is convenient and complaisant, who
goes through the marriage ceremony with her, and places
the /*/*, the Hindu equivalent of our wedding-ring,
round her neck. He is feasted, and then politely shown
the door. The wife is then at liberty to receive as many
other men as she sees fit, but the husband — never ! That
would be disgraceful and highly immoral.
I might enumerate hundreds of kindred customs and
habits in savage races, but do not consider it necessary ;
I merely wish to establish the fact that conjugal affec-
tion does not exist among savages. The savage mother
has the same affection for her offspring as the cat or the
dog has for hers. She attends to it just as long as it is
helpless, "but as soon as it is able to look into the pot
standing erect, she leaves it to itself and seems to forget
all about it." Where polyandry exists it is not reason-
able to expect that the man has any regard whatever for
the children of his wife. This is true also where polyandry
and polygamy exist combined together. In his poetry
and his drama, and the savage is a born poet and actor,
the savage depicts the scenes of his every day life. The
events of the hunt, in the field or on the flood, are re-
cited or acted with wonderful realism. Love enters into
a number of their poems, but it is an intensely sensual
love, a carnal and an animal love. Rapine, lust, and
feasting go hand in hand, and tread the measures of
every savage dance together.
The savage is a creature of to-day ; he lets to morrow
take care of itself. When there is plenty, he gorges him-
self with food to repletion ; when there is nothing to eat,
he fasts with stoical equanimity. Says Captain Lyons :
" Knillitleuk had already eaten until he was half seas over.
He was dropping asleep, with a red and burning face
and open mouth. His wife was cramming him, stuffing
bits of half-boiled meat down his throat with the help of
her first finger, steering clear of his lips. She carefully
watched the process of deglutition, and immediately filled
up any void that might appear in the orifice with a stopper
of raw fat. The happy man did not stir ; he moved noth-
ing but his molars, chewing slowly, and not even open-
ing his eyes. From time to time a stifled sound escaped
him, a grunt of satisfaction." The Mescalero Apaches
tighten their belts around their empty stomachs and go
in quest of prey, nothing, in the shape of an animal,
comes amiss to them as food while out on a marauding
expedition. Grasshoppers, lizards, snakes, a chance
bird, anything is eagerly devoured in order to sustain
life until they can make a grand coup on some un-
guarded ranch. At the right moment they rush in, kill
the men, and carry off the women, children, horses, and
mules. They then turn and strike a bee line for home,
driving their captives before them, nor do they halt
until they have regained their encampment, where they
are received with yells of welcome. Immediately a
bacchanalian orgy of feasting begins. A horse is
knocked on the head and devoured before his flesh has
ceased to quiver ; nor do they stop for cooking until the
edge of their hunger has been considerably blunted.
The savage is essentially a believer in witchcraft, and
most of them are devil-worshippers. They are intensely
superstitious, and see in every event of nature wonderful
auguries and prophetical signs.
Among the Inoits and kindred races individual property
does not exist. All things are held in common. When
these people visited a ship for the first time, they picked
up anything which pleased their fancy. They did not
consider it stealing. ' ' A man cannot steal from himself, ' *
said an Aleut ; " what is yours is mine, and what is mine
is yours. The Great Mother has given to all alike."
So much for the savage ; now let us consider his con-
gener, the congenital criminal, who, to a certain extent,
is modified by his surroundings. When Marco Polo wrote
his celebrated work people considered him a romancer.
When an Indian returns to his tribe after a visit to Wash-
ington and relates to his brethren the wonders he has
seen in his travels, they move their hands before their
mouths and shake their heads. Deaf mutes make the same
signs when they wish to express incredulity.
I expect that some of my readers will consider me a
second Marco Polo, and will treat me with the same scant
ceremony that the unsophisticated Indians bestow upon
their travelled brother ; yet I assure them, in advance,
that the following history of the criminal is true in every
particular. Men are prone to disbelieve because they
cannot see the wound in the side with their own eyes, and
cannot place the tips of their fingers in the punctured
palms. St. Thomas was only intensely human, and I do
not, therefore, have the poor opinion of him which most
people have. Man is a veritable terra incognita to most
men, though they do not know it, and when an observer
tells them that he has discovered something new about
man, doubting Thomases spring up everywhere. I only
ask such critics to live as I have lived, with and among
criminals, and they will soon cease to be infidels. I can-
not be elaborate in a non technical article, neither can I
go into certain details without giving offence, but, strip-
ped of unnecessary verbiage and absolutely devoid of all
false sentiment, the following history is but a plain nar-
298
MEDICAL RECORD.
[September 8, 1894
Tative of the ethics and aesthetics of the criminal, revealed
to me by a personal and intimate acquaintance with him
in his daily life. Those in authority, whose duty it is to
watch and guard against the criminal, will tell you that crim-
inals herd together, and during my intercourse with them
I always found them living in circumscribed communities.
Remember always that in this paper I am speaking of the
congenital criminal and not the professional criminal, nor
the occasional criminal. Let me say, also, that the so-
called "tough" is not usually a congenital criminal.
The tough will fight and will commit other anti-social
acts ; he will even commit murder, but he is generally
incited thereto by whiskey or by passion. He never
commits murder for the sake of personal benefit like the
congenital criminal. He is not an habitual thief, nor is
he ever guilty of incestuous acts ; moreover, the tough
will work, but the congenital criminal never, unless com-
pelled. The tramp is hardly ever a congenital criminal ;
he is, usually, only an occasional criminal.
Perhaps the reader will be interested in learning how I
obtained my passport to thiefdom. I obtained it on one
occasion in the following manner : In the first place, I
called on the chief of police and explained the object of
my researches and my plan of operations. I deemed this
necessary, so that if " run in," I might have a friend at
court. I then hired a room in an office building and
furnished it with a desk and some chairs, and for several
days, lounged about the low saloons in the poorest and
most criminal section of the city. I saw any number of
criminals, but bided my time ; I was looking for a typical
criminal, a chief in his tribe. I seldom or never make a
mistake in my diagnosis of criminality, and so soon found
the very man for whom I was looking. A few drinks of
"red eye" and several "rum holers," made him com-
panionable. I explained to him that I had come to the
city from an inland town where I had barely escaped
being "pinched" for "flim-flamming;" that I knew
where a " trick could be turned " in the city if I had some
one to help me. He readily agreed to furnish the tools
and render me all the help necessary for half the ' ' boodle, ' '
so I deliberately planned with him to rob my own room.
I had placed in the desk in this room twenty five dollars,
and to make a long story short, I assisted him in burglariz-
ing my own room and in robbing myself. We divided the
money, and he, as I expected, then invited me to go with
him to his " mot cab," * *., woman's room. It was here
that I made the acquaintance of the congenital criminal.
This colony of criminals numbered about two hundred,
and were herded together — men, women, and children —
in two small tenements. Sometimes a dozen men, women,
and children would be found occupying one small room.
No modesty was observed by these people. A tub or
bucket did duty as a necessary, and the calls of nature
were attended to publicly. As it was summer, and the
weather very warm, these people stripped themselves naked
when in their rooms, the younger ones even running about
the house and into the courts entirely nude. The women
had their favorite " cully," but almost everyone of them
practised polyandry. Some of them did this secretly,
' bat most of them were open in their adultery, and the men
were fully aware of the fact. Prostitution was a source
of revenue in which the putative husband shared without
any shame or compunctions of conscience. He only
grumbled when his " mot " did not bring in much money.
In this colony I saw two examples of incest, one a father
living with his daughter, and another, a brother living
with his sister. There were probably many more in-
stances, but they were cursory and did not attract my at-
tention. These people were fully aware of the fact that
these acts were considered criminal by people not belong-
ing to their tribe, and that they would be punished if ap-
prehended. They had nothing to fear, however, from
their associates, for, like the Aleutians, they saw nothing
wrong in it. "Why not? the otters do it!" When
the head of the family goes off on a marauding expedition,
and he is frequently absent for weeks at a time, he leaves
his partner in charge of the family. This man is the
cicisbeo of the woman, and during the absence of the hus-
band fulfils all of his duties. These men are true savages
in the treatment of their women ; they beat and maltreat
them on all occasions, and almost every woman in the
colony bore the marks of her * ' cully's ' ' brutality. Here,
also, I saw many instances of sexual perversion. These
disgusting performances cannot be described or even
hinted at. Suffice it to say that the religio sexual abomi-
nations of the Aleutians have their autotypes among their
civilized (so called) congeners. The girls become pros-
titutes early in life. They are nominally match sellers
or flower-venders, and do a thriving trade among the
brokers and various agents, etc., who have their offices
down in the city. One little girl, not ten years old,
showed me a twenty-dollar gold-piece which she declared
had been given her by a certain " grave and reverend
seignior, ' ' high up in banking circles. The money which
these precocious little sinners (ought I to call them sin-
ners ? I am convinced that they do not consider them-
selves such), take in is given to their mothers. When
these girls arrive at a marriageable age, say from fourteen
to eighteen years, they " take up " with some man in the
colony and become his "mot," or woman. The boys
are thieves from earliest childhood. They sometimes sell
newspapers, but do this merely to mask their real busi-
ness, which is pocket-picking. When older they become
sneak-thieves, thugs, and burglars. The criminal, like
the savage, is improvident and wasteful. When he has
made a successful haul he lives on the fat of the land.
The " growler " fairly smokes, it is " rushed " so rapidly!
The pots and kettles in the scantily furnished kitchen
corner are filled to overflowing. The women are all en-
gaged in rude cookery, while the men prepare for the
coming feast by stimulating their stomachs with numer-
ous potations. The dinner is served and all fall to, like
veritable savages as they are, and eat and drink until
slumber overtakes them. The criminal delights in bright
colors and tawdry jewelry. His aestheticism, like that of
the savage, is rude and uncultivated. He will cover his
fingers with enormous rings, and will wear cravats and
handkerchiefs of the most pronounced colors ; he does
this, however, when on dress parade. When on business
bent, like the savage, he, almost literally strips himself
to his breech-clout ; he does not care to have his move-
ments hampered by "bum togs" when he is about to
' ' crack a box. " He is filthy and uncleanly in his habits ;
he never bathes from one year's end to another. Para-
sites swarm on his person, and the odor of his body is rank
and animal-like. His knowledge of medicine and the
kindred sciences is crude and savage. Incantations, sor-
ceries, and simples (some of the latter are horrible and
disgusting compounds) are his materia medica. I ac-
cidentally sprained an ankle while with these people, and
was treated by an old crone of the colony. She bathed
the foot and ankle with decomposed urine, all the while
mumbling :
•' From toe to knee, from knee to toe,
In and alx>ut the devils go ;
Chase 'em, liquor, chase 'em fast,
And from this foot drive 'em at last."
This treatment proved very efficacious, for the pain
vanished and the swelling disappeared as if by magic.
Urine is a favorite lotion with the congenital criminal.
The women use it as a face wash, and the men consider
it the best medicine in the world for bruises and con-
tusions.
The congenital criminal has his god, but he is not the
God of the Christian. He is the god of luck or chance,
and his wishes are consulted and obeyed with as much
fidelity by them as are those of the Christian's God by
his devotees. Bad Luck is their devil, and he is treated
with as much consideration as his antithesis, Good Luck.
Here is where the devil worship of the Aleutian is paral-
leled. Here we see an evidence of concrete ethics such
as we find in all savages ; there is no abstract love of
God such as civilized Christians feel. The congenital
criminal, like the savage, recognizes the good and evil
September 8, 1894]
MEDICAL RECORD,
299
principles, but he applies them to his personal welfare
and not to his spiritual. He is a savage, and the idea of
morals has not yet been evolved in his brain.
The savage and the congenital criminal are born poets,
and both love a certain kind of play-acting. Like the sav-
age, the criminal likes to witness scenes akin to his every-
day life and aspirations, acted on the stage. The border
drama, in which there are many murders and much crime,
is his great delight. He cares nothing for comedy, un-
less it is obscene and lasciviously suggestive. He loves
music and dancing, but both the music and the dance
must be carnally exciting, or he will have none of them.
He is a poet, and almost invariably speaks in figurative
language ; so is, and does, the savage. His poems de-
pict his every- day life, because he is, from the nature of
things, essentially a realist. All are familiar with the
lucubrations emanating from our jail-birds. Most of
the poems obtained by myself cannot be printed. Some
of them are real poetry, though based on obscene and
lascivious topics, and expressed in rude, slangy language.
The criminal is an artist also, and his work is strikingly
like that of the savage. His drawings are mostly porno-
graphic, depicting men and women in immodest and las-
civious attitudes, and according to Mayhew, savages are
guilty of the same thing. The congenital criminal is
born with his tendency to criminality firmly stamped on
his brain ; it is an inheritance from his father and his
mother. He considers the laws of society to be all
wrong ; his social laws, his ethics, are the only right
ones. His logic is all wrong with us, but all right with
him. The congenital criminal is a moral imbecile ; no
amount of punishment will ever evolve in his brain any
idea of morality. This is an established fact, and can-
not be gainsaid. But he is antisocial, therefore danger-
ous ; what shall we do with him ?
PROVISIONAL TREATMENT OF INSANITY.
By SANGER BROWN, M.D.,
CHICAGO, ILL.
LATE ACTING MEDICAL SUPERINTENDENT OF THE BLOOMINGDALE ASYLUM, NSW
YORK ; PROFESSOR OF MBDICAL JURISPRUDENCE AND HYGIENE RUSH MEDICAL
COLLEGE ; ATTENDING NEUROLOGIST COOK COUNTY HOSPITAL ; MEMBER OF
THE LONLON NEUROLOGICAL SOCIETY.
I wish to deny at the outset any intention of assuming
a hostile attitude toward the asylum treatment of the
insane, or that it is the main purpose of my communica-
tion to advocate the home treatment or care of the in-
sane. I preface what I have to say in the above manner
in order to escape, if possible, from the imputation, which
a hurried reader might charge to me, of being in the
main opposed to the asylum treatment of insanity, and
in a general way favoring by preference the home treat-
ment of the disease. I do this because experience has
taught me that in medical societies or gatherings, where
I have thrown out any suggestions along the lines con-
sidered in this paper, I have almost invariably been mis-
understood by a few at least, if not by the majority.
I feel, however, that the subject is one of considerable
importance, and even at the risk of being misunderstood
I shall venture to express myself upon it.
My principal proposition is that when it is demon-
strated in a given case that insanity actually exists, it
does not necessarily follow that it is the best practice to
immediately send the patient to an asylum. It is the
purpose of this paper to present arguments in support of
this proposition.
From fifty to seventy five years ago the asylum or mad-
house was for the most part a place for the custodial care
of violent or dangerous lunatics, and it was rather the
exception that the chief officer was a medical man ; and
if a medical man, it was perhaps a still greater exception
if he devoted much time to the actual study of insanity
in its varied aspects. Howbeit there were a few con-
spicuous exceptions, and by way of digression I want to
take this occasion to say that we are more indebted to
them for the advancement that has been made in the
treatment of the insane than we are generally aware of.
It was the common practice in those days to leave the
care and treatment of the insane in asylums mainly to
the attendants, the physician seeing and prescribing for
them mainly at the attendant's suggestion ; in many
instances large quantities of the favorite " sleeping po-
tions" and "quieting draughts" were placed in the
hands of attendants with instructions how to use them.
As can readily be understood, it generally happened in
these times that the attendant really knew much more
about the actual problems of treating the insane than the
physician, and if he told the physician that this patient
needed quieting medicine, and that one must be kept
strapped to a chair, and another must be kept locked in
his room, his word was law, and said patients were often
so treated, not for days and weeks, but continuously for
long months and years. But, somewhere about twenty
or thirty years ago, resident medical c fficers more or less
generally began to actually make a study of the care and
treatment of the insane, until now it is rather the ex-
ception for attendants to know more about any part
of the treatment of insanity than asylum physicians.
Though it would be both instructive and interesting to
trace step by step the changes as they have occurred, it
may be asserted quite safely that within the above-men-
tioned time there ft no department of medicine in which
there has been a more striking metamorphosis or a more
practical advancement.
Cases that for years had lived behind bars, in their
own filth, having their food passed to them, either in
the public jail, public madhouses, or at the house of
some relative, under the new order of things in the mod-
ern asylum were often, much to the astonishment of their
relatives, found in a condition of cleanliness and com-
parative comfort, successfully employed at some healthful
out-door occupation.
To all classes of observers this change appeared quite
marvellous, and to none more so than to the general prac-
titioner of medicine, so that he, urged on by the reports
of the medical officers of the hospitals for the insane,
soon came to adopt the routine practice of promptly
sending all patients to an asylum whenever the existence
of actual insanity was demonstrated ; and on the whole it
is probable, if the practitioner had never served on the
medical staff of an asylum and thus had an opportunity
of gaining a practical acquaintance with insanity, that this
was the wisest course for him to pursue. He did not
know at all how his patient would be treated when he
reached the asylum. He was only thoroughly convinced
from his reading and observation that to send the pa-
tient to an asylum was the proper thing, and he often
surmised that there were some mysterious influences in
operation which were in some way beneficial and which
were favored by the association together of a compara-
tively large number of the insane. This, like most sur-
mises, was very far from the actual fact.
To prevent the patient from injuring himself or
others, to see that he have proper food, rest, sleep, exer-
cise, occupation, and diversion, and do not fall into per-
nicious habits, is the main purpose at the asylum ; it is
not easier to do this with two or more patients than with
one, it is only more economical ; it could always be some-
what more effectively accomplished with one patient.
There is no mystery about it whatever ; natural aptitude
and a thorough familiarity with the various phases of the
disease are the essential elements of success in the treat-
ment of insanity, if only the necessary funds are at hand.
Now, while it is always within the power of the very
wealthy to equip a private establishment, with a resident
medical attendant for the exclusive treatment of a single
individual, and whether the case is curable or not such
treatment may be made superior to any other, it often
happens that cases are seen where, without any great
expense the indications of treatment can be better carried
out, say in a general hospital or a private family other
than that of the patient, than in an asylum, and if it be
a young person with an acute attack, a considerable ex-
300
MEDICAL RECORD.
[September 8, 1894
pense ought to be incurred in order to provide, for a time
at least, proper treatment outside of an asylum.
Asylums have grown to be so numerous and such a
large number of young medical men are employed as
assistants, that now there is coming to be quite a large
sprinkling of practitioners outside of asylums who have a
practical knowledge of insanity, men who know when
brought in contact with a case how it ought to be treated,
and whether, in view of all the circumstances, it is neces-
sary to hurry the patient off to an asylum or not.
I shall not at this time attempt to describe the particu-
lar class of patients most suitable to non asylum or pro-
visional treatment, nor the measures to be adopted to
meet these indications, my purpose being to try to im-
press upon the mind of the practitioner the importance
of carefully studying every case of insanity, satisfying
himself as to the diagnosis and prognosis and then con-
sidering how the indications for treatment may be best
met.
Such cases are often somewhat perplexing and trouble-
some, and I fear it has been too much the practice of late
years, sanctioned by usage, not by science, to dismiss
them hastily to an asylum, without due regard to facts
or consequences.
34 Washington Strest.
grogves* of Medical gtimce.
The Effect upon the Nursling of the Mother's Diet.
— The feeding of infants on artificial foods is a grow-
ing evil for which, although they inveigh against it,
physicians are in a large degree responsible. Efforts are
made to explain the evil away on such grounds as the
desire of the mother to avoid the inconveniences of her
natural duties, or of changed conditions of life causing
inability to furnish food in sufficient quantity, if at all,
or of deficient quality of the mother's milk, or other con-
ditions, for all of which the mother is responsible. These
conditions do exist in a greater or less degree, but aside
from actual and acute disease, the maternal conditions
may be tersely summed up in the statement that the
mother is unwilling to make the sacrifices necessary if
she performs her duty to her child. The responsibility
of physicians lies in weakly conceding to the patient's
desires, in place of strenuously insisting upon the
mother's every effort to carry out the provisions of nature.
In these days of milk- foods, prepared foods, substi-
tutes for mother's milk, etc., mothers do not under-
stand that the nature which provides organs for bearing
children, also provides organs for nursing children, and
intends that these organs should be for use rather than
ornament. She does not realize that the products of
modern science at best are but poor substitutes for the
products of nature. If the physician would insist upon
the mother performing her natural functions despite her
assertions that she "cannot nurse the child," "never
could nurse her children," " didn't have milk enough,"
" nipples too small or too tender," or " milk left her in
two or three months," etc. — if the physician should in-
sist, and the mother persist, both would be surprised to
find that long abused nature would still be willing to do
her proper work. Patient endurance of discomfort, per-
sistent effort, and proper food will eventually demonstrate
the ability to nurse their infants, in nine out of every
ten mothers who assert the necessity, in their individual
cases, for " bringing up the baby on the bottle." And
that, too, without scouring materia medica for imaginary
galactagogues, and likewise to the very great benefit of
both mother and infant.
During his six years' service at the Preston Retreat
Dr. Joseph Price gave the medical profession, through
that institution, some most valuable object lessons in
obstetrical science. There was no secret in the methods
used to make that institution the model maternity of the
world, so far as professional results are concerned. His
guiding principles were care, cleanness, and common
sense. The strictest supervision of every detail, scrupu-
lous practical cleanness and not so much of theoretical
cleanliness, and simplicity in all matters, enabled him to
complete his service with a mortality record never equalled
in private or public maternity work. It was a law with
him " to allow the mother to bear her own children,"
and it was equally the rule to require each mother to
nurse her own infant during her stay in the institution.
So very rare were exceptions to this rule necessary, that
a nursing bottle could not be found in the entire insti-
tution. The patients in the Retreat were in no respect
an exceptional class, save in the fact that so large a pro-
portion of them were ill-nourished and impoverished in
physical health when they entered the hospital — con-
ditions which would entitle them to claim inability to
nurse infants. Another fact of interest was noted,
namely, that many mothers, who while in the house
furnished abundant food-supply, and left the institution
with thriving babies, would, after leaving, put the baby
on the bottle as a matter of personal convenience, and in
a surprising proportion of such cases would lose the
babies within a few months.
The moral to be drawn is that almost every woman
who can bear a child can nourish it. Attention to the
body functions, generous supply of simple, nourishing
food, and early and persistent efforts to establish and de-
velop the mammary secretions were the only methods
used to secure these results. In general practice the
physician is too apt to give up the contest too early or to
rely upon some form of stimulants to the glands, which
eventually proves delusive if not injurious. It is a com-
mon practice to administer alcoholic beverages in the
form either of ale, beer, or porter to nursing women for
the purpose of increasing the milk supply. Beyond
question these articles are capable of doing much injury
to both mother and child, and their indiscriminate em-
ployment for such purposes should be interdicted.
Dr. J. W. Byers, in the Annals of Gynecology and
Pediatry, has made some pertinent remarks on this sub-
ject. He says : " The truth is, in this practice of using
alcoholic drinks the profession has followed the customs
and whims of the laity, rather than the usual process of
instructing and leading the latter. That there are con-
ditions and circumstances in which the administration
of malt liquors is of decided benefit to both mother and
child, no one will undertake to gainsay. But that they
are indicated in every instance of deficient lacteal secre-
tion, or that the exigencies of the case ever render neces-
sary their use to the extent as is commonly employed,
none can maintain or justify. The promiscuous and
general practice of using malt liquors by nursing women
is irrational, does a vast amount of harm, and often
causes disease in the suckling. We know that the mam-
mary gland, for all practical purposes, may be con-
sidered as an organ possessing functions of a twofold or
mixed character, namely, secretion and excretion.
Under normal physiological conditions the first of these
processes is in almost exclusive operation, though, as
shown by experiences, the slightest alteration in the con-
dition of the organism, whether of an emotional, medi-
cal, or dietetic character, may so change this secretion
that it becomes to all purposes and effects an excretion,
and an innocuous, healthy pabulum for the child is con-
verted into a deleterious or poisonous substance. Ex-
perience is very general in showing that the milk fats and
albumins in increased proportions have a decidedly in-
jurious effect upon the digestion of the infant when taken
into the stomach in excessive quantities. From a number
of experiments conducted by Zaleski he found these
substances in the milk in excessive proportions whenever
the mother had partaken of alcohol. In each case where
the mother was tested with malt liquors, the fat and al-
bumin appeared and caused more or less disorder and
distress of the digestive apparatus of the suckling. These
deleterious influences, however, were not the worst.
Analysis of the milk further revealed the fact that it
September 8, 1894]
MEDICAL RECORD.
301
actually contained alcohol and the micro-organisms
peculiar to malt liquors ; that the liquor drank by the
mother actually passed out in toto through the mammary
gland and on into the child's stomach, and there pro-
duced all the phenomena incident to digestive disorders
and febrile disturbances. These facts point to the belief
and support the attitude, that the mammary gland under
certain conditions exercises the function of an excretory
organ, and that under some circumstances it becomes
nothing more than a filter through which the food and
drink taken by the mother passes directly into the
stomach of the child. This being true, we are in a position
to understand and appreciate the importance of the rela-
tion of the diet of the mother and the well being of the
child. When we prescribe alcohol for the mother, we
at the same time do so for the child. The diet of the
mother is a stage in the milk- producing process, and the
milk she produces, is, in every instance, the result, and
only the result, of the food of which she partakes. If it
be improper, unsuitable, or contaminated, the milk will
express this in a proper ratio. In the case that beer or
ale is administered it will find this outlet, and while it
does not evidence deleterious influences to the extent of
producing the worst results in the form of either colic,
indigestion, or diarrhoea, in every instance its effects are
present, and these are always among the possible results
of its use. The effects of fat and albumin, when present
in breast milk in excessive proportions, in producing evil
effects on the child are too well recognized to dwell upon.
That the more severe of stomach disorders — gastrointes-
tinal catarrh, enteritis, or even cholera infantum — are due
to these substances, as a result of the abuse of malt
liquors in the mother, is certain, though such is not
generally admitted or recognized. Take care not to
advise a woman whose milk supply is reasonably full to
resort to beer or other' liquors in order to increase it.
Always impress upon them the increased risk to the child
incurred by using them." — The Medical and Surgical
Reporter.
The Effects of Quinine on Pregnancy. — A collective
investigation of this subject has been recently undertaken,
with these conclusions: 1. The existence of pregnancy
is no bar to the administration of quinine. 2. For fevers
and other affections during pregnancy in which quinine
is indicated, the effects of the drug are more marked than
those of any other. 3. That abortion following the ad-
ministration of quinine is either the result of the original
malady or the effect of idiosyncrasy. 4. That allowing
for an idiosyncrasy, in cases in which a tendency to abor-
tion exists, and in others as a matter of precaution, qui-
nine is best administered combined with a sedative
(opium). 5. Hence the old-standing view of the action
of quinine on the duration of pregnancy is not borne out
by the clinical experience collected in the replies. — In-
dian Medico- Chirurgical Review.
Dermographismus. — Dr. Ehrmann describes a pecul-
iar condition of the skin occurring under various circum-
stances, and depending for its appearance upon mechani-
cal irritation. He distinguishes three degrees of this
condition : In the first there appears one after another
contraction of the cutaneous muscular tissue, with anaemia
of the parts affected, then hyperemia, and finally transu-
dation ; in the second the muscular contraction is very
slight, the anaemia is not so marked, and there is hyper-
aemia of the superficial layers of the skin only ; and in
the third there is only transitory reddening of the skin.
But the more common form of case is that in which, on
the portion of skin affected, small raised patches of oedema
appear around the roots of the hair, so that on stroking
the skin with some blunt body, or even by the pressure
of the clothes, or a button, etc., only an isolated group
of white papules appear, which cause an irritation of the
skin and consequently soon lose their characteristic ap-
pearance, owing to being scratched by the patient. In
such cases cutaneous pruritus is diagnosed a " pruritus
nervosus. ' ' In some cases recorded the appearance closely
resembles that of lichen ruber planus. Ehimann draws
a distinct difference between dermographismus and urti-
caria. The latter is caused by the action of some toxic
substance, this being derived from some affection of the
skin or of the digestive organs, or some pathological prod-
ucts are formed (auto-intoxication) ; but he admits that
in some cases of urticaria, in which the nervous system is
affected, that disease and dermographismus may exist to-
gether. This condition has been observed after mental
excitement, such as fright, or in cases of neurasthenia
and hysteria. He considers the influence of the nervous
system as sufficient to produce dermographismus, and
that the presence of a toxic substance is not necessary.
Examination of the urine demonstrated the presence of
indican in only one out of fourteen cases. — Allgemeine
Wiener Medicinische Zeitung.
Epidemic* Skin Disease. — At a recent meeting of the
Dermatological Society of Great Britain, Dr. Savill
showed eleven cases of dermatitis which had attacked
nearly five hundred children in a day school where the
average daily attendance was about one thousand. {The
Lancet) It was thought by their teachers to be ring-
worm of the face, and they were taken to a neighboring
hospital for such, but it was shown not to be ringworm
because the scalp had not been attacked by the disease in
any case, and no characteristic spores or mycelium could
be found after careful search. Moreover, the disease re-
sembled a dry eczema occurring in patches, not healing
in the centre as ringworm does, nor had they the raised
border. They were chiefly on the face, though some of
the children had patches on the arms and legs. In the
discussion which followed, Dr. Stephen Mackenzie re-
garded the condition as a common and comparatively
trivial affection; but Dr. Savill pointed out, in reply,
that the cases of these children very closely resembled
the youngest of the cases with the epidemic skin disease
described in 1891. Many of the cases of this disease he
had subsequently seen (such as those at the Bethnal
Green Workhouse in 1893) ^^ been very much milder
than the 1 89 1 cases ; and it would be a matter for subse-
quent inquiry and research whether the cases of these
school children belonged to the same category or not.
At any rate, there seemed evidence to show that the dis-
ease, whatever it might be, was a contagious one, spread-
ing as it had done so extensively in this school among
children who, when not at school, must live under such
varying conditions of environment that it would be hard
to find a local cause in operation common to them all.
Treatment of Appendicitis. — Dr. Swain holds that,
since about ninety per cent, of cases of appendicitis re-
cover spontaneously, early operative interference in
nearly every form of appendicitis is not justifiable.
{Therapeutic Gazette!) Cases of simple and plastic
appendicitis are to be treated by rest in bed, moderate
amount of liquid diet, purgatives, rectal injection if nec-
essary, local application of leeches or fomentations, and
hypodermics of morphine for the relief of pain. As soon
as pus is present operation is indicated. This may be
performed during the first week, but is more commonly
required during the second. When in doubt as to the
presence of pus, there is usually no great harm in delay-
ing operation. If, however, the symptoms are steadily
growing worse and the pulse becoming rapid, operation
is indicated. Section, then, is called for in suppurative
cases, in cases where there is good ground for suspecting
deep suppuration, and also in the relapsing and rapidly
perforating cases. The best incision is the oblique one,
placed at right angles to an imaginary line drawn from
the right superior iliac spine to the umbilicus. This
should be from two to four inches long, and should be
placed about two or three inches internal to the iliac
spine. In suppurative cases the incision should be placed
over the seat of suppuration, since thus there is less risk
of opening the peritoneal cavity. The appendix should
be removed in suppurative cases only, when this operation
is readily effected without opening the general cavity.
302
MEDICAL RECORD,
[September 8, 1894
The risk of fecal fistula is lessened by suturing the mus-
cular and mucous walls of the stump of the appendix, and
then invaginating this into the caecum and stitching the
peritoneum over it.
Safranin Reaction in Sputum. — A simple test as an
aid to diagnosis is suggested by Zenoni. {The Lancet.)
It depends upon the fact that mucin is colored yellow by
safranin, while albumin is stained red. In the sputum of
bronchitis mucin predominates, while in that of pneu-
monia there is a much larger proportion of albumin.
Zenoni, therefore, prepares a cover-glass specimen of the
sputum by spreading the latter out in a thin layer on the
former, places it at once in absolute alcohol, and leaves
it for a quarter of an hour ; by the end of that time the
film becomes coagulated and fixed to the glass. The
preparation is then stained in a half saturated aqueous so-
lution of safranin. When the cover-glass is removed it
is partially dried and then placed on a white ground and
examined. If it is stained a yellow color mucus pre-
dominated in the sputum, and the case may be assumed
to be one of bronchitis only, while if a red color appears
albumin was the chief constituent, and pneumonia was
probably the condition present. This test, if proved to
be trustworthy, would be a considerable aid to diagnosis
in those cases in which the physical signs of pneumonia
are doubtful. Especially would it be of value in the
case of children if a sample of sputum could be obtained,
as can usually be done with a little trouble. But further
trial will be required before it can be generally accepted.
The Surgical Treatment of Perforation from Gastric
Ulcer. — Few cases offer more temptation to the advent-
urous surgeon, and in few, unfortunately, have his en-
deavors been rewarded with less success than those of
rupture of a gastric ulcer into the peritoneal cavity.
The affair seems, on the face of it, so absolutely simple ;
the patient may be in perfect health, with the exception
of this little perforation and the resulting extravasation
of the contents of the stomach into the peritoneum, and,
moreover, in the majority of cases in which the rupture
has been sudden and the symptoms typical, the perfora-
tion has been in accessible regions— on the anterior wall
of the stomach — and yet, so for, few attempts to sew up
the opening seem to have been attended with success.
Great interest, therefore, attached to the case reported
by Mr. Morse, of Norwich, England, in which a young
woman having symptoms of gastric ulcer was suddenly
seized with symptoms of perforation, and was treated by
him successfully by means of celiotomy and suture of
stomach. Abdominal section was performed within five
hours of the accident ; the contents of the stomach were
found in the peritoneal cavity ; the viscus was withdrawn
aad a perforation found ; the stomach was thoroughly
washed out and the wound united. No food was given
by the mouth for sixty hours, and in three weeks the pa-
tient was well. The points of importance conducing to
the success of this case would seem to be, 1, early opera-
tion, before irrevocable septic mischief has arisen through
absorption from the peritoneal surface ; 2, washing out
the stomach as a preliminary to introducing the sutures ;
this was managed by introducing a large cannula through
the perforation, and alternately filling this viscus with
water and emptying it until the fluid came away clear ;
3 , drawing the stomach out through the wound, so as to
perform the washing and suturing with facility ; and 4,
most important of all, the very great care taken to thor-
oughly wash out the peritoneum. The manoeuvre
adopted by Mr. Morse, with this object, will probably
be useful for other purposes also. Instead of merely
passing a tube to the various regions of the abdomen,
leaving the return water to wash out the fragments, two
large tubes were passed side by side to every part of the
cavity, and the flushing was continued at each spot until
the return fluid was clear ; by this arrangement the ex-
travasated stomach contents were washed out through
the tube, instead of drifting in the stream from one part
of the abdomen to another. It is to be hoped that other
surgeons will be able to obtain like success in the treat-
ment of this otherwise very fatal accident. On a very
different footing stands the proposal to treat perforation
of the bowel in enteric fever, as was shown by the dis-
cussion at the Medical Society of London on March
9th. The patient is already seriously ill, and, although
the accident, of course, happens suddenly, the signs of
its occurrence are often by no means typical. The
stupor of the patient leads to the symptoms being more
or less masked, the moment of onset may not be discov-
erable, the pain may not be severe, and the patient may
only seem to pass from a bad into a worse condition.
Moreover, the ulcers are generally multiple and the in-
testine rotten, so that the stitches may have to be in-
serted in unhealthy tissues, possibly even in the bases of
other ulcers ! A certain number of such cases also re-
cover under medical treatment. The operation, then,
would seem a much less hopeful one than that for per-
foration of gastric ulcer. — Medical News.
Extramedian Incision in Laparotomy Dr. Flatau
has, since 1890, abandoned the practice of cutting in
the median line in ovariotomy and other abdominal
operations performed on women. Out of thirty three
cases where the incision was made outside the middle
line, not one has been complicated by hernia of the ci-
catrix. He cuts one centimetre, or two-fifths of an inch,
to the left of the linea alba, laying bare the rectus, the
fibres of which are easily parted (The British Medical
Journal), In only three or four of the cases did he di-
vide an artery that required ligature ; pressure forceps
were always sufficient to stop hemorrhage from veins.
After a little gentle pressure on the muscle all oozing
ceased, and the wound was quite dry by the time the
peritoneum was divided. Flatau objects to washing the
edges of the wound with carbolic lotion, as the irritation
thus set up may interfere with immediate union. He
has never met with any difficulty in manipulating on the
right side of the abdominal cavity, the incision being
made on the left of the middle line. He uses braided
silk, carefully boiled, for the sutures. He enters the
suture close to the edge of the integument, includes as
much muscle and peritoneum as possible, and brings
the suture out close to the opposite edge of the skin.
This method prevents the turning in of the edges of a
wound made through thin atrophied parietes, so often
seen where the tumor is of large size.
Lactophenin in Enterio Fever. — Dr. Von Jaksch has
tried lactophenin in eighteen cases of typhoid fever, and
finds the results very encouraging. Some of the cases
were severe, with great prostration, hypostatic pneu-
monia, or other complications. The drug may be ad-
ministered in one half to one grain doses in starch cap-
sules, up to six grains in the day if necessary, according
to its antipyretic and sedative effect. No unpleasant
symptoms were produced by the drug, except in one
case, where the first one half-grain dose produced sick-
ness and vomiting ; but even here subsequent doses pro-
duced no bad effects. On two occasions the pulse was
felt to be somewhat irregular while the drug was being
administered. The drug lowered the temperature, and
the subsequent reactionary rise of temperature was unac-
companied by shivering except in one case out of about
three hundred and sixty miscellaneous cases in which the
drug was given. The great advantage claimed for lacto-
phenin in typhoid fever, however, is its sedative action ;
delirium vanishes, the mind becomes clear, and the pa-
tients all experience a pleasant subjective feeling, such
as is given by no previous method of treatment ; appe-
tite quickly appeared in all cases. To what extent
chance played a part in the happy results obtained, and
whether the drug really cuts short the course of the dis-
ease must be left as questions to be decided by further
observations. No protection against hemorrhage or
relapses can be expected from this drug any more than
from other methods of treatment. — Centralblatt fuer in-
nere Median, j*
September 8, 1894]
MEDICAL RECORD.
303
Medical Record:
A Weekly Journal of Medicine and Surgery.
GEORGE F. SHRADY, A.M., M.D., Editor.
Publishers
WM. WOOD & CO., 43, 45, & 47 East Tenth Street
New York, September 8, 1894.
PATERNAL IMPRESSIONS.
•
A sex war is threatened. While the retention of the
time- honored " male " in the Constitution is trembling in
the balance, a British innovator is making a stealthy
claim for the recognition of " paternal " impressions over
the well-known maternal variety of prenatal influence.
Dr. Cullen is the " surgeon-accoucheur," as he styles him-
self, who unblushingly publishes in the Provincial Medi-
cal Journal his vindication of fatherhood in so serious a
matter as the transmission of impressions to the unborn.
It is quite safe to assume that an outraged motherhood
will not calmly submit to this unheard of masculine en-
croachment on a prerogative founded in nature and sanc-
tioned by medical tradition.
At the outset of his learned discourse the " chirurgien-
accoucheur" is inclined to be a trifle apologetic, which
modest spirit is hardly in keeping with the revolutionary
nature of his doctrine. He admits that the modern
physiologist, with microscope in one hand and his last
mounted slide in the other, is undeniably sceptic about
all matters incapable of material demonstration, and
sometimes overlooks the fact that much, if not all, prog-
ress is but the pursuit of theory.
We cannot follow the author too closely in his chase
of theory, though the mental exercise is doubtless brac-
ing and exhilarating enough. Dr. Cullen is lucid in style
and simple in diction. There is no mistake about his
views. For example :
Concerning the ovule, he personally inclines to the be-
lief that, " apart from the theory of continuity provided by
the latent germ idea, which, up to a certain point, seems
incontrovertible, the latent germ contains very little of
the individuation of the parent organism prior to the be-
ginning of maturition in the Graafian follicle, and that
the inheritance of the maternal characteristics continues
from that point to impregnation and onward to the ex-
pulsion of the embryo from the uterus. The element of
chance, which forms a law in the pollination of plants, has
no analogy here, since the conditions are not similar, for
we presume that ovules and spermatozoa are equal one to
the other, and capable of similar results under similar and
suitable circumstances.19
It is certainly comforting to be assured that the human
father does not procreate in the haphazard fashion of
plants. This brings us to the author's chief contention,
namely, that the male element has influences upon the
female beyond that of mere fertilization, and that these
influences should be termed paternal impressions.
The following narrative ought to be conclusive to all
except frivolous sceptics : " A friend, resident in Spring-
barn, possessed a fine female dog of pure Dalmatian breed.
Accidentally she mated with another who was no choice
of her master, and, to the latter* s supreme disgust, pre-
sented him with a generation of collie mongrels. This
was bad, but when informed that his Dalmatian was now
ruined for breeding purposes, he declined to credit the
statement and resolved to test it for himself. In process
of time he had her warded by a pure, male dog of her
own breed, belonging to a gentleman in Kilsyth, and on
this occasion she dropped six puppies — three of them,
however, being perfect collies to such details even as the
claws. Here, it is evident that the mother not only im-
presses the conception, but the conception retaliates with
the paternal impress. The same law holds good with
swine, cattle, horses, and other animals. Nisbet, in
1 Heredity and Marriage,1 refers to it as occurring
among widows who have married again and borne chil-
dren resembling those by their first husbands. Sir J. Y.
Simpson related to Dr. Harvey a similar fact Poultry
may bear a sequence of fecundable eggs from one impreg-
nation. This is an allied paternal impression."
The eminent " chirurgo-obstetrician " is at all events
impartially complimentary. After having told us that
husbands are more circumspect than plants, he makes
" honors easy " by informing the reader that " widows
who have married again " may be classed with certain
mammals and selected poultry.
What have the ardent woman suffragists to say about
the next quotation ?
"In attempting to explain paternal impressions it is
necessary to prove paternal superiority. That woman is
not the aggressive equal of man is a fact and not a fault.
Menstrual, maternal, mammary, and emotional features in
her nature prevent her equality, and where a striking in-
dividual exception has occurred it has been at the expense
of what we define as feminine characteristics. The intel-
lectual female becomes masculine from the very charac-
teristics which mark her distinction. Her physical nature
with remarkable frequency possesses the same distinction,
and is barren in a reproductive sense. The same law ap-
plies no doubt to men of genius also, and is explicable in
the sense that you cannot both have your cake and eat'it.
External mental expenditure, if it may be so termed,
when intense and complete, leaves nothing for internal
transmission, and Galton's industrious work on ' Heredi-
tary Genius ' notwithstanding, genius is not hereditary.
The exceptional female whose talents have given her a
masculine equality, has only really unsexed herself, which
is an instinctive acknowledgment that prepotency rests
with the male. The ancient Greeks who through Plato
and Aristotle gave us systems of logic and philosophy
which denote the highest powers of reasoning, never
doubted this ascendancy. "orvAoc oucov iratScs tUrw
ap<r€v€s" (Male children are the pillars of a house) was
a dictum among them. So believed the Latin races, and
so others. Pedigree everywhere is reckoned through the
male, and this is no arbitrary proceeding but the instinct
of circumstances, and the outcome of accumulated experi-
ence."
We are also reminded that " the testicle is a most deli-
cately sensitive structure. A squeeze will illustrate this.
That its sensitiveness is not purely local, but has a consti-
304
MEDICAL RECORD.
[September 8, 1894
tutional effect, may be proven by the same means. Of its
nerve-supply and the ganglionic nature of it, there can
therefore be no doubt, and that it has a function beyond
a merely local secretion of the male element there can be
as little doubt, for it is evidenced by the mental change
produced by castration. Similarly, the dementia noted
to follow the loss of the ovaries in the female proves not
only the loss of the tissue itself, but the loss of a contin-
gent portion of the perfect organism, and one primarily
and absolutely in touch with the sensorial functions."
In his final summing up the author tells us that, the
immature ova and sperm-cells are simply latent germs
minus those vital and dynamic conditions which mature
them and constitute their activity after their conjunction,
but which in the case of the male element have been
fully impressed upon it prior to this union. With the
beginning of maturity in the Graafian follicle begins the
impress of the maternal characteristics upon the ovule,
which continue until full maturity of the conception in
the uterus — the conception and maternal organism being
marked by a mutual and striking affinity. This is also
evidenced even in nursing, as it is well known that excite-
* ment of the mother affects the nursling through the milk.
The spermatozoon, unlike the ovule, must be, and is,
fully equipped at the moment of impregnation with all
the characteristics of the male organism. The necessity
of this special equipment is arranged for by a much more
complex and detailed organ of reproduction in the male.
While the female characteristics are conveyed to the ovule
by the sympathetic system, they are continued to the ovum
by the nutrition. In the male the paternal characteristics
are conducted through a special ganglionic centre, and
are impressed upon the spermatozoon during an elaborate
and tedious transit through specially arranged tubing.
This ganglionic or reproductive nerve-centre in the
male becomes active near the completion of growth, and
its development is accompanied by those symptoms which
mark the arrival at adolescence. At this period all roads
lead to Rome, all thoughts lead to reproduction — until
the function is established.
That the function is dependent upon an active and
complete connection with an intelligent sensorium, is
proved by the fact that male imbeciles are impotent, and
also, I think, by the fact that imaginative and emotional
races are the most prolific. Were the reproduction pow-
ers contained in the latent germ they would be independ-
ent of subsequent mental development. The fact also
that diseases such as syphilis, contracted,in adult life, affect
the product of conception, and through it the mother,
proves that the spermatozoon is very literally an up to-
date creation, and that it very fully represents a concen-
trated extract of the mature paternal organism. That the
male element has an influence on the female organism
over and above that of fertilization, is incontrovertible ;
her first impregnation has literally a double result ; with
the conjunction of the respective elements there develops
a mutual product whose resemblance to the male organ-
ism would be infinitesimal, were its initial activities not
potent enough to affect, and afterward modify, those of
the mother.
Consequently the reproductive elements are latent
germs in the first instance, which attain maturity by
being charged with organic impressions from the parent,
much after the manner of charging a phonograph with
messages ; which messages are liberated in the female sys-
tem after meeting the suitable medium of the similarly,
though not equally, charged ovule ; or, to use another
metaphor, if we consider the individual as a book, each
spermatozoon is an index of the contents, but how printed,
is a conundrum precisely on a level with how facts or
ideas are recorded in memory, and we can conceive no
material method for the performance of that function.
To append any further comments to this brilliant
resume would be to invite possible misconceptions, which
must not be thought of in connection with paternal im-
pressions.
PAIN, PLEASURE, AND ESTHETICS.
The physician is more apt to think of pain in connection
with its avoidance by anaesthetics, than he is to associate
it in any way with pleasure and aesthetics. It is witbthe
psychology of pain that the author of a book, fresh from
the press of Macmillan & Co. has to do, and he treats of
it together with its correlate pleasure, laying stress upon
their special reference to aesthetics. In the first chap-
ters the place which pleasure and pain should occupy in
psychological classification is sought to be determined, as
well as the relationship between them. The conclusion
is reached that they must be looked upon as general
qualities, one of which must, and either of which may,
belong to any fixed element of consciousness. In the
course of his examination the author further concludes
that, we must assume the existence of an impulse within
ourselves which leads us to produce results which have
the power to attract others to us. This impulse might
be identified with the art impulse. The reader will
understand the trend of these preliminaries when, further
along, the attempt is made to prove that all efforts to
discover special qualities in beautiful objects which de-
termine their beauty have invariably failed. The mental
state of the observer of the beautiful in art and nature
must be studied, and principles of unity sought on which
to base the philosophic treatment of the subject. Es-
thetics are considered as a branch of the science of pleas-
ure and pain, but the author believes only those pleas-
ures to be aesthetic which are permanently pleasurable
in the memory. The aesthetic field is thought, therefore,
to vary with different races and different individuals, and
in the same individual at different times ; changing with
his change' of conception as to what is worthy in the
world surrounding him. To correct the individual taste
it is necessary to recognize the standard of others, and to
compare it with the taste of the educated and refined.
It is futile to try to force our standard upon others.
Upon page 215 the author gives the basis for pleasure-
pain phenomena. "Pleasure," he says, "implies use
of surplus stored energy, while pain implies a subnormal
reaction to a given stimulus.'' Pain, in other words, is
determined by the reception of a stimulus to which the
organ is incapable of reacting.
The author, Henry Rutgers Marshall, shows himself to
be quite at home with this very intricate problem, and
one's confidence is secured from the start by the thor-
ough acquaintance displayed with the views of other
writers. Even if one cannot accept all the theories, it
will repay the reader for the difficulties in gaining ac-
quaintance with the author's terminology, and some new
ideas will be found advanced.
September 8, 1894]
MEDICAL RECORD.
305
Uetus of thz Wtezk.
Vaccination in the Publio Schools. — The an ti- vaccin-
ationists in Brooklyn have been waging war against the
health authorities in that city with varying success, but
have been worsted in their latest contest relating to the
public schools. Under the recent decision of Justice
Bartlett of the Supreme Court, the principals are em-
powered to reject all pupils, who cannot produce certifi-
cates that they have been vaccinated.
Maladies of High Personages.— The Czar of Russia
is ailing, but just what his malady may be is uncertain,
one report being that he is suffering from the results
of repeated attacks of influenza, another that he has a
renal calculus. The Shah of Persia is troubled with his
eyes, and is in poor general health. The King of Siam
is a victim of the chloral habit. The Count of Paris is
dying from carcinoma of the stomach. Signor Crispi,
the prime minister of Italy, is slowly recovering from in-
juries received in a fall. The Queen of Italy is suffering
from nervous shock occasioned by the sudden death of
one of her attendants in her presence. The Pope is
subject to frequent attacks of syncope. The wife of
Prince Bismarck is ill, and the. Prince himself is so agi-
tated over her condition that it is feared that, should she
not recover, he will break down entirely. Dr. Schwen-
inger has been called to Varzin to be present in case
the condition of his illustrious patient should grow worse.
Mr. Gladstone was recently operated upon for cataract.
The young King of Spain is very delicate, though no def-
inite disease has as yet declared itself. President Cleve-
land is reported to be suffering from malaria and the
effects of overwork.
A Hospital for Consumptives is to be erected in
Toronto, Canada, Mr. W. J. Gage, of that city, having
made a contribution of £25,000 toward that purpose.
The Tri-State Medical Society, embracing in its
membership the three States of Georgia, Alabama, and
Tennessee, will hold its next annual meeting at the
Kimball House, Atlanta, on October 9th, 10th, and
nth.
A Prize Essay on Tuberculosis. — The Colorado State
Medical Society offers a prize of $100 for the best essay
upon " The Diagnosis of Tuberculosis by Microscopic
Examination of the Blood." The paper is to be of such
a length that not more than thirty minutes would be
consumed in its delivery. The name of the author must
be kept secret. Essays in competition for the prize
should be sent to Dr. Charles Denison, Denver, not
later than April 1, 1895.
Kiss Florence Nightingale is an honorary president of
the Tropical Section of the International Congress of
Hygiene and Demography, in session this week in Buda-
Pesth.
Sunstroke.— Surgeon-major Martin recognizes three
forms of sunstroke, viz. : The congestive or cerebrospinal,
the syncopal, and the pulmonary. In all these cases he
says death appears to be due to the absorption and non-
elimination of the toxines or leucomaines produced in ex-
cess by great muscular fatigue, and which rapidly poison
the system. This toxic saturation of the body is facilitated
by damp heat and stormy weather as much as by insola-
tion properly so called. When, in spite of precaution, a
soldier is attacked, he must be at once taken to a shady
or cool place, his clothes loosened so as to facilitate
breathing, artificial respiration should be practised, while
an assistant at the same time produces corresponding
compression over the body. While artificial respiration
is being performed the head of the sufferer is covered
with a cooling bandage, sinapisms are applied9 to the
lower limbs, and a subcutaneous injection is given every
hour of one Pravaz syringeful of ether. In the synco-
pal or pulmonary form, in which the nervous system is
prostrated, it is better to give injections of caffeine, as much
as a gram in the twenty- four hours, and in the conges-
tive form, while cold affusions are applied to the head and
sinapisms to the extremities, to give subcutaneous injec-
tions of pilocarpine to produce profuse perspiration ; and
then to aid in the elimination of the toxines purgative
enemata must also be given. — London Correspondence of
the American Practitioner and News.
Quack Nurses — Quackery is contagious and wide-
spread. There are quacks not only in medicine, but the
infection seems also to have invaded the profession of
nursing. From Detroit comes the announcement of the
organization of a " Correspondence School of Health
and .Hygiene," which proposes to give "instruction by
the correspondence method in the care of the sick."
The course of instruction, it is believed, " if thoroughly
studied by a reasonably intelligent person, will render
the pupil as truly a trained nurse as the great majority of
those who come from the training schools. ... No
previous training or study is required other than the
ability to read and comprehend." As to age, sixteen is
not considered too young nor fifty too old. It needs
scarcely be said that the art of nursing is not to be ac-
quired by correspondence, from reading, or even from
didactic lectures ; these measures may aid in the compre-
hension of the principles upon which intelligent and
rational nursing is based, but actual experience by the
bedside, in the hospital-ward, and in the sick-room, is
absolutely essential. — Medical News.
Large Families do not seem to be so very rare even
in these latter days. We recently referred to the fecun-
dity of Canadian women, and now England comes to the
front with large families. A London family paper not
long since offered a prize of one guinea to the woman
subscriber who could prove that she had the greatest
number of children. The prize was divided between two
women, each of whom had twenty-five children. The
first sixteen women entered on the list of competitors had
a total number between them of two hundred and eighty-
eight living children.
Freckles. — A paragraph seasonably going the round of
our exchanges attributes to Hager the assertion that
freckles can be removed by the application, every other
day, of an ointment composed of white precipitate and
subnitrate of bismuth, each one drachm ; glycerine oint-
ment, half an ounce.
Diphtheria Antitoxin. — At a late meeting of the Ber-
lin Medical Society Dr. Baginsky criticised rather un-
favorably the report of the antitoxin treatment of diph-
theria made at a previous meeting by Katz, to which we
referred in a recent issue. He said that the credit of the
discovery was due to Bogola, of Sienna, who first made in-
3o6
MEDICAL RECORD.
[September 8, 1894
oculations of a diphtheritic material in 1868. Analyzing
Kate's report, he said that of 128 cases only 14 died, and
from these deaths those attributed to scarlatina, septic
poisoning, etc., were eliminated, leaving a mortality from
the disease or the drug of only about thirteen per cent.
But, if the same process of elimination was carried out
in cases treated by the ordinary methods, he believed that
the difference in favor of the new mode would be found
to be very slight, if indeed there was any.
The Mortality of European Cities. — The annual
death-rate per 1,000 of the following cities, as computed
for the returns for the first week in August, is : Paris, 19 ;
Brussels, 19; Amsterdam, 12; Rotterdam, 17; The
Hague, 15; Copenhagen, 15; Stockholm, 15; Chris-
tiania, 16 ; St. Petersburg, 62 ; Moscow, 43 ; Berlin, 19 ;
Hamburg, 19; Dresden, 19; Breslau, 33; Munich, 26;
Vienna, 23 ; Prague, 24 ; Buda-Pesth, 25 ; Trieste, 30 ;
Rome, 16; London, 17; Liverpool, 27; Birmingham,
14; Manchester, 21; Dublin, 20; Edinburgh, 14; Shef-
field, 18, and Swansea, 10. The excessive rate for the
Russian cities is due largely to the epidemic of cholera.
Boraoie Acid. — The greater part of the crude boracic
acid imported into England comes from Tuscany, in the
immediate neighborhood of Castelnuovo. It is originally
dissolved in the waters of an underground hot lake, which
sends off steam charged with about three per cent, of
boracic acid through many openings, called " fumerolles,"
on the surface. The steam is condensed, and the add
dissolved in fresh water, from which it is crystallized in
tubs. The acid is then packed in casks and shipped from
Leghorn to England, where it is refined into the pure
pulverized boracic acid familiar to our readers. — Medical
Press.
A Medical School for Women is about to be established
in St. Petersburg under Government auspices. A similar
institution was organized through private initiative a
number of years ago, but was soon closed by the authori-
ties, and since that time the Government has always
frowned upon the higher education of women.
Professor Josiah Parsons Cooke, Professor of Chemistry
at Harvard, died at his summer residence at Newport, on
September 3d. He was sixty seven years of age. He
was graduated from Harvard in 1848, and had been con-
nected with the University in a teaching capacity since
1850.
The Eighth International Ophthalmological Congress
was held in Edinburgh during the first week in August,
under the presidency of Dr. Argyll Robertson. Drs.
Henry Power and Swanzy were elected vice-presidents,
Dr. Berry, general secretary, and Drs. Parent, Hess, and
Fergus, assistant secretaries. The honorary presidents
elected were: Drs. Panas, Meyer, Landolt (France),
Zehender, Leber, Hansen Grut, Reymond Snellen, Roosa,
Knapp, Critchett, Priestley Smith, Little, Pridgin Teale,
and Reid.
In his presidential address Dr. Robertson referred to the
death of Donders and Becker which had occurred since
the seventh Congress was held in Heidelberg in 1888.
In Donders he said had been lost one of the greatest
ornaments of the world of science, and in Becker the
ophthalmological world had lost an able surgeon whose
discoveries in the anatomy and pathology of the lens were
classical. He referred also to the absence of Helmholtz,
the greatest physicist of the age, and expressed the earnest
hope that he might have a rapid recovery from his serious
illness.
The Cholera has not decreased much during the past
week, neither has the disease invaded new territories,
with the exception of Austrian Silesia. It is reported to
be terribly virulent in Russian Poland, where the phy-
sicians are unable to cope with it owing to the fact that
the inhabitants conceal their sick and treat them with
domestic remedies, fearing that the doctors will experi-
ment upon them. Thirty of the seventy-four political
districts of Galicia are infected, 200 new cases and 95
deaths having been reported there on August 31st. The
disease has been introduced into Silesia by the Austrian
troops returning from the manoeuvres in Galicia. In
Germany, during the two weeks ending September 3d,
there were 121 new cases and 53 deaths. Isolated cases
continue to be reported from Amsterdam, Rotterdam,
Maastricht, and other towns in Holland and Belgium.
Electrical Treatment of Bed Hoses.— Dr. Helling
says that a red nose is due to contraction of the arterioles
and dilatation of the veinlets. He claims to have cured
a number of cases by the application of a continuous
current of moderate intensity for five to ten minutes
daily.
A Cattle Quarantine Station.— All horned cattle,
sheep, and swine imported into this country must be kept
in quarantine for a period until all danger of the devel-
opment of tuberculosis, pleuro-pneumonia, foot-and-
mouth disease, anthrax, or hog cholera has passed. The
period of quarantine for cattle is ninety days, that for
sheep and swine fifteen days. The Government pro-
vides the quarters for the animals free of expense to the
owners, but the latter must pay for the transportation of
the animals to and from the station, and for their keep
when there. There are stations of this kind at several
places along the coast, but the most important one is at
the Garfield Farm, near Passaic, N. J.
The Dangers of Thyroid Extract.— Dr. W. D. James
reports in the June number of the British Journal of
Dermatology a case of glycosuria caused by thyroid ex-
tract given for the relief of psoriasis. The patient was a
medical man, had taken the extract in small doses for
some time without effect upon the disease, and then in-
creased the dose quite suddenly. At the end of a week
he began to suffer severely from depression, with frequent
flushings and palpitations. The nervous symptoms in-
creased, and the patient felt and looked a very old man.
Before another week elapsed his thirst became unquench-
able ; the quantity of urine greatly increased, the breath-
ing became embarrassed, the pulse rose to 132 per minute,
and the smell of acetone was detected in the breath.
The urine had a specific gravity of 1.032, and sugar was
freely found by all tests. The thyroid treatment was at
once stopped, and antidiabetic diet adopted, with the re-
sult that the quantity of sugar decreased daily, and disap-
peared entirely in a few days. No improvement was
noted in the psoriasis.
A Definition. — A London daily paper explains to its
readers the term " exploratory incision," which, it says,
" means quarrying into a patient on the chance of dis-
covering some disease in an internal organ which is cura-
ble by its removal."
September 8, 1894]
MEDICAL RECORD.
307
glewijKttXB un& gtotijcea of §taolt8.
Index Catalogue of the Library of the Surgeon-
General's Office, United States Army. Vol. XV.
Washington, Quarto, pp. 842. Government Printing
Office. 1894.
Vol XV. of this well-known series is somewhat smaller in
bulk than its predecessors. Its contents are from Uni-
versidad — Vzoroff, and covers 6,152 author titles, repre-
senting 3,312 volumes, and 4,235 pamphlets. It also in-
cludes 8,596 subject titles of separate books and
pamphlets, and 35,667 titles of articles in periodicals.
Its editor and compiler, Dr. John S. Billings, still has
charge of the work, and is to be congratulated on its ap-
proaching completion.
Weekly Abstracts of Sanitary Reports (1-52), vol.
viii.
The volume contains the voluminous weekly reports of
the Supervising Surgeon General of the Marine Hospital
Service for the first half of the year 1893, has 1,300 pages
of contents, and is of value chiefly to the sanitarian and
statistician in need of official data.
Burdbtt's Hospital and Charities Annual, 1894,
being the Year Book of Philanthropy. Fifth year.
By Henry C. Burdett. London: The Scientific
Press, Limited. New York : C. Scribner's Sons.
This useful volume is replete with information regarding
the charities of the English-speaking world, and notwith-
standing its nearly six hundred pages is a marvel of con-
densation. It touches upon almost every subject in
which philanthropy is concerned; it discusses philo-
sophical problems, character and cost of work done,
sources of revenue, as well as directs into proper channels
the contributions of that very large class who disburse
in a perfunctory way a moiety of their income, without
the least care for its destination. A paragraph upon the
professional philanthropists, who live on their share of
the subscriptions, well portrays an aberrant species not
unknown even in our millennial hemisphere. The group-
ings of hospitals, asylums, homes, and orphanages are
admirable, and constitute a coup <T ail as searching as
comprehensive. In fact, in this annual, besides the
enormous labor bestowed upon its compilation, about
which the general reader takes but little thought, there
is a wealth of texts capable of being amplified into
many sermons. To say the least, the author has made
an encyclopaedic addition to a much needed literature
for the physician who looks beyond the mere emolu-
ments of his profession.
The Truth about Homceopathy. By Dr. W. H. Hol-
combe. Philadelphia: Boericke & Tafel. 1894.
This is a posthumous manuscript which is a defence of
homceopathy. Although it contains no new argument,
it is well written, and as such may be considered a desir-
able addition to the class of literature to which it be-
longs.
Annales de l'Institut de Pathologie et de Bact£rio-
logie de Bucharest, publtees par Victor Babes,
Professeur a la Faculty de M£decine et Directeur de
rinstitut. Deuxteme Ann6e, 1890. 4to, pp. 506.
Bucharest, 1893.
This handsome volume is the third part of the " Annals
of the Institute of Pathology and Bacteriology of Bucha-
rest," and contains the papers published from that labor-
atory during the year 1890. Thirteen papers in all are
included, the majority of which are here given in both
the French and Roumanian languages. All have ap-
peared before in different medical periodicals ; they are
here collected for convenience of reference. Among
them are three papers on glanders and its bacillus, one
on scarlatinal nephritis, two on the association of bac-
teria in the production of disease in general, and of the
lesions of tuberculosis ; three on different phases of tuber-
culosis, including the results of treatment of lupus by
tuberculin, and an exhaustive paper on the different
forms of the Plasmodium malaria?. Many of the papers
are handsomely illustrated by colored plates.
Transactions of the New York State Medical Asso-
ciation, for 1893, vol. x. Edited by E. D. Ferguson,
M.D , New York. 8vo, pp. 585.
This volume contains the usual variety and number of
valuable communications from its talented contributors,
and is in every way the equal to any of the former edi-
tions, which is saying all we can in its praise. The
frontispiece is an excellent portrait of the late Dr. A. L.
Carroll, one of the founders of the Association, whose
obituary by Dr. Gouley is a model of its kind and well
befitting the subject. A very comprehensive decennial
index also adds to the value of the volume.
The Practice of Medicine. By Edwin M. Hale,
M.D., author of "New Remedies/ ' "Diseases of
the Heart." Emeritus Professor of Theory and Prac-
tice, Chicago Homoeopathic Medical College, etc. 8vo,
pp.1018. Chicago: Gross & Delbridge. 1894.
This work, which is very complete in its way, is in-
tended more especially for practitioners of homoeopathy,
although it has a strong liberal tendency toward what
the author styles the old school of practice. The author
is certainly very liberal in his views, refreshingly dog-
matic in his condemnations, and emphatically positive in
drawing the line between what is and is not tenable in
the present accepted doctrines of disease. There is no
mistaking what he means when he gives the results of his
personal experience in "proving" and in the ultimate
results of treatment. The reader everywhere in the text
finds the different drugs, of large and small degree, in
strange relations with each other, that are hardly explain-
able on the score of a compromising liberalism as to their
respective actions. With a laudable effort to reconcile
treatment to the latest discoveries in bacteriology, he is
hardly consistent in his attempt to explain the action of
germicides with the doctrine of similiasimilibuscurantur.
The task is professedly a difficult one, and he makes as
good a showing as is possible under the circumstances.
His descriptions of the clinical phenomena of disease
are terse and to the point, and are made especially inter-
esting by numerous historical references not usually found
in similar works. The chapters are short, the subjects
numerous, and their discussion interesting and suggestive.
The frontispiece, which is the only illustration in the
work, gives an excellent likeness of the author with his
autograph.
Medical Journals not Appreciated. — The following
reply was returned to a circular letter soliciting subscrip-
tions to a certain medical journal :
Faribault, Minn.
Your Copy of the Jurnal come, and the letter
to — askin me to send fifty cens and git it fur a yeer. . I
don't nead no jurnals. When I git a tuff case I go off
inter sum secrit plase and tell the lord all about it and
wate for him to put inter my minde what ter do. That's
bettern jurnals and syklopedes and such. If we hed more
lord trustin docters and less colleges weed fare better.
The lord noes morn all the doctors and if we go to him
fur noledge it ill be bettern jurnals.
Fraternally in the lord,
A Christun Docter.
P. S. — I've practist medisen morn fifty yeers. Yore
ken publish this letter if you want ter. — Northwestern
Lancet
Royal Ladies who Smoke. — A census has been taken
of the cigarette-smokers among the ladies of the courts
of Europe, and it has been found that the majority of
them indulge more or less openly. Among them are the
Queens of Italy, Spain, and Portugal, the Czarina, and
the Empress of Austria.
3o8
MEDICAL RECORD.
[September 8, 1894
jtacietg 3$ep0Vts.
CANADIAN MEDICAL ASSOCIATION.
Jhventy seventh Annual Meeting, held in St. John, N. £.,
August 22 and 2j, 18Q4.
(Special Report for the Medical Record.)
Dr. T. T. S. Harrison, of Selkirk, Ontario, the Presi-
dent of the Association, called the meeting to order, and
introduced several delegates from foreign medical soci-
eties. Among these were Dr. L. Duncan Bulkley, of
New York, delegate from the American Medical Asso-
ciation, and Dr. Jonah, of Eastport, from the Maine
Medical Society. Drs. Charles O'Reilly, I. H. Cam-
eron, and J. E. Graham, delegates of the Ontario Med-
ical Association, were also present. A large number of
new members, chiefly from the Maritime Provinces,
were admitted. Letters of regret were read from Sir
Charles Tupper, Drs. Osier, Marcy, Bray, Mullin, and
- McLean.
Epilepsy.— Dr. Hattie, of Halifax, read a paper with
this title, dealing chiefly with theories concerning the
etiology of the affection. He gave an extended report
of certain experiments and of the post-mortem changes
that he had observed. These changes, however, he
thought might be rather the result of the nerve storm
than the cause of it. The most probable cause lay in
the action of some toxic irritant, itself the product of
some systemic disease. Anaemia is present in most cases
of epilepsy, and the speaker thought that this might
possibly be the condition upon which the disturbance
depended. On the supposition that the poison might
be absorbed from the intestinal tract, he had adminis-
tered intestinal antiseptics in conjunction with the bro-
mides, and, comparing the number of paroxysms occur-
ring under this method of treatment with the number
observed when the bromides alone were administered, he
was led to the conclusion that there was at least a modi-
cum of truth in his assumption. Under the new method
there was a very marked diminution in the number and
frequency of the attacks.
The paper was discussed by Drs. Cameron, of Toronto,
and Wright, of Ottawa.
Antagonism of Erysipelas and Tuberculosis. — Dr.
Muir, of Truro, reported a case of tuberculous disease of
the arm which had been cured by accidental infection
with erysipelas. The patient was a woman, thirty- nine
years of age, who had suffered from well-marked and typ-
ical tubercular ostitis of the arm for fourteen years. Ex-
amination of the discharge from the sinuses showed the
presence of the tubercle bacillus. The sinuses were
opened and scraped and an iodoform dressing was ap-
plied, but little or no improvement followed the opera-
tion. Five weeks later the wound became accidentally
infected with erysipelas. The patient was very seriously
ill for some time, but finally made a good recovery from
the erysipelas, soon thereafter it was observed that the
original trouble was improving, and in a comparatively
short time the tuberculous disease was entirely healed.
The speaker exhibited some photographs showing the
condition after the attack of erysipelas.
Presidential Address. — The subject of the President's
address was, " My Experience and Observation in the
Practice of Medicine Extending over Half a Century."
The address dealt chiefly with the clinical signs and
treatment of the various diseases commonly met with
among the early settlers in the woods, of the more usual
domestic remedies employed by these pioneers, and of
the difficulties and hardships of the medical practitioner
in those days. He referred also to the fact of the dis-
appearance of miasmatic diseases and murrain since the
country had been extensively cleared up and drained,
and dwelt upon the problem as to how and by what
means the specific germ-diseases were introduced into a
new country. He did not believe that the specific causes
could originate de novo, yet it was often difficult or im-
possible to say whence they came. The latter portion
of the address was devoted to a discussion of the matter
of inter-provincial registration, which he favored, and
which he thought it was in the power of this Association
to bring about.
A vote of thanks was moved by Dr. Bayard, of St.
John, seconded by Dr. Hingston, of Montreal, and car-
ried with much enthusiasm. Dr. Wright, of Ottawa,
moved, and Dr. I. H. Cameron, of Toronto, seconded,
that a committee be appointed, representing the various
provinces, to consider the suggestions made in the Presi-
dent's address, in relation to the question of inter-pro-
vincial reciprocity in medical practice.
Appendicitis. — Dr. James Bell, of Montreal, read a
paper with this title, which was based upon the results of
his work in the Montreal General Hospital during the past
eleven months. He had had forty eight cases, of which
forty were operated upon ; all of the patients, both those
operated upon, and those treated expectantly, recovered,
except three. The speaker believed that all cases of ap-
pendicitis should be in the hands of the surgeon from
the beginning of die attack, and in the majority of in-
stances an operation should be resorted to as soon as the
diagnosis was definitely established.
Dr. Hingston, of Montreal, discussed the question
from the conservative side. He had prevented the oper-
ation, he said, about thirty times, and only in one case did
he regret that he had not counselled the surgical interven-
tion. He did not want the younger members of the As-
sociation to go away with the idea that operation was
the first thing to be thought of in every case of appen-
dicitis they might have. They could not argue from the
results of Dr. Bell's cases, for in the first place Dr. Bell
was an able and experienced surgeon, and in the second
place the cases that came under his care were for the
most part of a very serious character and really calling
for operation.
Sir James Grant, of Ottawa, reported two cases he
had had which seemed at first to be fit for operation, but
one was in a gouty and the other in a rheumatic subject.
He did not operate, and both cases recovered. He did
not believe that the cause of the inflammation in these
cases was the presence of a foreign body in the vermiform
appendix.
Dr. Shepherd, of Montreal, pointed out that the sur-
geons always got the worst cases, so that it was difficult
from a comparison of statistics to determine just what
was the proportion of cases which should be operated
upon and how many should be treated by medical means.
His idea was, as a rule, to operate after the acute attack
had subsided. He thought that the tender-point of
McBurney should be referred not to the appendix but
to the inflamed condition of the mesenteric glands, for
the appendix might be found on the right side, in the
pelvis or up under. Strange was in favor of non-inter-
ference until the presence of pus could be made out.
He had usually refrained from operating during the acute
stage, and had never had cause to regret it.
Dr. Cameron, of Toronto, said he followed Treves in
this matter ; wait until pus forms, then open and drain.
He thought that it would be unfortunate if the experi-
ence of a hospital surgeon of skill should be permitted to
determine the matter one way or the other.
Dr. Bell, in reply, said that it was conceded by all
that no man could say definitely just when to operate in
all cases. Out of the forty cases in which he had oper-
ated there was perforation in thirty-two ; in three the
appendix was gangrenous, in two it was bound down by
adhesions ; in three other cases the symptoms pointed to
very grave inflammation, yet no abscess was found and
the gut was not perforated. He used to follow the ex-
pectant plan, and his losses were much greater than now.
The most extreme mortality after these operations is two
or three per cent. If the patients were let alone, perfora-
tion and collapse might occur at any moment. The very
mild, or rather short, cases in which all the symptoms
September 8, 1894]
MEDICAL RECORD.
309
passed away within twelve hours, need not be interfered
with, for they were probably cases of csecitis. He be-
lieved that the method advocated by Treves was not ac-
cording to the principles of true surgery.
Eye-strain Headaches. — Dr. Morrison, of St. John,
read a paper with this title. These headaches had been
treated by tenotomy, but this was dealing with the effect
only and not with the cause; the operation relieved
some of the reflex troubles for a time, but the ultimate
result was not good. The real trouble was an imperfect
curvature (it might be very slight) of the cornea. This
condition added to the work of the delicate muscles of
accommodation, when much near work was to be done
with the eyes, and overtaxed the ciliary muscle, from
which resulted the distressing reflex headache. The
pain was usually situated in the neighborhood of the
temples, but sometimes extended to the occiput and
down the back of the head. Numbness sometimes oc-
curred in other parts of the body, and digestive disturb-
ances were likewise at times a marked symptom. A
proper correction of the myopia, hypermetropia, and
astigmatism, together with the administration of tonics,
removed the insufficiency. The speaker reported some
of the cases of headache that he had been called upon to
treat, where the proper management of the trouble had
been neglected because no examination of the eyes had
been made. The muscle would recover just as a sprained
limb would if properly treated. The use of suitable
glasses was a crutch for the over-strained ciliary muscle.
Diseases of the Ovaries and Fallopian Tubes. — Dr.
Lapthorn Smith, of Montreal, followed with a paper
on the treatment of diseases of these organs. The sub-
jects of gonorrhoea! and tuberculous salpingitis, tumors
of the ovaries, and ovarian congestion were dwelt upon,
their most prominent symptoms pointed out and their
treatment sketched. Many cases were reported and
numerous pathological specimens shown.
Influence of the Mind Upon the Body. — Dr. Bayard,
of St. John, delivered the Address on Medicine,
taking this as his title. He gave a brief .r£sum6 of the
general anatomical and physiological features connected
with the nervous system, and pointed out that various
mental phenomena were causative of marked changes in
the body, particularly in respect to the action of the
vasomotor nerves. He had known pain to disappear in
the presence of sudden danger, and he quoted Hunter
as saying : " My life is at the mercy of any scoundrel
who chooses to put me in a passion," and, strange to
say, that was the cause of his death. It is believed that
the elaboration of the blood constituents is interfered
with when the individual is under emotional excitement.
The speaker then discussed many of the various nervous
troubles so common at the present day, and suggested
methods for their treatment.
In connection with one of the points referred to in
the address, Dr. Bayard moved, and Dr. Hingston sec-
onded, that in the opinion of the Association, the sys-
tem of education generally pursued in the Dominion of
Canada draws too largely upon the brain- tissue of chil-
dren, and materially injures their mental and bodily
health. It was objected that this resolution was too
sweeping in its wording, and that there was no sugges-
tion as to what department of the school system was at
fault, nor as to what portion of the Dominion the strict-
ures more especially applied. Our young people, Dr.
Cameron said, were not suffering from too much educa-
tion, neither were their elders for that matter. The
educational system had been the subject of the best
thought of the best men in the country, and he believed
the motion was altogether too condemnatory. A resolu-
tion was than passed that the matter be referred to a
committee, consisting of Drs. Powell, Hingston, Gra-
ham, and Bayard, to report at the next meeting.
Functional Hepatic Disorder. — Dr. J. £. Graham, of
Toronto, presented a communication entitled " Some
Functional Derangements of the Liver,1' in which he re-
viewed the history of the physiology and pathology of the
liver, and showed that there are other and no less impor-
tant functions of the organ than the secretion of bile.
He outlined the work of the liver and demonstrated the
very important functions that it has to perform in the
human economy. Its importance as a blood elaborating
and fat-forming organ in the foetus must be great, since
we know that it is equal in weight to all the rest of the
body at the end of the first month, in the proportion of
one to three at the end of the third, and of one to six-
teen at the end of the fifth month. The speaker then
discussed the question of " hepatic inadequacy," a con-
dition induced by the action of certain poisons upon the
hepatic cells. The hepatic cells stored up the glycogen
until it was needed by the economy, and when this
function was impaired various clinical phenomena were
observed. As regards the treatment of "biliousness,"
the exact cause of this condition should be searched for
and found, if we were to hope for success in relieving the
trouble. The diet should be most carefully attended to ;
starchy foods should be absolutely forbidden, but milk,
because of its ready assimilation and diuretic action,
should be regarded as of great value. The reader rec-
ommended certain forms of exercise as of value in as-
sisting the circulation. Massage over the gall-bladder,
as promoting the egress of bile, is helpful, and free pur-
gation is essential. He then discussed the various drugs
used in hepatic disorders, calomel, euonymus, podophyl-
lum, etc., and their several indications. When the elab-
oration of urea is incomplete, treatment directed
toward an increase of metabolism — massage, bathing,
the drinking of mineral waters, etc. — is to be recom-
mended. The great point to aim at is to secure and, if
possible, restore the integrity of the hepatic cells.
Brain Operations. — Dr. Hingston, of Montreal, re-
ported four cases of brain operation, two of which were
for epilepsy. One was for the relief of paralysis of cer-
tain muscles of the arm in a young man who had received
an injury to the skull some twenty years before ; there
was also spasm of some of the muscles of the face. The
operation afforded almost complete relief. The speaker
employed a trephine two inches in diameter, which he
contended was much superior in some respects to those
in ordinary use and of smaller size.
Amputation at the Shoulder-joint. — Dr. Shepherd,
of Montreal, related the history of a case in which he
had removed the entire upper extremity for a chondro-
sarcoma involving the shoulder joint, and another of
removal of a large enchondroma of the pelvis. The first
operation had been but seldom performed, this being the
first that was on record as having been done in Canada.
The paper was discussed by Drs. Hingston, Cameron,
and Steves.
Prevention of Tuberculosis.— Dr. Inches, of St John,
read a paper with this title, in which he advocated the
necessity of increased activity on the part of the profes-
sion, the public, and the government in dealing with this
disease. The patients themselves needed much instruc-
tion in regard to the disinfection of sputa, so as to lessen
the danger to others in the house. Even in well-kept
consumption hospitals, he said, there is some danger of
infection. He dwelt upon the difficulties connected
with notification, registration, and isolation. He bad
found it very difficult, even among his wealthy patients,
to secure isolation and fresh air, and of course it is infi-
nitely more difficult to secure such among the poorer
classes, who are often not in position to carry out the
necessary measures looking to this end. The speaker
held that special sanitaria should be established, so that
every patient who could not be properly looked after at
home might find a place where his necessities could be
attended to.
Treatment of the More Ordinary Skin Diseases. — Dr.
L. Duncan Bulkley, of New York, read an interesting
paper on the treatment of skin diseases by the general
practitioner. He said that there were really only a few
skin diseases that made up the bulk of those coming under
the care of the general practitioner, and if we learned to
3io
MEDICAL RECORD.
[September 8, 1894
diagnose and treat these we should be in position to cure
the greater number of diseases of the skin ; the few rare
cases could be sent to a specialist. He urged the neces-
sity of paying more particular attention to each individual
case, and of not treating all alike because they had a dis-
ease with a common name ; routine should be avoided,
and careful inquiry should be made into every detail of
the patient's system and habits. The history of the
eruption, and of former eruptions, the family tendencies
as to the presence of asthma, rheumatism, etc., should all
be made the subject of painstaking inquiry. If the gen-
eral practitioner were well acquainted with acne, eczema,
and syphilis, he would be able to treat satisfactorily the
majority of cases of skin diseases that came under his care.
As to eczema, too much was often done — the disease was
over treated. He had grown more and more convinced
of the great necessity of constitutional treatment in all
these cases of skin affections, and had often had occasion
to observe that the correction of some fault in diet or
mode of life was sufficient to effect a cure. The speaker
further emphasized some of the more important points to
be observed in the treatment of acne, syphilis, psoriasis,
and urticaria.
The Contagiousness of Tuberculosis. — Dr. J. F. Mac-
do nald, of Nova Scotia, read a paper with this title, in
which he advocated the bringing of the matter of the con-
tagiousness of this disease before the people through the
medium of the public press. He favored a system of reg-
istration, careful disinfection, government inspection of
infected places, the establishment of sanitaria, and the
enactment of laws to hinder the infected from spreading
the contagion.
Nasal Cauterization. — Dr. Kirkpatrick, of Halifax,
presented a communication on the subject of cauteriza-
tions of the nasal mucous membrane, in which he uttered
a warning note against the indiscriminate introduction
of strong caustics into the nasal cavity. He had seen en-
tire destruction of the membrane and other serious con-
sequences follow an abuse of these remedies, which were,
however, of such exceeding value when properly and ju-
diciously employed.
Other papers read were : " Adhesions of the Soft Pal-
ate, and their Treatment," by Dr. Hamilton, of Mon-
treal; "The Present Status of Asthenopia," by Dr.
Buller, of Montreal; " Hysteropexy,' ' by Dr. K. N.
Fenwick, and "A Medico-legal Romance," by Dr.
Steves, of St. John.
After the customary votes of thanks, the meeting was
closed by the President. It was decided to hold the
next meeting of the Association in Kingston, Ontario.
Typhoid Fever and Vaccination.— Doctor William
Finder observed that after typhoid fever patients recover
they are very susceptible to vaccination. This observa-
tion has been verified many times during a number of
years, and the writer suggests that others confirm or dis-
prove the theory. So satisfied is Dr. Finder with the
correctness of the observation, that he now re vaccinates
his typhoid patients as soon as they recover from the
fever. — Medical News.
Erysipelas Toxins in Malignant Disease.— The fol-
lowing are the conclusions of Dr. William B. Coley, in
an article on this subject in the American Journal of the
Medical Sciences for July, 1894: 1. The curative action
of erysipelas upon malignant tumors is an established
fact. 2. This action is much more powerful in sarcoma
than in carcinoma. 3. This action is chiefly due to the
toxines of the erysipelas streptococcus, which may be iso-
lated and used with safety. 4. This action is greatly in-
creased by the addition of the toxines of bacillus prodi-
giosus. 5. The toxines, to be of value, should come from
virulent cultures and should be freshly prepared. 6.
The result obtained from the use of toxines without dan-
ger are so nearly quite equal to those obtained from an
attack of erysipelas, that inoculation should rarely be re-
sorted to.
AMERICAN MEDICAL ASSOCIATION.
Forty-fifth Annual Meeting f held in San Francisco, CaLt
June J, 6, 7, and 8, 1894.
(Continued from VoL 45, page 799.)
SECTION ON PRACTICE OF MEDICINE.
Third Day, Thursday, June 8th.
Typhoid Fever. — Dr. John Eliot Woodbridge, of
Youngstown, O., read a paper on this subject in which
he claimed that typhoid fever, if a germ disease, and of
this he felt confident, could be aborted. The disease
was, he said, on the increase, and was limited by no geo-
graphical lines. The author claimed that he could cure
every case of typhoid fever if he saw it early enough.
Treatment by means of antiseptics such as thymol, guia-
col, eucalyptol, etc., was the course pursued by him in
these successful cases.
Diagnosis and Treatment of Diseases of the Stomach by
the Stomach -Tube.— Dr. A. W. Perry, of San Franciso,
Cal., stated that most disorders of the stomach depend-
ed upon fermentations or abnormal accumulations in
quantity or quality in that organ. The fermentations
were acetic, lactic, butyric, cellulose, etc. Lactic-acid
fermentation develops normally within fifteen to twenty
minutes after digestion commences, but is held in check
by the hydrochloric acid of the gastric juice. Acetic
and butyric fermentations are prevented by a more rapid
and complete emptying of the stomach. By means of
the stomach- tube we can determine dilatations, and
determine the chemical composition of the stomach con-
tents. Spasm of the glottis may interfere with the intro-
duction of the tube. To overcome this the speaker is in
the habit of touching the back of the pharynx with his
finger. Cocaine may be used. In some cases the circu-
lar fibres of the oesophagus contract and thus obstruct
the passage of the tube. Reflex spasm of the glottis is
the obstacle in the greater number of cases. The stom-
ach-tube should be used only every other third or
fourth day. During the intervals the internal adminis-
tration of an ' antifermentative is recommended. The
speaker uses resorcin, gr. v., after meals, and finds this
does not interfere with the digestive processes. The use
of the stomach-tube will prove valuable in the diagnosis
of cancer and ulcer of the stomach, by allowing a quanti-
tative test for hydrochloric acid.
The author finds lavage of benefit in the treatment of
the following stomach disorders : Acute and chronic gas-
tric catarrh, dilatation of the stomach, not dependent
upon pyloric stricture, various fermentations, causing re-
flexes, cancer, ulcer, and finally in obstinate singultus.
Dr. Freeman, of Indiana, commended the paper and
suggested a method to render the oesophagus tolerant.
In his experience he found that by the frequent use of
the oesophageal bougie between the acts of lavage the
oesophagus established a tolerance of the tube.
The Law of Equivalence in Medical Science. — Dr.
R. W. Murphy, of San Francisco, Cal., expressed the
belief that before many years have passed prophylactic
measures will be discovered for such diseases as Bright's
disease, cancer, tuberculosis, etc., as has already been the
case with the small-pox, hydrophobia, etc. He called
attention to the great diversity of treatment directed tow-
ard the same disease, and believed we should have more
practical textbooks and drug action, both as regards
maximum and minimum dosage.
He predicted that the physician of the future would be
the man who closely watches the dual action of his drugs.
In the case of calomel, cited as an instance, we may find
physicians recommending a dosage varying from ^ grain
to 60 grains for the same disease and under apparently
the same conditions. The same may be said regarding
almost all of the drugs in use.
Among other remedial agents electricity is largely
employed without thought of the law of equivalence.
Experiments should be a thing of the past
The following papers were read by title: "Cham-
September 8, 1894]
MEDICAL RECORD.
3ii
pagne and Strychnine in Chest Troubles of the Aged," by
Dr. Edward Buxton, of National City, Cal. ; " The Treat-
ment of Erysipelas," by Dr. James M. Anders, of Phila-
delphia, Pa. ; " The Use of Turpentine in the Treatment
of Diphtheria," by Dr. E. W. Kellogg, of Milwaukee,
Wis ; " Lung Gymnastics in the Treatment of Chronic
Disease," by Dr. L. P. Walbridge, of Decatur, 111. ; "A
Clinical Study of Scarlatina at High Altitudes," by Dr.
J. N. Hall, and Dr. William P. Munn, of Denver, Col.
THE NEW YORK PATHOLOGICAL SOCIETY.
Stated Meeting, April 25, 1894.
George C. Freeborn, M.D., President, in the Chair.
Abnormalities of the Heart — Dr. L. Pearce Bailey
presented two specimens showing abnormalities of the
heart. The first one showed a fourth cusp to the aortic
valve, and also some vegetations. The second specimen
was from a child who had died at birth from prolapse of
the umbilical cord. A fibrous cord was found stretched
across the aorta.
Primary Thrombosis of the Pulmonary Artery. — Dr.
George P. Biggs presented specimens of the above. A
man, forty-seven years of age, had been brought to the
New York Hospital in a bad condition, supposed to be
suffering from pneumonia. No history was obtainable,
and he died a few hours after admission, and without a
careful record of the case having been made. At the
autopsy the first feature of interest observed was a great
depression of the diaphragm, especially on the left side.
On the right side it was at the fifth intercostal space,
and on the left at the eighth intercostal space in the
mammary line. It had pushed the spleen down until its
upper border was on a level with the upper border of
the left kidney. From the left pleural cavity 1,200 c.c.
of a greenish serum had been collected, and this fluid
was found to contain fibrin in considerable quantity.
The heart was so much displaced as to be almost en-
tirely to the right of the median line. The entire left
lung, with the exception of the upper half of the upper
lobe, was compressed by this fluid. The pleura was
thickened and in the recent state was covered with fibrin.
There was no evidence of a recent tubercular process in
the lung itself, or in the pleura, except at one point — a
small cheesy nodule in the parietal pleura. On scraping
this and staining it, it was found to contain a large
number of tubercle bacilli.
The pleurisy, the speaker said, was probably of tuber-
cular character, although the lesions of tuberculosis in
the lung appeared to be all of a chronic character. The
lung of the opposite side was poorly aerated. There
were a number of adhesions at the apex, and in the upper
half of the upper lobe were a number of pigmented
fibrous cicatrices with small cheesy areas scattered
through it. The pulmonary artery going to the lower
lobe contained a large ante-mortem thrombus, which was
rather soft, but distinctly adherent to the vessel wall just
beyond the origin of this branch* from the main pulmo-
nary artery of that side. The pulmonary tissue supplied
by this vessel was very much congested, but was not
cedematous, and there was consolidation. The thrombus
seemed to have almost entirely occluded the lumen, but
the usual effects of thrombosis were not very well
marked. The heart was not nearly as much dilated as
one would have expected with such extensive impairment
of the lungs. The valves were normal except for slight
atheromatous patches near their bases on the left side.
The coronary artery showed quite marked atheroma,
especially near its origin. The muscle of the heart ap-
peared to be perfectly normal. There were no other
lesions of importance. The pericardium was not
affected.
The speaker said that the first case of primary throm-
bosis which he had presented to the Society was thought
to be very unusual, and some of the areas were thought
to be pneumonia. He was sure that the case just pre-
sented was the fourth of the kind that he had seen this
winter, in which all possible sources of emboli had been
sought for, yet none found. One of the other cases was
quite similar to this one, the opposite pleural cavity
being filled up with fluid. From the appearance of the
organs in this case at the autopsy, it was not evident why
it should have resulted in this way, except that the fluid
had been allowed to remain so long that it had inter-
fered with the action of the heart and the circulation in
the opposite lung, thus causing death.
Small Bound-cell Sarcoma of the Ovary. — The Presi-
dent presented the half of a sarcomatous ovary which
had been removed from a married woman, twenty nine
years of age, who had had one child five years before.
The tumor was supposed to have begun its growth shortly
after the birth of the last child, four and a half years
ago. It continued to grow until it measured 16 x 12
ctm., and weighed 1,100 gm. If this history were re-
liable, it would seem to indicate a very slow growth for
a small round-cell sarcoma.
Sarcoma of the Ovary. — The President also presented
a sarcoma of the ovary engrafted on an ordinary cyst-
adenoma. The specimen had been removed from a
woman forty five years of age, who had had five chil-
dren, the last one fourteen years ago. This tumor had
been first noticed nine years ago. She had suffered from
flooding at intervals up to one year ago. The tumor
had remained about the same size until two months ago,
when it had suddenly began to grow very rapidly. At
the time of the operation it measured 26 x 13 ctm. On
close examination the central portion of the tumor was
found to be made up of an ordinary cyst-adenoma, and
small cysts filled with colloid material. Around the
periphery was a sarcomatous mass — a mixture of small
and large round cell sarcoma in which the large cells
seemed to predominate, and the stroma was rather
scanty.
The speaker said he thought it .had been an ordinary
cyst-adenoma up to the time when the growth had be-
come so rapid, and that at this time the sarcomatous de-
generation had begun. Probably, if the tumor had been
left alone the whole mass would have been converted
into a sarcoma. This was one of the first well-marked
examples of sarcomatous degeneration that he had met
with. He had examined upward of 1,000 ovaries, and
out of this number had found only from five to seven
sarcomata.
Dr. George P. Biggs referred to one case of large
cystic tumor of the ovary which he had seen, in which,
from the gross appearance, it was thought to be multilocu-
lar cyst, but on microscopical examination it had been
found to be distinctly made up of sarcomatous tissue, as
if a change had begun to take place in it similar to that
found in the specimen just presented.
Dr. Freeborn said that on a previous occasion he had
presented, in connection with a large series of ovarian
tumors, one other specimen of sarcomatous degeneration.
It was a multilocular cyst which had been reduced to
three main cysts. On microscopical examination the
septa of these cysts had proved to be sarcomatous.
Dr. S. T. Armstrong said that the only case he had
seen was in 1880, in the female hospital in St. Louis.
The patient was an unmarried woman who had been pre-
viously confined in an insane asylum for acute mania for
three years. No abnormal condition connected with the
ovary had been found. She recovered from the mania,
and finally entered the hospital in a wretched condition.
She died shortly afterward.
Dr. Thomas H. Manley said that solid tumors of the
ovary were sometimes carried for years with but little
inconvenience except that due to weight, and he was
familiar with a few cases occurring in those past the
menopause, in which there was no question about a re-
duction having taken place in the size of the growth,
and having been accompanied by an amelioration of
the symptoms. He would ask whether this sarcomatous
degeneration was to be regarded as a malignant change,
31*
MEDICAL RECORD.
[September 8, 1894
or rather as a process whose object was to hasten resorp-
tion. He had seen a specimen exhibited recently at the
Harlem Medical Association by Dr. McLean, in which a
tumor had been honey combed, leaving only a core.
The President said he did not think that anyone had
ever seen a carcinoma or adenoma in the abdomen dis-
appear, except by operation. It was well known now
that after the menopause solid tumors of the ovary and
uterus did increase in size, but he thought that in the
vast majority of cases, if these tumors could be examined
and their structure determined, it would be found that
they belonged to the fibroid order. He could not
accept the theory that this sarcomatous change was a
conservative effort of nature, because in his case the
history showed that two months ago there had been a
rapid increase, and from both macroscopical and micro-
scopical study, it appeared that this sarcomatous change
had taken place at the time that the growth of the tumor
had become so rapid. The tumor referred to by Dr.
Mauley was a pure cystic sarcoma which had probably
started as a solid sarcoma. It had overgrown itself, so
to speak, and hence necrosis had taken place in the cen-
tral portion. This was not the condition in his specimen.
The Society then went into executive session.
Stated Meeting, May 9, 1894.
George C. Freeborn, M.D., President, in The
Chair.
A Lacerated Spleen. — Dr. Thomas H. Manley pre
sented a lacerated spleen. It had been removed from a
young sailor who had fallen from a mast, a distance of
twenty feet, and striking against a rail, had sustained
an injury in the region of the spleen. There was no dis-
turbance of the sensorium, but there was profound and
persistent shock, and he was in this condition when first
seen by the speaker in consultation with his colleague,
Dr. Charles B. White. There was no visible injury to the
abdominal wall, and no distinct dulness on the injured
side. There had been slight retching, but no vomiting
except a little mucus. The symptoms pointed to in-
ternal hemorrhage, or to perforation of the intestine.
The only pain complained of was localized below the
left nipple. Assuming that there might have been a
perforation of the intestine, laparotomy was resorted to.
The peritoneal cavity was found to be filled with blood
which was escaping freely from the spleen. A portion of
the border of this organ had been torn nearly off. The
lacerated fragment was quickly ligated and removed, but
the man died on the operating-table.
The speaker said that he did not think it was possible
in the living subject to produce a laceration of the spleen
by a blow or fall, unless this violence was sufficient to
produce disorganization of the overlying muscular tissues,
which was not the case in this instance. His theory was
that, as the man was only about twenty years of age, and
the bones were not yet fully ossified, the spleen had been
caught by the movable thorax and crowded up against
the spine. He would like the opinions of the members
on this point.
Dr. T. M. Prudden said he had seen several cases in
which there had been laceration of the liver without in-
jury to the abdominal wall.
The President said that within the past eighteen
months several cases of extensive rupture of the liver had
been presented to the Society, and in these there had
been no evidence of injury to the abdominal walls.
Cranio-Tabei. — Dr. Thomas S. Southworth pre-
sented a specimen of cranio-tabes. The calvarium was
very thin, and showed the condition of cranio tabes par-
ticularly well on the left parietal bone. The specimen
had been taken from a child of about nine months, who
had given every evidence of rachitis. It had been
thought at one time that possibly hydrocephalus was de-
veloping, but the measurements of the head were found
to be no greater than normal. At the autopsy, no un-
usual quantity of fluid was found in the ventricles of the
brain.
Uric-Aoid Infarcts of the Kidney.— Dr. Southworth
also presented a specimen from the same child, showing
uric-acid infarcts of the kidney. He said it was not
uncommon to find in the newly born, that the pyramids
of the kidneys were filled with minute particles of uric
acid or urates, but masses of the size shown in this speci-
men were certainly unusual. This condition raised the
question of clinical interest — were these masses dissolved
and absorbed, or were they passed along the ureters? If
the latter occurred, it would afford an explanation of
much of the colic and persistent crying of young in-
fants.
Dr. O. C. Ludlow said that his clinical experience
had abundantly confirmed the truth of this suggestion
about the causation of much of the colic in the newly
born. It was not uncommon to see such a sediment on the
the diaper, or about the meatus urinarius, and under such
circumstances it would be found that the administration
of alkalies would quickly relieve the colic, and at the
same time cause the disappearance of the sediment.
Sarooma of the Antrum of Highmore. — Dr. R. C.
Myles presented the pterygoid process and posterior
part of the antrum of Highmore, and the pterygoid mus-
cles, which had been removed from a case of sarcoma of
the antrum of Highmore. The patient was a man thirty
years of age, who had been referred to him by Dr. Wyeth
for examination. A portion of tissue removed by the
curette from the antrum was submitted to Dr. Prudden,
who found it to be a large round-cell sarcoma. It was
growing very rapidly. All of the sarcoma, as well as the
superior maxilla, were removed by Dr. Wyeth two months
ago. The patient is doing well, and so far there has been
no recurrence. At first, owing to the loss of the ptery-
goids, the mouth was drawn to one side, but practice
had overcome this difficulty. These cases of malignant
disease of the antrum were not usually diagnosticated
until the disease was far advanced. There were ordi-
narily very few symptoms, and hence at first these cases
were apt to be obscure. He thought, if diagnosticated
sufficiently early, all of them would recover. He would
therefore strongly advocate an exploratory operation for
diagnostic purposes.
Exostosis and Ecchondroma of the Vomer was also
presented by Dr. Myles. It had been situated between
the perpendicular plate of the ethmoid and the vomer,
just beneath the sphenoid bone. He had found that in
nearly every instance the cartilage had extended up to,
or very nearly up to, the sphenoid bone. The specimen
was concave on one side.
A Water-sampling Apparatus. — Dr. T. M. Chees-
man exhibited the apparatus. He said it involved no
new principle, but was an adaptation of a device de-
scribed in " Fluegge's Micro- Organismen," and originat-
ed, he believed, with Pasteur. Its object was to collect a
sample of water from a given level in a vacuum bulb by
breaking off the end of the capillary tube when the
bulb had reached the desired level in the water. Glass
bulbs, 2.5 ctm. in diameter, and having a neck 2 ctm. in
length, are drawn out into capillary tubes, and these are
given a double bend. The gaseous contents of the
bulbs are then driven out in the usual way by evaporat-
ing a few drops of water in them, and then sealing the
ends. In such a bulb the surface of tap water could be
easily collected by breaking off the end of the tube with
the finger. The sample thus obtained should then be
placed in a large, cotton-plugged sterilized tube, and
carried in an ice pail to the laboratory. The object of
the apparatus exhibited was, however, to facilitate ob-
taining samples at different depths or from inaccessible
places. It had been suggested by Dr. Prudden, and
had been elaborated by the combined talent of several
others. Its utility had been fully demonstrated in actual
practice.
The apparatus consists of a metal tube of small
calibre, and about one metre in length, divided off into
September 8, 1894]
MEDICAL RECORD.
3*3
equal ports. To the lower end of this tube are soldered
two rings for supporting two vacuum bulbs. Beneath
these two rings are two broken rings arranged to slide on
the end of the tube. They are held in place by a rub-
ber strap or band.
In collecting samples, the capillary ends of the bulbs
are broken off when they have been immersed respectively
at the levels from which it is desired to take samples of
the water. The breaking off of these ends is accom-
plished through the instrumentality of small copper wires
attached to their bent ends, and actuated by the finger
of the operator. Breakage is facilitated, and fracture at
the desired point is insured, by making a cut previously
in the glass with a file or diamond at the proper point.
Formalin and Bacterial Growth.— Dr. Cheesman also
exhibited specimens showing the effect of formalin in
arresting the growth of bacteria, and its effect on gela-
tine already fluidified by bacterial products. Formalin,
he said, was a forty per cent, solution of formaldehyd
(C H20), a gaseous body produced by subjecting methyl
alcohol to oxidation. It is soluble in water in all pro-
portions, and is placed on the market in a forty per cent,
solution. As it is very inflammable, care must be taken
about employing it near a light or fire, and it is impor-
tant that the preparation should have been recently pre-
pared, as it loses its properties by keeping.
Dr. Cheesman then exhibited the following specimens :
The first one was a potato which had been cut in half
without antiseptic precautions, and one-half smeared with
the soil clinging to the outside of the potato, and the
other half with a culture of B. prodigiosus. Both halves
had been kept for fourteen days in an air-tight jar,
charged with the vapor of formalin. No growth had
developed.
The second specimen showed the effect of formalin
vapor upon a culture of B. mycoides in gelatine, grown
for three days at a temperature of an ordinary room be-
fore being subjected to the formalin vapor. The growth
had been arrested and the fluidified gelatine on the sur-
face had become solid. The medium still remained
clear, but had undergone a slight change in color.
The third specimen was a " roll tube "of B. subtilis,
one of the most actively fluidifying species. The growth
had been arrested by the formalin vapor.
The fourth specimen was a water-plate upon which,
after two days of growth, about 1 c.c. of formalin had
been placed, and the cover sealed on with paraffine. The
growth had been completely arrested.
The speaker said that formalin had the peculiarity of
rendering solid gelatine which had once been fluidified by
bacterial products. So far as he knew, ordinary gelatine
as well as that which had been fluidified by bacteria, was
thus rendered incapable of being liquefied by heat. It
was claimed by those who had introduced formalin, that
the microscopical appearances of the bacteria colonies
were not affected by the formalin. If this were true, it
would be useful for making microscopical " mounts " of
colonies cut from gelatine plates. The cut section from
the gelatine could be placed on a slide, surrounded by
gelatine, covered with glass, and placed in an atmosphere
of formalin. It could be varnished to prevent drying.
The President remarked that he had seen a published
statement by one experimenter, to the effect that the
heat from a Bunsen burner would char the gelatine which
had been acted upon by formalin, but would not fluidify
it
Epithelioma of the Hand. — Dr. Henry Power pre-
sented microscopical sections of an epithelioma of the
hand. According to the clinical history, the patient, a
man seventy-five or eighty years of age, had had an
epithelioma on the back of the hand for about eight
years. He suddenly developed marked jaundice, ema-
ciated rapidly, and died in eight weeks. At the autopsy
the organs were found to be normal except the liver and
gall-duct. The latter was distended and contained some
gall-stones. There was a growth in the neighborhood of
the common bile-duct, which completely occluded it It
seemed to be composed of adenoma, some fibroma, and
in places closely resembled in structure the epithelioma
of the hand. The latter showed very large epithelial
" pearls," and also some peculiar cells which gave the
appearance of having a thick capsule.
Uenr Qnetvnmznta.
A NEW ASEPTIC TREPHINE.
By EMORY LANPHEAR, M.D., Ph.D.,
ST. LOUIS, MO.
PROFESSOR OF OPERATIVE SURGKSY AND CLINICAL SURGERY IN THE ST. LOUIS
COIABGI OF PHYSICIANS AND SUSCHONS.
Surgeons who have had much experience in opening
the skull by means other than the chisel, will bear out
my assertion that the ordinary Gait trephine is not and
cannot be made aseptic ; furthermore, it is exceedingly
liable to get out of order at a most inopportune moment.
The Roberts trephine was made to overcome this diffi-
culty; while it is a thoroughly aseptic instrument, it
possesses the disadvantage of being liable to drop to
pieces at the most unfortunate and critical point of the
operation ; otherwise it is perfectly satisfactory. Bear-
ing in mind the faults of these two instruments, I have
sought to remedy the deficiencies by the invention oi
the trephine here pictured.
This instrument consists of but three pieces ; it can be
taken apart in an instant; and is thoroughly aseptic.
The sharp blade is attached to a large, strong metal
handle through which passes the centre pin, held in place
by a little key which transfixes shaft and pin. Upon
withdrawal of the key the centre pin can be removed
without taking the saw from its groove, if so desired.
The hole for the centre- pin is large, of smooth bore, and
can be readily cleaned with a piece of gauze, and the
whole instrument can be boiled without danger of rust-
ing.
Acknowledgment of indebtedness to Messrs. Tiemann
should be made for valuable suggestions in regard to
modification of original plan.
Trismus neonatorum. — Dr. I. Stefanesco, writing in
Spitalul, No. 8, 1894, says that the greatest mortality
among the new- born in the district of Ilfov, in Rouman-
ia, is from tetanus arising from infection through the um-
bilicus. In a careful study of a series of these cases he
has found that the chief cause of this infection is the
practice, very common among women in the country
districts, of being delivered lying on a bed of straw in
supposed imitation of the Virgin Mary.
314
MEDICAL RECORD.
[September 8, 1894
A NEW UVULATOME.
By SAMUEL GOLDSTEIN, M.D.,
NEW YORK.
ASSISTANT SURGEON, NEW YORK THROAT AND NOSE HOSPITAL ; ASSISTANT SUR-
GEON, OUTDOOR DEPARTMENT, MOUNT SINAI HOSPITAL.
Amputation of the uvula, in vogue even as far back
as the Hippocratic era, is to-day classed among minor
operations upon the throat. The instruments used dur-
ing primitive ages hardly find a place in the armamen-
tarium of the surgeon of this progressive age. Then the
unfortunate possessor of this organ, when hypertrophied
or relaxed, suffered much torture in its abscission. Even
to-day, with the many modified and complicated instru-
ments, the patient is often compelled to undergo much
shock through delay in the proper working mechanism
of such appliances.
With the means at hand, however, the general prac-
titioner, as well as the specialist, finds no hesitancy,
when deemed necessary, in removing a portion of this
organ.
After having tried many of these instruments with the
usual amount of success, I was compelled to resort to the
use of the forceps and curved scissors.
In the use of these simple instruments, both hands of
the operator are engaged ; the tongue must be depressed
either by the patient himself, or by the aid of an assis-
tant.
The patient is left in full possession of his senses, and
comprehends fairly well what is about to ensue.
That alone to the sensitive mortal creates very often
a feeling akin to fear, and a wish that the operation were
speedily performed.
It has been my experience, in the main, in amputa-
ting the uvula, to meet a class of patients whose throats,
on account of the condition of this pendulous organ,
were extremely sensitive, and to whom the touch of the
tongue depressor, unless very carefully used, occasioned
considerable gagging.
This would delay and prolong operative work.
In just such cases I have experienced much difficulty
in having the patient properly depress his tongue, thus
preventing expeditious and successful performance of
this otherwise simple operation.
With these facts in view, believing that some simple
contrivance could be planned whereby the surgeon him-
self could perform the entire operation, without inter-
vention of either patient or assistant, I have made this
uvulatome, hoping that it will supply for others, as it
has for me, a long-felt want
^ In drawing the plans, I have endeavored to keep in
view the following points :
1. That the instrument be so constructed as Xofit and
cut uvulae of any diameter, whether hypertrophied or re-
laxed.
2. That the knife be concealed, so as to give the pa-
tient no cause to fear operative procedure.
3. That the entire operation be performed by the sur-
geon'himself.
4. That the instrument can be readily taken apart for
cleaning.
This uvulatome consists of an upper and lower set ot
rings or claws, and between these a concealed knife.
Each set of claws (there being two segments to each
set) is attached to a staff. A cannula incloses them at
their narrowest parts. It is by the backward and forward
movements of this cannula (at the lower end of which is a
ring for the thumb) that the claws are drawn together,
holding the uvula firmly, and relaxed, releasing the
uvula.
Between the staffs of the claws is the staff of the knife
(which is released by the cannula being pushed forward,
lifting a catch) to which two rings are attached. The
knife glides between the two claws and its action depends
upon the backward and forward movements of the index
and middle fingers in the rings attached to the staff.
Each set of claws is so arranged that the tongue of the
one fits between the two lips of the other.
The upper set have their inner surfaces smooth, so as
not to injure the stump of the uvula, while holding it
firmly ; the lower claws have their inner surfaces serrated,
in order to better hold the amputated part, after the
uvula has been cut.
The working mechanism is as follows :
The uvula is examined, and the exact amount to be
amputated is determined. The surgeon depresses the
tongue with the left hand (holding the uvulatome in the
right), and with the thumb in the ring at the end of the
cannula, and the index and middle fingers in the rings on
either side of the staff of the knife, place the uvulatome
in position, encircling the uvula.
The thumb ring is pushed forward (from the operator),
thus pushing the cannula over the claws, and bringing
them together grasping the uvula tightly ; then with the
index and middle fingers, poll
backward (toward the opera-
tor), cutting through the uvula.
The operator should bear in
mind, that it is very important
to first grasp the uvula well with
the claws, before bringing the
knife into action.
To release the stump, the op.
posite action of the thumb opens the claws ; and like-
wise, the opposite action on the staff of the knife pushes
that backward.
The amputated portion of the uvula will be found
caught in the serrated teeth of the lower set of claws,
which for this purpose are made to fit closer together, so
as to grasp the part of the uvula about to be cut, more
tightly.1
I wish to express my thanks to Messrs. Geo. Tiemann
& Co., for the excellent and thorough manner in which
they have executed my plans.
166 East Ninety-third Street.
The Predilections of French Woman Students. —
Of the total number of women university students in
Paris, 155 are on the list of the medical faculty, 164 on
the list of the faculty of letters, 7 in the department of
science, and 3 in that of law. Of the 155 medical stu-
dents, however, only 16 are Frenchwomen, while of
the 164 students under the faculty of letters, 141 are of
French birth.
Gold Mines in Cemeteries. — A writer in Le Temps,
of Paris, has been travelling in America, and, of coarse,
relates his " impressions." What struck him particularly
was not the Falls of Niagara, the inquisitiveness of re-
porters, or the consumption of pie, but the fillings in
American teeth. He has consulted the statisticians and
finds that the amount of gold annually pounded into our
dental cavities reaches the respectable figure of 800 kilo-
grammes, representing a value of half a million dollars.
All this precious metal is buried with the Yankees when
they die, and consequently at the end of three short cen-
turies the cemeteries of the United States will contain gold
to the value of $150,000,000. He thinks this will prove
too tempting to the practical mind of the future American,
and foresees the day when companies will be organized to
mine the cemeteries and recover the gold secreted in the
jaws of deceased ancestors.
» Should troublesome hemorrhage follow the operation, the emer-
gency can be met by reclamping the claws of the uvulatome over the
stump, and keeping it in this position until all bleeding has ceased.
September 8, 1894]
MEDICAL RECORD.
315
OUR LONDON LETTER.
(From our Special Correspondent.)
HOLIDAY SIGNS — THE TEMPERANCE BREAKFAST — DR. LONG
FOX'S ADDRESS — IS LUNACY INCREASING?-* PROFESSOR
JEBB ON THE UNIVERSITIES — A QUINQUENNIAL CENSUS
DEATH OF DR. C R. ALDER WRIGHT — A STATUE TO
SYDENHAM THE NEW ELEMENT IN THE AIR — THE
OPHTHALMOLOGICS CONGRESS — THE MIDWIVES* QUES-
TION— POOR LAW SCANDALS — THE CHELSEA HOSPITAL —
CHOLERA — SMALL POX — DR. WIGLESWORTH.
London, August 17, 1894.
The holidays have begun in earnest. The exodus from
Bristol was rapid, and except a few who went to Oxford,
most of our friends have left London. Still it is not
quite accurate to say " London is left without doctors,"
as some people are fond of remarking; for there are
plenty to do all the work that has to be done, and some
of those who remain in town declare they have too much
time on hand, and would be glad of more practice.
After the Bristol week, with its discussions and un-
bounded hospitality, a little repose is a relief; and, then,
a change of air will be most acceptable.
Among agencies at the Bristol meeting outside the As-
sociation the breakfast given by the National Temperance
League was most notable. This is the twenty- fifth year
in which the League has given a breakfast, and on this
occasion Dr. Long Fox, the President of the Association,
occupied the chair and delivered a most impressive ad-
dress. He did not attempt to go over the old arguments
nor to offer new ones respecting the temperance question,
but contented himself with pointing out the immense in-
fluence of his professional brethren, and making an ear-
nest appeal to them to use that influence aright. " We
want more power and greater influence," said Dr. Fox,
"and when we see whole families in the lowest state of
degradation from the drunkenness of one parent or both,
and now and then trace the change to prosperity on giv-
ing up the drink, it seems to me one of the strangest
things on earth that anybody should shrink from be-
ing an apostle of temperance." When the cheers that
greeted this sentiment had subsided the President added :
" Speaking in the presence of some of the most thought-
ful and excellent members of our body, may I say if we
have light on this subject it behooves us to use it in a
missionary spirit. We can do something in tins way to
remove the stones from the king's highway. The cry
comes down to us, ' Watchman, what of the night ? ' It
hath been long, O Lord ! and very dark, but already over
thine eternal hills the red light gloweth that heralds the
approach of morning. Already out of the people of our
beloved land some sixth part have shaken themselves free
by thy grace from the hideous evil that tends to the de-
struction of the nation. We look for thy sun to rise ere
long and flood this chosen country of thine with fuller and
deeper light from thee. God grant that the coming gen-
eration may see a nobler and more effectual fight against
this great evil, the most pregnant cause of poverty, disease,
and crime. May the common-sense of England and the
righteousness of England so permeate the daily life of
the nation that, by and by, there will be no need of this
society or of kindred societies, because the freedom of
which we so justly boast will include freedom from all
excess." Among the speakers who followed were Pro-
fessor Murdoch Cameron, Drs. J. J. Ridge, W. G. Mac-
kenzie, Roger Hughes, and Norman Kerr. All these
made good points, but I may safely say not one produced
so deep an impression as the testimony of Dr. Long Fox,
who showed his earnestness by snatching time to attend
this breakfast amid the numerous distractions to which
he was subjected as President of the British Medical As-
sociation. This noteworthy breakfast was on Thursday
morning. In the evening of the same day the dinner of
the Association was celebrated as usual, when wine was
served as freely as ever, and as much nonsense was talked
as usual — so at least I gather ; but I did not spend my
evening at that dinner.
Is insanity on the increase, is a question that the news-
papers have often taken up, sometimes giving expression
to alarming forebodings. It has always seemed to me that
the facts did not justify the sensational statements that
have been freely circulated, and the " Report of the Lunacy
Commissioners " does not substantiate them so far as I
have been able to examine. The census statistics show
that there is a considerable reserve of cases unknown to
the commissioners, and this reserve has fallen from 17.7,
in 1871, to 10.9 in 1891. In those twenty years the
cases known to the commissioners increased from 82.3
per cent, to 89.1 ; but this only shows that a larger num-
ber had passed into asylums, and so became known to
the commissioners. Statistics also show that new cases
were fewer in the last decade than in the preceding one,
and the increase so freely talked about is therefore partly
due to the accumulation of cases, which has been brought
about through the decreased mortality and increased lon-
gevity of the insane. There has been an increase in the
ratio of insanity to the population, but it is all confined
to the old, or rather to those above forty five years of
age. It can hardly be supposed that this is due to new
cases at advanced ages, and it seems clear that all the ap-
parent increase has had no real existence. Improved
treatment, greater willingness of the public to resort to
asylums, decreased death-rate, increased longevity, accu-
mulation of old cases, and other causes account for the
figures, and we may reassure ourselves that the nation is
not becoming insane.
Professor Jebb has published his very interesting address
at the Cambridge University Local Lectures Association,
in which he takes broad views of the duties of our old uni-
versities. The address is entitled " The Work of the
Universities for the Nation," and is worthy of the pro-
fessor's great reputation. Passing by his happy sketch
of the earlier history of these seats of learning, he points
out how they have enlarged their scope and have at
length stepped out from their own gates to extend their
influence in a wider sphere. No doubt many still have
misgivings as to this movement ; but so far it seems to have
succeeded, and will probably be the means of drawing a
larger number into nearer association with the universi-
ties. Mere technical instruction is not their proper work,
but rather to bring students to see and apply general
principles to all their work— even in the most technical
employment. In no branch is the higher culture of
greater importance than in the sciences which underlie
medicine, and the influence of the universities on the
profession is most important. Our relations with other
learning have grown more intimate in spite of our devo-
tion to science, and the Association has, I have no doubt,
been mutually benefited.
London is to have a quinquennial census — to be begun
in 1896. This is not undertaken for statistical ends in
general, but in order to carry out the arrangements for
the equalization of rates. This measure seems to be just,
but the richer parishes will contain a considerable num-
ber of dissentients to this view. The County Council
is to be saddled with the expense, which will amount to
;£6,ooo or ,£7,000. No doubt it will tend to the accu-
racy of vital statistics and be useful for other purposes,
but the manner in which it is brought about, as a sort of
side issue, is characteristic of the ways of politicians.
The medical school of St. Mary's Hospital has sus-
tained a serious loss in the decease of Dr. C. R. Alder
Wright, F.R.S., the distinguished lecturer on chemistry.
His many researches are familiar to all who have paid
any attention to the progress of chemistry. His share in
the discovery of apomorphine, and his work on the alka-
loids of aconite, are the most important from a medical
point of view, but they are only a small part of his scien-
tific investigations. He lectured at St. Mary's for nearly
a quarter of a century, and his many pupils will regret his
3i6
MEDICAL RECORD.
[September 8, 1894
death. He took the Doctorship in Science at the Lon-
don University soon after that degree was instituted, and
has contributed to the repute in which it is held.
London, August 23, 1894.
At the Oxford meeting of the British Association for the
Advancement of Science a pleasant event was the unveil
ing of the statue of Sydenham by the President of the
Association and Chancellor of the University, Lord Sal-
isbury. On behalf of All Souls' College, Sir Henry Ar-
land begged the acceptance of the statue by the Univer-
sity, and the Chancellor in accepting it made graceful
allusion to Sir H. Arland's work, and to the growth and
renewal of the study of nature, of which the museum
where they were assembled was the outcome. It is curi-
ous that Sydenham, who was a Fellow of All Souls', did
not take his degree at Oxford, but at Cambridge, and it
has been conjectured that this was due to his Roundhead
proclivities or connections, but we redly have hardly
any reliable information about him until he had estab-
lished his position as the leading physician of his day.
It is sometimes said that he was never admitted as Fellow
of the London College of Physicians on account of po-
litical feelings, but there is no proof of this. The col-
lege was very likely as much a clique as it is in our own
day, and Sydenham, like some of our contemporaries,
might object to show subserviency to the governing
clique.
Of course, the sensation of the Oxford meeting was the
announcement that a new elementary body had been iso-
lated in the atmosphere. You will have heard of all this
from other sources, so that I shall only say a word. This
new element — if indeed it be one — is even more remarka-
able than nitrogen for its indifferent qualities. Perhaps
it may be after all another form of nitrogen, but on this
chemists have not had time to come to an agreement.
But the discovery, or even the looking for an unrecog-
nized element in the atmosphere, is full of suggestion for
the future, to say nothing of the reproof it offers for
neglecting to do so in the past.
The International Ophthalmic Congress, the eighth of
the series, has been celebrated at Edinburgh under the
presidency of Dr. Argyll Robertson, who referred in his
address to the circumstance that the first department of
medicine to institute such a congress was ophthalmology.
That was thirty-seven years ago. The deaths of Don-
ders and Becker since the last Congress (which was held
at Heidelberg in 1888) were touched upon with due rev-
erence, and the illness of Helmholtz was spoken of with
sympathy. There were some one hundred and fifty
members present at this Congress, and I hear that some
valuable papers were brought forward.
Dr. Rentoul is continuing his campaign on the mid-
wives' question. He has just issued a pamphlet entitled,
" The Proposed Formation of an Inferior Order of Mid-
wifery Practitioners: A Reply to Dr. William Carter's
pamphlet." This reply is one that will give much satis-
faction to a large number of medical men. The few
who are so anxious to recognize midwives and register
them are very fond of putting forward the plea of suffer-
ing parturient women, as if their opponents were not
equally humane. The truth is, there are too many doc-
tors in most localities, and it is no wonder they do not
relish the proposal to register midwives. Consulting ac-
coucheurs have little experience of the requirements of
the people.
Scandals connected with the Poor Law seem to multi-
ply, or perhaps it is that they are being made more pub-
lic. Some of these I have already reported and others
are cropping up. The British Medical Journal has been
busy in the matter lately, the editor following up the in-
vestigations set on foot so many years ago by the Lancet,
and claiming credit for work undertaken and paid for by
the proprietors of the Lancet The infirmaries are some
of them well managed, but it must be admitted that the
nursing is in a great many inferior — and, in some it may
almost be said there is no nursing at all/
The Chelsea Hospital for Women has taken the next
step in its reorganization by electing its honorary staff.
This has been reduced in number and a couple of out-
siders have been introduced. The others have been
chosen from the former staff, which, as you will remem-
ber, had resigned. We shall hear more of the matter
yet. Already some statements have appeared on behalf
of the staff which go far in support of the view I have ex-
pressed.
The cases of cholera in a vessel arriving in the Thames
have been reported as real Asiatic cholera, the comma
bacilli having been found. Another suspicious death
occurred in Battersea and was submitted to Dr. Klein,
but in this case he was unable to confirm the suspicion
from bacteriological examination. Every precaution is
being taken to guard the port of London, and cases of
diarrhoea on board vessels arriving are ordered to be noti-
fied.
Small- pox continues to hold its ground, though with
considerable variations from week to week. In the last
return there were only 22 cases. There were 10 deaths
registered, of which 7 were in the parish of Marylebone,
where Dr. Blyth has been most active in preventing the
spread of the disease. He is well supported by his sani-
tary authorities, who seem conscious of their responsi-
bilities, and we have little doubt that all necessary meas-
ures will be taken. The outbreak has given a much
needed impetus to vaccination, in spite of the follies of
the antis. A strictly localized outbreak produces infi-
nitely more alarm than a more wide-spread epidemic, and
thus inoculates a larger number of people with fear, and
there is a rush to the vaccination stations.
Dr. Wiglesworth's wound was more serious than at
first reported. The carotid artery was wounded and
had to be tied. He walked through a corridor for some
distance to his house, applying pressure himself until as-
sistance was obtained. It is satisfactory to learn that he
is going on well.
MEDICAL COLLEGES AND THE MEDICAL
PROFESSION.
To the Editor of the Medical Record,
Sir : Perhaps many interested readers with far abler pens
than mine will feel in perfect accord with the quoted
remarks of Dr. Cochran, as found in the Medical Rec-
ord of July 28th, editorially referring to the marked in-
crease in the number of medical colleges in the United
States.
Statistics yearly show a great army enlisted in the
study of medicine, and comparatively large classes of
graduate students. It is amazing to think of the num-
ber of these so-called medical colleges. It is also a mat-
ter of wonder and more than apparent concern to regular
practitioners where the army of annual recruits are to go.
Here in Ohio, with a dozen times as many colleges as
are needed, and with a large migration of young doctors
from other States, we now startle the population of our
great State with the fact that every three hundred and
fifty people have their physician. This, of course, is
only approximate, for there never can be an even distri-
bution, and, if there could, every physician well knows
that it requires an allotment of eight hundred to one thou-
sand persons to even earn a livelihood in the practice of
medicine.
Dr. Cochran suggests the only real remedy. Let every
State follow the example of Alabama and limit the num-
ber of colleges chartered. Let the requirements in the
few allowed be in accord with the professional spirit of
the age.
There is no excuse for even this great State having
more than two medical colleges. The writer can name
medical colleges in this State where clinical work in any
department is entirely unknown. Yet the degree that
ought to signify so much is belittled. Perhaps Pennsyl-
vania has fewer medical schools compared with her great
importance and population than many of the other States.
September 8, 1894]
MEDICAL RECORD.
3*7
But who can honestly claim that old Pennsylvania really
needs more than two or three high-grade medical schools?
So we might go over the list of States with the s&me re-
sult.
It seems far more just that each State should have cer-
tain colleges of high standard which would put every
State and the whole medical fraternity on equal footing,
than that young men graduating recently should be sub-
jected to a senseless so-called examination by one of the
several State boards for the ostensible purpose of experi-
mentation. So far as its protective features go for the
people at large, it is simply a sham. The author can.
name three examiners on one of the most prominent
State boards who never attended but two five-month
terms of lectures in their lives. Every physician in prac-
tice knows how soon he forgets many of the even impor-
tant details of a subject, and how soon he gets notions
peculiar perhaps only to himself. Is it just to expect
such men to be able to give a student graduating from a
well conducted school an impartial and strictly righteous
test ? We believe it to be neither fair for examiner nor
for the student. The whole idea of State board exami-
nation is a sham, and will surely be exploded ere many
years, as it most heartily deserves to be.
One good general law providing for the regulation of
the number of medical colleges, the establishment of a
certain adequate standard, the abolition of quackery, and
one fair but very thorough collegiate test by a combined
board of faculty of college and corresponding State au-
thorities would do more good, give better satisfaction to
the profession, afford at least more than a show of real
protection to the people, and be vastly fairer to those
young men and women who filled the requirements. In
addition, no good reason can be given why one such test
should not be accepted as satisfactory, wherever the per-
son interested might wish to locate and practise.
W. C. McGee, M.D.
Littlk Sandusky, O.
CLIMATE AS AFFECTING THE PRINCIPLES
OF APPLIED THERAPEUTICS.
To thb Editor of thr Medical Record.
Slr: Too much attention is given by the teacher of
therapeutics, in the average medical school, to exact
dosage, minimum and maximum doses, and the specific
action of drugs, and not enough to the circumstances
which may attend any case to which a physician may be
called.
The beginning practitioner is all at sea. He has been
taught that he can accomplish certain or positive results
by the use of such therapeutic agents as have come into
use in the progress of medicine. Accordingly, he gives
a dose and then watches for it to act characteristically
and immediately, as he would watch the dial of a steam
gauge when a fire is built in the furnace of a steam boiler.
Not getting the expected result, he mumbles " idiosyn-
crasy " to himself and tries another drug. He hops from
one to another and is tortured by anxiety, fear of failure,
dread of public condemnation, etc. If he is so fortunate
as to meet with cases which would not require any prompt
and decided measures until he can begin to shape his
senses and learn the practical use of drugs, he will gradu-
ally learn that which ought by some means to have been
taught him in college, but which seldom or never is
taught.
How few authors or teachers of medicine ever consider
the matter of how climate may influence the action of
drugs, or of what particular drugs may be modified in
their action by differences in climate. The text or teacher
says that a certain drug produces such an effect if given
in such a dose, at such a time of the day. Its action is
modified by the diet of the patient, perhaps by the dis-
ease from which he is suffering, and by some other drugs
which should, or should not, as the case may be, be ad-
ministered along with the drug under consideration.
Then follows a list of the uses of the drug, but seldom a
list of the abuses of the same, which would be of vastly
more importance to the student and patients.
Drugs, which in New England, the Middle, and upper
Mississippi Valley States produce a characteristic action,
may utterly fail to characterize themselves in the South
or on the Pacific coast. Cathartics which, in the States
east of the Rocky Mountains and above Mason and
Dixon's line, produce their effect when given in such
doses as are prescribed by the faculty in those regions,
produce small or no effect on the Pacific coast Nar-
cotics are less effectual here and more depressing in
their subsequent effects. The much lauded and most ex-
cellent system of milk diet is limited to a minority of the
class of cases to which it would be applicable in other
portions of our country. Many small children will not
take milk when well, and cannot take it, no matter what
the process of preparing it may be, when they are sick.
While the climate here is such that butter seldom gets
rancid or unpalatably soft, even when subjected to the
ordinary temperature of the air, yet milk from healthy
cows, and handled and kept in the most cleanly manner,
will ferment and curdle in less than twelve hours, unless
scalded or boiled. People who were fond of milk as an
article of diet on the other side of the Rockies come to
dislike it here. Very few native-born Californians ever
touch milk after once becoming accustomed to a general
diet. Very few can take milk when sick. It is a most ex-
asperating affair at times to find a suitable diet for the
sick. As a rule, meat broths, free from fat and reasona-
bly condensed, administered in quantity of from three to
five ounces to an adult every two or three hours, is our
mainstay in the class of cases which we are told to keep on
milk in the East. The milk will curdle in tough masses
and be vomited, or set up a diarrhoea clue to fermentation
and sadly aggravate the case.
Lobar pneumonia and capillary bronchitis axe more
frequent than other forms of acute pulmonary disease.
Pneumonia rarely gives as high a temperature here, or as
characteristic symptoms as in countries having rigorous
winters, and rarely terminates by crisis, but by lysis.
It is harder to decide upon the proper time to admin-
ister stimulants, and a greater quantity will be tolerated
than in the eastern portion of the United States.
All diseases are apt to follow a slower course than in
the East, and convalescence is much slower and less sure.
In regard to the much lauded climates of the South-
west, to which many patients are shipped who are suf-
fering from pulmonary troubles, I feel sure that few phy-
sicians would continue to send patients there if they
could see the country. The mental, moral, and physi-
cal conditions are all depressing to any new-comer, un-
less he be philosophical enough to make the best of the
poverty of nature. The alkali dust, barren plains, hot
days, and cold nights, with ragged Indians, dirty, ragged,
nomadic, mixed inhabitants, poor food, poor accommo-
dations, absence from home and friends, strange climate,
and fatigue of a long journey, make a combination of
most unsuitable circumstances for an invalid. The tour-
ist on a pleasure excursion sees only the best, hears the
best, tastes the best, and believes the best. More can be
done for pulmonary cases, especially when the disease is
well advanced, by keeping them in a pleasant, well- ven-
tilated room, kept at a constant temperature throughout
the twenty-four hours, and the best hygienic measures
carried out, together with such remedies as the necessity
of the case may require from time to time, than in any
or all of the health resorts of the earth. This may not
be the popular view of the case, but it is the practical
side of it.
E. A. Smith, M.D.
Santa Claka, Cal., August 13, 1894.
The Value of a Doctor's Health.— Dr. W. S. Lump-
kin, of Atlanta, Ga., sued that city for $ 10,000 damages,
alleging that the injurious fumes from an open sewer had
ruined his health. The jury found in his favor to the
amount of $400.
3i«
MEDICAL RECORD.
[September 8, 1894
f^edical Stems.
Contagious Diseases— Weekly Statement— Report of
cues and deaths from contagious diseases reported to the
Sanitary Bureau, Health Department, for the week end-
ing September 1, 1894.
Cuat.
Deaths.
62
108
33
14
17
3
0
4
14
a
113
33
13
2
Tuberculosis
Typhoid fever
Scarlet fever
Cerebro-spinal meningitis .
Measles
Diphtheria
Small-pox
Quackery is rampant in Paris, though, perhaps, they
have not as many faith healers and itinerant impostors as
we have in America ; yet there is a larger proportion of
regularly educated physicians who, weary of the restraints
imposed by the regular profession, boldly announce their
wares through every sort of advertising medium. And
why should they not, when the venerable scientist,
Brown -Sequard, is the greatest sinner of them all?
Everywhere, on lamp-posts, in urinals, in railway sta-
tions, and in the most out-of the-way places along railroad
lines, in every direction, one will see large banner posters
advertising the " Sue de Brawn Sequard; tres pre-
cieux," etc., for nervousness, diminished sexual power in
men or women, old or young. — Paris Correspondent of
Medical and Surgical Reporter.
Dr. L. C. Lane is- the leader of the Cooper school fac-
tion of the profession in San Francisco. He has recently
donated a handsome hospital to Cooper Medical College,
which college already occupies a handsome building for
college purposes, donated by Dr. Line. A marble tab-
let in the auditorium of the college informs the reader
that the building was erected out of funds earned by Dr.
Lane in his profession. As the site and buildings must
have cost on toward a half-million of dollars, Dr. Lane
has likely made more money out of his professional work
than any other medical man who has ever lived. — Medi-
cal Sentinel.
Portland's Hospitals. — While we have much to felici-
tate ourselves upon regarding the character of the work
of our Portland hospitals, says the Medical Sentinel, yet a
visit to a city of any considerable size, or to a city the
size of Portland, will convince anyone that in numbers,
at least, Portland falls far behind in this matter. Take
San Francisco, for instance. A half-dozen hospitals
there are equal, for San Francisco, to what the hospitals
here are for Portland. Their larger capacity will com-
pensate for the difference in the size of the two cities.
But beyond these there are about twenty five other
hospitals in San Francisco. It is quite likely that a
number have to struggle vigorously to subsist, but the
fact that they do subsist year after year, is evidence
that there is a place for them. •» A city has to reach a
certain size before hospitals devoted to special lines, or
managed for special nationalities or civic divisions of
mankind will flourish. Portland is fast approaching such
period. It may have reached it.
Sterilization of Catgut by Heat.— Professor M. Schul-
ler, of Berlin, says (Aerztl. Praktiker, No 30, 1894) that
the question of sterilization of catgut is of importance
not only to the surgeon and gynecologist, but to every
general practitioner. The physician should not content
himself with the material offered by druggists and dealers
in surgical supplies, but he should be able to sterilize it
himself. The methods thus far employed to sterilize
catgut are tedious, and for the most part unreliable. The
author first tried dry heat, but gave this up as being too
tedious. He then experimented with hot fluid, of differ-
ent kinds. None proved as satisfactory as oleum lavan-
dulae, an ethereal oil free from oxygen and of very agree-
able odor. Catgut loosely rolled up in rings is placed in
a wide-mouthed bottle containing lavender oil. The
bottle is to be filled up to the stopper, which latter
is to touch the surface of the oil. Care is to be taken
that all the catgut in the bottle is well covered, because
parts which have been above the surface of the oil
during the process of sterilization will become brittle.
The bottle, hermetically closed, is placed in the steam
sterilizer and there subjected for a half hour to a temper-
ature of from 106 to no° C. The catgut having been
sterilized in this manner is supple and does not tear under
ordinary force. The catgut is removed from the bottle
by means of sterilized forceps for immediate use, or to be
placed in sterilized water or in carbolic acid solution
until needed for use. The lavender oil possesses the
special advantage over many other fluids, especially oils,
in that the same oil can be used repeatedly.
Prize Essay of the Colorado State Medical Society.
— The conditions for the $100 Prize Essay voted by
the Colorado State Medical Society (June 21, 1894) on
the following subject : " The Diagnoses of Tuberculosis
by Microscopic Examination of the Blood." Prefeteoce
to be given to new evidence and the detection of the
pretubercular stage. All stages, however, to be included
and microscopically differentiated. Paper to be con-
densed to read in thirty minutes time ; to be typewritten
and the authorship kept secret till the award of tjie ex-
amining committee is made known. Prize open to any-
one; essay to be written in the English language in
comprehensive style and as free from purely technical
expressions as possible ; accuracy of definition and clear-
ness of diction considered. The committee to reserve
the award for an essay they deem sufficiently meritorious,
i.e., the rules to be observed enabling a diagnosis to be
made from the blood alone without the patient being
seen. A prize committee of three was appointed, Drs.
Charles Denison, H. A. Lemen, both of Denver, and
Dr. S. E. Solly, of Colorado Springs. (Dr. L. A. Fisk,
of Denver, alternate), and all essays to be handed in
under seal by April 1, 1895.
The following test is suggested as not unreasonable :
Seven persons being in one room, representing, respec-
tively, a person in health, a case of anaemia, one of
leucocythemia, one pretubercular, and three representing
the three stages of consumption i.e., 1st, infiltration, 2d,
softening, and 3d, excavation (advanced and extensive).
In another room the microscopic examination of the
blood of several of those, to determine from whom the
specimens were taken. It is expected that the ordinary
use of the }, -fo, ^ , or ^ immersion lenses will answer.
If not and there is any doubt, full explanations as to
instruments or lenses used should be furnished.
The Association of American Medioal Colleges. —
Resolutions adopted at a meeting held in San Francisco,
Cal.t June 7, 1894.
Resolved, That colleges, members of this Association,
shall require of all matriculates an examination as fol-
lows : 1. An English composition in the handwriting of
the applicant of not less than two hundred words ; said
composition to include construction, punctuation, and
spelling. 2. Arithmetic, fundamental rules, common
and decimal fractions, and ratio and proportion. 3.
Algebra — through quadratics. 4. Physics— elementary
— ^age- 5* Latin — An amount equal to one year's
study, as indicated in Harkness Latin reader. (The
above resolution does not apply to students exempt
from the entrance examination, as per Sec. 2, Art. III.)
Resolved, That the following classes of students be
recognized as entitled to apply for advanced standing in
colleges members of this body: a. Such graduates of
recognized colleges and universities as have completed
the prescribed courses in chemistry and biology therein.
b. Graduates and matriculates of colleges of homoeopathy.
c. Graduates and matriculates of colleges of eclectic
medicine, d. Graduates and matriculates of colleges of
September 8, 1894]
MEDICAL RECORD.
3i9
dentistry requiring tiro or more courses of lectures before
conferring the degree of D.D.S. e. Graduates and ma-
triculates of colleges of pharmacy. /. Graduates and
matriculates of colleges of veterinary medicine. It is
provided, however, that the above class of students be
required to comply with the provisions of the entrance
examination, and to prove their fitness to advanced stand-
ing by an individual examination upon each branch
below the class he or she may desire to enter.
Resolved, That students graduating in 1899 or subse-
quent classes, be required to pursue the study of medicine
four years, and to have attended four annual courses of
lectures of not less than six months' duration each.
The Medical Profession in Texas is not a Unit, if we
may be allowed to form a conclusion from a perusal of
the pages of the Texas Health Journal In the issue for
July Dr. Cunningham has an article with the vigorous
title : " The Amazing Infatuation of the Texas State
Medical Association in Pompously Parading its Appalling
Ignorance of the First Principles of Sanitary Legislation ;
and its Unbounded Cheek, and Unmitigated Gall in
Presuming to Instruct Congress in the Proper Perform -
formance of its Duties — Succinctly Set Forth.1 '
The Physicians of Louisville are obliged to pay a li-
cense fee of 1 10 a year to the city.
Penetrating Wound of the Abdomen. — Dr. Dumitru
Popescu reports in Spitalul, No. 12, 1894, the case of a
peasant sixty-five years old who fell from a hay-rick, im-
paling himself upon a pitch-fork, one prong of which
passed through the abdomen. He remained suspended for
a time, until the weight of his body broke the prong and
he fell to the ground. After himself pulling out the
penetrating body he went home, and five days later ap-
plied for relief at the hospital. The abdominal wound
was suppurating and there were symptoms of intestinal
strangulation. Laparotomy being performed, there
were found to be some adhesions and a hernia of the
epiploon through the rectus muscle. The strangulation
was relieved, and the inflamed epiploon severed, and the
peritoneal cavity thoroughly irrigated with sterilized
water. The man made a good recovery. The fork had
entered in the left hypochondrium, and passing through
the abdomen, had again penetrated the peritoneum and
torn the rectus muscle, but had been then arrested by
the elasticity of the skin.
The Michigan "Jag Cure Act. "—The Legislature of
Michigan recently enacted a curious statute known as
the "Jag Cure Act." It allows a justice, upon the con-
viction of a disorderly person, instead of requiring a re-
cognizance for good behavior, to accept recognizance
conditioned that the defendant will take the cure for the
liquor habit in conformity with the rules and regulations
of some corporation administering the cure. The su-
preme court of Michigan has held the act unconstitu-
tional, on the ground that it remits the nature and extent
of the punishment to the determination of the fluctuat-
ing rules of a private corporation, and transfers, in a
measure, the pardoning power of the governor to that
body. — Scientific American.
Treatment of Gonorrhoea at the Hooker Hospital —
At the Necker is the most complete arrangement for the
study of gonorrhoea to be found in Europe. The clinic
is under the charge of Professor Guyon, while the out-
patients' department is conducted by Dr. Ganet.
Each case is thoroughly examined physically and the
discharges microscopically before treatment is given, care-
ful histories taken, and all changes in treatment recorded.
As -the daily clinic is large, the statistics from such a
place should be exceeding valuable and reliable.
The irrigators proposed by Professor Guyon are in con-
stant use, both in acute and chronic gonorrhoea and in
cystitis. The liquid is placed one and one-half yard (or
metre) above the bed or table upon which the patient
lies, and the force thus obtained is sufficient to convey
die liquid into the bladder, a small glass tip at the end
of the rubber tube being held firmly in the meatus. In
this manner he uses the potassium permanganate treat-
ment. From one to two litres of a watery solution of
potassium permanganate, in varying strengths, from 1 to
4,000 to 1 to 1,000, depending upon the stage of the
disease, are passed into the bladder once or twice daily,
the patient raising himself to a sitting posture and
emptying his bladder from time to time. In this way '
the bladder may be thoroughly irrigated without the
passage of a catheter, which, in cases of stricture, will
often be of considerable advantage. In the same way
solutions of silver nitrate (1 to 1,000), and of sublimate
(1 to 5,000), are used in cystitis. Professor Guyon also
uses stronger solutions of silver nitrate (one per cent, to
five per cent.) and of cupric sulphate (two per cent, to
seven per cent.) in obstinate cases of gonorrhoea. — Paris
Correspondent TTierapeutic Gazette.
Cauterizing Ovaries instead of Removal of them. —
Dr. Pozzi, at Hopital Broca, has now practised cauteri-
zation of painful ovaries for over two years, and consideis
the plan very successful In one case, in which he
operated upon both ovaries, the woman has since given
birth to a child. He performs his laparotomies in the
ordinary recumbent position ; -draws the ovaries out of
the abdominal opening. If the ovary is totally diseased
he removes it ; but if a part is found to be healthy, he
amputates the affected portion, cauterizes the stump,
then sews the end with silk. If there are some small
cysts, he opens them by touching with the Paquelin
point. The ovary being returned to the abdomen, he
examines and treats the other in a similar manner.
Often as many as six small cysts are opened in this way
in each ovary. — Paris Correspondent Therapeutic
Gazette.
Old Age and the Death-rate. — Only 906 persons in
a million die from senility, while 1,200 succumb to gout,
18,400 to measles, 27,000 to apoplexy, 7,000 to erysipe-
las, 7,500 to consumption, 48,000 to scarlet fever, 25,000
to whooping-cough, 30,000 to typhoid and typhus, and
7,000 to rheumatism. The averages vary accord-
ing to locality, but these are deemed pretty accurate as
regards the population of the globe as a whole. — Medical
Age.
Lady Mary Wortley Montagu on Inoculation.— In
an article in the Popular Science Monthly for July,
1894, Mrs. Plunkett quotes the following account of
small-pox inoculation from Lady Mary Montagu's let-
ters : " Apropos of distempers, I am going to tell you of
a thing that I am sure will make you wish yourself here.
The small-pox, so general and so fatal among us, is en-
tirely harmless here by the invention of ingrafting, which
is the term they give it here. There is a set of old
women who make it their business to perform the opera-
tion in the month of September, when the great heat is
abated. People send to one another to know if any of
their family has a mind to have the small pox. They
make parties for the purpose, and when they are met —
commonly fifteen or sixteen together — the old woman
comes with a nutshell full of the matter of the best sort
0/ small-pox, and asks what vein you will please to have
opened. She immediately rips open the one that you
offer to her with a large needle, which gives you no
more pain than a common scratch, and puts into the
vein as much venom as can lie upon the head of her
needle, and after binds up the little wound with a hol-
low bit of shell, and in this manner opens four or five
veins. The Grecians have commonly the superstition of
opening one in the middle of the forehead and in each
arm and on the breast, to make the sign of the cross ;
but this has a very ill effect, all the wounds leaving little
scars, and is not done by those that are not superstitious,
who choose to have them in the legs or in that part of
the arm that is concealed. The children or young pa-
tients play together all the rest of the day, and are in
perfect health till the eighth ; then the fever begins to
seize them, and they keep their beds two days, very
3*o
MEDICAL RECORD.
[September 8, 1894
seldom three. They have very rarely above twenty or
thirty in their faces, which never mark ; and in eight
days' time are as well as before their illness. Where
they are wounded there remain running sores during
their distemper, which I doubt not is a great relief of it.
Every year thousands undergo this operation, and the
French ambassador says that they take the small-pox
here by way of diversion, as they take the waters in
other countries."
Restriction on the Sale of Patent Medicines.— A bill
has been introduced in the Iowa Legislature providing
that every patent medicine offered for sale in that State
shall have a printed statement on the wrapper giving the
ingredients of the preparation. The penalty for dis-
obedience to this law is a fine, not exceeding $ 100, or
imprisonment for six months in the penitentiary.
Strophanthus is recommended by Dr. Skworzow in
the treatment of inebriety. In the few cases in which
he has tried it, it was given in seven-drop doses of the
tincture. It gave rise to vomiting and profuse dia-
phoresis and quickly excited a distaste for alcohol which
was said to persist after the withdrawal of the drug.
Unequal Dilatation of the Pupils is regarded by
Dentrfe as a sign of great value in the diagnosis of pul-
monary tuberculosis. It is present, he* says, in the
majority of cases of this disease.
Books as Carriers of Infection.— Dr. McNicoll, an
English health officer, states in a recent report that a
book was kept under the pillow of a small- pox patient
until his death. It was then taken in charge by his son,
who lived in another part of the town, and after being
kept without disinfection for four weeks in his house,
was offered for sale to an artisan, who kept it overnight.
While there the artisan's wife perused the book, with the
result that, fourteen days later, she developed the rash of
small-pox.
BOOKS RECEIVED.
Manual of Practical Anatomy: Upper Limb, Lower
Limb, Abdomen. By D. J. Cunningham. Vol I. 660 pages,
8vo, illustrated. Published by Young J. Pentland, Edinburgh &
London. Imported by J. B. Lippincott Company, Pa. Price,
$7.00.
Manual op Practical Anatomy : Thorax, Head, and
Neck. By D. J. Cunningham, M.D. Vol. II. 8vo, 647 pages,
illustrated. Published by Young J. Pentland, Edinburgh ana Lon-
don. Imported by J. B. Lippincott Company, Philadelphia, Pa.
Clinical Medicine : A Manual for the Use of Students
and Junior Practitioners. By Dr. Judson S. Bury, London.
8vo, 468 pages, illustrated. Published by J. B. Lippincott Com-
pany, Philadelphia, Pa. Price, $6.50.
Diseases of the Nose and Throat. By F. De Havilland
Hall, M.D. 8vo, 524 pages, illustrated. Published by P. Blakis-
ton, Son 8c Co., Philadelphia, Pa. Price, $3.00.
Human Physiology. By John Thornton, M.A. 8vo, 436
ages, illustrated Published by Longmans, Greene & Co., New
fork. Price, $1.50.
Transactions of the Fifteenth Annual Meeting of the
American Laryngological Association, held in the City
of New York, May 22, 23, and 24, 1893. 8vo, 165 pages, illus-
trated. Published by D. Applet on & Co., New York.
The Diseases of the Will. By Th. Ribot. 8vo, 134
pages. Published by the Open Court Publishing Co., Chicago, 111.
Price, 75c.
Small Hospitals. Establishment and Maintenance. By
Dr. A. Worcester. And Suggestions for Hospital Archi-
tecture, with Plans for a Small Hospital. By William
Atkinson, Architect, 8vo, 114 pages, illustrated. Published by
John Wiley & Sons, New York. Price, $1.25.
An Illustrated Dictionary of Medicine, Biology, and
Allied Sciences, Including Pronunciation, Accentuation,
Derivation, and Definition of the Terms Used in Medi-
cine, Surgery, Anatomy, Etc. By George M. Gould, M.D.
Royal octavo, 1,633 pages, illustrated. Publishers, P. Blakiston,
Son & Co, Philadelphia, Pa. Price, Full Sheep, net, $10.00;
Half Morocco, net, $10.00; Half Russia, with Thumb Index, net,
$12.00.
Medical Chemistry. By Elias H. Bartley, M.D. Third
Edition. 8vo, 684 pages, illustrated. Published by P. Blakiston,
Son & Co. Price, $3.00.
page
Yorl
Text Book of Abdominal Surgery. A Clinical Manual
for Practitioners and Students. By Skene Keith, F.R.C.S.
Edin., assisted by George E. Keith, M.B., CM. 8vo, jo8 pages,
illustrated. Published by J. B. Lippincott Company, Philadelphia,
Pa.
Index-Catalogue of the Library of the Surgeon-Gen-
eral's Office, United States Army. VoL XV. Royal oc-
tavo, 842 pages. Washington, D.C
Retrospect of Surgery. By Francis J. Shepherd, M.D.
8vo, 259 pages. E. M. Renouf, Montreal, Can.
Essentials of Anatomy. By Charles B. Nancrede, M.D.
8vo, 388 pages. Illustrated. W. B. Saunders, Philadelphia, Pa.
Price, $1.00.
Essentials of Nervous Diseases and Insanity. By John
C. Shaw. 8vo, 194 pages. Illustrated. W. B. Saunders.
Practical Lectures in Dermatology. By Condict W.
Cutler, M.D. 8vo, 233 pages. G. P. Putnam's Sons, New York.
Price, $2.00.
Uric Acid in Causation of Disease. By Alexander Haig.
Illustrated. 8vo, 400 pages. Second edition. J. & A. Churchill.
Price, 10s. 6d.
The Care and Feeding of Children. By L. Emmett Holt,
M.D. 8vo, 66 pages. D. Appleton & Co. Price, 50 cents.
A Manual of Instructions in the Principles of Prompt
Aid to the Injured, including a Chapter on Hygiene and
the Drill Regulations for the Hospital Corps, U. S. A.
By Alvah H. Doty, M.D. 8vo, 304 pages. Illustrated. Second
Edition. D. Appleton & Co.
A Clinical Manual. By Dr. Andrew MacFarlane. 8vo, 139
pages. Illustrated. G. P. Putnam's Sons, New York City. Price,
$1.25.
Diseases of the Skin. By Malcolm Morris. 8yo, 555 pages.
Illustrated. Lee Bros. & Co., Philadelphia.
Bee Line Repertory. By Stacy Jones, M.D. i6mo, 210
pages. Boericke & Tafel, Philadelphia, Pa. Price, $1.03.
An International System of Electro-Therapeutics for
Students, General Practitioners, and Specialists. By
Horatio R. Bigelow, M.D., and others. Royal Octavo, 1160
pages. Illustrated. The F. A. Davis Co., Philadelphia, Pa. Price,
Cloth, $6.00 net ; Sheep, $7,00 net; Half- Russia, $7.50 net.
Medical Microscopy. By Games E. Reeves, M.D. i2mo,
237 pages. Illustrated. Published by P. Blakiston, Son & Co.,
Philadelphia, Pa.
The American Institute of Homoeopathy. i2mo, 109
pages.
Macrobiotic, or our Diseases and our Remedies. For
Practical Physicians and People of Culture. By Julius Hensel.
8vo, 201 pages. Published by Boericke & Tafel, Philadelphia, Pa.
Price, cloth, $1.50; by mail, $1.60.
Inebriety or Narcomania By Norman Kerr, M.D. Third
edition. 8vo, 780 pages. Published by H. K. Lewis, London,
England. Price, 21s,
Essentials of Diseases, Eye, Nose, and Throat. By
Edward Jackson, M.D., and E. B. Gleason, M D. l2mo, 290
pages. Illustrated. Published by W. B. Saunders, Philadelphia,
Pa. Price, $i.ca
Transactions of the Indiana State Medical Society,
1893. 8vo, 378 pages. Indianapolis, Ind.
Atlas de Laryngologie et de Rhinologie. By A. Gonguen-
heim, and J. Glover. Quarto, illustrated. Published by G. Masson,
editeur, 120 Saint Germain, Paris, France. 1 Vol. Price, 50 fr.
Precis de Clinique Thbrapeutique. By le Dr. A. F. Plicque.
8vo, 592 pages. G. Steinheil, Paris, France. Price, 7 francs.
Transactions of the Association of American Physi*
cians. Vol. IX., 1894. Held at Washington.
Beard's Nervous Exhaustion (Neurasthenia). Third and
enlarged edition. By George M. Beard, M.D. Edited, with Notes
and Additions, by A. D. Rockwell, M.D. 8vo, 292 pages. E. B.
Treat, New York City.
Hand-book of Obstetric Nursing. By Francis W. N.
Haultain, M.D., and Tames Haig Ferguson, M.D. Small octavo,
243 pages. Illustrated. J. B. Lippincott Co. Price, $1.00,
Transactions of the Medical Society of th* State of
California. Session of 1894. San Francisco, Cal.
A Treatise on Appendicitis. By George R. Fowler, M.D.
8vo, 190 pages. Illustrated. Published by J. B. Lippincott Co.,
Philadelphia. Price, $2.00.
The Science of Vital Force. By W. R. Dunham, M.D.
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Dermatology. By various authors. Edited by Prince A. Mor-
row, A.M., M.D. 8vo, 976 pages. Illustrated. Published by D.
Appleton & Co., New York City.
Medical Record
4 Weekly yournal of Medicine and Surgery
Vol. 46, No. 11.
Whole No. 1245.
New York, September 15, 1894.
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©riflitml %xXit\zs.
REPORT TO THE NEW YORK CITY HEALTH
DEPARTMENT ON THE USE OF BACTERI-
OLOGICAL EXAMINATIONS FOR THE DIAG-
NOSIS OF DIPHTHERIA. .
By HERMANN M. BIGGS, M.D.,
NEW YORK.
PATHOLOGIST AMD DIRRCTOR OP THB BACTBRIOLCGICAL LABORATORY.
Early in January, 1893, a communication was addressed
to the Health Board of New York City recommending
the systematic employment by the Health Department
of bacteriological examinations for the diagnosis of diph-
theria. This recommendation was made in view of the
following considerations there detailed :
" 1. The practical differentiation of diphtheria from
other diseases affecting the upper air-passages is of great
sanitary importance.
" 2. It is admitted by all clinicians of experience in
this disease that it is often impossible, either from the
riimral history or the anatomical lesions, or both, to
make an accurate diagnosis of diphtheria. There are no
constant differences which separate the simple non-con-
tagious forms of inflammation from the diphtheritic and
communicable types, and it is only in a rather small pro-
portion of cases that an early and reliable diagnosis can
be arrived at from any data obtainable. The records of
the Health Department of New York City have shown
this in a very striking way. In the cases of suspected
diphtheria under treatment at the Willard Parker Hos-
pital, in which the diagnoses were made by the Depart-
ment inspectors and confirmed by the Department diag-
nosticians before the removal of the patients to the
hospital, subsequent bacteriological examinations showed
that from thirty to fifty per cent of these cases were not
diphtheria, but were cases of pseudo-diphtheria.
"3. All recent bacteriological investigations made to
show the value of such examinations for the diagnosis of
diphtheria are in accord in stating positively that reli-
able conclusions may be reached by this method in from
twelve to twenty-four hours. These investigations in-
clude those made by Baginsky in Berlin, Martin in
Paris, and Koplik and Park in New York. The results
arrived at in these investigations have been confirmed by
the subsequent histories of the cases examined. In those
cases in which bacteriological examinations have shown
the absence of the Klebs Loeffler bacillus, the mortality
has varied from one to five per cent., and the cause of
death has usually been broncho pneumonia, and not the
local disease ; while in those cases in which bacteriolog-
ical examinations have shown the presence of the Klebs-
Loeffler bacillus, the mortality has varied from twenty to
nearly fifty per cent. Further, it has been demon-
strated that in the cases in which the Klebs- Loeffler ba-
cillus is not found there is little danger of the transmis-
sion of the disease to others ; while from the cases of
true diphtheria (as shown by bacteriological examina-
tions), even when the disease is of the mildest type, fre-
quent and numerous instances of infection have been re-
corded.
" 4. The employment of bacteriological examinations
for the diagnosis of diphtheria would have an important
influence on the work required of officials of the De-
partment and the cost of this work. Bacteriological in-
vestigations in diphtheria have shown that accurate con-
clusions can be arrived at as to the nature of the dis-
ease in most cases within fourteen hours. Investigations
made by Dr. Park, at the Willard Parker Hospital, show
the Department has in the past provided for the main-
tenance and treatment of a large number of patients
having pseudo diphtheria. This has been at a large un-
necessary annual cost, and the facilities of this Depart-
ment for the treatment of cases of true diphtheria have
been thereby limited. In addition to this, under the
regulations of the Department at present, a large num-
ber of cases of pseudo- diphtheria must be repeatedly vis-
ited by inspectors, and the rooms, clothing, etc., after con-
valescence, thoroughly disinfected. This is at a further
large cost to the Department, and the expenditure of
much valuable time. If the Department was prepared to
avail itself at once in all cases of means for the bacterio-
logical diagnosis of diphtheria — as this can be arrived at
in so short a time — any definite action could, as a rule,
be held in abeyance until a conclusion as to the nature
of the disease had been reached. In those cases in which
the results showed the disease was pseudo diphtheria, the
Department would be at once relieved frcm further ac-
tion.
" During the year 1891, 4,874 cases of diphtheria were
reported to this Board, and so far as can be judged from
the data at hand, at least one-third, and perhaps more, of
these were not diphtheria.
" 5. The resort to bacteriological examinations for the
differentiation of true diphtheria from pseudo diphtheria
would constitute an important step in advance.
"The Health Department of New York City deter-
mined during the cholera outbreak in 1893 to depend
solely on bacteriological examination for the diagnosis
of Asiatic cholera. No State or Municipal Sanitary
Board has as yet officially adopted bacteriological ex-
aminations for the diagnosis of diphtheria, but in this
city these would be of far greater value in the diagnosis
of diphtheria than in the diagnosis of cholera, became of
the greater prevalence and constant presence of diph-
theria here. The formal recognition of this method by
the Board would be received by the profession as an im-
portant indication of the determination of the Board to
keep the work of the Department thoroughly abreast of
the most recent discoveries of scientific medicine.
" 6. In addition to the work on the diagnosis of diph-
theria, there would naturally arise from such examina-
tions investigations as to the best methods to prevent
the extension of this disease."
In the report just quoted, the appointment of Dr. Will-
iam H. Park as bacteriological diagnostician and in-
spector of diphtheria, was recommended. Dr. Park's
name was suggested because of the special investigations
that had been carried on by him during the previous year
in the hospitals under the control of the Health Depart-
ment, and because of his special training and fitness for
this position.
After some unavoidable delay, early in May of 1893,
Dr. Park was appointed, in accordance with the reccm-
mendation, " Bacteriological Diagnostician and In-
spector of Diphtheria."
The Health Board at that time determined to make
use of bacteriological examinations for the diagnosis of
diphtheria, not only in all cases admitted to the hospital
wards, but also in all cases of suspected diphtheria occur-
ring in the city where the co operation or consent of the
322
MEDICAL RECORD.
[September 15, 1894
attending physician could be obtained. This action
was determined on with a view to giving precision to
the work of the Department in the prevention of this
disease.
During the first weeks after the commencement of this
work the number of cases examined weekly was compara-
tively small, but this number has continually increased
until, during the last few months, a large proportion of
all the cases of suspected diphtheria occurring in the
city have been subjected to bacteriological examination.
As the scope and extent of the work increased, it was
found it would be impossible for Dr. Park to perform all
of the actual bacteriological examinations, and Mr. Alfred
L. Beebe, inspector of bacteriology in this Department,
was assigned to assist him.
From the beginning those in charge of the work had
little doubt of its ultimate success, but they appreciated
the importance of the change that was made in the sani-
tary management of this disease, and did not feel assured
that the physicians of this city would quickly avail them-
selves of the opportunities thus afforded to them.
At first, as far as possible, the inspector of diphtheria,
or special inspectors assigned to this duty, visited physi-
cians who reported cases of diphtheria and explained to
them the purposes of the work. These inspectors made
inoculations from cases only after a request or the specific
consent of the attending physician had been received.
After a short trial, however, it was evident that a large
majority of the physicians of New York would be glad to
avail themselves of the assistance offered by the Depart-
ment. A further step was then taken to increase the fa-
cilities for such examinations. A number of depots were
established throughout the city (these now number about
forty) where culture-tubes and the directions required for
making the inoculations could be obtained by physicians
without charge. These depots were generally established
at drug stores, at convenient points, and arrangements
were made for the collection of the tubes left at these
depots by Department collectors late in the afternoon of
each day. For convenience and safety in transporting
the tubes, small wooden boxes, holding culture-tubes,
were supplied from each of the depots. Each box con-
tains all that is required for making a culture, i.e., a
culture-tube, a swab for inoculating it, and a blank for
recording the name, address, etc., of the patient. Each
box with its contents is known as " a culture outfit'1
The following cards, giving directions for making the
cultures and the addresses of the depots where tubes
could be obtained, were also supplied with the tubes :
Hralth Department.
Division op Pathology, Bacteriology, and Disin-
fection, Bacteriological Laboratory,
White, Centre, Elm, and Franklin Streets.
Directions for Making Cultures in Cases of Suspected
Diphtheria.
The patient should be placed in a good light, and, if a child,
properly held. In cases where it is possible to get a good view of
the throat, depress the tongue and rub the cotton swab gently, but
freely, against any visible exudate.
In other cases, including those in which the exudate is confined
to the larynx, avoiding the tongue, pass the swab far back, and rub
it freely against the mucous membrane of the pharynx and tonsils.
Without laying the swab down, withdraw the cotton plug from the
culture-tube, insert the swab, and rub that portion of it which has
touched the exudate gently but thoroughly back and forth all over
the surface of the blood -serum. Do not push the swab into the
blood- serum, nor break the surface in any way. Then replace the
swab in its own tube, plug both tubes, put them in the box, and
return the culture outfit at once to the station from which it was
obtained.
A report will be forwarded the following morning by mail, or
can be obtained by telephone, after 12 noon.
Culture Out/its can be Obtained from the Following Station* Free 0/
Cost:
East Side.
71a Tremont Avenue Eichwort . 67th St. and 3d Ave Hoykendorff
E38th St. and 3d Ave Fraser 45th St. and 3d Ave Goetting
135th St. and Madison Ave Marsh I 43d St. and Park Ave Schoonmaker
116th St. and 3d Ave Engelhard t 41st St. & Park Av.,Van Horn & Ellison
115th St. and rat Ave New , 29th St. and 4th Ave Bagoe
110th St and Madison Ave Barnes 1 12th St. and ad Ave Proben
105th St. and 3d Ave Aaron s tarn I 1 ith St. and Avenue A Montesser
86th St. and Park Ave Falkenrecht 1 Spring St. and Bowery. Minor
West Side.
135th St. and 7th Ave Breen
125th St. and 8th Ave Spear
i22d St. and 7th Ave Hetneinann
98th St. and Columbus Ave.. Rosen son
93d St. and Columbus Ave Dorn
73d St. and Boulevard Kerley
72d St. and Columbus Ave. . Cassabeer
411 West 59th St Dougherty
46th St. and 5th Ave. . . Bartlett & Liell
36th St. and 9th Ave Rupp
29th St. and 5th Ave Frazer
22d St. and 9U1 Ave Smirh
157 8th Ave Lins
148 8th Ave -Udey
12th St. and 6th Ave Ridgeway
8th St. and 6th Ave Rigdov
283 Bleecker Sl McCord
172 Varick St J©
Form of Blank with each "Culture Outfit."
Return swab and both tubes.
DIPHTHERIA.
Name of Maker of Culture
Date Time
Name of Patient Age
Address
Att. Phys. Address
Duration of Disease
I low Contracted
Can Case be Isolated ?
Location of Membrane
Was Inoculation Satisfactory ?
Clinical Diagnosis
Return swab and both tubes.
The diagnosticians, and later the medical inspectors
of the Department, were supplied with leather pocket-
cases, containing a number of culture-tubes and swabs,
and were given instructions regarding the methods of
making the inoculations. These arrangements being
completed, the following circular was delivered, by spe-
cial messengers, at the office of every physician in this
city:
Health Department,
No. 301 Mott Street, New York, July, 1893.
Circular of Information Concerning the Use ok Bacte-
rial Cultures for the Diagnosis of Diphtheria.
Recent bacterial investigations have shown that a considerable
proportion of the cases of pseudo-membranous and exudative in-
flammations of the throat and upper air-passages, commonly consid-
ered as diphtheria, and having the anatomical appearances found in
diphtheria, are not true diphtheria. These cases may be called
pseudo- or false diphtheria.
It has also been shown that a considerable number of cases which
are apparently false diphtheria prove on bacterial examination to
be true diphtheria. While in true diphtheria the mortality is very
high and the danger of transmission to others is great, in false diph-
theria the mortality is low and the danger of infection slight. The
differential diagnosis between true and false diphtheria can be made
by bacteriological examination within twelve hours, while without
this the differentiation is difficult or impossible.
The Health Department is now prepared to make use of bacte-
rial cultures for diagnosis in all cases of suspected diphtheria occur-
ring in the city, and desires that in every case either the physicians
should themselves make the inoculations, or should authorize an in-
spector to make them. They should be made in every suspicious
case at the earliest possible moment, for during convalescence the
specific organisms often disappear from the throat, and the full
benefit of a positive diagnosis is not obtained unless it is made early
in the disease. ,
The inoculations are made by gently rubbing a cotton swab
against the throat, and then drawing it over the surface of the
culture-medium. When the physician desires to himself make the
culture (and this is usually the better plan, for it can be done earlier
and is more agreeable to the family), he can obtain, free of cost, a
culture tube and swab, and the simple directions necessary for
their use, at any one of the druggists whose addresses are given.
After the inoculation the tubes are to be returned at once to the
dniggist from whom they were obtained. The tubes will be col-
lected by the Department every evening.
In cases where an inoculation has not been made by the attending
physician, the medical inspector will make one, unless for any rea-
son the physician requests that none be made when he notifies the
Department of the case.
The diagnosis will be ready by noon of the following day. The
attending physician can obtain this immediately by telephoning to
the laboratory, or when this is not done, he will be notified by mail.
Cases which prove to be false diphtheria will not be visited by the
Health Department inspectors. Cases, on the other hand, which
prove to be true diphtheria, will be subjected to the usual rules and
regulations covering contagious diseases.
The materials required for making inoculations can be obtained
from the druggists named, free of cost.
All communications on this subject should be addressed to Dr.
Hermann M. Biggs, Chief Inspector Pathology, Bacteriology, and
Disinfection, No. 42 Bleecker Street (Telephone " 1191 Spring").
By order of the Board of Health,
Charles G. Wilson, President.
Emmons Clark, Secretary,
September 15, 1894]
MEDICAL RECORD.
3*3
As soon as it was possible to still further enlarge the
work, a new investigation was instituted. This was the
determination, by bacteriological examination of second-
ary cultures from the throats of convalescent cases of
diphtheria, how long the bacilli of diphtheria persist dur-
ing convalescence.
After a sufficient number of examinations had been
made to draw accurate conclusions, the following circu -
lar was printed, and ordered to be sent to the physician
with the report of the result of the bacteriological exam-
ination of the first culture. In it, the important an-
nouncement is made that, in the future, no case will be
considered free of the contagion of diphtheria until this
fact has been established by culture test.
Health Department.
Division of Pathology, Bacteriology, and Disinfection,
No. 301 Mott Street, New York, 189—.
No. 42 Blef.cker Street.
To Dr. -.
Sir : During the last few months a series of investigations have
been made in the bacteriological laboratory of the Health Depart-
ment to determine how long the Loeffler bacilli remain in the throat
after the disappearance of all false membrane in cases of diph-
theria.
The results obtained are extremely significant, and have caused the
Department to establish a new rule regarding the discharge from
observation of patients who have suffered from diphtheria, and re-
garding the time of disinfection of the premises.
During the past three months 405 cases of true diphtheria have
been subjected to repeated bacteriological examinations performed
at short intervals during the course of the disease and during con-
valescence.
In all of these cases cultures were made at the beginning of
the disease, again after the lapse of three or four days, and
finally at short periods after the complete disappearance of the false
membrane, until the throat was found to be tree from the diphthe-
ria bacillus. In 245 of these 405 cases the diphtheria bacilli disap-
peared within three days after the complete separation of the false
membrane ; in 160 cases the diphtheria bacilli persisted for a longer
time, namely : in 103 cases for seven days, in 34 cases for twelve
days, in 16 cases for fifteen days, in 4 for three weeks, and in 3 for
five weeks after the time when the exudation had completely disap-
peared from the upper air-pa sages. In many of these cases the
patients were apparently well many days before the infectious agent
had disappeared from the throat. These results show that in a
considerable proportion of cases persons who have had diphtheria
continue to carry the germs of the disease in their throats for many
days after all signs and symptoms of the disease have disappeared.
No doubt the disease is largely disseminated by these persons who
are apparently well, and who mingle with others while their throat
secretions still contain the diphtheria bacilli.
These experiments have led the Health Department to adopt the
role, that no person who has suffered from diphtheria shall be con-
sidered free from contagion until it has been shown by bacteriologi-
cal examination, made after the disappearance of the membrane
from the throat, that the throat secretions no longer contain the
diphtheria bacilli, and that until such examinations have shown
such absence all cases in boarding-houses, hotels, and tenement-
houses must remain isolated and under observation. Disinfection
of the premises therefore will not be performed by the Department
until examination has shown the absence of the organisms.
Secondary cultures, as in the case of primary cultures, may be
made by the attending physician, if he so desires ; otherwise they
will be made by the inspector of the district in which the case oc-
curs. This applies only to cases occurring in boarding-houses, ho-
tels, and tenement-houses — not to those in private houses.
In this connection an interesting observation has been made
showing that in diphtheria cases which have been subjected to fre-
quent irrigation with antiseptic solutions from the beginning of the
disease the bacilli disappear more rapidly than in those in which
such irrigations have not been employed. The Department would
feel grateful for any data which the physicians of this city may fur-
nish as to the treatment employed in each case, in order that more
reliable conclusions may be reached as to the best mode of treat-
ment.
It has been also found, that occasionally when culture-tubes are
inoculated immediately after irrigation of the throat with antiseptic
solutions, the cultures do not show any Loeffler bacilli, although
subsequent examinations may demonstrate their presence. This ob-
servation should be noted in making inoculations.
Very respectfully,
Hermann M. Biggs, M.D.,
Chief Inspector of Pathology, Bacteriology \ and Disinfection.
Approved by the Board of Health.
Charles G. Wilson, President.
Emmons Clark, Secretary.
Blank to be filled out and returned with secondary cult-
ures.
Return swab and both tubes.
Diphtheria— Later Cultures.
Number of Culture, 2d, 3d, 4th, 5th, 6th, 7U1, 8th.
Date Inspector or Physician
Name of Patient Laboratory Number
Address
Duration of Disease
Is the place ready for disinfection if the culture is found free from
diphtheria bacilli ?
During the first few months, in order to test the results
of the examinations and to make the liability to error as
slight as possible, the following plan was adopted :
All cases which yielded no diphtheria bacilli were
turned over to special inspectors, who made, if possible,
in every case, a second culture, and followed up the pa-
tient for some time after recovery. From the informa-
tion thus secured, the bacteriologists of the Department
were able to decide more and more surely how far they
could base an absolute diagnosis on the examination of
a culture.
In the first circular issued, the Health Board an-
nounced that cases which proved on bacteriological ex-
amination to be false diphtheria, would not be kept under
the observation of the Department. Some physicians
who heartily approved of the work of the Department in
its treatment of diphtheria, believed that in this step it
had proceeded too far, and that the false cases, though
less contagious than the true, were yet sufficiently so to
render isolation and supervision necessary. From a large
experience the Health Board believed these cases were so
rarely serious in their results, and were so little, if at all,
contagious, that visits from Department inspectors were
unnecessary. Nevertheless, before issuing the circular,
one hundred and fifty consecutive cases were investigated,
all sources of contagion sought for, and the patients kept
under observation for two weeks after convalescence. In
none of these was isolation or disinfection required. The
evidence obtained so completely confirmed the previous
experience that the Health Board felt justified in con-
cluding it was unnecessary to exercise any sanitary super-
vision over cases of false diphtheria. Those who believe
they have met with cases of false diphtheria which have
been the cause of severe or fatal illness in others, have
probably either mistaken the nature of the first case, or
have been dealing with some other infectious disease (such
as scarlet fever), in which the inflammation of the throat
is merely a secondary lesion.
In order to make the possibility of error in the routine
work as small as possible, for some months the follow-
ing circular has been mailed to physicians with every re-
port :
Health Department.
Division of Pathology, Bacteriology and Disinfection,
No. 4a Bleecker Strbet.
New York, February 20, 1894.
To Physicians : It is the earnest desire of the Health. Depart-
ment that the service in the bacteriological diagnosis of diphtheria
be made as perfect as possible and as useful to physicians as it can be
made. When cultures are left at any of the depots before 4 P.M.,
it is the aim to return in every case a report of the bacteriological
diagnosis on the following day. Reports are mailed before one
o'clock, and should be delivered to the physician before the last mail
of the day. Earlier reports can be obtained by applying to the Lab-
oratory by telephone (No. 1191 Spring) after 12 M.
When the bacteriological diagnosis does not harmonize with the
clinical facts and the history, as shown by antecedent or subsequent
cases of diphtheria, and where there are any defects or reasons for
complaint regarding the service in any respect, physicians are ear-
nestly requested to report these promptly to the Chief Inspector, Dr.
H. M. Biggs, No. 42 Bleecker Street. Knowledge of defects in the
service can only reach the Department through such reports, and
the service can only thus be improved and perfected.
Physicians are requested to read carefully the accompanying circu-
lars describing the character of the work and method of procedure,
and to follow exactly the instructions given. Thus uniformity in
method and accuracy in results will be insured.
Hermann M. Biggs, M.D.,
Chief Inspector of Pathology, Bacteriology \ and Disinfection.
3^4
MEDICAL RECORD.
[September 15, 1894
Depending on the results after the examination of pri-
mary cultures, one of the following blanks is filled out
and mailed to the attending physician before 12 m. of
the day following that on which the culture was made :
Dr.
Nkw York,
189-
Dear Sir : The examination of the culturesmatle by inoculating
the tubes with the exudation from the throat of on
shows the presence of the diphtheria bacilli.
The case is therefore one of true diphtheria.
Chief Inspector.
Inspector of Diphtheria.
Health Department.
Division of Pathology, Bacteriology, and Disinfection,
Bacteriological Laboratory, 42 Bleeckrr Street.
Dr.
New York,
189—
Dear Sir : The examination of the cultures made by inoculating
the tubes with the exudation from the throat of on
docs not show the presence of any diphtheria bacilli.
The case is therefoie not true diphtheria,1 but pseudo- or false
diphtheria, and no further cognizance will be taken of it by the De-
partment unless by the special request of the physician in attendance.
Chief Inspector.
Inspector of Diphtheria.
Health Department.
Division op Pathology. Bacteriology, and Disinfection.
Bacteriological Laboratory, 42 Bleeckbr Street.
Nkw York, 189—
Dr.
Dear Sir : The examination of the cultures made by inoculating
the tube with the exudation from the throat of on
does not admit of an exact bacteriological diagnosis, for
the following reasons:
A. The inoculation was made at so late a period in the disease
that it is possible that the diphtheria bacilli, though now absent,
were at an earlier time present.
B. The growth on the culture media was so scanty that it is prob-
able that the inoculation was not properly made, or that some anti-
septic had been applied to the throat shortly before obtaining the
material for inoculating the tube.
C The culture media was badly contaminated.
D. The serum in the tube was too dry to permit of the growth of
the diphtheria bacilli.
a. Another culture is requested.
b. The case will be treated as one of diphtheria.
c. The case will be treated as one of false diphtheria unless the
physician in charge of the case requests otherwise.
Chief Inspector.
Inspector of Diphtheria.
After the examination of each secondary culture and
depending on the result of the examination, one of the
following blanks is filled out and forwarded to the at-
tending physician and to the Chief Inspector of Disinfec-
tion:
Laboratory Xo.
Hbalth Department.
Division of Pathology, Bacteriology, and Disinfection.
Bacteriological Laboratory, No. 43 Bleeckrr Street.
Dr.
New York,
189-
Dbar Sir : The examination of the culture made by inoculating
the tube from the throat of on shows the pres-
ence of the diphtheria bacilli.
The case is therefore not yet ready for disinfection, but needs a
further culture.
Hermann M. Biggs, M.D.,
Chief Inspector.
William H. Park, M.D.,
Inspector of Diphtheria.
Laboratory A7».
Hkalth Department.
Division of Pathology, Bacteriology, and Disinfection.
Bacteriological Laboratory, No. 4a Bleeckbr Street.
Dr.
New York,
189-
Dear Sir : The examination of the culture made by inoculating
1 This conclusion is based on the supposition that the directions
have been properly carried out and that the inoculation was made be-
fore the commencement of convalescence. After convalescence is
established the bacilli often disappear from the exudate.
the tube from the throat of on does not show
the presence of any diphtheria bacilli.
The case is therefore ready for disinfection, if the other circum-
stances allow.
Inspector of Diphtheria.
Chief Inspector.
In the beginning of this work some physicians familiar
with bacteriological investigation feared that it was Dot
safe to trust the inoculation of the culture-tubes to physi-
cians unskilled in bacteriological methods. The Depart-
ment has found, however, that physicians may as a rule
be relied on to carefully follow the simple directions as to
the procedure required to make satisfactory inoculations
of culture-tubes, and that the diagnoses based on the bac-
teriological examinations of such tubes can be safely ac-
cepted.
A communication was forwarded to the Health Board
in November, 1893, recommending the adoption of an
amendment to the Sanitary Code, which should include
so called " membranous croup " with the contagious dis-
eases concerning which the Department requires reports
from physicians. This recommendation was based on the
results of the bacteriological examinations of a consider-
able number of cases of croup, which showed that more
than eighty per cent, of them were really cases of laryn-
geal diphtheria.
The detailed results of the work for the first year, both
as to the bacteriological examination of suspected cases
of diphtheria and the experimental work on questions
allied to this, are contained in the appended report from
the Bacteriological Laboratory, by Dr. William H.
Park, Bacteriological Diagnostician and Inspector of
Diphtheria, and Mr. Alfred L. Beebe, Inspector of Bac-
teriology, by whom this work has been performed.
There is also appended a report from Dr. A. Campbell
White, Resident Physician at the Willard Parker Hos-
pital, detailing the results obtained from an important
series of investigations made to determine the influence
on the persistence of the diphtheria bacilli of systematic
irrigation of the throats of diphtheria patients with vari-
ous antiseptic and cleansing solutions. The results are
not as satisfactory as had been hoped for.
The question is naturally and properly asked, as to
what influence this work has had on the prevalence of
diphtheria in this city ? In reply to this it can only be
said that there has been a large increase in the number of
cases of diphtheria occurring during the last year in many
of the large cities of the world, and New York has suf-
fered from this semi-epidemic influence, but to much less
extent than some other cities. The number of cases re-
ported weekly had begun to increase before the initiation
of this work and this increase has continued notwithstand-
ing it. The total number of cases reported during the
last year has been considerably greater than during the
previous year, but the number of cases apparently occur-
ring in the city has been unquestionably increased by the
more universal reporting of cases by physicians. It is,
of course, impossible to say how much greater the real in-
crease of cases would have been without the work which
has been carried on by the Department, and the inability
of the Department to completely control the spread of
the disease will be readily understood by reference to the
description of the methods of dissemination of the dis-
ease contained in the detailed report from the Bacterio-
logical Laboratory appended herewith.
It may be said in conclusion that the success of this
new departure of the Health Department of New York
city has far exceeded all anticipation. The Health Board
was the first sanitary board in the world to officially
adopt and provide for the making of such bacteriological
examinations, and the course of the board in this matter
has been carefully watched by sanitary authorities in vari-
ous parts of the world. Constant inquiries have been
made as to the conduct of the work, and many requests
for circulars and for information as to the manner in which
the work is carried on have been received. Numerous
September 15, 1894 J
MEDICAL RECORD.
325
representatives of other health departments have been in-
structed, in the Bacteriological Laboratory, in the meth-
ods employed ; and the plan of work, as devised by this
Department, has been adopted, without modification, by
the health authorities of many other cities.
THE SURGICAL TREATMENT OF SURGICAL
KIDNEY.
By ROBERT F. WEIR, M.D.,
PBOPCS>OK OF SUEGSKY IN THE C >LLRGE OF PHYSICIANS AMD SURGBONg, NEW
YOKK ; SURG ION TO TdB. NEW YORK HOSPITAL, ETC.
Suppurative pyelo-nephritis, suppurative interstitial ne-
phritis, and surgical kidney are the ordinary names given
to a disease which, originating, as a rule, in the bladder,
generally affects, according to Delafield,1 both kidneys.
This observer gives the following excellent, though brief
description of the pathological changes usually found in
this affection.
"The pelves of the kidneys are congested and coated
with pus or fibrin. The kidneys themselves are swollen,
congested, and studded with foci of pus The smallest
foci are not visible to the naked eye, but with the micro-
scope collections of pus cells are found between the
tubes, with swelling and degeneration of the epithelium,
within the tubes. The larger purulent foci look like white
streaks or wedges running parallel to the tubes, and are
surrounded by zones of congestion. The larger abscesses
replace considerable portions* of the kidneys. The ureters
are in some cases inflamed, their walls thickened, and their
inner surface coated with pus or fibrin. The bladder
presents regularly the lesions of acute or chronic cystitis.
It is a very fatal disease. So far," continues Delafield,
"as I know, all the cases die, and when nephritis is
once established there is no further control over thecase."
This may be said to represent very fairly the impres-
sion common to the profession from various authoritative
sources concerning this very frequent complication of
acute or chronic inflammatory and obstructive affections
of the bladder. The following case, however, shows
that some modification may be made in the foregoing
statement concerning the prognosis of such cases.
Henry W. D , a young man, twenty-five years of
age, was admitted to the surgical wards of the New York
Hospital on April 2, 1894, with the history that four
years previously he had had pneumonia, which was fol-
lowed a few months later by an attack of scarlet fever,
accompanied by nephritis. From this latter complica-
tion albumin and casts persisted for a considerable
length of time afterward in the urine. He never en-
tirely regained his health, though previous to this time
he had been noted as an athlete. About one year ago
he had a mild attack of urethritis, which did not extend
to the deep urethra. Three months ago he contracted a
second and severe urethritis, which invaded the bladder.
He suffered from an increased frequency of urination,
with tenesmus and a discharge of blood and pus. Gono-
cocci were present in this discharge in great numbers.
This trouble subsided gradually under local treatment,
which consisted of irrigation, at first daily with a one
per cent, solution of creolin, then with a quarter of a
grain solution of silver nitrate every third day, supple-
mented by irrigation twice a day with a quarter of a
grain solution of zinc sulphate. During the last month
applications had been made to the posterior urethra with
a Keyes syringe. Two weeks later urination had so far
improved that the bladder was evacuated but once in
every four hours. The urine was acid in reaction ;
specific gravity, 1024 ; but still contained considerable
pus and about ten per cent, of albumin. About twelve
days prior to his admission into the hospital, without any
assignable cause, the last instrtftnentation being nearly a
week anteriorly, he developed a chill, succeeded by a
temperature of 1010 F., with prostration, vomiting, and
diarrhoea. These symptoms subsided on decubitus, with
fluid diet, subnitrate of bismuth, and oxalate of cerium.
1 Letters on Practical Medicine and Pathology, 1800.
Eleven days ago, that is, the next day to the above at-
tack, pain in the loins was first complained of and was
of the character of lumbago. The next day he suffered
a relapse of his febrile symptoms, the temperature rose
to 1030 F., and the pain in the back increased in sever-
ity. Tenderness could be readily excited by bimanual
examination in the renal region, particularly on the
right side. By the rectum the bladder was normal, nor
was there any increase in the frequency of urination.
Two days later the temperature had fallen to 1010 F. ;
but the lumbar tenderness increased and was more
markjed in the right loin and hypochondrium. He was
then admitted to the New York Hospital on the medical
side, where, after a temporary stay, he was transferred to
the surgical division.
During the seven days that elapsed between his en-
trance into the hospital on March 28th, to April 4th,
when surgical interference was resorted to, he had four
chills, the temperature rose daily, ranging between 1030
and 105^° F. When seen by me April 3d, in con-
sultation with Dr. Peabody, the physician then on duty
in the medical ward of the hospital (to whom the case
had been first referred as one of severe typhoid fever, but
by whom this diagnosis was speedily rejected), the pa-
tient's condition was a most serious one. The urine
was discharged in quantities ranging from fifty to sixty
ounces per diem. It was moderately turbid, contained
pus, and was voided without much bladder irritation;
pulse, 1 16 to 1 20. Pain was complained of in the right
lumbar region. Pressure in that place alone, or conjoined
with pressure in front, gave rise to a decided tenderness.
This was not experienced on the left side. Some ten-
demess was, however, found on both sides, but after re-
peated trials it was found to be confined to the spinal
muscles themselves. For when pressure was brought to
bear directly over the region of the kidney external to
the erector spins muscles, no pain was developed on the
left side but considerable on the right side. Moreover,
by bimanual examination on the right side, it was
thought that an enlargement of the kidney could be
made out. My own impression at that time was that
the patient had probably an abscess of the kidney, or
possibly several such, of considerable size. I did not
think that he had the ordinary condition known as the
" surgical kidney," because of the single-sided nature of
the symptoms and its somewhat slow development. I,
however, felt that there was urgency in his case and that
an exploratory incision should be made down to the
kidney and this organ opened in the hope of evacuating
the contained matter. It was considered advisable in
the condition of the patient, to fully acquaint his family
of the great risk the operation might bring the patient
into and the possibility of not affording him any benefit
whatever if it should be proven to be a general renal in-
fection. Any hope of relief, however, was grasped at
by them, and under ether anaesthesia on April 4th, with
the patient in the usual position, an incision was made
just outside the quadratus lumborum muscle from the
twelfth rib down to the crest of the ilium, and thence
forward to and a little above the anterior superior spine
of the ilium, the flap raised up and the kidney exposed.
It was found to be twice its usual size. It was irregular-
ly and deeply congested, and also irregularly swollen,
particularly so on its inferior surface. Puncture in two
or three directions with the aspirator needle gave no evi-
dence of pus. An incision was then made along its ex-
ternal border, about its middle, and revealed imme-
diately the nature of the disease. This incision, an inch
in length and nearly an inch in depth, disclosed on its
two sides numerous miliary abscesses and streaks of
hemorrhages and pus which showed that we had to do
with an ordinary surgical kidney. The rather desperate
venture was, however, taken of advising and practising
an extirpation of this infected and infecting kidney, bas-
ing this action upon the assumption that no symptoms
pointed decidedly toward an invasion of any great ex-
tent of the left side.
326
MEDICAL RECORD.
[September 15, 1894
With the ample room afforded by the incision just de-
scribed (Kftnig's) the kidney was rapidly enucleated,
heavy silken ligatures being passed around it, and its
pedicle secured. The kidney was separated beyond the
ligature, the wound packed lightly with weak iodoform
gauze and the lower edge of the wound secured by silk-
worm gut sutures.
Immediately after the operation the temperature
dropped from 105 ° F. to 990 F. and remained subnor-
mal the three following days, with a moderate amount of
vomiting. From the fourth day onward the patient
made an uninterrupted and rapid recovery, being dis-
charged from the hospital on April 20th, three weeks
later. At that time, his urine, though not absolutely free
from pus cells, was nearly normal. However, it con-
tained still, on bacteriological examination, a few but a
diminishing number of the rods of the colon bacillus,
but no treatment was thought advisable, except that he
should spend as much time the present summer in the
open air as the ordinary rules of hygiene demanded.
The report of the pathologist of the hospital, Dr. Fer-
guson, on the removed kidney, is that it measured 14 x
6}£ x 4 ctm. and that its capsule was thickened and
adherent. Various cut surfaces beside the exploratory
incision showed a great number of abscesses of miliary
size in the pyramids and also in the cortex. The kidney
substance also contained a large number of minute hem-
orrhages ; the pelvis was dilated, its mucous membrane
contained many small hemorrhages but was otherwise
pale. No gonococci were found on bacteriological ex-
amination, but numerous colonies of the bacillus coli com-
munis were developed under culture.
I will simply add to the foregoing history that though
the literature of the surgery of the kidney is now so large
that it may already include the consideration of this
question of surgical kidney in its application for relief by
surgical measures, yet I have so far failed to find any
similar cases ; carrying my investigation in the Index
Medicus, however, only as far back as the year 1886.
The first question that comes to the mind of every sur-
geon reading this report is, How often may such a fort-
unate condition of affairs be found in cases of surgical
kidney ? I had, of course, known that surgical kidney was
occasionally one-sided, but believed this to be a very
rare occurrence, but its frequence was unknown to me.
An imperfect endeavor has nevertheless been made to get
some further light upon this latter point. I cannot pre-
tend to have made anything more than a cursory examina-
tion for data in this direction, but it is not difficult to
place the fact squarfely in position that this form of sup-
purative nephritis may not infrequently be confined to
but one side. For instance, Goodhart, in an article in
Guy's Hospital Reports of 1874, collected 270 cases of
deaths from urinary disorders, and in these were 130
cases of surgical kidney, as follows : In 100 strictures, 41
of suppurating kidney, of these 3 cases one side only af-
fected. In 27 prostatic hypertrophy, 20 suppurating, 1
confined to one side. In 14 cancers of the bladder, 6
suppurating, 2 confined to one side. In 44 stone, 31
suppurating, 8 to one side. In 29 cancer uteri, etc., 6
suppurating, o to one side. In 56 from paraplegia, 26
suppurating, 56 to one side. This makes an average of
14& per cent, for onesided renal infection.
In the article whence these statistics were taken, how-
ever, the condition of surgical kidney is more or less
mixed up with single or multiple abscesses of considera-
ble size. Therefore, its value is not as great as it would
otherwise be. I have taken pains, therefore, to collect
from the records of the New York and of St. Luke's
Hospitals, in this city, forty-five cases, of which six were
one sided in their lesions, and also from the brochures of
Malherbe, aDe la Ftevre dans les Maladies des Voies
Urinates," 1872, and of Bazy, " Des Lesions des
Reins/ ' etc., 1880, other cases, in six of which one-sided
lesions existed, which make a total of 71 well-defined,
undoubted acute cases of surgical kidney. Of these both
organs were affected in 59 cases and only one organ in 12
cases, that is to say there were about twenty per cent that
could be attacked, other things being equal, surgically.
We can, therefore, feel more hopeful in such conditions
than, I must admit, I certainly have been in the past.
From the manner in which the kidney substance pout-
ed out beyond the divided capsule after the first incision
was made into this organ I could not but feel on reflec-
tion that even in those cases, perhaps, where both sides
were involved, something might be done for the relief of
tension as well as for the egress of pus, etc, by means of a
free incision similarly made into the kidney substance.
Hence, in conclusion, with the happy experience of the
present case I would consider it hereafter justifiable, if
the patient's general condition would warrant it, in a
case of acute septic invasion of the kidneys to make on
one or both sides an exploratory incision not only in the
hope of relieving the acute interstitial invasion, but also
of perhaps encountering a larger and well defined focus
of pus, which pathological condition cannot always, it is
fully understood, be readily discriminated from the more
dangerous lesions of the veritable surgical kidney.
Should the symptoms point, as in the case just narrated,
to one kidney only, or should a double exploratory inci-
sion show the same result, a nephrectomy may with some
hope now be resorted to.
END TO END INTESTINAL ANASTOMOSIS BY
THE USE OF MURPHY'S BUTTON, WITH
REPORT OF CASE.
By WILLIAM W. STEWART, M.D.,
COLUMBUS, GA.
On February 27, 1894, I was asked by Drs. C. L. Will-
iams and R. E. Griggs to operate upon a case of stran-
gulated hernia which that day had fallen into their hands
as city physicians.
History. — E , male, aged twenty-three ; occupa-
tion butcher. Well developed, six feet in height. From
earliest recollection had been troubled with an oblique
inguinal hernia of left side, which previously had been
easily controlled by the wearing of a truss. February
25th arose at 6 a.m., and before applying truss bathed
and dressed. While thus occupied hernia came down,
causing with its descent some pain, which attracted his
attention. On trying to reduce hernia he found he was
unable to do so, and summoned medical assistance.
Opiates, cold and hot applications, taxis, and the usual
rdle of methods of relief were tried successively by his at-
tendants with no avail. This was continued till the
morning of the 27th, when case was reported for the hos-
pital. Patient was immediately removed by the order of
Drs. Griggs and Williams to the hospital, where at 3 p.m.
I first saw him. Condition at that time was one of pro-
found shock. Limbs flexed upon the abdomen. Facial
expression pinched and drawn. Some tympanites ; pulse,
145 to 160 ; respirations quick and jerky ; constant hic-
cough ; vomiting persistent prior to entering hospital.
At 3.30 p.m., in the presence of Drs. C. L. Williams,
J. H. McDuffie, and J. P. Martin, of Birmingham, Ala.,
and assisted by Drs. George J. Grimes, R. E. Griggs,
and McD. Blanchard, the operation was performed.
Ether was administered; site of operation was well
scrubbed with tincture of green soap and hot water and
shaved, then washed with bichloride solution of 1 to
1,000. An incision was then made from a point just
above external ring to bottom of scrotum. Tissues were
swollen and oedematous ; sac being opened, there gushed
out three to four ounces of blood-stained serum, having
some bad odor, which brought into view a large purplish
black mass adherent to bottom of sac, which proved to
be omentum. This beiqg drawn to one side, a mass of
small intestine about ten inches in length was exposed.
Intestine and omentum both proved gangrenous and ex-
tremely friable. Internal and external ring were then
both incised, freeing the strangulation and giving more
room for operative procedure. Gangrenous intestine
September 15, 1894]
MEDICAL RECORD.
327
was drawn well out, and a shoemaker's stitch with a knot
in each stitch was taken through mesentery along entire
length of gut to be excised, thus controlling perfectly
all hemorrhage. Intestine was then grasped by two as-
sistants just past the gangrenous demarcation between
thumb and forefinger, and well compressed. Then with
scissors ten inches of gangrenous gut was excised. A
purse-string suture was then introduced into both ends
Fig. z.
of gut and Murphy's button adjusted, by which both
peritoneal surfaces were brought into perfect apposition.
Sutures were then placed, closing gaps in mesentery.
Gut was carefully cleansed and dropped back into ab-
dominal cavity.
Attention was now turned to the omentum, which
formed the principal bulk of the hernial mass, eighteen
inches of which proving gangrenous and friable, its re-
moval was necessary. Same ligature stitch was introduced
as was used in mesentery, and mass excised. Sac was then
carefully freed and transfixed with silk ligature and
stump sewed into wound. Wound was closed with silk-
worm-gut sutures and tight compression-bandage applied.
Condition of patient from first to last was very bad, ra-
dial pulse often becoming almost imperceptible, calling
for frequent hypodermic injections of strychnia, nitro-
glycerine, and whiskey. After being placed in bed a
Fig. a.
hot, normal salt solution enema was given, which
quickly raised volume of pulse.
By morning patient reacted nicely and continued
comparatively free from pain. Pulse remained high,
140 ; temperature ranged from 990 to ioo° F. till the
third day, when it reached normal.
On the third day high enema was given, which was
followed by copious action. These were continued every
second day, each time being followed by passage of fe-
cal matter till the thirteenth day, at which time the but-
ton was passed and immediately followed by three large
movements slightly streaked with blood, since which no
blood has appeared, bowels continuing to move twice
daily. Abdominal wound healed kindly; wound in
scrotum did not, as some of the cellular tissue became
gangrenous and was removed, this being caused by the
strangulated condition in which it remained for so long.
Diet was restricted to milk till the fifteenth day.
This method of end to end intestinal anastomosis has
advantages so patent that it im-
mediately recommends itself to
every abdominal surgeon. Its ad-
vantages are: 1. The rapidity with
which anastomosis can be per-
formed. 2. The normal continu-
ity of the lumen of the gut is re-
tained. 3. The perfect apposition
of peritoneal surface under gen-
tle pressure, thereby guaranteeing
prompt and perfect union. 4. Ap-
position produced prevents per-
fectly escape of gases into peri-
toneal cavity. 5. When button
passes there is nothing left in in-
testinal coat other than normal
tissues.
Dr. Murphy, by his genius, has made all abdominal
operators his debtor through the gift of his "button,"
a perfect mechanical contrivance which changes often
Fig.
extremely difficult and hazardous procedures to rapid
and much safer operations.
The button, as now manufactured, is of nickel plated
brass. The material used in its manufacture can, I
think, be improved upon by substituting aluminum for
the brass, thereby reducing its weight, which will facili-
tate its passage from the intestine.
SOME PRACTICAL OBSERVATIONS ON SO-
CALLED MALARIA BEING A WATER-BORNE
DISEASE.1
By W. H. DALY, M.D.,
PITTSBURG, PA.
The writer has for the past twenty or more years spent
probably an average of two months annually in the rec-
reative sports of the field, forest, and stream. The
largest proportion of these holiday jaunts have been
passed in the lowlands, or in the swamps of the lake-sides
or sea-side, in the pursuit of wild-fowl shooting. Many,
if not most of these regions were, and are generally ad-
mitted to be, intensely malarial in character, notably the
vast Kankakee swamps in Indiana.
In former years, before the writer had noticed certain
conditions, and used certain precautions, he was subject
to malarial disease of a continuous or recurrent type,
clearly traceable to his having drunk the shallow well-
and swamp- water of these regions.
Observations and studies on the subject, and investiga-
tions made in various districts from Manitoba to Louis-
iana, and all along the southern coast of the Atlantic
Ocean, and of Cuba, Yucatan, and other districts in
Mexico, lead the writer to the conclusions that so called
malarial disease is not easily, if at all, contracted by in-
haling so-called malaria or bad air, of the low, swampy,
or new lands, but it is distinctly, if not almost exclusively,
due to drinking the water that has come into contact
with, and become infected with the malarial germs or in-
» Read before the meeting of the American Climatological Associa-
tion, in Washington, May 29. 1894.
3**
MEDICAL RECORD.
[September 15, 1894
fas via that exist in the earth and waters of the swamp
and lowlands. This germ does not ordinarily, if at all,
fbat in the air during th; day, nor does it find easily a
vehicle in the fog or vipors of the night.
Indeed it is difficult to understand how one is to avoid
the night-air, even if it is conceded to be deleterious — a
conclusion I much doubt. Does any other air than night-
air exist at night ? Is it possible to breathe any other ?
Is there any habitation sufficiently sealed against the out-
side air to make the breathing of outside night- air im-
possible ?
I understand the United States Navy Department years
ago nude, aid they may still, for aught I know, make, a
point of advising the anchorage of war vessels in streams
and waters of malarial districts so as to avoid the air-
currents from the swamps near by, lest the air, laden
with poison, should be inhaled by the officers and sail-
ors.
I will venture to say that no air from the foulest swamp
can be more deadly than the foul air that is produced by
the emanations from the air passages, and from effete
m tfter from human beings crowded into the hold of a
ship. That sort of air is indeed malarial, while the
swamp air I believe to be comparatively safe and whole-
some, but of the swamp water beware for any other pur-
pose than ablution.
I am fully aware that in taking the ground I here oc-
cupy I may be considered to be too radical, and that
my position may bs regarded as untenable. If so, I
can only answer that every observing medical man must
and is bound to tell honestly and fairly what he has gath-
ered from his own experience, observation, and studies,
and it must be considered that my observations have been
prolonged, extensive, and fairly intelligent, and made
not, so to speak, second-hand, but personally and upon
the ground in districts distinctly malarial, and that dur-
ing the years that I and others had been careful to avoid
the mists and fogs of the malarial regions, as well as the
out-door night-air, but all the while using the surface-,
swamp-, or shallow well waters for drinking, I, as well as
others of my friends, suffered from malaria, so called;
Dut later on, and during the past twelve years, while ab-
staining from drinking the surface- or well water, and
with the utmost freedom of exposure to the out-door
night-air, fogs, rain, and mists, at all times, night and
day, we have enjoyed complete immunity.
Whoever has shot wild fowl knows full well that the
best opportunities come to a sportsman amid storm and
rain, with the early mists of the morning, and when
the marshes are redolent with the vapors of the evening,
just at nightfall, when the wild fowl are flying to and fro,
seeking their favorite haunts in the marshes to sleep.
Then there is the journey of miles homeward to the
club-house, farm house, or camp, in the small ducking-
boat, that brings one to the fireside possibly not earlier
than eight to ten o'clock at night, so that exposure is
positive, and close to the marsh and water, as one is
sitting in a small boat.
I mention the foregoing as relevant, since medical men
are still the readers and learners from the classic text-
books of Watson, Tanner, and Niemeyer, not to speak
of many others.
Tanuer says, in his most attractive style : " It is worth
remembering that malarial districts are most dangerous
at night, and that this poison lies low, or, as Dr. Watson
says, Moves the ground.' " And Dr. MacCullach says:
" It is a common remark in many parts of Italy, that as
long as laborers are in an erect position they incur little
danger, but that the fever attacks those that sit or lie on
the ground.' '
All of the older and most of the new text books lay
stress upon the strictly malarial feature of the disease,
that is to say, that the poison is breathed into the sys-
tem. Some of the newer writers, it is true, give some
prominence to the source of contagion, from drinking
the infected land- or swamp-water, but still adhere to the
belief in the medium of the air as a chief or equal source
of infection. This latter belief is a gross fallacy in my
opinion, and will not stand the test of practical proof, if
the factor of drinking land- and swamp-water is elimi-
nated.
In recent years, through the digging up and renewing
oT the aqueducts, which for centuries had supplied the
city of Rome with drinking water, it was discovered
that many of her wealthy and leading citizens had, dur-
ing the period of her grandeur and decadence, actually
been guilty of clandestinely draining the sewage from
their country and suburban villas into the very aque-
ducts that supplied the city and their fellow citizens with
drinking water.
Can there be a greater example of public degradation,
and can any evidence be stronger than this, that a larger
part of the Roman fever, which is unmistakably mala-
rial, has been due to contaminated drinking-water rather
than to infected air ?
As I say, during these earlier years that I and others
of my sportsmen friends drank freely from the running
brooks and streams and from the swamps, we also en-
dured for the sake of the sport of shooting wild fowl,
an occasional shake with the ague and many of the other
disagreeable symptoms that, while they do not amount
to an actual chill, make one feel about as wretched as it
is possible for one to feel and go about. And I and the
others were all the time taking heavy doses of quinine as
an antidote. In fact, no trip was ever taken to the
swamp for wild fowl without plenty of quinine and a lit-
tle whiskey.
But during the past twelve years, and since we have
avoided drinking the surface-water, and, when it was pos-
sible, even the deeper well-water of the region except
after boiling the same, I have been quite free, as have
been others of my friends whom I have advised.
If one cannot get boiled water any other way, it is well
enough to take the water that has been boiled in a brew-
ery, viz., in form of beer.
It is now generally conceded that the malarial germ
is the cause of the fever. Lemaire, Klebs, Crudeli, and
others have isolated certain forms of bacillus, which
they believe to be specific of malaria. Laveran first,
and Richard and Marchiafava, and Cella, also found in
the blood three forms of protozoa, one of which partic-
ularly produced intermittent fever by inoculation. The
germ is infusorial, and exists in the water and soil. .
E Maurel, in the Semaine MidicaUJ announced to the
French Association for the Advancement of Science,
that it is always easy to distinguish a healthy from a ma-
larial soil.
The water from the malarious districts always contains
numerous micro-organisms, some of which are possibly
Laveran's corpuscles in an early stage of their develop-
ment, but it is not yet certain that the germ has been
isolated outside of the human body.
In regard to the real value of Laveran's corpuscles in
the production of malaria, he himself believes them to
be indirectly concerned in the production of the infec-
tion, although their relation to it has not been absolutely
demonstrated. It is probable, according to Rougette,2
that the malarial microbe gives rise to symptomatic fever
by reason of its activity in producing leucomaines. Dur-
ing the access of fever the microbe is eliminated by nat-
ural emunctories.
The liver is a destroyer of leucomaines ; * but, as my
paper is upon the question of the manner in which the
so called malarial infection enters the human body)
whether through the air-passages, or the digestive tract
by means of drinking-water, I must not wander into
other phases of the subject. I am firmly convinced that
farther investigation will as surely lead us to the knowl-
edge that so called malaria is, strictly speaking, a water-
borne disease, as it is that we are now being led to the
right conclusion, by Ernest Hart and others, that chol-
1 Annual Universal Medical Sciences, 1888.
■ L* Union M6dicale.
* Annual Universal Medical Sciences, 1888.
September 15, 1894]
MEDICAL RECORD.
3*9
era is also a water-borne disease ; and it is our duty to
educate the profession, and the public, especially those
who make up the population of the malarial districts,
that it is the water they drink, and not the air they
breathe, that decides whether they will suffer from ma-
laria or not.
It is a great pleasure to have come into contact with
many of the intelligent medical men, who practise in
the southern and malarial districts of our country, whose
beliefs are far in advance of the vague and obsolete views
of many of our writers of text- books. If there were as
many such men in our profession as there ought to be,
the use of quinine as an antiperiodic would soon become
unnecessary. In fact I regard the malarial type of fever,
in the United States at least, as clearly preventable as
any other disease that we have to deal with, and by the
simple method of drinking only carefully collected and
uncontaminated rain-water, which, as a simple precaution,
might be boiled.
I have observed on some of the plantations of the
South, that among certain cattle and horses that have
been shipped from the North for breeding purposes,
many of those that were turned out on the marshes to
drink the surface-water sooner or later sickened and
died with what was known as climatic fever (malarial) ;
but the animals that were kept stabled, and drank only
the deep well- and cistern-water, would thrive as well as
they did in the North.
In the British Medical Journal of October 21, 1893,
Oswald Baker, surgeon of the British Army, writes that
on the steamer Scindia, which sailed from Bombay for
Marseilles on August 5, 1893, there occurred several
cases of acute malarial fever that were, from the account
given by Mr. Baker, clearly traceable to the drinking-
water, which was taken on the ship at Bombay, and not
in any way due to the air that the patients breathed. ,
It is a pleasure to note in the medical journals — the
great educators of those who write text-books — the accu-
mulating testimony of careful observers, who agree with
my observations and experience herein set forth.
In the Medical Record of January 28, 1893, E. D. S.
writes that five out of a family of six, adults and children,
had suffered pretty continuously for the past six years
with malaria (so diagnosticated by the best physicians),
at times being quite seriously ill, with temperature 1040
F. Quinine was administered. Seven months ago a
Pasteur filter was introduced, and quickly every symptom
of malaria disappeared. Another family had the same
experience.
Dr. L L. Von Wedekind, U. S. Navy, in the Medi-
cal Record of February n, 1893, gives a history of
some cases which indicate that to drinking the land-
water was traceable the cause of malarial fever on the
coast of southwestern Africa. The doctor says " that
land-water is considered as a cause, and a prominently
exciting cause, with naval medical officers,11 as is proven
by the orders issued by medical officers of the differ-
ent ships serving on the coast, prohibiting the use of
native water for drinking purposes.
In the region about Elizabeth, N. J., some years ago,
in conversation with some well-educated medical men —
among others Drs. W. J. Lumsden and Oscar McMullen,
who were and are careful observers, I learned that their
outbreaks of malarial fever (fresh cases) usually occurred
in the early autumn, following a period of rainfall and a
few subsequent warm days, but new cases only occurring
among those who drank the land-water.
The inhabitants who used the storm-water, carefully
stored in clean cisterns, especially above ground, uncon-
taminated with the soil- water, are immune from the at-
tacks, and while the disease during the past two years
has presented some varying features to these gentlemen,
such as catarrhal jaundice, of an endemic character,
traceable to malarial influence, as well as other forms,
there does not appear to be anything to controvert the
evidence that these patients took their malaria in water,
either as drink, or upon the leaves of the turnip-top,
greens, kale, spinach, cabbage, or other vegetables that
grow close to the ground and have surface water on their
leaves. These vegetables are abundant and usual in the
culinary supplies of the region.
One may ask, Why do not the New Yorkers and Phil-
adelphians also get malaria from the same surface-water,
dew, and moisture upon the leaves of these same vege-
tables, shipped from this productive region to those cit-
ies ? The answer might well be that they do unless the
leaves are well washed in uncontaminated running- water
before being presented for use as table food.
Dr. R E. Boyken, of Smithfield, Isle of Wight County,
Va., informed me that thirty years ago he had studied
this subject, and had since induced as many of his pa-
tients and fellow- citizens of his county as possible to
adopt the cistern-water as a beverage, and all those fam-
ilies who fell in with and followed out his views are of
healthy and ruddy complexion and iree from malarial
disease, while those who continued to drink the land-
water are subject to attacks of malarial fever.
That so called malaria is an autochthonous disease, find-
ing its way into the human body through the food chan-
nels, there can be little or no doubt in the mind of the
original and unfettered observers.
It is true we have not found what we know to be the
malarial germ and isolated it outside of the human
body, and we are not sure either that we have found the
typhoid germ in the soil or in the suspected drinking-
water; yet we are quite sure that we trace typhoid
origin through these sources.
Let us eliminate the atmospheric factor in malaria by
noting in each case if the soil-, surface-, or shallow well-
water has been drunk by the patient. If this has been
done, the case is obviously one that has been exposed to
the infection in its most potent form. There can be no
scientific question more strictly in the line, and touching
the true object, of this learned Association than this, and
it is to be hoped that in the future papers will be invited
from those who have had an opportunity of observing
data bearing upon this, the chief phase of this unsettled
question.
We do not merely want a rehash of old dogmas from
the text- books, or echoes from time-worn unfounded
opinions, garbled by one so-called authority from an
antecedent authority, but let us have the fresh and un-
biased observations and views of the thousands of intelli-
gent medical men who have the opportunity in their
own neighborhoods to make original observations and
report them.
Dr. W. J. Lumsden, of Elizabeth, N. J., recently
wrote me that his case- books show that fully ninety- eight
per cent, of patients who have suffered from malaria for
the past ten years got their supply of drinking-water
from the dug wells of the region. Those inhabitants
who used the water from driven- wells, thirty or more
feet deep, have had an unmistakable improvement in
health. A driven- well is made by driving an iron pipe
with a perforated inlet down deep into the earth, through
strata of clay or mail, which seals off the surface land-
water. So it will be understood that the water from the
driven-well is pretty securely sealed against surface-
water by its small calibre and tight fit in the soil through
which it penetrates.
Since writing this article I observe the growth of
medical opinion is gaining strength along the lines and
in the direction of the contention of this paper. The
Journal of the American Medical Association, of May
12, 1894, contains the following :
" Dr. Richard H. Lewis, of the North Carolina State
Board of Health, has prepared a circular letter for the
medical men of his State, regarding the influence of well-
water in the production of fever and ague. He gives a
homely illustration in the recited history of two families
who resided as next-door neighbors in one of the eastern
towns of his State. The two families each contained
two adults — father and mother — and seven children.
The two families were friendly, but their homes were
330
MEDICAL RECORD.
[September 15, 1894
sufficiently separated to require independent water-sap-
plies for each. One family drank from what was re-
garded with pride as ' the best well in town/ the other
of rain-water caught in wooden tanks. The members of
the first family were constantly sick with malarial disease
of one kind or another. Those of the second never had
even a chill."
It is the wish to build up a line of testimony of a like
character, if such can be obtained through the medical
men of North Carolina. To this end he has written the
appended letter, giving an invitation to a co-operative
study of the well-water origin of malarial diseases.
" Dear Doctor : The evidence that malarial diseases
are introduced into the system in many, if not most, in-
stances through the medium of the drinking-water, is to
my mind conclusive. The water containing the germs, or
Plasmodia, is surface- or superficial soil-water. Those
living in malarial districts who confine themselves to
water from cisterns or wells driven or bored beneath the
stratum of marl or impervious clay — in other words, be-
yond the water which soaks down from the surface — are
to a large extent free from attacks. If the people of our
eastern counties could be generally convinced of this
fact, and thereby induced to act upon it, the health
conditions of that really fine section would be revolu-
tionized for the better. To bring this about is the ob-
ject of the Board of Health. In order to do this, facts
must be presented to them in the concrete — not by il-
lustrations from ' Asia and Spasia and t'other side o'
Hillsborough,' so to speak, but by instances from among
their own neighbors. I write to ask you if you know
any facts bearing on this subject, and if so, that you will
write them to me in detail at your earliest convenience.
Give me the name and post-office of the head of the fam-
ily having the experience. If not personally familiar
with the facts, send me the name and address, that I
may write to him direct."
WATER IN DIET AND THERAPEUTICS.
By BRADFORD C. LOVELAND, M.D.,
CUFTOM SPRINGS, N. Y.
The subject of water in diet and in therapeutics is one
which has engaged the thought of medical men more or
less since the infancy of the art. Yet I fear it is to-day
given very superficial attention by too many of the pro-
fession.
The Medical Record of March 3, 1894, gives a very
interesting editorial on water, setting forth its ancient
prestige, and undoubted worth in combating disease,
but refers principally to its external use.
I might fill this paper with observations and experi-
ence as to its external use, but my object is to show its
use in diet, and in internal medicine.
Among the earliest medical writers we find water
praised in terms which could not apply to any other article
of food, or remedy in disease.
Galen said : " Cold water quickens the action of the
bowels, provided there be no constrictions from spasms,
when warm water should be used.
" Cold drink stops hemorrhage, and sometimes brings
back heat. Cold drinks are good in continued and
ardent fevers."
In biliousness, plethora, obstinate ophthalmia, spasms,
headache, gastric fever, hiccough, cholera morbus, he
recommended tepid or warm water drinking.
Celsus recommended water in fulness of the stomach,
headache, pains in the joints, diarrhoea, hemorrhoids, and
in hysterical and hypochondriacal conditions.
Hoffman pronounced water a universal remedy. He
asserts that " it is suited to all persons at all times."
Cheyne said, " Without all peradventure water was the
primitive original beverage, and is the only simple fluid
fitted for diluting, moistening, and cooling."
But enough quotations ; suffice it to say that the in-
ternal use of water as a remedy has been prescribed and
written upon, from the earliest times, by such men as
Gregory, Londe, Sir John Ross, Lanzani, Drs. Currie,
Forbes, and John Bell.
In the early part of this century Priessnitz, while using
so many external water treatments, did not fail to see the
great value of its internal use. And his followers, in the
early-time "Water Cure " in this country used to pre-
scribe the drinking of water in quantities which would
seem to most of us to be incredible.
In the present time it seems more popular for physi-
cians to prescribe some bottled water with a thrilling
prophecy of rapid cure on the label, when, in reality, any
good, wholesome water would do quite as much, or per-
haps more, good ; for patients will hardly drink enough
to benefit them when it costs them from twelve to twen-
ty five cents or more a quart. And besides that, they
will frequently abstain from drinking ordinary water be-
cause they have been ordered to drink Wild Cot Lithia
Water.
What is the mission of water in the body?
Besides the object of relieving thirst, it acts as a sol-
vent for, and an aid to the absorption of, all the digested
food material, which it takes with it on its way to the
blood.
The water in the blood forms a medium for holding in
solution and suspension all the organic and inorganic
compounds needed for the nourishment of the tissues, and
also the effete materials on their way to the various ex-
cretory organs.
As the water filters out through the kidneys and the
glands of the skin, again its solvent power is used, as it
carries with it the urea, creatine, phosphates, sulphates,
chlorides, and other useless materials from which the blood
needs constant cleansing.
Should water, then, become deficient in the body from
any cause, osmosis in every part must be impeded to a
greater or less degree, as there are varying degrees of se-
lective affinity for water in the different organs.
Perhaps the bowels are the first to suffer, becoming
constipated from lack of moisture in the intestinal secre-
tions ; then the liver, the bile becoming thick. Next the
kidneys suffer, being compelled to excrete too concen-
trated a secretion.
Too great concentration leads to precipitation of solu-
ble ingredients, forming calculi, as gall-stones or renal
calculi.
Then, too, we will find the digestive fluids are too thick
and cannot accomplish their work well.
Another most serious consequence of lack of fluid in
the blood is the congestions, both primary— from over-
work of certain organs, as the liver and kidneys — and re-
flex— from nervous irritations, these commonly occurring
in the head and spine.
The lack of fluid in the blood also predisposes to
arterial degeneration with its accompanying evils, and
the uric-acid diathesis may in part be traceable to such a
cause, for the concentration of blood and secretions ren-
ders assimilation or oxidation more difficult and less per-
fect.
Then, again, the abnormally concentrated blood, with
the retention of excrementitious material, acts as a slow
poison, producing mental depression and other symptoms.
When there is a marked increase in the amount of
water ingested for a few days, or even for a few weeks, it
may be that the only apparent action is on the kidneys,
but later the bowels and skin will show the effect by be-
coming more active.
That the blood may be changed by the judicious use
of water, I have abundant evidence, as two or three cases
will prove.
Case I— July 8, 1893, Mrs- D , aged thirty-
five, came to me with the impression that she was anaemic
from chronic malaria, complained tha,t she felt unreason-
ably and unaccountably depressed, seemed to have lost
her love for her children and her home. Suffered with
gas in her stomach. Was taking a prescription contain-
ing iron, arsenic, and quinine. She had been complain-
September 15, 1894]
MEDICAL RECORD.
33*
ing of above symptoms only for a few weeks. On exami-
nation I told her that she was not anaemic but the reverse,
and had a congested stomach and liver, and asked her if
she was accustomed to drink water. Her reply was :
" Very little, for I am seldom thirsty." An examination
of blood was necessary both to convince her that she was
not anaemic, and also that she needed to drink water.
Blood examination showed, haemoglobin, one hundred
and eighteen percent; red corpuscles, 6,440,000 to c.mm.
Treatment : Moderate doses of nux vomica and hydrastis,
six to eight glasses of water daily, and a diet largely of
vegetables and grain foods. On the 27th of the same
month blood examination showed, haemoglobin, one hun-
dred and five per cent; red corpuscles, 5,480,000 c.mm.
With the change in blood had come a change in her
digestion and a removal of sufficient of her bad feelings,
mental and otherwise, so that she went home and again
took up the care of her family. Keeping up the water-
drinking and diet at home.
Case II.— February 20, 1893, Mrs. P , aged forty-
eight, rheumatic gout, subacute, six months' standing,
had not menstruated in two years. Inquiry showed
chronic constipation. She rarely ever drank water,
except in the tea or coffee she took at her meals. Had
been a nervous invalid previous to her present illness. I
could not induce her to drink water until I had shown
her the concentrated state of her blood by examination.
She always insisted that it gave her a load in her stomach.
February 20th. — Haemoglobin, one hundred and twenty
percent.; red corpuscles, 7,080,000 c. mm. Treatment:
Diet, meat sparingly; vegetables, fruit, and grain foods
freely, except sugar and white bread. Water, aj£ to 3
quarts per day. Medicine: Phosphate soda, 30 grains
before each meal in a glass of hot water.
April 5th. — Blood examination: Haemoglobin, one
hundred and ten per cent. ; red corpuscles, 5,020,000
cmm. Treatment continued.
June 2d. — Haemoglobin, one hundred per cent. ; red
corpuscles, 4,120,000 cmm. During the above time her
constipation was cured. Her arthritis stopped attacking
new joints, and the inflammation subsided in the ones
already diseased. The disease has remained checked,
although several of the joints in her hand are still, and
will probably remain, stiff.
Case III.— February 25, 1893, Mrs- J- p > aged
forty-four, plethoric habit, suffered from acid stomach
and had repeatedly passed biliary calculi. The last at-
tack of the kind occurring after she came under my care.
Had almost constant pain and feeling of pressure in head
and back of neck.
February 25th. — Blood examination: Haemoglobin,
one hundred and eighteen per cent. ; red corpuscles,
6,800,000 cmm. Treatment : Diet, such as to exclude
concentrated starchy foods and sugar, and limiting meat
to one meal a day. Water, 2^ to 3 quarts per day.
Medicine : Phosphate of soda, 30 grains, in a glass of hot
water before each meal. Treatment continued till June
6th, when blood examination showed, haemoglobin, one
hundred and eight per cent ; red corpuscles, 6,300,000
cmm. This was a chronic case, so that improvement was
slow, but all the troublesome symptoms were much les-
sened, and while I have not seen her since June last, I
heard from her frequently until last December, during
which time she had continued the treatment and had also
continued to improve.
The above cases will be sufficient to illustrate what I
consider the influence of water on a considerable class of
cases, for while I did give medicines, still I think the re-
sults were due much more to diet and water than to
medicine.
Dentistry and the Postal Service. — The regulations
of the British Post-Office require that every unsound
tooth shall be taken out of an applicant's head before he
can be employed. An unfortunate girl who recently was
examined for promotion had fourteen teeth taken out at
one sitting.
A COMPARATIVE STUDY BETWEEN THE RE-
SULTS OBTAINED BY EXAMINATION OF
THE STOMACH CONTENTS BY MEANS OF
A STOMACH-TUBE AND EINHORN'S STOM-
ACH-BUCKET.
By GEORGE S. DICKINSON, M.D.,
•RIB, PA.
The examination of the stomach contents serves the pur-
pose of ascertaining the chemical condition of the gas-
tric juice. As is well known, the main point of examina-
tion is to determine the amount of HC1 present, or the
total acidity, and the presence of the ferments pepsin and
rennet. The acidity is, as a whole, formed by the presence
of free HC1, the lesser part by acid salts and acid albu-
minates, except in grave pathological conditions, when
we find the acidity to consist of organic adds, the prin-
cipal one being lactic acid.
f The chemical examination of the stomach contents is
best made either one hour after Ewald's test breakfast,
or three or four hours after Leube's test dinner. The
test breakfast consists of a roll without butter, and a cup
of weak tea without sugar or milk.
^ The test dinner consists of thirteen fluid ounces ot
either flour or barley soup, two ounces of scraped beef,
one and two-thirds ounce of wheat bread.
Einhorn and Ewald prefer the test breakfast for cor-
rect examination. The examination is best performed
as follows : First, test with litmus paper, to ascertain if
the contents be acid, alkaline, or neutral ; the next step is
to test with congo paper, to ascertain the presence of free
acids. The Uffelmann's reaction or test serves to show
the presence of lactic acid. This test is performed as
follows : Take about two drachms of a two per cent,
phenol solution in a test tube, then add a drop of liq.
ferri sesquichlorati. If lactic acid be present in any
quantity the solution will turn canary yellow.
To determine the total acidity, take five c.c. of the
obtained gastric contents which has been filtered, and
add a drop of phenolphthalein ; after this is done add
as much of a one-tenth standard solution of sodium hy-
drate until the filtrate begins to turn red, then multiply
the number of c.c. of the sodic solution used by twenty,
which gives us the total acidity. After having ascertained
the total acidity, the next step is to determine the amount
of free HC1 present. This is done by adding a drop of
congo red to five c.c. of the filtrate, then by adding the
one-tenth sodic solution until the filtrate begins to turn
reddish- brown.
The quantity of the reagent used, multiplied the same
as in ascertaining the total acidity, gives the amount of
free HC1 present. Having found the quantity of free
HC1 present, we look for the ferments, the most impor-
tant one of which is pepsin ; but as the presence of one
ferment shows the presence of the other, there is hardly
any necessity of making other than the test for rennet.
This test is performed as follows: Take about two
drachms of milk and add a few drops of gastric juice,
then place in warm water for ten to fifteen minutes. If
rennet is present the milk will become curdled, and will
not flow out of the glass.
Having now described the usual method of examining
the stomach contents obtained by means of the tube, I shall
briefly describe Einhorn's bucket and the method of its
use, and append hereto a table of the results of the exam-
ination made of the contents of the stomach of the same
individuals and at the same time, firstly by the stomach-
tube, and secondly by Einhorn's bucket, showing com-
parative results obtained from both methods.
As is well known, the insertion of the tube, although
the procedure is not a difficult one, is, notwithstanding,
very disagreeable to some people, and sometimes its use
is not allowable, especially in cases where there is a sus-
picion of ulcer. Einhorn1 devised the stomach- bucket,
to be used instead of the tube in cases of very nervous
people, and also where the tube would be otherwise
1 Max Einhorn : Mbdical Record, July 19, 189a
33*
MEDICAL RECORD:
[September 15, 1894
objectionable. The bucket is of solid silver, about three-
fourths of an inch in length, shaped like an empty cap-
sule, and has a little rod at the top where the silk is fas-
tened. On one side is a wedge-shaped opening and on
the other is a small hole about the size of a pin-head,
which acts as a vent. The bucket will hold about half a
drachm. The method of introduction is as follows : A
silk thread is fastened to the arch of the bucket and a
knot is made at a distance of sixteen inches from the at-
tachment ; then, in order to obtain a sample of the stom-
ach contents, the patient is asked to open his mouth
widely and the bucket is placed on the root of the
tongue, almost in the pharynx, when the patient should
be told to swallow. The vessel after a short time, one or
two minutes, enters the stomach. As soon as the knot
of the thread is at the lips, the bucket is in the stomach,
for the distance from the teeth to the cardiac orifice is
usually sixteen inches. The bucket is permitted to re-
main there for about five minutes and then withdrawn.
Daring the withdrawal of the apparatus a resistance is
usually felt at the introitus oesophagi. To overcome this
difficulty, when the apparatus is at that narrow point the
patient should swallow. By the act of swallowing the
larynx is pushed forward and upward, and thus the pas-
sage is free and the bucket can be withdrawn easily. If
the stomach is not empty, the bucket returns filled, and
the amount is sufficient for making various important tests.
In people suffering from an abundant secretion of the
a very small amount. Having ascertained the presence
of HC1, the acidity can be approximately determined by
gradually diluting one drop of the contents with water,
until the above-mentioned Guenzburg's reaction for
HC1 begins to disappear. Normally the stomach con-
tents can be diluted from eight to ten times, and yet ob-
tain Guenzburg's reaction. In this way cases where we
are able to dilute five times, or even less, must be con-
sidered as cases of subacidity, and cases where we are able
to dilute more than twelve times as cases of hyperacidity.
In cases where no acidity whatever is found, we have to
deal with anacidity.
The test for rennet is done as previously described.
Take much care in introducing the bucket, and yon
will not meet with any failures. The silk should be good
and strong, and must be changed very often. It is best
to speak to your patient while the bucket is being swal-
lowed, or to make him laugh, in order to assist the backet
into the stomach. We very seldom meet with persons
who cannot swallow the bucket. The bucket has been
used by many in this country and in Europe ; Stockton,
of Buffalo, Fenwick, of London, Stewart, of Philadelphia,
and others. Tweedy (in the Dublin Medical Journal
of Medical Science of February, 1894) reports cases in
which he has used it advantageously.
While studying under Dr. Einhorn, of New York, I
made the following examination to compare the two
methods :
E
I
Name.
Date.
W. M..
F. G
anuary 3, 1894 —
'ebruary 25, 1894.
3 M. S. . . January 5, 1894 . . .
4jM. K . . . February 11. 1894. .
5 A. H...! January 5, 1894...
6JF. G.. . I February 15, 1894
7 W. G... .February 15, 1894..
8 W. S . . . 'February 4, 1894.
Stomach Tube.
Stomach Bucket.
Time when examined.
One hour after breakfast. . .
One hour after breakfast. . .
One hour after breakfast. . .
. J One hour after breakfast. . .
. One hour after breakfast . . .
. I One hour after breakfast. . .
One hour after breakfast. . .
. 1 20 minutes after breakfast. .
9 M. B . . . I February 8, 1894. . . . One hour after breakfast. . .
jo S. S . . . . I January 2, 1894 One hour after breakfast. . .
njK. K. . . . January 2, 1894 One hour after breakfast. . .
12 W. F . . . March 3, 1894 1 >i hour after breakfast ....
HCl. Acidity.] ^^
I I
Rennet. HCl.
13 S. L...
March 4, 1894.
. Two hours after breakfast.
100
96 I
xco
94 ,
*> 1
80
76
68
54
40
86
80
82
75
70
60
56
56
40
I Present.
Present.
Present.
Present
Present.
Present.
Present.
Present.
Present.
Present.
Present.
Present.
I How many
l times di- Rennet
luted.
Remarks.
18 +
20 +
x8 +
«5 +
22 +
6+
8 +
15 +
8 +
7 +
5 +
Present. ;A very nervous patient.
I Present. 1
'Present. I
Present. ■
Present.
Present. |
Present.
Present. One hour after meal stomach was empty.
A case of hyperkinesis.
Present.
Present
I o Very little contents with tube.
Present Too small amount of stomach contents
with tube to make examination.
Present. Too little to make acidimetric test.
mucous membranes the bucket might become filled with
mucus before entering the stomach, and then, in emptying
the vessel, one would find clear mucus instead of chyme.
In such cases it is necessary to make the trial again and
to cover the opening with a thin gelatinous capsule, which
keeps away the mucus from the vessel on its way to the
stomach ; there the capsule is quickly dissolved and the
stomach contents can now enter the bucket. On its return
from the stomach, the bucket being filled, the mucus can-
not, to any extent, enter into it. As with the tube, the
best time to use the bucket is one hour after Ewald's test
breakfast. The bucket should always be dipped into
warm water before using, in order to wet the inside so
that the stomach contents may readily enter it. After
using the bucket, as well as any other part of stomach
apparatus, it should be washed in an antiseptic solu-
tion.
The method of examination of stomach contents
obtained by means of the bucket is, according to Ein-
horn, as follows : The contents are emptied on a small
porcelain dish, then, by means of litmus paper, as-
certain whether the contents be acid or not ; if acid it
will turn the paper red. With congo paper, whether
there are free acids or only acid salts, die presence of
free acids turns the congo paper blue, otherwise the
paper remains unchanged. If there are free acids the
test should be made to ascertain the presence of HCl.
For this purpose take one drop of the contents, and one
drop of Guenzburg's solution, and mix them thoroughly
in a porcelain dish, which is then heated over an al-
cohol lamp until the fluid evaporates; a cherry- red
color appears in the same spot if HCl be present, even in
As a whole, from this table we can see that the method
of ascertaining the acidity by means of dilution of stom-
ach contents obtained by Einhorn's bucket corresponds
closely with the results obtained by the acidimetric sys-
tem, although there are sometimes exceptions (as for in-
stance Case 6). The stomach-bucket, and the simple
method of testing the gastric juice as ^described above
deserve high recommendations.
438 East Sixth Strkst, Erik, Pa.
The Consumption of Beer. — According to some sta-
tistics compiled in Vienna there was a vast consumption
of beer in the world during the year 1893, amounting to
over 4,500,000,000 gallons. Germany heads the list
with 1,202,132,074 gallons, an increase of 34,000,000
over 1892, the consumption being thirty-three gallons
per head, ranging from sixty-two gallons in Bavaria to
twelve gallons in Lothringen; Great Britain second,
1,165,752,000 gallons, or thirty per head ; America, in-
cluding the whole of the western hemisphere, is third,
with more than 1,000,000,000 gallons, or sixteen per
head. More than 7,270,000 tons of malt and 82,000
tons of hops were used in the manufacture of the beer
for the world.
The American Medical Association. — The State of
Virginia with over 2,800 physicians has 38 members in
the American Medical Association ; North Carolina with
1,600 physicians has 17 members ; Texas gives from
her 3>7oo doctors 71 members; Mississippi, 21; Ken-
tucky, 87 ; Maryland, 49 5 Louisiana, 29 ; South Car-
olina, 18. — The Southern Clinic.
September 15^ 1894]
MEDICAL RECORD.
333
POINTS TO BE REMEMBERED IN THE PRAC-
TICE OF ANTISEPTIC SURGERY.
By EDWARD PENDLETON, M.D.,
OWBNSBORO', ICY.
i. Remember to boil instruments for thirty minutes be-
fore an operation, when time permits.
2. Remember to use clean, filtered, boiled water in all
operations.
3. Remember to immerse instruments only in a car-
bolic or Listerine solution ; the mercurial solution blackens
the instruments and ruins the edges.
4. Remember not to dip soiled cotton in an antiseptic
solution, after it has been about the wound ; use a new
piece.
5. Remember not to touch a sponge or instrument
that has fallen upon the floor ; it might get back into the
vicinity of the wound again.
6. Remember to put the suture or ligature back into
the antiseptic solution when it has touched anything that
is not aseptic.
7. Remember that the surgeon and his assistants are
to scrub, cleanse, and disinfect their hands and forearms
before an operation.
8. Remember that the vicinity of the wound is to be
shaved, scrubbed, cleansed, and disinfected.
9. Remember not to use a rubber bandage in forcing
blood out of a part, like a gangrenous or tuberculous
limb, but simply apply constrictor above the point of
disease.
10. Remember to use no antiseptic upon the peritone-
um or any of the viscera ; if the operation was aseptic,
antiseptics could do no good ; if the operation was not
aseptic, antiseptics could not make it aseptic.
11. Remember to try always to arrest a bleeding ar-
tery by torsion, only use the ligature as a dernier ressort.
i2# Remember that venous and capillary hemorrhage
can be arrested by the application of a hot mercurial lo-
tion to the bleeding surface.
13. Remember to use cocaine in amputating toes,
fingers, etc., and in circumcision.
14. Never give ether when albumin is present in the
urine, or when there is any pulmonary trouble.
15. Remember always to open an abscess by a free in-
cision, wash out abscess cavity with a carbolic solution
(1 to 10), insert a perforated drainage tube in the deep-
est part, and apply a moist antiseptic dressing.
16. Remember to wash gun- and pistol-shot Wounds in
a mercurial lotion (1 to 3,000), and pack the wound with
iodoform gauze, so that it can heal from the bottom.
1 7. Remember to use black pins in surgical dressings ;
they will not rust and can be more readily seen.
18. Remember to let all rubber goods, such as cathe-
ters, rubber bandages, fountain syringes, rubber sheets,
rubber bags, rubber aprons, dry before they are put away.
19. Remember to boil all instruments that have been
used about a person with cancer, syphilis, or tuberculosis,
in a carbolic solution (1 to 30).
20. Remember always to cleanse a hypodermic needle,
and run a piece of wire through it after it has been used.
21. Remember to thoroughly wash, cleanse, and dry
all instruments after each operation.
22. Remember to use gauze sponges, which can be
thrown away after they have been used.
23. Remember to use silk in suturing parts about the
face.
24. It is not necessary to have a easeful of instru-
ments to perform an operation, only a few are at times
necessary.
25. Remember always to cleanse and disinfect a cathe-
ter after it has been used ; the most common source of
infection of the bladder is by an unclean catheter.
26. Remember to use moist antiseptic dressings in all
septic cases, such as abscesses, bone felons, lymphadenitis,
etc., or where primary union is not expected.
27. Remember to remove silk sutures on the third or
fourth day.
28. Remember that the edges of a wound have to be in
exact apposition, and no turning under is to be present
if union by first intention is desired.
29. Remember to dust iodoform over the line of su-
tures covered by iodoform gauze, cotton, tissue, and a
rubber bandage.
30. Remember to use the fingers in anointing instru-
ments instead of putting the instruments which are soiled
into the ointment.
529 Locust Street.
EXCISION OF HEAD AND FOUR INCHES OF
SHAFT OF HUMERUS, WITH CASE.1
By W. E. GUTHRIE, M.D.,
BLOOMIKGTGN, ILL.
It is not my purpose to enter into an historical discus-
sion of resection of the upper end of the humerus, nor to
describe the minutiae of the operation except in so far
as may be necessary to show the feasibility of the opera-
tion, and the possibility of procuring return of function
in the injured member.
Reports of investigators prove that this resection is no
more dangerous than amputation at the shoulder-joint,
and, if successful, the result amply compensates for the
increased trouble of the excision. If done for old dis-
location of shoulder with anchylosis, or for disease of
the head of the humerus where there is not extensive
destruction of tissue, the periosteum can be saved, and
thus much of the bone be restored. Experience, how-
ever, has generally shown that the best result to be
expected in most cases is a loose flail-like joint. Gun-
shot wounds, which have been the most common cause
for this' operation, usually produce so much destruction
of tissue as to make the salvation of periosteum a difficult
matter. Especially is this true when the wound is
inflicted by a shot gun at close range. The shot strike
the bone, and then, scattering, carry destruction into the
tissues around the joint. If the amount of bone excised
be large, and a generous amount of periosteum be un-
saved, the arm may be immobilized, using the body for a
splint, and a flail joint expected, or the end of the hume-
rus may be placed in the glenoid fossa, and anchylosis
almost certainly awaited.
From all the reports of this operation which I have
been able to collect and study, it appears that such a
favorable result as I have had the good fortune to obtain
in the case to be presented to you to day is remarkably
rare.
October 22, 1893, James H , eighteen years of age,
was near Towanda, 111., hunting squirrels with a shot-
gun loaded with small shot. Being somewhat wearied
by his tramping he sat down on a rail fence to rest and
refresh himself, placing the stock of his gun on the rail
below and holding the barrel loose in his arms before
him. By some means the butt of the gun slipped from
its resting place and fell, striking the hammer on the
rail and discharging the piece. The entire charge (shot,
burnt powder, and wads), together with shreds of cloth-
ing, tore through the anterior border of the axillary space,
severing in its course the pectoralis major, long head of
the biceps, the anterior fibres of the deltoid, part of the
short head of the biceps, the infraspinatus and teres
minor muscles, crushing the head of the humerus and
shattering the upper portion of its shaft, and destroying
the insertion of the subscapularis and supraspinatus mus-
cles. After shattering the bone the shot scattered in
every direction through the enveloping muscles. The
opening through the skin was at least an inch and a half
in diameter, its margins ragged and bruised.
He was soon seen by Dr. W. H. Reedy, of Towanda,
who picked out some pieces of bone, and had him re-
moved to his home, about six miles away, and advised
that I be called.
It was several hours after the accident when I reached
his bedside. He had partially reacted from the shock ;
1 Read before the Illinois State Medical Society, May x6, 1894.
334
MEDICAL RECORD.
[September 15, 1894
but as he had not sufficiently reacted for operation, and
there was very little hemorrhage, and the lights at our
disposal were poor, the wound was cleaned and tempo-
rarily dressed, awaiting the morrow for operative atten-
tion. Sunday morning, October 23d, assisted by Drs.
Reedy and Anderson, the patient was anesthetized with
A.C.E., and the axillary artery being in good condition,
resection of the head and upper four indies of the shaft
of the humerus was done. The wound was enlarged up-
ward to a point even with the top of the head of the
humerus, and through this opening the pieces of bone
were removed one by one, care being taken to strip the
periosteum from each piece before removal, and a portion
of bone was scraped off with each muscular insertion into
the broken bone. The removal of the periosteum, ten-
don, and muscle was surprisingly easy by reason of the
chisel-edged raspatory used. The fragments being re-
moved, the point of the shaft was pushed up through the
wound by an assistant and sawed off even with a chain-
saw. The most time was consumed and the greatest
difficulty encountered in cleaning out the shot, burnt
powder, scraps of clothing, and dead muscular tissue.
He had been under the anaesthetic two hours and a
quarter before I was satisfied that I had made the wound
as clean as possible. The cavity was then carefully
washed out with a sublimate solution, and about two
ounces of a ten per cent, solution of iodoform in ether
poured into the depths of the wound, and the latter
thoroughly packed with iodoform gauze.
Ordinarily I believe it good practice to raise the arm
before dressing until the end of the severed humerus rests
in the glenoid fossa. In this case I did not follow this
course, fearing that the great destruction of tissue in the
neighborhood of the joint would later infect the open
end of the bone and cause suppuration and perhaps sep-
sis. So the axilla was thoroughly padded, the arm left
at the side in a natural position, the forearm placed
across the chest, and the whole immobilized by numerous
strips of adhesive plaster. There was no subsequent
hemorrhage, no pain, no elevation of temperature above
one hundred degrees. Through the gauze there was a
copious serous oozing. Two days later the gauze was
removed without disturbing the arm, two drainage-tubes
were inserted, one downward to the end of the humerus
and one backward into the depths of the wound, and the
portion of the opening made by my knife was closed by
suture. As stated before, there was no pain and no in-
flammation. The only complication was vomiting and
pyrosis for several days. Otherwise he made an uninter-
rupted recovery. Drainage by means of rubber tubes,
and later silkworm gut, was kept up for several months,
a stray shot coming away occasionally. For several
weeks it has been entirely healed. It is now a little
more than six months since the operation. As you see,
there is no shortening of the arm. Nature has replaced
the bone removed by another growth, the upper end of
which you can feel rests in the glenoid fossa ; the axilla
is of full capacity. When I push upward on his elbow
you see I raise the whole shoulder, thus proving the bone
has been entirely restored. This young man is a farmer,
and prides himself that he has " made a hand " on the
farm this spring. He milks the cows with both hands,
feeds himself with the left hand (the injured side), and,
although the range of mobility of the arm is not large, it
is gradually increasing with restored muscular power, and,
all things considered, the result is very satisfactory. I
show you also the portion of bone removed by me. I
have had the pieces placed in their natural relation to
each other and glued together. A portion of the head
you see is missing, the portion, I suppose, that was re-
moved at the scene of the accident.
As near as I can find, this case is unique on account
of the amount of bone restored and the remarkable res-
toration of function in so short a time.
The Contagiousness of Tuberculosis is denied by Dr.
Sprae, of Norristown, Pa.
gttpgness at gfcjeaical Science.
Care of the Mouth in Sick Persons.— Rosenbach says
that in many illnesses there is almost sure to be second-
ary trouble in the mouth if preventive measures be not
taken {The British Medical Journal). A warning sign
is dryness and redness of the tongue and mucous mem-
brane of the mouth, with difficulty in swallowing ; fur-
ther signs are an evil odor from the mouth, coated
tongue and gums, bleeding of the gums, etc. Just as
special care of the mouth is required in patients with
carious teeth, smokers, and chewers of tobacco, so it is
also in the case of unconscious or paralyzed persons ; pa-
tients with fever or suffering from chronic digestive com-
plaints; those taking medicines, such as mercury or
iodides, or who, on account of general weakness, have to
take strong alcoholic drinks; but, perhaps, the most
important class of those in whom special care of the
mouth must be taken are patients with fever. Parasites
are always present in the mouth, but it is only when the
tissues are weakened that they undergo invasion by these
parasites, which become then really pathogenic. There
is nothing which one can do for sick persons which is
unimportant, and by neglect in the care of the mouth
convalescence may be retarded. Rosenbach concludes
with the following rules : (1) Patients with good diges-
tive powers, free from fever, and with no loss of con-
sciousness require no more than the ordinary care of the
mouth. (2) In children and very old patients the less
solid food taken the greater should be the care with the
mouth. They should rinse the mouth out several times
a day with lukewarm water containing a little common
salt, tincture of myrrh, or eau de-Cologne added to stim-
ulate secretion. When there is a tendency to bleeding
of the gums, or when the teeth are bad, a pinch of pow-
dered boric acid may be twice daily rubbed in between
the lips and gums. Patients with false teeth should re-
move their false teeth when, owing to loss of appetite
or chronic gastric disturbance, they cannot take solid
food. (3) In patients with partial loss of consciousness
the mouth should be examined several times a day for
small sores, such as may arise from the pressure of the
teeth on the lips, etc. Such sores should be powdered
with a little boric acid or chlorate of potash, and the
cracks at the corners of the lips heal quickly if dried
with a clean towel and treated with boric acid or vase-
line. The mucous membrane may be stimulated by
wiping the tongue and mouth, and pressing on the
tongue with a moist towel every two or three hours ; if
necessary, the hinder part of the tongue should be
cleaned with a wad of cotton- wool fastened to a stem.
If the patient sleep with the mouth open the air in the
room must be kept moist ; a moistened layer of muslin
laid on the mouth may be of some service. (4) Patients
with fever should have something to drink — cold water
or weak lemonade — at least every hour ; one must not
wait until the patient asks for drink. Besides preventing
dryness, the fluid maintains the activity of the glands
and the whole function of the mucous membrane. Many
patients are prevented from drinking by a painful, dry,
and cracked condition of the lips, and therefore all fev-
erish patients should, from the commencement of their
illness, have their lips rubbed several times a day with
vaseline or fat. In protracted cases of fever the mouth
may also be swabbed out with oil, fat, or greatly diluted
glycerine.
Total Abstainers in the Indian Army. — The Army
Temperance Society of the British army in India has
grown from 13,000 members in 1890 to over 22,000
members to-day. Out of 1,100 regimental courts- mar-
tial for 1893, onty 39 *** t0 try members of the Tem-
perance Association, and of 2,680 courts martial of
all classes for that year, only 73 concerned temperance
men.
September 15, 1894]
MEDICAL RECORD.
335
Medical Record:
A Weekly Journal of Medicine and Surgery.
GEORGE F. SHRADY, A.M., M.D., Editor.
Publishers
WM. WOOD & CO., 43, 45, & 47 East Tenth Street
New York, September 15, 1894.
AS OTHERS SEE US.
Last year medical men and matters on this side of the
Atlantic were observed and freely commented upon by
that veteran medical journalist, Mr. Ernest Hart. We
have again been subjected to observation and comment
. by one of our transatlantic brethren — a German. A
book recently published by Dr. Placzek,1 a Berlin neu-
rologist and litterateur, pictures the medical profession
in this country with the pen of a discriminating observer.
The surprise and pleasure which the revelations of his
journey produced upon the author are quite naively told.
A few extracts from the work may enable us to " see our-
selves as others see us."
In his introduction, the author expresses surprise and
admiration of the spirit which pervades our eleemosynary
institutions. " The European physician, whose vision is
narrowed by the diminutive size of his own country, does
not conceive that beyond the wild-heaving Atlantic there
lies the land of promise, par excellence, a land of im-
measurable resources, in which the talents of the indi-
vidual may hew out a career unimpeded by European
class distinction.'1 The author believes that the pilgrim-
ages now made to Europe by our physicians will cease ;
that schools will ere long be created whose disciples, as
" thoroughly educated as their European colleagues, will
reach out toward the goal of knowledge with the same
zeal, the same ability, and the same thoroughness. ' ' With
the penetration of a skilled observer, Dr. Placzek, in de-
scribing our hospital system, emphasizes the fact that we
do not rely upon the state for aid as they do in Germany,
but " the cruel help yourself," which rules in all branches,
permeates also, strange as it may seem, all purely humane
efforts." Nor is he slow to recognize that, " while our
institutions built and maintained by the state are often
sadly defective, most of those initiated by private enter-
prise are models of astonishing completeness." . He
acknowledges that the European errs in regarding the
American as a "dollar hunter" devoid of all sentiment,
citing as evidence the fact that a vast stream of money
flows constantly into the coffers of our hospitals, much of
which is given " in memory of a wife, son, or daughter,"
as recorded pathetically on tablets over some of the beds.
The shadowy side of the picture is brought out in his
reference to the fact that, despite their great wealth, these
corporations accept the services of medical men without
compensation, and that the lay directors entirely control
1 Die Medicinische Wissenschaft in den Vereinigten Staaten. Rei-
sestudien von Dr. med. S. Placzek, Nervenarzt in Berlin. Leipzig :
Georg Tbieme. 1894.
the affairs of the hospital. He especially condemns the
authonty of the superintendent, which he erroneously
regards as supreme in all our hospitals. The comfort and
elegance of our hospitals are brought into striking con-
trast with those of Germany, and this is emphasized by
well executed illustrations. Our ambulance system and
our training-schools for nursing elicit the author's highest
encomiums, and are held up as examples worthy of imi-
tation. He is struck by the extravagance in the arrange-
ment of our dispensaries (which he calls the children of
sorrow of medical practice) ; he justly condemns the reck-
less disregard of the interests of the profession displayed
in their administration. Under the caption of " Thera-
peutic Tendencies," the author alludes to the contrast
between German therapeutic nihilism and the implicit
faith in drugs of the average American, which he attrib-
utes to imperfect education. He assigns the latter as a
cause of the glaring disregard of the newer therapeutic
methods, citing rational hydrotherapy as an example.
" The process of development through which this thera-
peutic method is passing, in order to conquer the position
to which it is entitled, will always be noteworthy in the
history of American medicine. To the zeal of a New
York physician, who is conducting the battle for the
introduction of this powerful agent with unflagging
industry, the credit will be due if the opposition to
this method, which has long ago attained recognition
in Europe, shall be overcome." He finds electro-diag-
nosis and therapeutics as little "the general property
of the profession here as it is in Europe, and he regrets
to note that massage is entirely in the hands of laymen."
Our insane asylums receive extensive notice, and many
illustrations are furnished to emphasize their elegance
and comfort. Our quarantine system is regarded as too
exacting ; its excessive demands being illustrated by the
detention of the Normannia last summer. " The Amer-
ican's fear of contagion is well known ; he expects pro-
tection from the quarantine officer; " thus Dr. Jenkins's
rigorous measures are condoned, the European idea of
the American doctor, that he is a sort of inferior being, a
practical merchant, is regarded as a great error by the
author. "Reality develops quite a different picture,"
says he. " In vain do we look over there for the large
and showy signs announcing the doctor to be "a prac-
tical physician, surgeon, and accoucheur, or specialist for
larynx, throat, or n ose. ' ' Not even the well- known ' ' free
to the poor" is found anywhere. Nothing of all this,
only a small' sign in the inside of a window stating the
doctor's name and office hours." An extract from the
Code of Ethics concludes this interesting chapter, with
the statement that our " codex of morals is far more strict
than that customary in Germany."
Our educational facilities are fairly well presented, they
are concluded with a just criticism upon the following
defects: 1. Imperfect preparatory education. 2. Ex-
cessive theoretical instruction. 3. Insufficient clinical
teaching. 4. Insufficient practical activity. 5. Brevity
of course of study.
Our sanitary and hygienic affairs are largely, and upon
the whole favorably, commented upon.
Taking the book as a whole, we have reason to be
proud of the impression made upon a representative
German colleague, whose clearness of perception is equalled
by the fairness of his criticisms.
OO
MEDICAL RECORD.
[September 15, 1894
SOME EXPERIENCES OF THE DOCTOR'S
WIFE.
The doctor's wife has had many kind and sympathetic
things said about herself and her lot. A whole book has
even been written regarding her trials, her duties, and
her pleasures. The theme is a fertile one ; and a Brook-
lyn doctor's wife has recently and -happily enriched it
through the columns of the New York Times. Some of
her comments will no doubt wake responsive notes in
the minds of the many doctors' wives who read the Med-
ical Record.
" The apologies of the people who do not employ my
husband as a physician/' says the Brooklyn lady, " are
the funniest things yet. It is an extremely delicate
thing to receive these apologies in a delicate manner.
You really do not know what to do. I think sometimes
a doctor's wife who says just the right thing must be in-
spired. You have to say the very best things you can
for the physicians they employ. This is a big world and
a hard world, and it is always best to say all the good
you can about every one. People are apt to ask your
advice, too, about which you consider the best, the reg-
ular or the homoeopathic school of medicine, but al-
though they ask the question they are very likely to feel
terribly grieved if you say anything against either school. "
It is a standing grievance with some wives that they
have to be called " Mrs. Doctor."
" How many times," she says, "I hear that expres-
sion. People do not seem to realize that you got the
'Mrs.' alone and not by degrees, but by just a few
words. The certificate one gets at that time has nothing
to do with degrees or ' Mrs. Doctor.' I suppose it is be-
cause of ' Mrs. Doctor ' that there is hardly anything I
have not been asked to do when the doctor was out,
from setting a broken arm to pulling a tooth. And the
people will not see why I cannot do it.
" One man wanted a prescription. He said he knew
exactly how the signs looked on paper, if I would only
make them. The druggist would not give him the medi-
cine without the paper. Another man could give an ex-
act description of the bottle some medicine was taken
from if I would only get it for him."
The Brooklyn doctor's wife would evidently be glad to
join the " Society for the Abolition of the Doctor's
Title," for she says :
" The life in a house behind a brass sign seems to me
different from other lives. There you are ticketed.
When you stand in the window you are not a private
woman in a private house. You are Mrs. Doctor So-and-
So to every one who happens to look your way.
" You are never sure of an evening, and you may sit
waiting with gloves on until long past calling time, and
the doctor won't come after all. To be a doctor's wife
means to go to dinner-parties alone, with your escort ar-
riving perhaps with the second or third course. It is a
dual life, with the doctor's wife spreading herself like thin
varnish over it all. Then, and it is not the least of all,
the doctor's wife has to look after the family carving."
From all of which we should infer that if a young
woman were to take any advice about marrying a doctor
it should be Punch's general admonition: "Don't."
Fortunately advice is not asked as to matrimony by the
woman of to-day.
fjcxrrs of Ifee SSSCeefc.
Free Alcohol. — The result of the unintentional plac-
ing by the new tariff bill of alcohol used in the arts on
the free list will, it is said, reduce the price of tinctures,
perfumery, and spirit varnish from fifty to sixty per cent.
Milk from Tuberculous Cows. — In a recently issued
Agricultural Department report, on tuberculosis in cat-
tle, by Theobald Smith, chief of the animal pathology
department, it is stated that investigations undertaken
by the department show that the milk of tuberculous
animals is not so infrequently infected as supposed. Milk
of animals in the earliest stages of the disease and with
perfect udders, does not contain tubercle bacilli. Only
those showing signs of labored breath and emaciation
should be gravely suspected, and their milk excluded at
once from sale.
A Statue to Claude Barnard will be unveiled at Lyons
on October 26th. The French Academy has appointed
MM. J. Bertrand and Brunetiere to represent it on the
occasion. The Academie des Sciences will be repre-
sented by MM. Chauveau and Bouchard. As the first
French Congress of Internal Medicine will be in session
in Lyons at the time, it is expected that the ceremony
will be exceptionally brilliant.
The American Academy of Medicine. — At the annual
meeting of the American Academy of Medicine, held at
Jefferson, N. H., the following officers were elected:
President, J. McFadden Gaston, M.D., of Atlanta;
Vice-Presidents, Rufus P. Lincoln, M.D., of New York ;
William T. Smith, M.D., of Hanover; Helen C. Put-
nam, M.D., of Providence; Victor C. Vaughan, M.D.,
of Ann Arbor ; Secretary and Treasurer, Charles Mcln-
tyre, M.D., of Easton, Pa.; Assistant Secretary, Edgar
M. Green, M.D., of Easton, Pa.; Member of Council,
Charles C. Bombaugh, M.D., of Baltimore. The next
meeting will be held in Baltimore, May 4, 1895.
Deaths from Chloroform. — From August 10th to Sep-
tember 1st, there were three death} from chloroform an-
aesthesia in London hospitals.
A Hew Pulmonary Disease — "Pulmonea." — Dr. J.
W. Power, of Caylloma, Peru, says in The Lancet that
pulmonea is a name given by the native Peruvian miners
to an affection of the chest simulating acute pneumonia
in the consolidation stage, and might easily be mistaken
for it. In these altitudes (15,600 feet) the sudden daily
extremes of temperature (750 to 380 F. average) natural
to the climate, and the inhalation of the irritating dust
of the dry stamps of the mills and smelting fumes, make
cases of pulmonea of daily occurrence. Miners with
pulmonea will present themselves complaining of inabil-
ity to woik, of a dull pain under the heart and between
the shoulders, of cough and sometimes blood spitting,
and distress of breathing. Inspection of the chest shows
increased and quickened breathing. There is increased
vocal fremitus, with marked dulness on percussion, and
increased resonance over both lungs at the back of the
chest — under, as it were, the seat of pain. Sometimes
roughened breathing can be heard, but not tubular.
However, there are no febrile symptoms, and the ab-
sence of these and the tubular breathing are the only
differences between the two affections. I have made ne-
September 15, 1894]
MEDICAL RECORD.
337
cropsie of two men whom I had previously treated for
pulmonea, who had died from the effects of mining acci-
dents, and in both cases I found the glands in the pos-
terior mediastinum greatly enlarged, inflamed, and
thickened, forming a compact mass in a situation which
would just correspond to the seat of pain, and I have no
doubt that these glands were the cause of the symptoms
and physical signs which I have described. Their con-
dition was probably caused by the irritating matter con-
tinually inhaled by the men. With regard to treatment,
painting the back with iodine, and syrup of the iodide of
iron given internally, with a few days in the froth air,
will remove all the unpleasant symptoms, but not the
physical signs.
A Hew Oat. — The various medical societies, acade-
mies, sections, etc., which are about to begin the fall and
winter season will be interested in learning that Lord
Raleigh has discovered a new kind of gas, resembling
nitrogen.
Pasteur's Vaccination. — The authorities of Lower
Austria have decided that a station for vaccinating
against rabies shall be established in the neighborhood
of Vienna.
St. Louis has an Electric Ambulance. — The St Louis
authorities have adopted a plan of conveying patients
from the Dispensary to the city hospital by means of an
electric railway ambulance. A street car, with electric
motor attachments, has been fitted up as an ambulance,
and the system has been successfully put to work. It is
intended to run the car to all parts of the city in response
to ambulance calls. The car will be permitted to make
an average speed of twelve miles an hour.
The Tri-8tate Medical Society, with membership from
Illinois, Iowa, and Missouri, will meet in Jacksonville,
111., October 2 and 3, 1894. Valuable papers are prom-
ised from leading members of the profession of Chicago,
St. Louis, Kansas City, Indianapolis, Keokuk, Spring-
field and other places. A large and profitable meeting
is anticipated.
The Cholera. — The epidemic in Russia has assumed
large proportions again during the past week, or else, as
is very probable, the invasion of new districts for several
weeks past was kept secret by the authorities until the
number of cases became so great that further conceal-
ment was impossible. During the week ending Septem-
ber 8th, 6,376 new cases and 3,192 deaths were reported
in Russia proper, and the weekly average of new cases in
Russian Poland is 5,000, with a mortality of about fifty
per cent. The disease is^very prevalent in Nijni-Novgorod,
where the annual fair is now being held. In Gaiicia
and Bukowina, during the three days ending September
9th, there were 533 new cases and 304 deaths. Since
the beginning of the epidemic there have been 6,958
cases of cholera and over 3,000 deaths in these provinces.
The weekly average of new cases reported in Germany is
about 50. It is believed that the Rhine is infected, as
cases have occurred on the Rhine steamers. The disease
is undoubtedly epidemic in Marseilles, although the au-
thorities persist in their denials that cholera is present
there. Most of the Mediterranean ports have established
quarantine against that city. Other towns in France in
which one or more cases of the disease have occurred are
Paris, Bordeaux, Lassay, Rheims, Reuil, and Mancelsur-
Scille. An increase in the number of cases is also re-
ported from Belgium, eleven deaths having occurred in
Liege on September 5th, and new cases are constantly
being discovered in towns on the Meuse and Sambre
rivers, and also in places along the Maas, which is the
continuation of the Meuse in Holland. A Bavarian im-
migrant died in Cumberland, Md., a few days ago with
symptoms pointing to cholera, but an investigation by
the Marine Hospital authorities has shown that the case
was not one of Asiatic cholera.
Failure of Halftone's Inoculations. — A dispatch to
the London Times iiova Calcutta, dated September nth,
says that during the recent cholera epidemic at Lucknow
several soldiers who were inoculated with Dr. Haffkine's
virus were attacked, and that the proportion of mortality
among them was the same as among ordinary patients.
This contradicts the results of the experiments conducted
by Drs. Haftkine and Simpson, in Calcutta last June. It
was then said that few, if any, of those inoculated were
attacked by the disease, or if attacked they promptly re-
covered.
Dr. William G. Dabney died recently from typhoid
fever in Charlottesville, Va. He was graduated from the
Medical Department of the University of Virginia in
1868, and at the time of his death was professor of ob-
stetrics and the practice of medicine in that institution.
The International Congress of Hygiene and Demog-
raphy, which closed its session in Budapest, on Satur-
day last, will hold its next meeting in Madrid.
Hong Kong is officially declared to be free from the
plague, and the port was opened to commerce on Sep-
tember 10th.
Yellow Fever. — The steamer Samuel Tyzak, which
arrived in Baltimore from Havana on August 31st, had
four cases of yellow fever on board. One of the men
died in the Maryland University Hospital, and another
occupied a bed in one of the wards before the nature of
his disease was discovered. The bark Alice, also from
Havana, is at quarantine at Cape Henry, with three
cases of the same disease.
Dr. ffoah Sanborn died in Bayonne, on September
6th. He was born in Tamworth, N. H., in 1837, but
had been a resident of Bayonne for twenty-two years.
He served throughout the Civil War as a surgeon in the
Northern Army, and at the time of his death was one of
the attending staff of the Bayonne City Hospital.
Signor Crispi, Prime Minister of Italy, is reported
to be suffering from a cataract.
The Craig Epileptic Colony. — It is probable, as we
learn from authentic sources, that the epileptic colony
will not be opened for actual work under two or three
years. There is perhaps already some trouble about
patronage.
Dr. George Thomas Jackson, of this city, has been
appointed foreign Secretary for the United States of the
Third International Congress of Dermatology to be held
in London, July 31 to August 4, 1895.
Hog Cholera is epidemic in Lyons County, Kan.
Over four thousand hogs are said to have already died
from the disease, and many breeders have lost their en-
tire stock.
33»
MEDICAL RECORD.
[September 15, 1894
Dr. Charles H. Williamson died on Monday, Septem-
ber 10th, at St. John's Hospital, in Brooklyn, in his
sixty-eighth year. He was born in Virginia, and served
as a medical officer in the United States Navy for some
years preceding the breaking out of the rebellion, when
he joined the Confederacy. At the close of the Civil
War he served as surgeon in the Pacific Mail Steamship
Company.
The Cause of Liverpool's High Death-rate.— Some re-
marks having been made about the high rate of mortality
in Liverpool, the medical officer of health in that city has
prepared an explanatory statement, in which he attributes
the apparent unhealthiness of the town to the density of
the population, there being no rural or semi-rural districts
within the municipal area, as there are in other places.
While in Liverpool there are 1 14 houses to the acre, there
are only 39.9 in Manchester, 38 in Birmingham, and so
on to Huddersfield, which has only 8 to the acre.
The death-rate in Liverpool is 23 per 1,000, and in Man-
chester only 18 2; but taking the township district of
Manchester, which, to a certain extent, corresponds to
Liverpool, the death rate there is 27 per 1,000, which is
greater than that of Liverpool. Turning to London,
which, he says, is a very difficult place to say anything
about, the average death-rate is 21.3, but in what may be
called the urban district of London the rate is 26. The
death-rate in Liverpool during the last six months was
materially below the average of the last ten years.
English as a Universal Language. — At the session of
the American Social Science Association in Saratoga on
September 4th, Mr. D. G. Porter, of Waterbury, Conn.,
read a paper on " English as a Universal Language."
He said that in the present century there had been a de-
mand for a universal language. French and the so called
Volapuk had been advocated, and there had been a de-
mand for the revival of the Latin tongue ; but the Eng-
lish, the youngest of all the great tongues, seems to be
the survivor in the struggle for the supremacy. It was
largely owing to the fact, he said, that it was the lan-
guage which grew from the necessities of the common
people, without regard to the rules of orthography or
grammar. He traced the formation of. the English lan-
guage from the beginning of the fourteenth century, when
the Norman-French that had been forced on Great Brit-
ain as the language of its court and legal tribunals was
forced to compromise with the Saxon- Danish, which was
spoken by the peasantry, so that all classes of people
could converse and comprehend each other, and from
the necessities that urged that compromise has grown
that which requires that the spoken English should be the
universal tongue, for of its energy, begotten by the com-
pounding of races, grew the commercial supremacy of
England and her colonies, that had encircled the world
and carried with it the English speech, until now com-
merce requires it, and it is even supplanting French as
the tongue of diplomacy.
Mr. Porter is evidently not a reader of the Medical
Record, otherwise he would have had something to say
concerning the powerful claims of modern Greek to gen-
eral acceptance as the universal language of science. Of
course, if we believed English had any chance of being
adopted as the international means of communication,
we should gladly urge its claims ; but we fear there is
little hope of this. It is commonly said that our tongue
is understood and spoken by all educated men in Europe,
but anyone who has attended an International Medical
Congress on the continent knows how little truth there
is in this assertion. Of the three official languages,
English is the only one that is tortured beyond all rec-
ognition by the official translators, and of all the orators
at the general and section meetings, those speaking in
English have the smallest and the least attentive audi-
ences.
aftttutttg.
PROFESSOR HERMANN LUDWIG FERDINAND
VON HELMHOLTZ.
BHKLUf. GEBMANY.
Professor Helmholtz, the celebrated physicist, died of
apoplexy in Berlin on Saturday, September 8th. He was
born in Potsdam in 1821, and was educated as a physi-
cian, serving his term in the Charity Hospital. He turned
his attention almost immediately to the physical sciences,
and published his first book on " The Conservatism of
Force " when twenty- six years old. The following year
he was called to the chair of anatomy in Berlin, and the
year after that became Professor of Physiology at Konigs-
berg. Subsequently he filled the same chair at Bonn
(1855) and at Heidelberg (1865), and in 1871 was called
to the professorship of physical science in Berlin, formerly
held by Gustavus Magnus. It was during his Stay in
Konigsberg that he invented the ophthalmoscope and the
ophthalmometer. He wrote about one hundred and
fifty scientific papers and contributed largely to the phys-
iology of vision and hearing. Among his published
works of physiological interest were: "The Nerves of
the Invertebrata; " "Heat Generated by Muscular
Action;" ''Measurements Affecting the Periodical
Contractions of Muscles and the Distribution of the
Nerves Contained in Them ; " " A Method of Measuring
Small Intervals of Muscular Action;" a "Manual of
Physiological Operations."
He published on optics, "A Sketch of the Construc-
tion of the Living Eye," in 1851 ; "The Theory of
Permanent Colors," in 1852; "The Sight of Man," in
1855; and the "Manual of Physiological Optics," in
1856. In 1862 he published his " Theory of the Impres-
sions of Sound," and a little later a work which attracted
wide- spread attention, entitled " Sensations of Tone as a
Physiological Basis for the Theory of Music."
He loved science for its own sake and looked for his
reward in the pleasure occasioned by the search for
knowledge rather than in that caused by the possession of
knowledge itself. He developed this thought and showed
the spirit which had animated his life work in the course
of an oration which he pronounced on Gustavus Magnus,
his predecessor in the chair of physical science in Berlin.
" Knowledge alone," he said, "is not the design and
object of men on earth. Although science awakens
and cultivates the most subtle forces of the human mind,
yet he who studies only to know will not find the true
object of his existence in this world. ... A thor-
ough knowledge of the operation of the natural and men-
tal forces is all that scientists can attempt to acquire.
The student must feel himself rewarded by the pleasure
found in hailing new discoveries, new victories of human
effort and human thought, over opposing material forces.
He can find pleasure in the beauty which a well arranged
department of knowledge exhibits, in the coherence of
relation between its different parts, perceiving how one
part grows out of, or is developed by, others, and he
must find high enjoyment in the consciousness of having
contributed to the growing chapter of general informa-
tion, in thus assisting to manifest the supremacy of man
over the forces and material of nature."
September 15, 1894]
MEDICAL RECORD.
339
dPlinical §^m^tmtxxL
LARGE DOSE OF SULPHONAL FOR A CHILD.
By J. SUTCLIFFE HILL, M.D.,
BSLLOWS FALLS, VT.
Believing that the presentation of facts as a result of
our observation in cases that come under our care is of
interest to our professional brethren, and serve as lessons
for our guidance in similar cases in future, is my only
reason for presenting the following:
On February 24th, at 7 p.m., I was hastily summoned
to the bedside of a child, aged eighteen months. I found
an eclectic physician (?) present and learned that the
child was taken sick on the Tuesday preceding with
some form of bowel trouble. .
Status prasens : Child apparently unconscious, pupils
contracted, breathing shallow, but regular, pulse 120.
On questioning the eclectic he informed me that at 9
a.m. he had given 8 grains of sulphonal, and at n a.m.
8 grains more, at 1 p.m. 8 grains more, and between 3
and 4 p.m. 10 grains, making in all 34 grains in a little
over six hours. As the child was breathing regularly
and the pulse was good I deemed it a good case to wait
and watch the effect of suphonal in large doses and so
stayed with the patient all night.
The parents had promised me full control of the case
before I saw the patient. The child slept profoundly
over six hours, and as the parents had become quite
anxious for their little one, I managed to rouse the baby
and gave a few drops of aromatic spirits of ammonia ; the
child a|ain fell into deep sleep and slept four hours,
when I repeated the ammonia. This continued for over
twenty-four hours, when the child could be more easily
roused and called for nourishment. During this time
there had been difficulty in making water. There was
one peculiarity that was very apparent when the child
was recovering from the effect of the sulphonal, viz.,
ptosis of both eyes, which continued for four days, and
was very marked.
The case ended in complete recovery, no trouble either
of stomach or bowels. To me it was a very interesting
case as I have never prescribed over 10 grains of sul-
phonal at one dose in adult cases.
A CASE OF CHOLECYSTENTEROSTOMY WITH
THE AID OF THE MURPHY BUTTON— RE-
COVERY.
By HENRY MOFFAT, M.D.,
ATTENDING SURGEON, ST. JOSEPH'S HOSPITAL, YCNKBRS, N. Y.
The following case seems to me to present some features
of interest* and I trust will not be inappropriate, now that
so much attention is being paid to the surgery of the
gall-bladder.
L. S — — , a widow, aged thirty nine, a German do-
mestic, was admitted first to the surgical ward of St. Jo-
seph's Hospital on November 19, 1893, suffering from
intense biliary colic with a marked distention of the gall-
bladder. She was on the verge of collapse, and chole-
cystotomy was immediately performed by my colleague,
Dr. G. N. Banker, who was on duty at that time. He
removed eight large and six small stones. The patient
made an uninterrupted recovery and was discharged, De-
cember 23d, with a biliary fistula, which persisted for
about ten days longer, and finally closed spontaneously.
She had one slight attack of colic during January, which
was easily relieved, and remained well till February 5th,
when she was again seized with most violent pain in the
same region as before — the tumor reappeared and rapidly
increased in size. She was immediately brought back to
the hospital and came under my care.
On admission she was again in a partially collapsed
condition, slightly jaundiced, vomiting, and suffering
intensely, with a rapid and feeble pulse but no elevation
of temperature. The gall-bladder, swollen to the size of
a large orange, could be easily made out below and to
the mesial side of the former incision. In view of her
previous history, and believing that it would be extremely
difficult to assure myself of the freedom of the common
duct in a secondary operation, I determined to perform
cholecystenterostomy, using one of Murphy's anastomo-
sis buttons. In this view my colleagues, Drs. Banker,
Benedict, and Pyne concurred. The patient was there-
fore immediately etherized and an incision, about four
inches long, was made three-fourths of an inch to the
left of the old scar, parallel to and about two inches
from the median line, extending from one inch below
the free border of the ribs almost to the level of the um-
bilicus. The thickened and adherent peritoneum was
carefully incised and the distended gall-bladder was im-
mediately disclosed, though it was so bound down and
covered by old and strong adhesions that only about one
square inch of its surface could be cleared for manipula-
tion. The aspirator was used, and about two ounces of
slightly bile-tinged serous fluid was drawn out. The
presence of a stone could not be detected, but, feeling
perfectly assured that the common duct was obstructed,
I proceeded with the operation. The only loop of in-
testine which could be approximated with any degree of
safety was the hepatic flexure of the colon. I attempted to
drag one or two loops of the ileum to the point, but found
that strong adhesive bands prevented, and had I suc-
ceeded, would undoubtedly have produced dangerous and
probably fatal constriction of the bowel The male but-
ton was therefore placed in the colon in the manner de-
scribed by Dr. Murphy, and the female button in the
gall- bladder. This latter procedure was attended with
considerable difficulty, for the following reasons :
1. The adhesions from the previous operations had
bound the gall-bladder firmly down at the bottom of the
wound.
2. The surface freed from adhesion was so limited- that
it was found impossible to make the two stitches de-
scribed by Dr. Murphy on one side of the incision ; one;
however, proved just as satisfactory in this case.
3. The walls of the gall-bladder were more than one-
fourth of an inch in thickness, renderiog it difficult to
make them slip into the cup of the button when the ligature
was pulled taut. The buttons, being then safely in place,
were pushed home and a satisfactory approximation of
the parts was made without any undue tension on the
surrounding tissues. As there had been some unavoid-
able leakage from the gall bladder, I packed down to the
bottom of the cavity a strip of iodoform gauze and closed
the rest of the wound with sutures through the abdom-
inal wall and peritoneum.
The patient made an uninterrupted recovery. Her
bowels were readily moved on the third day by a dose of
magnesium citrate, and on the seventh day a gall-stone
about the size of a hickory-nut was passed per rectum.
She was allowed to sit up on the eleventh day, and dis-
charged at her own request on the eighteenth day after
the operation. The abdominal wound was entirely
healed, with the exception of a small superficial granulat-
ing surface, which soon cicatrized over ; but she had not
passed the button. Dr. Banker saw her several times
after she left the hospital, and anxiously awaited the ap-
pearance of the button. It was not until March 2d,,
twenty-five days after the operation, that it was finally
passed. She was at that time seized with colicky pains
over the whole abdominal region, and a dose of castor-oil
produced the long-expected button. She has since been
in perfect health and attending to her duties.
In reviewing the case the following points might be
noted : 1. The comparatively easy accomplishment, with
the aid of Murphy's button, of an operation which is ac-
knowledged by all surgeons to be one of the most diffi-
cult. To effect a perfect anastomosis between a loop of
intestine and a gall-bladder with thickened walls, and
bound firmly down in such an inaccessible position, with-
out the aid of any mechanical contrivance, would call for
340
MEDICAL RECORD.
[September 15, 1894
the highest technical skill and would be attended with
the gravest difficulties. From my experience in this case
I feel certain that the Murphy button has proved a most
valuable assistant.
2 It must, however, be noted that the danger of the
button becoming lodged somewhere in the intestinal tract,
is not by any means as trivial as Dr. Murphy wished us
to understand. In the above case, from the fact that a
gall-stone was passed on the seventh day, it must be in-
ferred that the button had at least partially sloughed
away ; for the stone was too large to pass through the
lumen of the button. And yet, in spite of the fact that
the colon was used, it took twenty-five days for the but-
ton to pass out of the body. There was, however, no
obstruction at any time, and the bowels moved every day.
3. The use of the colon, while not desirable, was ab-
solutely required in this case for the reasons given above,
and is not without precedent. Treves quotes a case of
Mr. Mayo Robson in which the hepatic flexure of the
colon was used for the same reason.
4. The effect of the loss of the physiological action of
the bile in the small intestine will be worthy of further
observation. At present writing, two months after the
operation, the patient is in perfect health, has gained in
flesh and strength, and her bowels are acting in a per-
fectly healthy manner.
A SUCCESSFUL PLASTIC OPERATION OF THE
FACE.
By J. J. MULLEN, M.D.,
PITTSBUBC, PA.
Os December 10, 1893, assisted by Drs. H. Atkinson,
of Connellsville, Pa., and J. D. Mullen, of Dunbar, Pa.,
where the operation took place, I performed a plastic
operation on the face of a girl, aged twelve, who had her
right eye and cheek entirely destroyed by the accidental
discharge of a loaded gun in the hands of her brother.
She presented a most pitiable appearance ; the lower eye-
lid was firmly adherent in the cicatrix on the face at
right angles to its former or normal position. The cica-
trix resulting from loss of skin, fascia, muscles, and bones
was permeated with powder and lead, extending from
the orbital space along the nose down, and included the
upper lip, running obliquely over the lower jaw up along
the face close to the ear to the outer commissure of the
eye. After satisfying myself that the stump remaining
from loss of the eye had cicatrized perfectly and no irre-
gular nodule remained, I dissected the lower eyelid out
of the scar and threw it over the patient's nose in a pair
of catch forceps. I now made a free and clear dissection
of the scar from the points described, with the exception
of a small portion along the nose and close to the eye,
which subsequently answered a good purpose. The dis-
section of the scar was not attended by much bleeding,
although I used a very sharp scalpel. The dissection be-
ing completed (which was the least difficult part), an in-
cision from the margin of the dissected wound on the
lower jaw, on the ear side of the wound, down on the
neck, three inches or more in length and one and a half
inch in width, its distal end being freed and the proxi-
mal at a point immediately below the ear, turned at right
angles, was brought up to within one half-inch of the eye,
where it was sutured to a small margin of sound skin.
The other flap was secured by going down on the chin
and neck, leaving, however, a portion of sound and un-
disturbed skin, which divided the space from which the
flaps were removed ; it was also turned at right angles on
the lower jaw and its free end secured to the small piece
of cicatricial tissue I left on the nose at the time of dis-
section. Both flaps were now sutured, one along the
side of the nose, and the other to a slight margin of
sound skin along the ear. The two free edges now in the
middle of the wound were united with catgut sutures.
A V-shaped opening was made at the outer commissure
of the eye into sound skin and the eyelid was brought
into it and secured by a suture, which was passed from
above downward into the wound and there tied. The
denuded surface on the neck was covered by freeing the
skin and fascia on both sides and suturing them to the
island of undisturbed skin which was left when the flaps
were removed. The wound being thoroughly dried was
dressed with boracic acid, and the dressing being secured
in the usual way the patient was placed in bed, where she
remained for eight days. Many of the sutures were ab-
sorbed on the sixth day, the whole of them were removed
two days later, and complete union had taken place in
the wound. The dressing was scarcely soiled during the
healing process. The result was very gratifying to. all
concerned.
A LARGE DOSE OF MORPHINE.
By W. S. GROOM, M.D.,
BRITT, IA,
September 22, 1893, 1 was called out of bed to go into
the country to see Airs. P . I found her in great dis-
tress and unable to describe her symptoms very accu-
rately. So thinking to relieve her distress and make
my diagnosis afterward, I gave a hypodermic of %. grain
of morphia, which I repeated in ten minutes, as there was
not the slightest result. In twenty minutes I prepared
the third dose, but I naturally hesitated in giving it. I
asked her if she ever took any opiate? She said, " Yes."
"Howoften?" Iasked. "Everyday." "Howmuch?"
" Thirty grains. ' ' Well that staggered me, but after care-
ful investigation I found it to be correct. She showed
me an ounce bottle of P. & W. label, said that she took
that much every sixteen days. She showed me a J£ -ounce
bottle that she had opened in the morning, and prepared
her morning dose, but she was unable to retain it. I
prepared a solution of fifteen grains morphia in very
hot water, and gave it hypodermically. It filled my hy-
podermic five or six times. The result was magicaL
One ounce P. & W. morphia every sixteen days beats the
record of any case I ever heard of.
FRACTURE OF THE HEAD OF THE FIBULA
BY MUSCULAR ACTION.
By D. B. HORTON, M.D.,
BATAVIA, N. V.
The only excuse in offering a report of this case is its
extreme rarity in practice, and the peculiar scientific in-
terest connected with such an accident. I was called to
see E. E , aged sixty-four, on the morning of Janu-
ary 29, 1889, and as I entered his room he stated that
he had broken his leg. I asked how he knew it was
broken, and he replied, " Because I felt it and heard it
snap, and cannot walk upon it." I readily diagnosed a
fracture of the head of the fibula of the right leg, three-
fourths inch from the upper extremity of the bone. The
fragments were separated one -half inch, but could be
easily brought together and crepitus obtained. As he
said that nothing struck his leg and there was no abra-
sion of the skin, my curiosity was excited, and I drew
out the following history of the case: While coming
home the night before, walking over a bad sidewalk, his
right foot caught in a hole in the walk, causing him to
stumble six or eight feet, and finally fall off the side next
to the fence. On attempting to rise he found his leg
useless, and he crawled along, and by the aid of a piece
of board finally reached home, fifteen or twenty rods
distant. It seems that while falling, and just at that par-
ticular time when the knee was twisted outward, leg
slightly adducted and slightly flexed upon the thigh, and
the foot on the walk, and he, still in an upright position
and making a desperate effort to save himself from fall-
ing, heard a snap like a bone breaking, and his leg gave
way. After a careful study of these parts it will be
plainly seen that this position is the only one in which
this accident could take place without traumatism. The
September 15, 1894]
MEDICAL RECORD.
34*
head of the fibula is so protected by the external tuber-
osity of the tibia that only by the leg being bent upon
the thigh is it in a measure exposed, and then by a vio-
lent contraction of the biceps the bone gives way at its
weakest part I found by flexing the leg upon the thigh
to about forty degrees that the parts were easily retained.
I applied a compress and bandage for a few days, and then
a plaster-of- Paris bandage for four weeks, holding it in this
flexed position, obtaining bony union and good result.
TREATMENT OF CEREBRO - SPINAL MENIN-
GITIS.
By T. J. HUTTON, M.D.,
SHENANDOAH, PA.
The uniformly successful results of the following plan
of treatment for this malady has been one of the chief
joys of my professional life.
The intense cerebral form is usually attended with
constipation that is almost obstipation : here open the
bowels with calomel or turpentine enemata. The mild
constipation met with in some cases of the cerebro spinal
form of malady is easily controlled by mild laxatives —
phosphate of soda in tepid milk, or simple warm-water
enemata. I write now of the cerebro spinal form, and
the essence of the treatment is : Put the patient into a
mild dozy condition by small doses of bromide of po-
tassa and opium, graduated to the age of the patient and
repeated often enough to maintain the dozy condition.
Draw a good blister over lower dorsal spine by canthari-
dal plaster sized to suit the age. Keep hot flat irons or
bottles filled with hot water to the patient's feet. Feed
the patient every hour or two with an ounce or few
ounces (according to age) of warm milk and eggnog
alternated with beef-juice — not beef- water. A suitable
doze formula for a patient aged ten or twelve years would
be about as follows :
3. Potass, bromid. 3jss.
Sol opii comp. (Squibb' s) J jss.
Syr. zingib.,
Aq. caryophy.,
Aq. pur U q.s. ft. 3 iv.
M. S.: A tcaspoonful every two or three hours by day; less
often by night.
A suitable eggnog formula is as follows :
3 . Granulated sugar I tablespoonfuL
Pure rye whiskey I tablespoonful.
Fresh milk 1 tumblerful.
A fresh egg well beaten up.
Hot water enough to fill a com-
mon-sized tumbler.
What will this treatment do? One thing it will not
do — it will not enrich undertakers. I have practised
since 187 1 ; have in that time treated quite a few cases
of this malady ; have had no death to date.
A CASE OF ENTEROLITH.
By W. C. PHELPS, M.D.,
BUFFALO, N. V.
I first saw the patient three years ago, when she was
suffering from a severe pain in the abdomen on the right
side. There were some induration at the seat of pain,
but it soon passed away and no operative procedures were
attempted, though an exploratory incision was thought of.
After this attack she was in good health excepting a pain,
of a neuralgic character, in her left arm, which was almost
always present. She was in her usual health until June
21st, when she was taken with a severe colicky pain. I
was called to see her, and relieved her with a hypodermic
injection of morphine. She was able to ride out that day
in the evening and thought that she had entirely recov-
ered. On the morning of the following day, however,
she was again attacked, and began to pass bloody mucus
from her bowels. Thinking that a dysentery was being
developed I ordered one and one-half ounce of castor-
oiL In three hours she had a movement of the bowels,
and a large stone, weighing over half an ounce, was
passed, with immediate relief to all her symptoms, includ-
ing the pain in the arm, which had been very severe
during the continuance of the pain in the abdomen. I
think that this stone was impacted in the small intestine,
and was the cause of the patient's illness three years ago,
and that it passed into the large intestine at the time of
her recovery, and had since been lodged in that portion
of the alimentary canal until it was finally expelled by
the dose of castor-oil. Authors state that it is always a
matter of years during which enteroliths are forming, even
as long as thirty years — generally not less than six.
A CASE OF PSEUDO-RABIES COMPLICATED
BY DELIRIUM TREMENS.
Bv J. D. GRISSIM, M.D.,
HOUSE PHYSICIAN TO ST. JOSEPH'S HOSPITAL, PATBBSON, N. J.
On August 1 2th a man, twenty- six years of age, a ple-
thoric German, applied for admission at St. Joseph's
Hospital, giving the following history :
Eight weeks previously he had been bitten by a dog,
whose teeth penetrated the coat and clothing, sinking
into the shoulder and leaving marks over the deltoid
and in the axilla. The dog had shown no signs of
rabies but was immediately killed. The patient declared
he thought no more of the matter until some weeks later
when some of his associates suggested the possibility of
hydrophobia and depicted to him the horrors of the dis-
ease. He became apprehensive concerning his welfare,
and his anxiety increased more and more until he began
drinking heavily to drown his thoughts, which he said
constantly dwelt on this one subject.
On the evening before entering the hospital, August
1 ith, he had difficulty in swallowing a glass of beer, which
increased his mental worry, and he spent a sleepless
night Upon admission to the hospital I found him ex-
ceedingly nervous and morose, dysphagia present to a
well-marked degree, preceded by tremor of the entire
body, and he objected seriously to the customary bath,
both before and during the process. He was admitted
at 4 p.m. At 7 p.m. he was given chloral, 20 grs. ; bro-
mide of potassium, 3j-, which dose was repeated at
midnight, with %. gr. morphine hypodermically. He
passed a very restless night, sleeping for only a few mo-
ments, waking with terrified cries. On the following
morning the patient was able to drink milk with ease,
but when he was urged to drink water dysphagia was
more marked and accompanied by peculiar sounds from
the throat. Temperature, 99$° F. ;■ pulse, 85 per minute.
He was exceedingly nervous and restless ail day. In the
afternoon he had hysterical spells of sobbing and terror
without any apparent cause, and said that he realized
that he was acting peculiarly but could not control him-
self.
Afternoon temperature, ioo° F. ; pulse, 90. At 9
p.m., besides the bromide and chloral, he was given y2
gr. morphine hypodermically, after which he slept a
short time.
At 11 p.m. he attempted to jump out of the window,
but was caught by an attendant. I was summoned, and
found the patient violently delirious, imagining he was
pursued by police and that they were concealed in the
room. He made frequent efforts to get to the window,
muttering incessantly in German and English, and in
fifteen minutes became so violent that I was obliged to
summon three attendants I had stationed conveniently,
and it required the united efforts of us four to hold him
in bed until he could be chloroformed and a canvas
sheet applied. As a result of his violent and persistent
struggles his heart action was about 200 per minute,
and his breathing labored and irregular. His face was
much congested, and his skin very hot and dry. I
thought venesection advisable, and while he was still
under chloroform I drew a quart of blood from the me-
dian basilic. This blood was at first very dark and
thick, but later became normal in color and consistency.
342
MEDICAL RECORD.
[September 15, 1894
His pulse improved in character, but not in rate, and
respiration became less rapid, but was still very irregu-
lar. He was given twenty-five minims of tincture of
digitalis hypodermically, but it had little apparent ef-
fect upon the pulse. As the effects of the chloroform
wore off, his struggles continued, and he died four hours
after the first appearance of delirium from sheer exhaus-
tion.
The case is one of interest from the fact that a very
peculiar neurotic affection should have been rendered
fatal by an intercurrent disease brought on by the pa-
tient's efforts to cure himself.
RESULTS FROM CIRCUMCISION.
By JOHN W. S. McCULLOUGH, M.D.,
ALLISTOK, OMT.
Among others, two cases are called to my mind, illustra-
tive of the value of circumcision, by the article of Dr.
Rosenberry, in the Medical Record of August nth.
Case I. — Boy, aged three and a half, very intractable,
incontinence of urine day and night ; treated with
strychnine and belladonna, then with strychnine and
atropia sulphate. These, however, failed. The prepuce
was very long and tight, so I performed circumcision,
using* cocaine anaesthesia. A complete recovery from
the incontinence followed.
Case II. — Boy, aged one month. Two years ago a
child in the same family, then of the same age as the
present patient, had severe indigestion, for which no treat-
ment was of any value. I advised circumcision, as the boy
had a tight and elongated prepuce. The operation was re-
fused, and eventually the child died. In the present in-
stance the child had indigestion, screaming fits at night,
and failed to thrive. The prepuce was, as in the former
case, long and tight, the orifice being extremely small.
My advice that circumcision be performed was concurred
in by the consultant, Dr. J. Harlan Reed, of Homing's
Mills. I did the operation without any anaesthesia, and
used a couple of silk sutures on either side of the central
tear in the mucous membrane. The wound healed with-
out any trouble and the child's indigestion and scream*
ing were gone almost from the hour of operation. Used
when required, there is no doubt of the value of this little
procedure.
PILOCARPINE IN THE TREATMENT OF
ACUTE AND CHRONIC URTICARIA.
By R. ABRAHAMS, M.D.,
MBW YORK.
ATTSMDIMG PHYSICIAN TO MOUNT SINAI HOSPITAL, OUT-DOOM DEPARTMENT.
My humble desire in this paper is to call the earnest
attention of the profession, particularly at this time of the
year, to the admirable action of a drug in a disease which
very often baffles the therapeutic ingenuity of the general
practitioner as well as the specialist. The symptom of
symptoms which the physician is called upon to combat
in acute or chronic urticaria is the terrible itching. It
is hardly an exaggeration to say that this symptom is
responsible for the many constitutional disturbances fre-
quently observed in this disease. The hydrochlorate
of pilocarpine promises immediate, certainly eventual,
relief and cure of all the symptoms and the disease itself
in a great majority of cases.
I do not wish to be understood as saying that pilocar-
pine is a specific for urticaria in the sense that mercury is
in syphilis or quinine in malaria, for, in the nature of
things, no drug can be a specific in a disease of a varied
and obscure etiology. But the claim is emphatically
made that the alkaloid will cure where all other means
will fail to relieve. Not to weary the reader with a long
list of successful cases, observed both in private and dis-
pensary practice, I shall mention but three, which are at
present most prominent before my mind, occurring re-
spectively in a man, woman, and child. Let, however,
every man try for himself and be convinced. Let him
employ this treatment after all other treatments prove of
no avail, my request being only that he observe the con-
ditions hereafter mentioned, which are so essential to a
good result.
Case I. — A friend of mine, a physician, had an attack
of acute urticaria. The burning and itching were dis-
tressingly intense. He was restless and sleepless, with-
out appetite and patience. Before I saw him he had ex-
hausted pretty nearly the entire list of remedies. After •
one hypodermic injection of pilocarpine he was relieved
The second injection cured him.
Cask II. — A lady, about fifty-five years of age, suffered
a very severe attack of urticaria. Her body and face
were one mass of burning wheals. I saw her in the
morning ; gave a hypodermic injection of pilocarpine.
At my second visit in the evening, all I found left of the
hives was the thankful victim to tell the tale of her by-
gone woes.
Cask IIL — A child, two and one-half years of age,
suffered from a lichen urticaria for the last two years,
always worse in the summer. I found the child in a
most miserable condition, pale and emaciated, no sleep
at night from the perpetual itching and scratching.
Treatment was kept up at various places and by various
men during the entire period. Six weeks ago I saw the
litde sufferer for the first time and at once put him on
pilocarpine internally. A week later the child's rest
was undisturbed at night and his appetite markedly im-
proved. To-day the child is free from all urticarial
miseries, and his health is in a first-rate condition.
The employment of pilocarpine in the treatment of
urticaria is not entirely new, nor yet is it very old. The
latest works on skin diseases and materia medica, as far
as I could ascertain, hardly mention it. My first les-
son in this new application of the drug I learned in
Dr. Lustgarten's skin clinic (Mount Sinai Hospital Dis-
pensary), with which I was connected as assistant for
nearly three years. The drug there is used freely and
satisfactorily, and on more than one occasion Dr. Lust-
garten, in private conversation, extolled the virtues of pilo-
carpine in the disease in question.1 I am, however, well
aware of the fact that this medicinal agent foiled to be of
service in the hands of some good men, even skin special-
ists. The failure, it seems to me, is due to one of three
causes : Either the urticaria was badly complicated by ec-
zema, the result of scratching or strong applications, or the
diagnosis was questionable, or the alkaloid was impure.
A case in point : After relating my excellent results with
pilocarpine in urticaria to an able physician he promised
to furnish me with corroborative evidence from his exten-
sive practice. A few days later he returned with evi-
dence— of disappointment. At my request I was shown
the patient, and found the fair dame a victim of a mild
scabies instead of hives.
Now as to the mode of administration and dosage. An
adult should get it under the skin, and a child by mouth.
The dose for an adult is from one-sixth to one-half a grain,
repeated every day or every other day, or oftener. For a
child one year old, the dose is from one-twentieth to an
eighth of a grain in distilled water every evening at bed-
time. For a child from two to three years old, the dose
is from one-fifteenth to one-sixth of a grain. By admin-
istering the alkaloid gradually, feeling one's way as it
were, no untoward accident should be anticipated.
Adults, however, seem to be more susceptible to its in-
fluence than children. A good precaution is to remain
with the patient after exhibiting the medicine from
fifteen to twenty minutes, and when given to children
mothers should be instructed to use a little red wine or
claret should the child show signs of weakness. I have
seen only one man that complained of marked weakness
after a hypodermic injection, and two patients were
severely salivated. The first was restored by a little
1 Brief reference was made by the doctor to the action of jaborandi
in urticaria at a recent meeting of the New York Dermatological So-
ciety (Journal of Cutaneous and Genito- Urinary Diseases, June, 1894).
September 15, 1894]
MEDICAL RECORD.
343
claret and the other two were relieved by holding ice in
the mouth.
It seems that in order for pilocarpine to be palliative
or curative in acute or chronic urticaria, it must make
the patient sweat freely. I found that free perspiration
is promptly and with a comparatively smaller dose pro-
duced in an adult than in a child, and herein is my guide
to the increase or diminution of the dose.
To sum up : 1. Pilocarpine in urticaria is the drug par
excellence. 2. Be sure of the diagnosis. 3. Before in-
stituting your treatment, clear off complicating lesions.
4. Get a pure drug. 5. Have patience. 6. Push the
drug to the point of tolerance.
In conclusion, I wish to state that in two cases of
jaundice where the itching was quite annoying pilocar-
pine proved useful, and I have seen it also allay the
burning and tingling sensations in other affections of the
skin.
156 Clinton Street.
UNSUCCESSFUL EMPLOYMENT OF POTAS-
SIUM PERMANGANATE IN A CASE OF MOR-
PHINE POISONING.
By C. MONROE McGUIRE, M.D.,
WALSBNBURGH, COL.
Having read in the Medical Record, and various other
medical journals, of the many experiments with potassium
permanganate with varying results, I have been urged to
report my case, where the so-called antidote was tried in
a case of an adult and found wanting.
I submit the following brief report, and will warn my
professional brethren to beware of trying any new remedy
until its physiological and pathological effects are known
to be as represented, as I came near losing my patient
by relying on permanganate of potassium.
On the evening of March 15th I was called to see Mr.
M , a travelling salesman, married, and of good
habits. He had lost his position through no fault of his
own, and was very despondent. I found him nervous,
pale, nauseated ; had been vomiting at frequent intervals
for the past three days. No appetite, bowels torpid, dull
headache ; he said he did not think he needed medical
aid, but his wife felt uneasy about him.
When I had examined him thoroughly and prescribed
for him, I did not feel that I had struck the " key-note M
as to the cause of his present condition. I assured him
he would doubtless be kept in for two or three days only.
On the evening of March 16th, at 5.30 o'clock, I was
hastily summoned to see Mr. M . The messenger said
he was dying (during the day it was known he had lost
his position, so my first thought was, Mr. M has made
an attempt to take his own life rather than stand the dis-
grace of being discharged). On entering the room I
found him lying upon a bed in a profound coma, face
cyanosed to a purplish dark color, breathing almost en-
tirely suspended, heart slow and strong. He had taken
the opiate only about one hour before, as it was afterward
ascertained ; the pupils were markedly contracted ; he
could not be made to recognize the loudest of noises. I
was sure he had taken morphine. I lowered his head,
raised a window, and practised artificial respiration till
he breathed, then I gave him atropine sulph., gr. ^, hy-
podermatically. Thinking the morphine had been all
absorbed, as I did not know at what time he had taken
it, I did not use the stomach-pump. Finally I got him
to swallow, and gave him FE. ipecac. 3 ss. by the mouth,
which in the course of an hour and a half produced
marked emesis. During this time several persons had
come in, and we had him upon his feet supported by two or
three men, and made him walk, or carried him rather, in a
perpendicular position until he finally could speak and
breathed without being told or made to do so by pressure
over the chest. I gave him strong black coffee and more
atropine sulph. while he was being walked around, until
he seemed out of danger or in a favorable way to recovery.
About this time my wife, Dr. Eva M. McGuire, came in
and corroborated my diagnosis. The patient's wife, of
course, expected him to die and asked me several times
what I thought of his chances for recovery ; I told her I
thought he would live, but to satisfy her sent for my
friend, Dr. W. H. Earnest.
At the time the messenger went the doctor was in the
country, so it was some time before he came, perhaps
three hours after I had first been called. The doctor
hearing of the probable ingestion of an opiate brought
with him one pound-bottle of potassium permanganate.
He also corroborated our diagnosis. He proposed potas-
sium permanganate in three- or four-grain doses by the
mouth, saying that he was not at all sure of its antidotal
powers, but thought it worth trying. I agreed, though I
felt sceptical of it. At the time when Dr. Earnest came,
I had not given any atropine for some time, and Mr.
M was so that he recognized all who came in. At
this time he was propped up in bed, when we gave him
three or four grains of potassium permanganate. He
seemed to be in a fair way to recover, though the pupils
were still markedly contracted. In perhaps twenty
minutes after the ingestion of the potassium permanganate
Mr. M sank into a deep coma; he could not be
roused by shouting into his ears, the breathing stopped,
he became cyanosed to a dark color, and life seemed to
be gone. I again practised artificial respiration, but this
time without any success at all. He had not breathed
for two or three minutes. During all this time Drs.
Earnest and Eva McGuire stood by, when finally I raised
him up and Dr. Earnest and I carried him in a perpen-
dicular position to the veranda, where we gave him to
two strong men who supported him in an upright posi-
tion till he breathed. When he had been walked in the
open air I gave him another hypodermatic injection of
atropine, gr. -fa9 and strythnia, gr. -fa. This was repeated
in an hour, when his pulse became stronger again. He
complained of dryness of the fauces and called for water
frequently ; we gave him strong coffee too. At 10 p.m.
Drs. Earnest and Eva McGuire went home. Relays of
men walked with him till 12 p.m., when I allowed him to
go in the house and sit up in a chair. I had to tell him
to breathe for about one and one-half hour longer, when
I allowed him to go to sleep, and he only breathed seven
to eight times per minute. I finally let him go to bed,
but sat by him till 6 a.m., when he breathed twelve
times per minute. He made a good recovery, and con-
fessed that he had taken morphine.
PSORIASIS TREATED BY THYROID EXTRACT
WITH NEGATIVE RESULT.
By CHARLES E. NAMMACK, M.D.,
VISITING PHYSICIAN, GOUVERNEUR HOSPITAL, NEW YORK.
Julius R , aged seventeen, tailor, native of Russia,
was admitted January 4, 1894. Eleven weeks before ad-
mission an eruption appeared on his face and extended
over the entire body, including the scalp, with the ex-
ception of the palms and soles. Considerable itching at-
tended the eruption. The case presented the classical
appearance of psoriasis universalis, with a more extensive
distribution than the writer had ever before seen, the
patches assuming all sorts of features as to size and shape,
and every region of the body being covered. The mu-
cous membranes were not affected. The patient had
never had a previous attack, nor could it be traced to
either parent. He is an underfed and overworked boy,
employed in a " sweater " shop. He gives no history of
alcoholism, rheumatism, syphilis, or venereal disease.
He was treated by arsenic, alkaline baths, and external
inunctions in the usual way, until January 23d, when my
colleague at the New York Hospital Out Patient Depart-
ment, Dr. Prince A. Morrow, called my attention to
Byrom BramweH's report of the efficacy of thyroid extract
in similar cases {British Medical Journal, October 28,
1893). A specimen was obtained from the New York
Biological Institute, and administered in gradually in-
344
MEDICAL RECORD.
[September 15, 1894
creasing doses, hypodermatically, up to twenty- five minims
twice a day, without the development of any physiologi-
cal action from the extract, and without any perceptible
influence on the eruption. All other medication had
been stopped at the time the thyroid administration
was begun. Through the kindness of Dr. Morrow an-
other preparation of thyroid extract, prepared by Dr.
Crary, was then obtained, and the patient was given five
drops of this twice a day, and the dose increased gradu-
ally until he had taken fifteen drops twice each day. No
other medicine was used. He received the usual ward
diet and was allowed to be out of bed. The thyroid ex-
tract did not increase the bodily temperature, nor accel-
erate the pulse, but a noticeable effect of its administra-
tion was a marked increase in the daily excretion of
urea, confirming the results reported by Dr. Ord and
Mr. White {Therapeutic Gazette, January 15, 1894). If
it be true that thyroidectomy increases the toxicity of the
urine, and that the function of the thyroid body is an ex-
cretory one (Medical Record, February 24, 1894, p. 246),
these observations have a peculiar interest, and the use of
thyroid extract a wide therapeutic field. In this partic-
ular case it carried the amount of urea excreted, on a
diet not very rich in nitrogen, up to from 875 to 1,025
grains daily. Its effect upon the eruption, however, was
negative, such improvement as occurred being fairly at-
tributable to the rest and hospital life. It was therefore
discontinued on the fifty-fourth day.
»9 East TwsNTY-rotnmi Street, March as, 1894-
PREMATURE LABOR BEFORE THE SIXTH
MONTH- SURVIVAL OF THE CHILD FOR
ONE WEEK.
By W. J. HILL„M.D.,
STATESVILLE, K. C.
Upon July 13 th last I was called to see Mrs. C at
two o'clock in the afternoon, and at five o'clock the
labor was completed in a natural way. Very little blood
was lost ; the womb contracted tightly, and the woman
did well generally. On January 18th she menstruated
last. Everything went along all right until she was
three and a half or four months gone, when she took
a trip of twelve miles into the country in a rough wagon.
Not being in the habit of riding she became very tired.
That night " her sickness " came on her. Being some-
what alarmed, she came home at once, believing she would
miscarry. From this time on until her confinement the
loss of blood was continuous, amounting at times to
flooding. Despite my efforts to control it by keeping
her in bed and the free use of ergot and other remedies,
I was importuned from time to time by herself and hus-
band to bring on labor, but insisted on waiting as long
as her life was not endangered, until the child was viable.
Very little quickening was felt. In fact, she was so sure
it would be born dead that she did not prepare any
clothes for it
The presentation was the one most usual. Though the
second stage was not protracted, yet the child was livid
and presented every appearance of being lifeless. As is
my habit, I suspended it head downward, and in a mo-
ment I saw evidences of life. By my aid in artificial
respiration it soon began to cry ; I then in a few mo-
ments had it snugly wrapped in soft warm wraps, and
had it laid away. After I had seen that the mother was
made comfortable, I turned my attention again to the
child ; I refused to allow it to be washed for two days,
neither did I allow it to be handled to dress it. It was
at first allowed the sugar cloth, then it was put upon its
mother's milk, which was milked from the breast and fed
to it from a bottle and nipple. Afterward it took the
breast. It slept well, bowels were regular in their action,
as were also the kidneys. It lived for seven days. The
nails were only shaped, but the infant had plenty of
hair. No vernix caseoea present. It was born with the
membrana pupillaris present. It measured eleven and a
half inches and weighed one pound and two ounces.
The morning after it was born I could cover the face
from view with a silver dollar. The mother has borne
four other children, and always went to full term. The
child was allowed to get cold, and this I think caused
its death. Upon examination I found that a consider-
able portion of the placenta bore evidences of having
been detached for some time. There was very little
fluid in the sac > it was of a brownish color with con-
siderable sediment in it. This fluid also came from the
mouth and nose of the child at birth. The mother
made an excellent recovery.
TREPHINING FOR TRAUMATIC CLOT.
By GEORGE G. HOPKINS, M.D.,
SUBCKON TO ST. JOHN'S HOSFITAL, ETC.. BROOKLYN, M. Y.
Charles Bolts, aged twenty- seven ; sea captain, single*
Admitted to hospital September 16, 1893.
Eighteen days previous, during a severe storm, he was
struck on the eminence of the left parietal bone by the
main boom and knocked overboard; he had strength
enough to catch a rope and was pulled aboard. His
yacht was shortly driven ashore and wrecked, and he
was pulled ashore by some of his crew in a semi-con-
scious condition. Later he lost consciousness, but for
how long a period I have been unable to ascertain.
On admission to the hospital the patient was unable
to give a clear statement of anything that had occurred
during the eighteen days that had elapsed since the in-
jury had been received. From friends who had watched
him constantly, it was ascertained that his actions were
very erratic. He would insist on going long distances
to see friends, and when he reached his destination he
wondered why he had come. He would stand for hours
in the rain and refuse shelter, but would not or could
not give any reason for so doing, etc.
He complains of headache, constant and severe, the
greatest pain being over the site of the traumatism ;
has persistent nausea with vomiting and constipation.
Examination : Head found to be symmetrical on both
sides. Tenderness exists over left parietal bone about
two thirds distance from external auditory meatus to me-
dian suture. Pupils are equal, responding slowly to
light. Puke, 75; temperature, 97.50 F. Urine, sp. gr.
1. 01 6, acid, amber color, no albumin, no casts, no
sugar.
There is no tubercular, rheumatic, nor syphilitic his-
tory. Had drank heavily a few weeks before the in-
jury.
September 21st. — To this date the patient had been
on the medical side under care of Dr. J. E. Langstaff,
who transferred him to the surgical side, and he came
under my care. Vomiting very frequent. Bowels ob-
stinately constipated. Headache persistent, and at times
delirium.
Ordered,
B . Potassii iod
'• brom....
M. S : T.i d.
$. Chloral hydrat ...
Spir. chloroformi .
M. S : T.i.d.
gr. lij.
v.
Pul. glycyrrh. comp., 3j.f repeated every four hours
until a free action of bowels is secured. Hydrobromate
hyoscin., gr. Tfo- p.r.n.
2 2d. — Bowels moved freely. Condition improved.
23d, a.m. — Has retained both medicine and nourish-
ment for twenty-four hours; p.m., had a severe attack
of vomiting.
24th. — Three movements during the night. Retains
nourishment and medicines. Slept seven hours. The
first sleep of more than a few minutes since admission to
the hospital.
October 7th. — Patient steadily improved till to-day.
He was allowed to leave his bed and go about for an
September 15, 1894]
MEDICAL RECORD.
345
hour. Nausea, frequent vomiting, and headache; re-
turned.
8th. — Consultation by Drs. Burge, Rand, Rochester,
LangstafT, Fairbairn, and Hopkins. The consultation
decided "symptoms due to shock," Dr. Hopkins dis-
senting, considering " symptoms due to clot." I consid-
ered operative interference imperative. Not being sus-
tained, concluded to wait as symptoms were abating.
nth — Symptoms all aggravated again.
1 2th. — Headache constant and severe. Determined
to trephine over the seat of pain.
Operation at 3.30 p.m. I operated in the presence of
the staff, assisted by Drs. Wallace, Simmons, and Hotch-
kiss. Anaesthetic, ether. A curved incision was made
through the scalp over the left parietal region, the skin
and subcutaneous tissues were dissected backward, the
periosteum was elevated, a seven-eighth inch trephine
was applied over arm centre, and a button of bone re-
* moved. The dura mater was slightly lacerated by the
trephine. Dura incised and turned back, and a clot one
fourth of an inch in diameter found partly organized and
removed. There was a pretty free hemorrhage, but it was
easily controlled by pressure. Pad of iodoform gauze in-
serted in the wound after douching with Thiersch's solu-
tion. Dressing, iodoform gauze ; returned to bed. But-
ton of bone not returned, having become soiled.
13th. — Comfortable night, temperature, ioo° F.
Has lost power of right arm.
14th. — No motion in arm or leg on right side, some
difficulty in speech. Headache entirely gone, nourish-
ment retained.
15 th. — Wound dressed, found perfectly aseptic. When
dressing was removed power returned to both leg and
arm.
19th. — Leg motion good, but that of arm impaired.
Speech thick. Headache only occasionally, and very
slight No vomiting since the operation. Sleeps all
night, and hallucinations and delirium have disappeared.
His general condition is greatly improved.
December 17 th. — Patient discharged from hospital.
Right leg has recovered perfect power, speech is good.
Full power in right arm has not returned, though he can
use it for all ordinary purposes, and it is steadily improv-
ing. Headache gone, eats and sleeps naturally.
June 22, 1894. — He has now been at sea for some
months and is perfectly well, but lacks strength in the
three smaller fingers of the right hand.
This case bears strongly upon a theory I have long
held, that there are many simple or weak-minded and
epileptic people in the world who have received a trau-
matism, and who, had they been promptly relieved by
surgical procedures, would have been saved from a living
death.
TREPHINING FOR DEPRESSED FRACTURE
TWO INCHES IN DIAMETER.
By GEORGE G. HOPKINS, A.M., M.D.,
B^OOKL 'N, K. Y.
Leonora B , aged five. Admitted to St. John's Hos-
pital May 4, 1894, apparently in a dying condition. She
had been kicked by a horse over the right temporal and
parietal region, causing a fracture which was two inches
in diameter and depressed at its centre full half an inch.
I proceeded to operate under chloroform, assisted by
Drs. Rand, Fairbairn, Simmons, Search, and Panton.
'All aseptic precautions were observed, an oval incision
was made extending beyond the line of fracture on all
sides, which was two full inches in diameter. The treph-
ine was applied at the junction of the two smallest frag-
ments and a Ji inch button of bone was removed, the
greater portion being taken from the sound bone. The
smallest piece was removed with forceps, as it had pene-
trated the cerebral substance, which was oozing, and to
have raised it would have lacerated the cerebrum still
more. Before the bones could be elevated to their nor-
mal position it was necessary to remove from the larger
fragment its outer edge for an inch in length by a quar-
ter of an inch in width.
The difficulty of replacement did not end here, as a
third fragment was removed before satisfactory repo-
sition could be accomplished. As a result of the opera-
tion, we had removed one piece of bone half an inch
square, and portions of bone around two- thirds of
the circumference of the fracture. A silkworm gut
drain was introduced between the overlying tissues
and the calvarium. The edges of the muscles and skin
were partly sutured. A piece of sterilized gauze was in-
troduced at right angles to the silkworm gut, and the
flap closed over it. Douches were of Thiersch's solution.
The wound was left undisturbed until the ninth, when
it was found perfectly aseptic, no pus having formed.
Gut and gauze were then removed. On the eleventh
the wound was again dressed, and is still perfectly aseptic.
On the thirtieth the wound was entirely healed.
The temperature never rose above normal. The
child was allowed to go home. Its mind is perfectly
clear and has been throughout.
" No injury to the head is so slight that it may not
cause death, and none so severe that a patient may not
recover from it.*'
PERMANGANATE OF POTASSIUM IN OPIUM*
POISONING.
By C. H. CALLENDER, M.D.,
M1W BOSTON, MASS.
H. C. W , seven years of age, child of well to do
parents. Has never been a very healthy boy, and on the
night of June 16th suffered from a slight bronchial
trouble which kept him awake the greater part of the
time. At 7.30 a.m. of June 17th the nurse gave him, as
she supposed, two drachms of arom. syr. rhei. He had
then eaten a good breakfast, played around a few min-
utes, complained of being sleepy, and gone to bed.
His mother, who was at this time confined to her bed
in the same room, knowing that he had not rested the
previous night, thought it nothing strange that he should
be sleeping and paid little or no attention to him. At
10.50 a m., some three hours after taking the dose, I was
hurriedly called (my office being less than seventy five
yards from the patient's home). I found the child in
his night dress lying in his nurse's lap ; face pallid,
shrunken, agonized ; pulse almost imperceptible ; respi-
ration very slow but not stertorous ; skin covered with
cold sweat. Asked what he had taken, and was assured
that there had been nothing but some cough-syrup dur-
ing the night, and the rhubarb.
Knowing the child as well as I did, and having seen
him while visiting his mother the evening before, being
sure that independent of the cough he was in better
health than he had enjoyed for a long while, I felt so
certain that he had obtained poison in some manner and
of some sort that, without asking any more questions or
making any more careful examination, I hurried to the
office for stomach-pump, medicine case, etc. I was
probably not gone two minutes* but before I was again
in the house the mystery had been explained, and the
bottle labelled rhubarb had been found to contain lauda-
num.
The pupils were very much contracted. Considering
the length of time since the dose had been taken I
thought the pump would be of little avail, and gave a
hypodermic of whiskey, ordered some hot water in bot-
tles, and then the thought of permanganate of potassium
came to me I was not certain that I had any of the
drug, but fortunately found about fifteen grains, and dis-
solved this amount in three ounces of water. It was
probably not more than five minutes after the nurse, on
going to the boy's cot, found something was wrong, be-
fore I had given him the first injection of permanganate.
I used the ordinary hypodermic syringe holding xxx.
minims, and injected deep every time.
At 10.56 a.m. I gave the first injection in the left arm.
346
MEDICAL RECORD.
[September 15, 1894
The pulse, which was very unsteady, was 46; respira-
tions, 8 to the minute. Twenty- five minutes later a
second injection was given in the same arm, and ten min-
utes after this the pulse was 54 and more steady ; respi-
ration 12.
At 11.30 a.m. a third injection was made in outer part
of the thigh. While introducing the needle I thought
he attempted to move the leg a little. Five minutes
later I put my finger on the eyeball and the lid closed
quickly. I noticed the pupils had dilated considerably.
Ten minutes later I called the child by name loudly, as
I had done a number of times before. He opened his
eyes and made a slight attempt to start up, as a person
would when suddenly aroused from sleep.
The fourth and last injection was given at a quarter to
twelve o'clock, and he fought against it pretty strongly.
Pulse now 68; respiration 16 to 18.
Although he still seemed drowsy, he easily recognized
the people in the room, and would call them by name
when requested to do so. With a person on each side
we now walked him about the room for a while. At
noon I felt safe in leaving him, and returning in one
hour's time found pulse, respiration, and eyes practically
normal. I saw him again in the evening, and with the
exception of some little pain at the points of injection I
could not see but that he acted and felt as well as ever,
and he has continued in good health to date.
The case is very much like one I witnessed while a
student, some eight years ago, that proved fatal. The
child, who was but eight years of age, took but little over
a drachm of laudanum, was in the hands of a good phy-
sician in two hours' time. The coma was not so pro-
nounced as in my case ; but in spite of external warmth,
friction, heart stimulants, whiskey, and atropia, he never
awoke. Therefore, taking both cases in view, I feel just
as sure as a person can be of anything in this world that
the child owes his life to the permanganate of potash.
It was not over one-half hour before the patient began
to show signs of improvement, and it was simply won-
derful how quickly he recovered after he once began to
do so.
A PAINLESS LABOR.
Dr. Robert N. Flagg, of Yonkers, N. Y., writes:
" Having attended a painless case of labor in a primipara,
I am inclined to ask the question, How often do we see
a normal delivery ? The rarity of the experience in my
practice, as well as in that of other practitioners with
whom I have conversed, leads me to give a brief ac-
count of its progress.
" An American woman, born of Scotch parents, aged
twenty- one, married eighteen months, ushered in her
first confinement by the rupture of the membranes some
three weeks before the expected time. This happened in
the early afternoon, and at nine o'clock I was sent for, as
it was still a question whether the labor was in progress.
I found the patient seated up in bed, not as yet having
had a pain, but a pressure at intervals of about fifteen
minutes. On examination I was surprised to find the os
welltfilated, thinned out, and every evidence of the com-
pletion of the first stage. I returned in an hour, finding
the head descending in the O. L. A. position, and very
steady pressure about every five minutes. The patient
still disclaimed having any pain, and as the pelvis was
small and the descent rather slow, I put on the forceps
and brought the head down upon the perineum. Before
I had time to remove the instruments, the head was
delivered, followed by the shoulders and body of a nine-
pound boy. The advent of this good- sized baby was
greeted by the cheery voice of the mother exclaiming,
' I have not had a single pain.'
" I had watched her through the second stage with great
interest, and can say that with the exception of some de-
cided straining and a redness of the face, there was no
sign of the labor whatever. The placenta came away
easily, and the lying-in period was uneventful. There
was no lack of normal sensation about the pubic region,
and her husband assured me afterward that she was not
devoid of sexual feelings.
" Using the term in a polite as well as pharmacal sense,
I consider this defecation of a baby as a missing link, lost
in the progress of the race and the over-development of
nerve- tissue.
" Here was something perfectly natural, but so like
the animals that one of my good patients considered it
decidedly unscriptural."
A CONGENITAL DEFORMITY.
Dr. James B. Thornton, of Boston, Mass., writes:
" From time to time the question of ' maternal impres-
sions ' is brought up by reports of interesting and pecul-
iar cases. To vary the monotony of the expression sup-
pose we use that of paternal impression and briefly detail
a case to support the term.
11 At 4.30 a.m., August 1 8th, the writer was summoned
to attend Mrs. H. L. E , in her first confinement
Birth was uneventful. On the following day attention
was called to a growth on the outer side of the left little
finger, near the junction of the middle and terminal phal-
anges. This growth was a veritable polypus (with a fine
pedicle about half an inch in length^ and about the size
of a large pea, but flattened rather than round. Exami-
nation showed it to be of a heloid consistency, and sec-
tion of pedicle caused but a small drop of blood to ap-
pear.
" The paternal interest in the matter was made apparent
by the father showing me a sessile growth in identically
the same location on his own hand, and which he stated
was congenital, and had been a source of much anxiety to
his parents, who feared it was of a malignant nature. In
his case the tumor had never been operated upon, and
had slowly grown smaller from his birth. If I can be-
lieve what was told me, the father and mother both made
an early examination of the baby in question soon after
its arrival, to find their fears confirmed."
MEMBRANOUS ENTERITIS.
Dr. J. M. Ward, of Cornelia, Mo., writes: "At a
recent meeting of die New York County Medical Asso-
ciation Dr. Coyle mentioned a case of membranous enter-
itis where the treatment was correction of diet, rectal in-
jections as a means of cleanliness, and keeping the bowels
regular. He does not say that he cured the case by that
treatment, and I venture to say that he did not. Early
this summer I had a similar case, that I cured by the in-
ternal administration of tar, and the daily injection of
tar-water. I received the treatment from Mr. David
Wark, of New York. Here is what he says :
" ' Treatment : Make of North Carolina tar a mass
with wheat flour and a few drops of water. Cut into
three-grain pills or put in capsules. Give four pills two
hours after meals. On retiring use an enema of three
ounces of tar- water and. retain. In a week or less the
bowels begin to move freely and normally, and all the
local and systemic symptoms begin to disappear. It
takes from two to three weeks to effect a cure. A grain
or two of the extract of wahoo as an intestinal tonic,
three times a day, completes the cure.' "
A Dog Receives Hospital Care. — The citizens of Bay-
reuth are mildly indignant because the favorite St. Ber-
nard dog belonging to the Wagner family was treated in
the city hospital. Dr. Landgraf, the family physician, and
also surgeon to the hospital, received the animal and oper-
ated upon him in the regular operating-room of the hos-
pital. The worthy burghers have petitioned the City
Council to pass a resolution condemning Dr. Landgrat
for his action.
The Universities of Holland, four in number, have
2,972 students, of whom 19 are women.
September 15, 1894]
MEDICAL RECORD*
347
jftocietg Reports.
THE NEW YORK PATHOLOGICAL SOCIETY.
Stated Meeting, May 2j, 1894.
George C. Freeborn, M.D., President, in the Chair.
Rupture of the Urinary Bladder. — Dr. Eugene Hoden-
pyl presented specimens from a case of extensive rupture
of the urinary bladder. They had been removed from a
woman sixty years of age, who had stated that six days
before her admission to the hospital she had noticed an
inability to move the legs or to urinate. She had re-
ceived little or no treatment up to the time of her ad-
mission. She was then found to be somewhat apathetic ;
the abdomen was distended ; there was complete paraly-
sis of the lower extremities, and a small quantity of
urine was escaping by drops from the bladder. The
next morning she was noticed to be gradually failing in
strength, and a few hours later she died. At the autopsy
the abdominal cavity was found distended with fluid
which was slightly tinged with blood ; there was no evi-
dence of peritonitis. At the fundus of the bladder was
a linear rupture, almost two inches in length. The
bladder was very large, and the mucous membrane was
intensely congested. The other abdominal organs and
the thoracic organs were normal. The dorsal portion of
the spinal cord showed minute areas of softening, and
the diagnosis of disseminated myelitis was afterward con-
firmed by a microscopical examination.
It was quite remarkable that there had been so little
discomfort and such slight inflammatory action notwith-
standing the amount of urine in the abdominal cavity.
It was unfortunate that a bacteriological examination
had not been made to determine the presence or absence
of bacilli in this fluid. The microscopical examination
showed intense congestion of the bladder mucous mem-
brane, but no inflammation. The rupture must have
been due to over-distention.
Prostatic Abscess. — Dr. George P. Biggs presented
a number of specimens of prostatic abscess, and made
some remarks on this subject based upon a study of the
autopsy records of the New York Hospital for the past
twenty-five years. In these records he had found ten
cases of prostatic abscess, after excluding a few cases
which were apparently peri-urethral abscesses, and did
not definitely involve the prostate itself. Case of tuber-
cular prostatitis had also been excluded.
The first specimen presented was from a man twenty-
two years of age. He had given a history of gonorrhoea
lasting for three months before his present illness. He
had recovered from his attack entirely at the time of his
admission to the hospital. Five days previous to his
coming to the hospital, he was seized with retention of
urine, and was catheterized daily. On admission, the
temperature was 1020 F., and the pulse 112. Examina-
tion showed a stricture in the deep urethra. On the same
day he had a chill and a temperature of 1 05 °. There were
repeated chills after this, with a morning temperature
of 990 and a evening temperature of 1050. Four days
after admission, a swelling appeared in the perineal re-
gion associated with some local pain and tenderness. A
median incision was made, and considerable pus evacu-
ated from the neighborhood of the deep urethra. The
patient died two hours later. At the autopsy, the spleen
was found to be considerably enlarged and quite soft ;
there was an abscess five ctm. in diameter, and numerous
smaller abscesses in the left kidney. The right kidney
contained two small abscesses. The pelves and ureters
were much dilated and inflamed. The bladder wall was
thickened, and contained a small quantity of purulent
urine. The left lobe of the prostate was the seat of a
deep abscess, 1 ctm. in diameter, from which a probe
could be passed to a peri urethral abscess 3 ctm. in di-
ameter, located just in front of the prostate. The me-
dian perineal incision had passed from the perineal ab-
scess into the urethra. The entire urethral mucous
membrane was thickened and covered with a false mem-
brane. There were evidences of a large calibre strict-
ure in the bulbous portion of the urethra. There was a
perforation in the left side of the urethra just in front of
the urethral orifice, and this communicated with an ab- <
scess in the left lobe of the prostate.
The patient died nine days after the infection of the
genito-urinary tract, and the cause of infection was prob-
ably the catheterization which was necessary before his
admission to the hospital.
The second case was that of a man fifty-four years of
age, who gave the usual history of stricture. Before
his admission, sounds had been passed tor the relief of
this condition. Ten days before his admission to the
hospital, he noticed a swelling in the right perineal re-
gion, and this increased rapidly in size. On admission,
the temperature was 102. 6° F., and his pulse 40, and
the urine contained a large amount of albumin with
granular casts. An abscess was found on the right side
of the anus, and it was incised the next day and consid-
able fetid pus escaped. After this the temperature was not
so high. About nine days after the first symptoms, he
developed considerable irritability of the bladder, and
examination of the urethra showed a stricture at four
inches, which would only admit a filiform bougie. Two
weeks after the onset of the first symptoms, external
urethrotomy was performed, and the urethra was cut to
No. 2, French. After this the temperature ranged from
990 and 1020. The patient became at first stupid, and
then unconscious, and finally died of heart failure eight-
een days after the performance of the external urethrot-
omy. No chills were recorded. At the autopsy, the
Kidneys were found to be the seat of quite extensive
chronic diffuse nephritis, and contained also multiple
miliary abscesses. The pelves and ureters were dis-
tended with purulent urine, and the mucous membrane
was inflamed. The bladder was greatly hypertrophied,
and the mucous membrane was inflamed and coated with
pus* The prostate had been converted into a series of
communicating abscesses, which had a capacity of two
abscesses. A pin-hole opening connected the abscess
with the urethral canal. The pus had infiltrated the
connective tissue behind the prostate as far as the pelvic
peritoneum, but there was no pelvic peritonitis. There
was an incised wound in the perineum which commu-
nicated with the bulbous portion of the urethra, but had
not opened into the prostatic abscess.
The interesting features were (1) a prostatic abscess
developing a few days after the dilatation of the stricture
with sounds, and (2) the relatively low temperature, the
highest being 102. 6°. The cause of death was general
urinary infection.
The third case was that of a man fifty years of age.
He denied ever having venereal diseases. Four weeks
prior to his admission he developed rather suddenly a
headache and a temperature of about 1030 F. Two
weeks later, quite violent symptoms of cystitis appeared,
associated with retention of urine. Catheters were used
daily for two weeks previous to his coming to the hospi-
tal. On admission, his temperature was ioo° F. ; respi-
ration, 34; pulse, 32. There was a large fluctuating
mass felt in the anterior rectal wall. He was catheter-
ized, and fifty-two ounces of urine drawn off. The urine
was acid, and contained five per cent, of albumin with
considerable pus and blood. He had a chill on the fol-
lowing day, and a temperature of 103. 40 F. He de-
veloped delirium, and a high temperature persisted. The
abscess was opened by a high perineal incision and con-
siderable pus evacuated, but the symptoms were not
relieved. He died in a condition of coma a few days
later. The autopsy was made thirty hours after death.
The spleen was three times the normal size, and quite
soft. The kidneys showed moderate chronic diffuse
nephritis, and contained a few groups of miliary ab-
scesses in their cortices. The pelves and ureters were
inflamed and distended with purulent urine. The blad-
34«
MEDICAL RECORD.
[September 15, 1894
der contained about four ounces of purulent urine ; the
muscular wall was hypertrophied ; the mucous membrane
was softened, thickened, and of a greenish color and there
was a small mass of fibrous exudation at the base. The
prostate had been destroyed by suppurative inflamma-
tion, the pus being situated in indistinctly outlined
spaces, having ragged walls, and not communicating freely
with each other. The incision in the left side of the
perineum had drained most of the abscesses on the left
side of the prostate, but those on the right side were still
full of pus. A sharply defined circular opening, 2 mm.
in diameter, was located in the anterior rectal wall, and
this communicated with one of the abscesses in the right
lobe of the prostate. There was another opening,
2 mm. in diameter, and in the left side of the floor of
the urethra just at its beginning. This communicated
with an abscess 2 ctm. in diameter, located just behind
the trigone. This abscess did not seem to communicate
with any of the others. The urethra was congested
throughout, but was normal in calibre. The mucous
membrane in the bulbo membraneous portion was super-
ficially lacerated in a longitudinal direction, probably
from the rough use of the catheter. An immediate bac-
teriological examination of the pus evacuated at the time
of the operation was made, and absolutely nothing found
in the cultures except the staphylococcus pyogenes aureus.
However, in the fresh pus stained on a slide, there were
also some diplococci of uncertain character. Cultures
taken at the autopsy developed, in addition to the sta-
phylococcus pyogenes aureus, a bacillus which grew very
rapidly and which was regarded purely as a contamina-
tion.
The points of interest in this c&se were, the develop-
ment of the cystitis and the accompanying prostatic
abscess, apparently as a complication of some acute
febrile process. He had been catheterized for two weeks
previous to his coming to the hospital. The abscess
cavities in the pro3tate were of large size. The one on the
right side communicated with the rectum, while that on
the left side communicated with the urethra, although
neither of the perforations were sufficient to drain the
abscesses. The chills were frequent and the fever rela-
tively high. The patient died of general urinary infec-
tion including the kidneys. The cause of the suppuration
seemed to be the staphylococcus pyogenes aureus, although
the other germs found in the fresh pus which failed to
grow in the culture, might have had some bearing on it.
The fourth case was that of a Russian, twenty-two
years of age, who was brought to the hospital in an am-
bulance after internal urethrotomy had been done at a
physician's office. The hemorrhage had been so pro-
fuse that a large catheter had been tied in the urethra,
and the patient hurriedly sent to the hospital. The
urine was found to be loaded with pus and blood. On
the day following his admission his temperature was
1 04. 50. The next day he had a slight chill, and the
temperature remained high. An abscess had then de-
veloped in the supra-clavicular region on the left side.
He became delirious and died nineteen days after ad-
mission. The autopsy revealed an extensive broncho-
pneumonia and an acute pleuritis. The spleen was
three times the normal size and very soft. The kidneys
were much congested and swollen, but contained no ab-
scesses. The bladder contained a small amount of pus,
and was acutely inflamed. The left lobe of the prostate
was enlarged, and on incision was found to contain a
large collection of pus. The axillae and supraspinous
fossae contained abscesses holding about six ounces of
pus. The cause of death was a pyaemia, the kidneys
and ureters not being affected.
The fifth case was that of a man twenty-eight years
of age, from whom no previous history could be ob-
tained, owing to his being in a comatose condition at
the time of entering the hospital. At this time his tem-
perature was normal, but on the following day it was
1020 F., and it remained between 990 and 1020 F. for a
period of three weeks. He remained constantly coma-
tose, and catheters were used to evacuate the bladder.
At the autopsy the cause of death was found to be the
rupture of an aneurism of the vertebral artery. Both
kidneys were congested ; the left contained a number
of miliary abscesses ; the right contained no abscesses.
The bladder was intensely congested, and contained
purulent urine. The prostate contained an abscess in-
volving not only the prostate but the peri-urethral tis-
sues in front, and communicating with the prostatic
portion of the urethra and extensively invading the tis-
sues into the pelvis. In this case, infection was evi-
dently the result of catheterization during the comatose
stage. The point of interest was the infection of one
kidney only. The abscess communicated with the be-
ginning of the prostatic portion of the urethra. There
was no chill, and only a moderate elevation of tempera-
ture.
The sixth case was that of a man twenty years of age,
who had sustained a fracture of the spine as a result of
diving in shallow water. It was necessary to catheterize
him. After this had been done several weeks, he de-
veloped a chill, followed by a temperature of 104. 6° F.
He then became delirious. The urine was found to con-
tain blood and pus in large quantities. The temperature
remained between 1020 and 1050 F. for sue weeks. He
passed into a state of low delirium, and finally died as a
result of fracture of the spine and infection of the genito-
urinary tract. The autopsy showed the spleen to be
large and soft. The kidneys were the seat of chronic
diffuse nephritis, and contained many miliary abscesses.
The bladder was hypertrophied and filled with purulent
urine. There was a large abscess about the neck of the
bladder, surrounding the urethra and communicating
with the rectum by two small openings, two and a half
inches above the sphincter. There was no communica-
tion between the urethra and the abscess, or between the
bladder and the abscess. The fever was relatively high
— 102.60 to 1 04. 6° F. for six weeks. The cause of in-
fection was catheterization. The communication was
with the rectum, and not with the urethra.
The seventh case was a man thirty-seven years of age,
who gave a history of having first had gonorrhoea eigh-
teen years before, and six or seven attacks since that
time. He had noticed symptoms of stricture for twelve
years. A stricture in the anterior portion of the urethra
was cut to No. 31 French. On the following day there
was a chill, with a temperature of 104 6° F. The tem-
perature ranged high— 101.80 to 105. 20 F. for a period
of seven days. The autopsy showed the spleen to be
large and soft. The kidneys were the seat of multiple
miliary abscesses, and both pelves and ureters were di-
lated and distended. There was a laceration of the ure-
thra just at its communication with the bladder on the
left side. The left lobe of the prostate contained a large
abscess, which communicated with the urinary tract at
the site of the laceration above mentioned — *'.*., prac-
tically at the urethral orifice. The abrasion was appar-
ently made during life, probably from the passage of a
hard instrument. The left knee-joint contained this
pus.
The eighth case was that of a man sixty- four years of
age, who gave a history of chronic nephritis for four
years. He had been frequently catheterized, owing to
retention of urine. He died of uraemia, without sus-
picion that the genito urinary tract had been infected.
The autopsy showed advanced chronic diffuse nephritis,
but no abscesses in the kidney. The bladder was hyper-
trophied, and its mucous membrane thickened and ulcer-
ated. There were abscesses in both the lateral lobes of
the prostate, and also in front of the prostate. There
was in this case simply an involvement of the bladder
and of the prostate, the pelves, ureters, and kidneys not
being affected.
The ninth case was that of a man forty-two years of
age, who had had gonorrhoea twelve years before com-
ing under observation, and constant gleet since that
time. He had applied at dispensaries for retention, and
September 15 1894]
MEDICAL RECORD.
349
had been catheterized and treated with sounds without
avail. Examination showed a stricture located at the
bulbo-membranous junction, and a smaller one near the
meatus. The latter was cut. Following this there was
a chill and a temperature of 101.80 F. The temperature
fell to 99. 40 on the following day, but rose again to
102. 20 F. The urine was diminished in quantity. He
died eighteen days after admission. At the autopsy, the
spleen was found to be quite large ; the kidneys were the
seat of advanced pyelo- nephrosis, but there were no ab-
scesses in the kidneys. The ureters and pelves were di-
lated and inflamed ; the bladder wall was considerably
hypertrophied and its mucous membrane acutely in-
flamed. The bladder contained a small amount of puru-
lent urine. There was an incision in the floor of the
anterior portion of the urethra. The stricture at the
bulbo membranous junction had not been operated upon
in any way. . There were two openings, one on each
side of the urethra, just at the beginning of the prostatic
urethra, and they led into abscess cavities in the pros-
tate, having a capacity of* one ounce. In this case, the
pelves, ureters, and bladder were infected, but the con-
nective tissue proper escaped.
The speaker said that out of the ten cases of prostatic
abscess in which the records had been examined, six
gave venereal histories, three denied such a history, and
in one no record was made in regard to it. Catheters
were used and appeared to be connected with the infec-
tion in five cases. In one case there was a question as
to the use of the catheter, no record having been made
in regard to this point, yet no good explanation had
been offered of the source of infection. In three cases
the infection was directly due to the operation of inter-
nal urethrotomy. In one the symptoms followed dilata-
tion of an old stricture by sounds. Seven of the ab-
scesses were large, and three comparatively smaU. Five
of them communicated with the urethra only, and all of
these communicated with the urethra in the posterior
portion of the prostatic urethra. One communicated
with the rectum alone; one with both rectum and ure-
thra ; and three small ones did not communicate with
either urethra or rectum. In five cases there was cystitis
and double pyeio-nephritis ; in one, cystitis and pyelo-
nephritis of one kidney ; in one, cystitis and pyelo-
nephrosis; in one, pyaemia with pyelonephritis; in
one, pysemia without pyelonephritis; and in one case
there was no infection beyond the prostate. In three
of the cases the temperature ranged between 1040 and
1050 F. ; in five between 990 and 1020 F. ; in two there
was no record of temperature, but it was probably quite
• low.
In all but one of the cases there was a history of the
use of instruments in the urethra some time previous, or
the infection followed immediately upon the operation
of internal urethrotomy. There was evidently secondary
infection, and it was quite possible that the severity of
the symptoms might depend somewhat on the organisms
producing the infection. The possible causes of death
were pyaemia, septicaemia, peritonitis, or a simple genito-
urinary infection exclusive of other diseases. Septicae-
mia was likely to occur in cases where there were large
abscesses without secondary deposits of pus. Peritonitis
might occur from extension of the inflammation to the
connective tissue of the pelvis to the pelvic peritoneum.
The prognosis should be guarded, owing to the fre-
quency with which prostatic abscess was associated with
general infection of the urinary tract. In eight of these
cases the kidney was involved. It would seem that the
most frequent cause of death was infection of the upper
portion of the urinary tract.
Dr. Samuel Alexander said that much credit was
due to the reader of the paper for the way in which he
had grouped his facts. There were acute abscesses oc-
curring as a result of gonorrhoeal infection of the urethra,
and they were, perhaps, more common than the chronic.
They were due to secondary infection, either through
sounds or injections, and were marked clinically by the
sudden onset of the symptoms — a chill and a much
higher temperature than was usually present in the
chronic cases. The diagnosis was not difficult if a rectal
examination were made ; the symptoms could be quickly
relieved by operation. He thought that all the cases just
presented should be grouped as chronic abscesses, because
the condition which predisposed to the infection was
chronic. Most of the cases there seemed to be a pre-
vious pathological condition of the urinary tract. In
half of the cases there was a stricture of the urethra, and
the autopsy showed secondary changes in the bladder
and kidneys, thus predisposing to general infection of
the genito urinary tract. One stnking peculiarity oi
this series of cases was the large size of the abscesses.
In most of the cases he had seen clinically the abscesses
had not been nearly so extensive. We should distin-
guish between abscess of the prostate and periprostatic
abscess. Regarding the prognosis, he would say that it
depended more upon the pre-existing condition of the
urinary tract and the severity of the infectirg cause than
upon anything else. Death was most rapid and the ab-
scess formation most extensive in those cases in which
there was a serious lesion of the urethra, causing obstruc-
tion, congestion, and infection. Regarding the mode
of infection in the cases in which no catheter had been
used, the speaker said obstruction in the urethra, by caus-
ing urinary overflow and congestion, led to infection.
This condition occurred most frequently in patients over
forty five. The perineal operation was, of course, the
one above all others for the relief of prostatic abscess,
and the moment such an abscess was suspected an open-
ing should be made in the perineum. Where suppura-
tion extended upward into the prevesical space this
operation was necessary ; but in addition to this it was
essential, as shown in the cases under discussion, that
dissection should be made between the prostate and rec-
tum and all the pockets evacuated, and the abscess cav-
ity curetted and treated aseptic ally.
Dr. Thomas H. Manley said that in those cases in
which the spinal cord had been destroyed in the lumbar
region as the result of injury, there were various modes
of death, the most common being by infection of the
genito urinary tract. Owing to the long, tortuous ure-
thra of the male, this mode of death was much more
common in males than in females. While he thought
all must agree as to the good results of careful asepsis,
the fact still remained that some subjects were morbidly
sensitive to the passage of any instrument into the ure-
thra. In cases of over distention from paralysis of the
bladder he had found that, in spite of every precaution,
infection and death were liable to result.
Dr. George P. Biggs said that the cases reported in
the paper were old ones, and in most of them infection
had occurred from catheterization by the patient himself,
or by some incompetent person, previous to the admission
of the patient to the hospital. The importance of mak-
ing a free opening should not be overlooked, for one of
the cases showed that, notwithstanding the communica-
tion of the abscess and the perineal opening, drainage
was not at all adequate to the needs of the case.
Congenital Absence of One Kidney and Ureter. — Dr.
R. G. Freeman presented specimens from a case of the
above. They were taken from a child aged ten months,
who up to a few days before death had been perfectly
well. It then developed croup, was intubated, and died
from broncho* pneumonia and extension of the mem-
brane. The right kidney and right ureter were absent.
The left kidney was quite large, weighing three ounces.
Three such cases had been presented to the Society —
one by Dr. Northrup, in 1887 ; two by Dr. Thacher,
in 1892 ; and one by Dr. Hodenpyl, last year. The
condition was said to be quite rare, and the left one was
the one most commonly absent.
The Society then adjourned.
Many Suicides of boys, from twelve to sixteen years of
age, have recently been reported in London.
35°
MEDICAL RECORD.
[September 15, 1894
Uexrj Instruments,
AN IMPROVED CILIA FORCEPS.
By CHARLES H. MAY, M.D.,
CHIEF OP CLINIC, DEPARTMENT OF OPHTHALMOLOGY, VANDHRBILT CLINIC, COL-
LEGE Or PHYSICIANS AND SURGEONS, MBDICAL DEPARTMENT OP COLUMBIA
COLLEGE, NEW YORK.
Epilation of the lashes is a very simple process ; but
frequently it is rendered difficult and tedious on account
of the improper and clumsy shape of the cilia or epilat-
ing forceps in the market. In blepharitis and in trichi-
asis in which epilation is performed there is no diffi-
culty in pulling out the coarser lashes ; but the fine and
short hairs often give us much trouble, especially when
they become moistened and slippery from tears and dis-
charges of the lids ; then we are apt to find that the for-
ceps no longer catch.
To obviate this difficulty, I have had a forceps con-
structed which is a modification of one I purchased
tine of office practice. The cut gives a sufficiently clear
picture to render further description unnecessary.
In the cut the handle appears attached at a greater
angle than experience has shown to be desirable, the
drawing having been made from the first specimen of the
of Windier, in Berlin, and which is referred to as
"Brecht's" in his catalogue. In general shape it re-
sembles the cilia forceps now in use ; it differs merely
in the construction of the extremities or points. These
are claw-shaped, delicate, having a width of *y2 mm.
The edges are curved, one being convex, the other con-
cave ; they are so arranged, through a slight difference in
curvature, that pressure exerted in clasping the instru-
ment tightens the grasp upon the hair and holds it firmly,
without any danger of cutting it off. The instrument
has given great satisfaction and has done away with the
annoyances already mentioned. It is manufactured by
Meyrowitz.
69a Madison Avenue, New York.
AN IMPROVED CONICAL RECTUM SPECULUM.
By ROBERT W. MARTIN, M.D.,
PHILADELPHIA, PA.
An instrument of precision applicable in the treatment of
two out of every three patients who seek the office of the
physician for treatment of the more ordinary diseases of
the rectum is certainly a desideratum.
When I presented my new ano rectal speculum to the
profession through the Times and Register (October 5,
1889), five years ago, I thought I had an appliance as
nearly perfect as it was possible to make. And, indeed,
for very many of the applications and minor operations
within the rectum it was, and remains to me, indispensable.
But longer use made it manifest that something was
needed to supplement its usefulness. Consequently, a
year ago, taking the ordinary conical speculum and en-
larging its field of view, I had it made on the model of
a symmetrical cone, truncated at a small angle, so that
the obturator would fall into position without the trouble
and delay of adjusting it to some particular line or mark
on the base of the cone. The outer end of the obturator
was supplied with a milled head of large diameter to
facilitate its removal.
The base of the speculum was fitted with a firm handle
of extra length and large grip adjusted to what was con-
ceived to be the proper angle. Thus was made an ap-
pliance with which any portion of the lower half, or more,
of the rectum and intra- anal tissues might be brought into
view by successive small portions for the purpose either
of inspection or treatment.
I have never used an appliance that has given me such
supreme satisfaction in treating follicular ulceration, poly-
poid, and other small growths, which constitute a very
large proportion of the cases of anal and rectal diseases
the physician is called upon to treat in the ordinary rou-
speculum manufactured. It is now made with the handle
attached at a much smaller angle with the axis of the
speculum, making it as efficient in treating a patient with
protuberant buttocks and deep seated anus as one with
wide-apart tuber ischii and a more accessible anus.
I am indebted to Messrs. George Tiemann & Co. for
their precision in executing my designs for the correction
of what was faulty in the old and the addition of what is
new to form a perfect new out of a faulty old form of
speculum.
X17 South Sixtkenth Street, August 15, 1894.
A SNARE WIRE RECEIVER.
By GEORGE E. ABBOTT, M.D.,
NEW YCBK.
This can hardly be called a new instrument. Yet to
some it may be a new and useful adjunct to their snare.
The usual routine, now, is to find the spool of wire,
then the cutting forceps, guess at the length, cut, drop
the spool, say something, wind up, and with difficulty
fasten the springy wire, adjust the wire, and find it makes
too small a loop, or, worse yet, too large a one, for the
screw has been " run up " as far as possible ; but the polyp
has not yet been cut off and the snare is thus anchored in
the patient's nose, to be delivered only by main force —
of course not by pulling upon the whole snare, but by
a straight pull upon the rod, through the cannula thus
severing the growth.
The better way is to make a trial wire first, allow its
ends to bend up at least a quarter of an inch, so as to
hold well, "run up " the screw and be sure the entire
loop will be drawn within the cannula, so as to com-
pletely divide the tissue within its grasp, with a few turns
to spare for possible slipping or stretching of the wire.
With this as a sample, straighten the wire of the spool,
and cut fifteen or twenty lengths.
Now cut a glass rod (scratch with edge of file and
snap it in two) one inch longer than the wires, so as to
allow of corks at either end ; heat the ends red hot so as to
round off the sharp edges ; put in the bottom cork and
cut it flush with the end of the glass, now the wires and
the cork at the top. You will thus have saved time and
labor, and very much annoyance when the patient is
anxiously waiting for you to operate. A simple tube
can be made by rolling some writing paper several times
around a pencil or other cylinder.
125 West Eighty-second Street.
September 15, 1894]
MEDICAL RECORD.
35i
(&owesvon&f>ucz.
EXAMINATION FOR CANCER-CELLS IN THE
LIVING TISSUE.
To ths Editor op the Msdical Rkcokd.
Sm : While reading the article in the Medical Record
of August 25, 1894, on "The Cure of Carcinoma of the
Breast by Radical Operation,' ' by Dr. William T. Bull,
the idea occurred to me, Why not, in operating for the
cure of malignant disease, make a microscopic examina-
tion of the living tissues of the wound, to ascertain
whether all the cancer-cells have been removed. If the
examination should reveal diseased structure still there,
it could be removed before the wound is closed. If
practical and practicable it seems to me that this would
be a great advantage to the patient, giving her a better
chance for her recovery, and reducing the mortality
from carcinoma. It would also lessen the number of
secondary operations. Could not a microscope be so
constructed that with it the living tissues of the wound
might be examined in situ, after the growth had been
removed and before closing the wound ? If this could
be done I think it would be very useful, as cancer-cells
are frequently left just in the edge of the wound. Of
course this is but a crude idea, but I would like to know
what the readers of the Medical Record think of it and
its practicability.
Albert Seitz, M.D.
McMlNNVILLK, TENN.
SOME SURGICAL OBSERVATIONS OF DR. FR.
RAVOTH.
To the Editor of the Msdical Rkcord.
Sir : Some years ago Dr. Fr. Ravoth published a small
volume containing short papers on a variety of surgical
conditions. The book is dated 1873, an(^ issued by
Ferdinand Enke, Erlangen.
It is thought that the author's views on varicose veins,
varicocele, etc., might be of interest, inasmuch as such
procedures are not found in some of the more recent
text-books on surgery, and seem worthy of consideration.
In the paper on the " Treatment of Varicocele by
Means of a Truss," the author refers to other writers, to
the results of treatment of hernia with truss, etc., and
states that under pressure of a truss-pad the varicocele
lessens in size, the testis soon becomes larger, and more
consistent, while the pain in the testis and cord ceases.
The enlarged veins being due to the weight of the blood,
if by appropriate constriction the vein is relieved from
this strain the part below the point occluded will re-
cover itself. He believes that this mild method is more
efficacious than the many ways of operative interference,
which are not free from danger.
These ideas may be applied to other venous varices,
e.g., in the legs. (The treatment of aneurism, by press-
ure on the distal side of the tumor, may be referred to
in this connection.)
The other papers are also of interest to the scientific
anatomist, surgeon, and practitioner. In this relation
worthy of special notice is his description of the surgical
anatomy, with treatment of shoulder and elbow, and dis-
locations of them. He does not believe that there is, in
any sort of sickness or injury, an absolutely pathognomonic
sign. Strong disapprobation is expressed for the practice
of making a " snap diagnosis," on which follows the
hunting up of symptoms to support the a priori judg-
ment. On the contrary, the correct method consists in —
1, Investigation of the history and cause; 2, inspection;
3, palpation, or manual examination.1 Such truths will
bear oft repeating.
The faulty union of fractured patella is attributed less
to imperfect nutrition than to failure in keeping up co-
aptation, for which bandaging should be applied to the
whole limb, and not merely in the vicinity of the lesion.
» Loc. cit, pp. 2IO, 21 1.
The same ideas apply to fracture of the shaft, etc., of
other bones. Bandaging restrains slight displacement
of fragments by muscular or other mechanical action,
thus allowing the healings to approximate thsX prtma in-
tentione.
F. B. Stephenson, M.D., U.S.N.
TWO MORE CASES OF PREVENTIVE INOCU-
LATION OF IMMUNIZED SCARLET - FEVER
BLOOD SERUM.
To the Editor of thk Medical Record.
Sir : One of my sons, aged seven, being stricken with
scarlet fever, I have inoculated, on the second day, two
of my other children, who had not had this disease, aged
five and two years. The blood serum was taken from
their older brother, aged nine years, who had had scarlet
fever six years before. Two drops, taken from a blister
on his breast, were used for each child, and there was
one inoculation only for each. There was no real isola-
tion— separate bedrooms during the night, but free inter:
course during the day. Now, the ninetieth day, no in-
fection has been observed.
Albert S. Ashmead, M.D.
Naw York, August 31, 1894.
Contagious Diseases— Weekly Statement.— Report of
cases and deaths from contagious diseases reported to the
Sanitary Bureau, Health Department, for the week end-
ing September 8, 1894.
Tuberculosis
Typhoid fever ,
Scarlet fever
Cerebro-spinal meningitis.
Measles
Diphtheria
Small-pox
Cases.
:i
69
29
o
17
no
16
Deaths.
107
20
4
3
o
27
X
The Dangerous Anti- Vaccinationists. — One of the
most striking testimonies to the mischief that a knot of
active anti-vaccinationists can do is shown in the expe-
rience of Stuttgart, the capital of Wiirtemberg, between
the years 1864-1869. Stuttgart was the focal point
from which radiated anti-vaccination influence, and, in
consequence, not only many private citizens but the
militia of that city were " unprotected/' It had a pop-
ulation of 1,760,000 souls less than New York, yet in
the five years indicated there were no less than 11,092
cases and 800 deaths. During that time there were 34
cases in the army of the whole country, but not a death ;
and now that vaccination and revaccination are not
only compulsory, but done under a faithful inspection,
the German army is the bright, conspicuous example,
shining like a beacon, for all the world to follow. If
Germany could build an impassable fence between her-
self and Russia, the whole country would soon show it-
self completely freed from the pest ; but there is always
an immigration from Russia into Germany of persons
from that land, where the persistence of cholera shows
the inability to cope with epidemics. — Mrs. -H. M.
Plunkktt, in The Sanitarian, August, 1894.
Medicaments Derived from Coal-Tar.— As a conse-
quence of the progress made in the manufacture of col-
oring materials from coal-tar, physiologists and physicians
have been able to experiment with a host of new prod-
ucts, some of which have found a place as therapeutic
or antiseptic agents. The substances submitted to such
experiments are of very diverse nature, but there is ob-
served in them, nevertheless, a limited number of char-
acteristic groupings. They are phenols, acetylated
amines, and sulphonated, sulphuretted, iodated, and chlor-
352
MEDICAL RECORD.
[September 15, 1P94
ated derivatives of the aldehydes. Methodical experi-
ments have not been numerous enough, and the data fur-
nished by biological chemistry are not precise enough to
allow us to establish any relation between the constitution
of these bodies and their physiological p roperties, pro-
vided any exists. Their applications, in fact, exhibit
many anomalies. We see products that are very differ-
ent as to constitution act upon the organism in a similar
manner, and substances that are analogous, from a
chemical point of view, produce very different therapeu-
tical effects. With the information that we possess upon
this subject it is hazardous to draw absolute conclusions.
The number of organic bodies proposed as antiseptics or
as medicinal products is very large, and one or more new
medicaments are observed to make their appearance every
day. We can mention but a limited number here, in
selecting the most important of them. We have arranged
these substances as antithermics and analgesics, and hyp-
notics and antiseptics. There is nothing absolute about
this classification. A large number of these products has
at the same time several of these properties. For exam-
ple, chloral, which we place among the hypnotics, is an
analgesic, and is even employed as an antiseptic, and
asaprol is at the same time an antiseptic and an anal-
gesic.
1. Antithermics and Analgesics. — Of all the artificial
antithermics, antipyrine or analgesine is the most widely
used up to the present. It is derived from phenyl-
hydrazine, which is itself obtained by dinitrating aniline
and in reducing the dinitro benzol thus obtained. This
phenyl-hydrazine is afterward condensed with aceto acetic
acid, and then, finally, the product is submitted to a
methylation. We have at last the dimethyl-phenyl-
pyrazolon that constitutes antipyrine. It is very soluble
in water, and this property permits of administering it
under the most varied forms — a quality that is highly
appreciated in pharmacy. It must be observed, how-
ever, that, as a general thing, solubility has no relation
whatever with the quickness of action and assimilation of
a medicament. Phenacetine, while being but slightly
soluble in water, acts, nevertheless, as quickly as antipy-
rine. The success of antipyrine has evoked a series of
experiments with the object either of preparing substitute
antipyrines and of analogous pyrazolons, or of associating
it chemically with other substances. In the first order
of ideas has been produced tolypyrine, which is a para-
methylated antipyrine in the phenylic nucleus, and then
chlorated, bromated, etc., antipyrines. In the second
series antipyrine has been associated with salicylic acid,
and this has given salipyrine. Tolysal is the salicylic
combination corresponding to tolypyrine. Apropos of
hypnotics, we may mention hypnal, which is a derivative
of antipyrine and chloral. Thalline and kairine are
quinoleic products that have been proposed likewise as
antiseptics. Among the oldest analgesics and antither-
mics we find acetanilide and antifebrine, which are pre-
pared by treating aniline with anhydrous acetic acid.
If, instead of operating with aniline, we start from
hydroxylated aniline, that is to say, from a product
which is both phenol and amine, and etherify it before
acetylation, we shall have phenacetine or phenedine.
Thymatecine is the phenedine of thymol, and exalgine
is derived from the acetylation of methyl aniline. Sali-
cylate of soda has been for some time employed as an
antirheumatic. Salicylic acid is a carboxylated phenol,
that is to say, a body that is at once phenol and benzoic
acid. It is prepared by passing a current of carbonic
acid over phenate of soda at a high temperature. Sev-
eral applications have been found for its derivatives,
among which may be mentioned salipyrine, that we have
spoken of above, and salol, which we shall find among
the antiseptics. Asaprol has the same action as salicylate
of soda. It is obtained by treating beta-naphthol with
sulphuric acid at a low temperature. It is the sulphuric
ether of beta-naphthol. It is offered in the state of cal-
cium salt very soluble in water. Under the name of
abrastol it has been used as a microbicide.
2. Hypnotics and Various Medicaments. — One of the
most frequently employed hypnotics is chloral, which is
the hydrate of trichlorated acetaldehyde. An endeavor
has been made to associate it with various organic sub-
stances. In this way have been prepared : Chloralose,
which is a combination of chloral and glucose ; hypnal,
which is due to the union of one molecule of antipyrine
and one of chloral ; and somnal, which is obtained from
chloral and urethane. Sulphonal is likewise a very
efficacious hypnotic, but its constitution has no relation
with that of chloral. Chemically, it is called the dietby 1-
sulphone of dimethyl methane. It is formed by the
combination of acetone with ethyl- mercaptan. Trional
and tetronal form part of the same series. For skin dis-
eases there have been proposed dermatol, which is the
subgallate of bismuth; sulphaminol, obtained by the
action of sulphur upon meta-oxidi phenyl- amine; resor-
cinol, which is a combination of iodoform and resorcine ;
and lysophane, which is chemically called triiodo meta-
cresol. Tumenol, thioline, and sulphonated thiophene
are designed for the same use. Piperazine, a nitrated
product of the closed-chain series, is diethylene-diamine.
One of the processes of preparing it consists in causing
ammonia to act upon bromide of ethylene. Orexine
serves to stimulate the appetite. It is a hydrochlorate of
phenyl-dihydro- quinazoline.
j. Antiseptics. — Among the organic antiseptics, we
find, especially, bodies with phenolic and aldehydic
functions, and halogenated derivatives. Phenol, beta-
naphthol and guaiacol are characterized by the phenolic
grouping OH directly connected with the benzolic or
naphthalic nucleus. The use of a large number of phe-
nolic derivatives has been recommended. Thus, salol is
salicylate of phenol, and betol is the salicylate of beta-
naphthol. The union of benzoic acid with naphthol gives
benzo-naphthol. Abrastol, of which we have above
spoken under the name of asaprol, is the salt of calcium
of the sulphuric ether of beta-naphthol. It is a microbi-
cide at present proposed for the preservation of wine.
Among the phenolic products of less importance we
may mention alumnol, sozol, daphtherine, phenoline,
cresine, and microcidine. Iodoform is triiodated me-
thane, analogous to chloroform as regards constitution.
This antiseptic has, as well known, an insupportable
odor. An endeavor has, therefore, been made to substi-
tute odorless and likewise iodated substances for it.
Among the bodies proposed to this effect we may men-
tion diiodoacetylene or diiodoform. In order to prepare
this alkaline hypoiodites are made to act upon an aque-
ous solution of acetylene, or water upon a mixture of
iodine and carbide of barium, or else by treating acety-
lene with iodine in the presence of an excess of potassa
at a low temperature. There likewise exists a tetraiodo-
acetylene. The other iodated derivatives are : Traumatol
(iodo cresylol), aristol (iodo-thymal), iodol (tetraiodo-
pyrol), and sozoiodol (diiodo-paraphenate of sodium).
Formol, which has recently been proposed as an antiseptic,
is form-aldehyde. It has the great advantage of being
volatile, and, consequently, of penetrating to the very
interior of the objects to be disinfected. Ichthyol, any-
tine, thiol, and thiolinic acid are sulphonated and sul-
phuretted derivatives of organic and mineral oils employed
in this state and that serve as solvents for products insol-
uble or but slightly soluble.
Among the substances mentioned, a small number
only will doubtless receive the sanction of practice, but
the road is laid out. On the one hand, syntheses are
multiplying with the object of finding new series, and,
on the other, the natural alkaloids are the object of nu-
merous studies. With the means now at the disposal of
chemistry, it is possible to study the active principles of
digitalis, belladonna, and a host of other natural products.
We shall certainly succeed in giving such alkaloids a
greater energy, perhaps new properties, and even replace
them by substances of which the syntheses will be only
the results of a study of the products, of their reduction
and of their decomposition.— Scientific American.
Medical Record
A Weekly ^Journal of Medicine and Surgery
Vol. 46, No. 12.
Whole No. 1246.
New York, September 22, 1894.
$5.00 Per Annum.
Single Copies, xoc.
Original Articles.
THE TREATMENT OF ABORTION.1
Bv BROOKS H. WELLS, M.D.,
ADJUNCT PROFESSOR OP GYNECOLOGY, NEW YORK POLYCLINIC; FELLOW OP THE
NEW YORK ACADEMY OF MEDICINE, THE NEW YORK OBSTETRICAL SOCIETY,
ETC.
I am prompted to write upon a somewhat worn subject
by the fact that during the past year I have met with an
unusually large number of cases of incomplete abortion
which have been allowed to run on until they have de-
veloped more or less grave septic conditions, or have
become seriously anaemic from the continued bleeding.
These cases, which I might use as illustrative, were
none of them from my clinic at the Polyclinic, where we
see them only too frequently, and where poverty, igno-
rance, and often previous treatment by equally ignorant
midwives lead us to expect conditions otherwise inex-
cusable, but were all of them from the upper and middle
classes, and were referred to me by intelligent physicians.
So it seems, in spite of all that has been said and written
in favor of active, efficient, and early interference,
many practitioners prefer to take the chances of time
and ergot in the hope, sometimes, it must be admitted,
realized, that all will finally come right. Others, recog-
nizing the necessity of action, but with an imperfect
technique, partially succeed in clearing out the uterus by
the aid of the ringer or curette, and in the attempt carry
infection into the uterine cavity.
It is true that cases of incomplete or neglected abor
tion do not usually die, either from the continued hem-
orrhage or from sepsis ; they struggle through a period of
acute anaemia, or fever and prostration, and finally may
recover perfectly, but more often are left with a chronic
infection affecting the endometrium or extending also to
the tubes and peri uterine structures, a condition which,
in the light of modern pathology, we cannot consider
inconsequential, knowing that it so frequently leads to
the most serious pelvic trouble. The truth of this state-
ment may be easily proved by reference to one's private
case- book, or by the records of any large gynecological
clinic. Thus, out of five thousand consecutive gyneco-
logical cases which have come under my observation at
the New York Polyclinic fourteen hundred and ninety-
two, nearly thirty per cent. (29.8), had aborted one or
more times, and of these five hundred and thirty-five,
nearly thirty-six percent. (35 .8), suffered from disease
of the uterus or appendages directly traceable to infection
following abortion. It is safe to say that the immediate,
thorough, and aseptic removal of the ovum, or its frag-
ments, in these cases would have prevented the greater
part of this disease and its attendant disability.
Before discussing our subject further it is necessary to
understand what we mean by abortion, and to sketch
briefly its causes, diagnosis, and course.
Abortion is defined by nearly all lexicographers as
" expulsion of the foetus before the seventh month, or be-
fore viability ; " but to insure clearness it is advisable to
limit the word to its stricter sense, of " expulsion of the
ovum before the end of the third month," and to employ
the term " miscarriage " for expulsion between that
period and the time when the foetus becomes viable.
Abortion or miscarriage may be from pathological
1 Read before the New York Academy of Medicine, April 26, 1894.
causes affecting the fetal or maternal organism, or may
be induced.
Maternal causes may be systemic — from poisons cir-
culating in or conditions impairing the mother's blood, or
disturbing the circulation mechanically, as syphilis, ma-
laria, the exanthemata or other fevers of severe type ; chol-
era, poisoning by CO, CO,, and other gases ; salts of
certain metals (lead, copper, etc.), and vegetable alka-
loids; albuminuria, cholaemia, iithiasis, anaemia; and
visceral (liver, lung, and heart) disease affecting vascular
tension.
Maternal causes may be local — from retro-displace-.
ment of the uterus, pelvic adhesions, endometritis, pel-
vic or uterine tumors. They may be reflex — from gastric,
rectal, or mammary irritation, mental shock, or excessive
emotion, exhaustion of nerve-force, as in chorea or in
epilepsy.
Fetal causes may be primary or the result of maternal
dyscrasia, and include disease of the fetal envelopes, as
fatty, hydatidiform, or fibrinous degeneration, or in flam-
mation or hemorrhage of the chorion or placenta,
death of the embryo, or any malformation affecting the
circulation of the foetus and causing hydramnion or oli-
gohydramnion.
Finally, abortion may result from combinations of any
of these causes. Induced abortion may be accidental,
legitimate, or criminal. Accidental causes may be uter-
ine traumatism from blows, falls, wounds, excessive or
violent coitus, etc., and we might again include here ex-
cessive emotion and mental shock. Criminal abortion
may be from general violence, mechanical injury to the
uterus or ovum, or from the administration of certain
drugs.
The symptoms vary with the time at which the abor-
tion occurs. If within the first six weeks the woman
may complain only of a moderate amount of lumbar pain,
dull and heavy or cramp like, or there may be no pain
and an amount of hemorrhage, which she may consider as
simply an excessive menstruation. Very often she does not
recognize the passage of any shreds of tissue, or clots,
and the abortion passes unnoticed. At other times por-
tions of chorion remain behind, and she comes to the
physician complaining of the prolonged spotting or flow.
Later, and up to the time when the placenta is fully de
veloped, the lumbar pains are more marked, the cramps
more severe and rhythmical, and the hemorrhage much
greater in amount. If the abortion be the result of nat-
ural causes and the death of the ovum has occurred sev-
eral days before its expulsion, it usually comes away
entire. If the ovum is alive, or if the abortion be in-
duced by mechanical means, the foetus usually escapes,
leaving the whole or a part of the chorion behind.
Bimanual examination shows the uterus enlarged, soft,
except during a contraction, the cervix softened and
more or less dilated, and often with a portion of the ovum
plugging the os. After the expulsion of the entire
ovum the pains and bleeding cease and the uterus con-
tracts. If a portion of chorion or placental tissue be re-
tained, the bleeding, pain, and dilatation may continue
until it is expelled, or the cervix may contract, the pains
become slight or cease, the bleeding stop, and the mass
be retained either to disintegrate and come away in the
discharge, to become septic, or, exceptionally, to develop
into a fleshy mole. Rarely there may be death and in-
fection of the ovum without producing either pain, hem-
orrhage, dilatation, or foul discharge, the only symptoms
354
MEDICAL RECORD.
[September 22, 1894
being cessation of uterine growth, followed by irregular
slight chills and septic fever.
After the third month the symptoms approach more
nearly to those of a premature labor. We have the rhyth-
mic pains, the hemorrhage, which i3 apt to be more pro-
fuse, the dilatation of the os, and, more often, the spon-
taneous evacuation of the entire contents of the uterus.
Abortion may be considered inevitable when the result
of a cause that cannot be removed, when the pains are
severe or rhythmical, the hemorrhage profuse, the os widely
dilated, or when any portion of the ovum has been ex-
pelled.
Threatened abortion may sometimes be averted when
the cause is a remediable one, and the pains, bleeding,
and dilatation are only moderate. When abortion be-
comes inevitable one of two things happens, either the
uterus empties itself entirely, or a portion of the ovum is
retained. In the first case the uterus contracts, the pain
and hemorrhage cease, there is a pinkish flow for a few
days, involution proceeds normally, and the condition
remains practically the same as before conception. If,
however, portions of placenta or chorion remain in the
uterus the clinical picture is changed. The symptoms
noted diminish at first, but do not entirely disappear ; the
pain may cease for a time and then reappear, and the frag-
mjnts be expelled, or the os may contract and the frag-
ment be retained until it gradually breaks down and passes
iway with the discharges. In this latter case the bleed-
ing continues, as a persistent leakage, often for from three
to six weeks, and may reduce the patient to an extreme
degree of anaemia, though it in itself rarely kills. Very
often, and almost certainly, if this incomplete abortion
be the result of criminal interference with the ovum, the
retained tissues become infected and we have aseptic pro-
cess begun which may induce serious and persistent pelvic
disease or directly destroy life. Sepsis is the condition
most to be dreaded, the condition to be most carefully
watched for, the condition to be most vigorously fought
against. We must always be on the watch for its first
symptom, and when we recognize it, whether it be as an
elevation of temperature, a chill, or a fetid discharge, we
must remember its probable source and explore the cavity
of the uterus. Septic material may be there even though
the cervix be perfectly contracted and hard, though there
b* no hemorrhage, no discharge, and possibly no other
local symptom. I have seen several instances to which
this description would apply, one of which ended in death.
But the sepsis is not usually of a virulent type, the case
runs on, the woman recovers from the immediate danger,
but the fever, the hemorrhage, the infection, have inter-
fered with involution ; the uterus remains large, heavy,
and soft, and is apt to become retro displaced ; the in-
fected mucosa, thickened, soft, and friable, becomes the
seat of a chronic endometritis which may at any time lead
to tubal and ovarian trouble, and the woman suffers in-
definitely from the metrorrhagias, the pelvic pains, and
the systemic depreciation which accompany these condi-
tions.
Treatment.— A local examination is always impera-
tively necessary when any of the signs of impending abor-
tion appear. Then, if the symptoms are not marked, if
the pains are slight and irregular, the bleeding moderate,
the os not much dilated, and the cause one that can be
remedied, as, for instance, retroversion, we may hope
by absolute rest in the recumbent position, by the ad
ministration of full doses of opium, and viburnum by
suppository, or morphia hypodermically, and by the re-
position of the displaced uterus, to carry the patient
through her period of danger and allow the gestation to
continue. If the cramps are regular and well marked,
the hemorrhage considerable, and, particularly, if the os
be dilated, these hopes will not be realized, the loss of
the ovum becomes inevitable, and it is our duty to hasten
its expulsion. As the method of procedure now varies
according to the period of gestation, we may draw a line
of division at the end of the third month and consider
the case as either " abortion " or " miscarriage."
Abortion. — As the uterus before the end of the third
month is still comparatively small and will not allow the
accumulation of any considerable amount of blood in its
cavity, the use of the tampon is sometimes permissible
before the expulsion of the foetus, not so much to check
bleeding as to excite more vigorous expulsive contrac-
tions. When expelled, the patient is to be put in the
dorsal position on a Kelly pad, the vagina and cervix
thoroughly cleansed by a douche of hot soap-suds rubbed
into all folds and crevices by the fingers, and followed
by irrigation with 1 to 4,000 warm bichloride solution.
Then a strip of sterile iodoform gauze is carefully
packed into the cervix and the vagina tamponed. This
packing is removed in from eight to twelve hours, and
afterward the ovum will be found loose in the vagina or
in the dilated os. If at this time no portion of the ovum
be expelled, that is, if its envelopes be still intact, the
packing may be carefully repeated. If any portion of
the ovum has been expelled, the remainder should be
removed at once, either with the finger, which can sel-
dom be used at this early period, with the ovum forceps,
or with the dull curette.
If there be reason to believe that the abortion has re-
sulted from criminal interference, if the case has been
allowed to run on for many days, if there b» endometritis
or any form of sepsis, the os should be dilated, prefer-
ably after the administration of an anaesthetic, the frag-
ments of the ovum removed, and the whole interior of
the uterus scraped carefully and thoroughly with the
sharp curette, washed clean with a strong watery solu-
tion of iodine and packed with a strip of sterile iodoform
gauze. This gauze should be removed in twenty-four
hours and the vagina irrigated. If septic symptoms con
tinue, the uterine cavity may be again irrigated with the
iodine solution, and a fresh strip of gauze carried to the
fundus.
The effective and safe manipulation of the curette and
gauze in this manner presupposes on the part of the oper-
ator a certain amount of skill and familiarity with its use.
Miscarriage. — After the third month the use of the
tampon for haemostatic or other purposes is reprehensible,
as the uterus is then larger and dilatable, so that a dan-
gerously large amount of blood may accumulate in its
cavity. If the hemorrhage from a miscarriage is moder-
ate, the treatment may be expectant for a limited time
until the entire ovum or the foetus be expelled. If the
foetus alone be discharged, the remaining portions of the
ovum should be immediately removed with the ringer,
aided, if necessary, by the ovum forceps or large curette.
If the hemorrhage be profuse there should be no delay,
the os should be dilated and the uterus cleared out at
once. Where there is sepsis the indication is for the use
of the sharp curette, irrigation, and packing, as already
described.
When we have legitimate reason for inducing abortion
it is best done by immediate clearing out of the uterus
after anaesthesia and rapid dilatation, the uterus being
washed clean and a strip of gauze introduced for drain-
age. When miscarriage becomes necessary the prelimi-
nary dilatation is usually best secured by the employ-
ment of an aseptic tupelo tent of the largest size that
can be inserted into the os, then, if the ovum be not
spontaneously and completely expelled it is removed
digitally or with instrumental aid.
To avoid danger and secure success in these manoeu-
vres it is necessary that they be done aseptically and by
one accustomed to surgical cleanliness. The hands and
arms of the operator should be scrubbed for five minutes
with a stiff brush with soap and hot water, and then
soaked for the same time in a 1 to 1,000 bichloride solu-
tion. The instruments can either be wrapped in a towel
and boiled at the time in a weak solution of soda for fif-
teen minutes, or may be carried already sterilized, and
laid on a sterilized towel ready for use. A strip or strips
of sterile iodoform gauze should also be prepared and
wrapped in a sterile cloth.
Tupelo tents may be sealed separately in small enve-
September 22, 1894]
MEDICAL RECORD.
355
lopes and baked for half an hour, and are then ready for
use when wanted. The Kelly-pad requires most careful
attention, and must be thoroughly washed in running
water, rinsed in the bichloride solution, and carefully
wiped dry each time after use. The fountain syringe
used for irrigation may be scrubbed in hot water and
soaked in bichloride, or boiled if used where there is a
suspicion of sepsis. The patient, after having had her
bladder and bowels emptied, is to be placed in the dorsal
position on a table ; or the hips may be brought to the
edge of the bed, a firm bearing surface for the Kelly-
pad being secured by a table-leaf, ironing-, or lap-board ;
and the external genitals and vagina thoroughly cleansed
with hot soap-suds, two fingers being used to rub over the
mucosa of vagina and cervix. This should be followed
by irrigation and rubbing with a 1 to 4,000 bichloride so-
lution. The parts adjacent to the vulva and the exposed
portion of the pad are then covered with wet sterilized
towels and the operation performed.
In conclusion, I may state my position briefly as follows :
Recognizing that any interference with the uterine
cavity must be looked upon as a possible source of infec-
tion, and must be made aseptically and with antiseptic
precautions to be free from danger, I strongly urge that
in every case where abortion or miscarriage begins
acutely and from natural causes, the ovum be removed by
the finger, ovum forceps, or curette, within twenty-four
hours after the abortion be Considered inevitable, if the
entire ovum be not then already expelled, complete ex-
pulsion being indicated usually by cessation of pain and
hemorrhage. In cases where a portion has been expelled,
where we find serious hemorrhage, where the ovum is
dead, where we have reason to suspect criminal inter-
ference, where there has been continual spotting, foul
discharge, or fever, the uterus should be explored and
emptied at once, as any delay greatly increases the risk
of sepsis. The sharp irrigating curette, followed by gauze
drainage, should always be used where there is septic
material present, or where the endometrium is diseased,
in other conditions the finger or a dull instrument is suf-
ficient.
71 Wbst Forty>fipfh Stkebt.
▲ Reminiscence of the Late Professor Hyrtl. — A cor-
respondent of The Lancet says that the famous anatomist
who has just died at Vienna was always considered an
eccentric man because his dress, his manners, and his
mode of life differed in some respects from those of other
people. It was particularly his time- worn garments that
made him conspicuous, and he used in his walks the same
soiled blouse which he wore while engaged in his labo-
ratory or in gardening — his favorite hobby. This charac-
teristic of Hyrtl gave frequent occasion for ludicrous inci-
dents, at which he himself used to laugh most. A few
years back, when he was still in possession of his eyesight,
he was accustomed to walk to Liesing, a charming Vien-
nese suburb, where, in the beer-garden of the brewery, he
refreshed himself with a glass of its well-known beverage.
One afternoon he entered the garden and seated himself
near a table at which a few merry Viennese burghers were
engaged in diminishing the contents of a dish of stewed
fowl. These gentlemen had no idea of the identity of
the newly arrived guest, and after eying his simple twill
suit came to the conclusion that he must be an inmate of
the Liesing asylum for the poor. A good portion of the
meal having been left uneaten, one of the guests called
the waiter and told him to take what was left to the poor
man sitting near them. The famous savant, appreciating
the joke, ate a few morsels and, after expressing his
thanks, left the garden. A few moments later two waiters
carried in a big bowl from which the heads of champagne
bottles were protruding. " We have ordered no cham-
pagne ! " cried the burghers, and their astonishment may
easily be guessed on their being informed that " the inmate
of the local asylum for the poor " had sent them the cham-
pagne as a mark of his gratitude for the stewed fowl, and
that the donor was no less a personage than Professor Hyrtl.
SOME RECENT MEASURES IN THE TREAT-
MENT OF EPILEPSY, WITH SPECIAL REFER-
ENCE TO THE USE OF OPIUM.
A Year's Experience with Flechsig's Plan.1
By JOSEPH COLLINS, M.D.,
VISITING PHYSICIAN TO THB HOSPITAL FOR NBRVOUS DISEASES ; ATTENDING
PHYSICIAN IO ST. MAlK'fi HOSPITAL; INSTRUCTOR IN NERVuUS AND MENTAL
DISEASES IN THB NBW YORK POST-GRADUATE MEDICAL SCHOOL.
The treatment of epilepsy to day is about as unsatisfactory
as it was ten years ago. That is, a decade that has wit-
nessed a considerable addition to our knowledge of the
causation and pathogenesis of this disease has seen no
striking addition made to its therapy.
It is not presumptuous to say that notwithstanding the
persistency with which other measures have been ad-
vocated and the extravagant results claimed for them,
that to day bromide of potash would not be exchanged
for all the other means combined. I do not mean to de-
cry the value of other measures, nor in any way to depre-
cate their claims in the treatment of this disease, but
merely to state what I believe to be a fact.
That there is no dearth of activity in searching for a
more curative agent than the bromides in this disease one
can satisfy himself by glancing at the literature of the
subject from year to year. Although many agents are rec-
ommended but few are chosen, after a more or less
thorough trial. Among the measures recommended within
the past few years those deserving of consideration have
been more particularly, 1, borax; 2,simulo; 3,antipyrin
andantifebrin; 4,nitro-glycerine; 5,antirabicvirus,under
which may be included for purpose of convenience the
" organic extracts ; " 6, the various combinations of the
bromides.
Among those recommended, but having very little claim
for their consideration, are 1, hypnotism ; 2, hydrastinine ;
3, salicylates ; 4, duboisine, picrotoxin, cannabis Indica,
belladonna, etc. ; 5, amylene hydrate; 6, osmic acid and
sclerotinic acid.
Since Gowera recommended the use of borax in epilepsy
twenty-five years ago, it has been used more or less in
obstinate cases that resisted the bromide treatment, and
in cases where for some reason the bromides could not be
administered. It has taken a definite place in the thera-
peutics of this disease, as is attested by tnany of the moat
trustworthy clinicians.2
Its efficiency compares in no way with the bromides ;
but as an alternate and adjuvant of the bromides it is,
when given in proper doses (about 3 ij. per diem), a use-
ful and valuable addition to our therapeutic resources in
this disease. Its efficaciousness is frequently seen in con-
trolling night attacks while the continuous administration
of the bromides prevent the day attacks. The drawbacks
to its use are the frequency with which it causes distress-
ing attacks of eczema, psoriasis, impairment of the diges-
tion and nutrition, and even toxic effects. Enthusiastic
reports of its efficacy and curativeness now and then crop
up/ but they are generally accompanied by such mea-
greness of detail or absence of a judicial weighing of
evidence, that they are to be taken with circumspec-
tion.
The place held by simulo in the treatment of epilepsy
does not compare favorably with borax. Since its intro-
duction by Dr. W. Hale White in 1888 it has apparently
never been extensively used. Although White's report
of its use in seven cases was encouraging, Eulenberg, who
tried it in both hysteria and epilepsy, was not favorably
inclined to it. Given in doses of from a half to two
drachms of the tincture three times daily, it will, in
1 Read before the New York Academy of Medicine. April 5, 1894.
• Folsom : Boston Medical and Surgical Journal, 1886 ; Mai ret : Le
Progres Medicale, February 6, 189a ; Stewart : Alienist and Neu-
rologist, January, 1891 ; Fere and Lamy : Nouvelle Iconographie de
la Salp&riere, November and December, 1889 ; Russell and Taylor :
Lancet, May 17 1890.
8 Dijoud : Lancet, July 18, 1891.
356
MEDICAL RECORD.
[September 22, 1894
some cases, especially of haut mal, give gratifying re-
sults, as it has done in one patient at present under
the writer's observation. It in no way compares with
the bromides.
Antipyrin and antifebrin have been used more exten-
sively in epilepsy than have most new remedies, and in
many caies with gratifying results. Lemoine 1 was struck
by the value of the first of these in a case which always
occurred at the menstrual period, in one associated with
migrain and in another of the type of epilepsia larvata or
psychical epilepsy. McCall Anderson and Jack report
a case of traumatic epilepsy cured J in three months by
the administration of antipyrin in doses beginning with
five grains three times a day and increased one grain a
day. The cure was effected when the patient reached a
dose of twenty-five grains. It is unnecessary to comment
on this case, except to repeat that a case diagnosed,
treated, and recorded as cured all within six months
should not be taken too seriously.
SalmV experience with antipyrin was not so satisfac-
tory. In fact he thought the results of its use were quite
negative. When given in conjunction with the bromide
of ammonium, as has been recommended by Wood, it
has given very gratifying results and is attested by Potts,4
May,* and Dana.0
A combination of antipyrin with the other bromide
salts is probably as serviceable as the combination with
bromide of ammonium. Arcade' reported cessation of
attacks for four months in moderate epileptics under this
treatment. The general consensus of opinion in refer-
ence to antipyrin and antifebrin is that the former is
preferable, and when given in from five to ten-grain doses
three to four times daily it materially enhances the value
of the bromides in the treatment of idiopathic epilepsy,
particularly in the less aggravated clinical forms.
Nitro-glycerine has been used to a considerable degree
in idiopathic epilepsy. It has been specially recom-
mended in cases that are attended with vasomotor aura.
One of the most recent writers who calls attention to its
use is Osier.0 It is most serviceable in cases of petit mal
and must be given in large doses, two to five drops of a
one per cent, solution, and in such doses it is apt to pro-
duce intensely disagreeable symptoms. Its value as a
therapeutic agent in epilepsy is slight.
Attention was first called to the beneficial effects fol-
lowing anti-rabic inoculation of epileptics by the cessa-
tion of attacks in two children who had been inoculated
for rabies by Pasteur.' Other cases showing the benefi-
cial results of this form of treatment have been reported
by Charcot,10 Giovanni,11 and Ariostigni.12
It is distressing, however, to have to repeat that these
cases were reported too early to be of very much service
in determining the value of anti-rabic virus as a form of
treatment.
It should be remarked here that some of the cases (Char-
cot's) were shown to gatherings of medical men merely to
demonstrate the effect the inoculations had in checking
the attacks temporarily. It is sufficient comment on this
way of breaking epilepsy to say that the results of its use,
limited though it has been, nor any theory on which its
efficacy might possibly be based, have not appealed to the
medical profession. A more recent treatment of epilepsy,
and one which has, to my mind, absolutely no raison
d'etre, has been introduced by Babes, of Bucharest, and
Gibier, of New York. It consists of the hypodermatic in-
jection of the extract of the cerebrum of the sheep,
freshly prepared. Although the two investigators quoted
above have made serious claims for its efficacy, it is prob-
1 Gaz. Med. de Paris. No. 52, 1887.
9 American Journal of the Medical Sciences, May, 1891.
9 Neurologisches Centrbl., No. 11, 1887.
4 University Medical Magazine, October, 1890.
• Detroit Medical Age, July 25, 1891.
• Text-book of Nervous Diseases, 1893.
7 Wien. Med. Presse, Nos. 13-15, 1889.
8 Journal of Nervous and Mental Diseases, 1888, p. 38.
e Wien. Med. Presse, No. 24, 1892.
10 Lancet, May 28, 1892.
11 British Medical Journal, September 4. 1892.
,a Revista de ciencias medicas, July 5, 1892.
ably no exaggeration to say that this agent is as nearly
useless in the treatment of epilepsy as any substance which
a physician essays to employ with a considerable eclat can
possibly be.
Not even the remotest rational explanation can be ad-
vanced for its use. The substance cerebrin has no
physiological action which would suggest it to be an
anti epileptic agent. At the present day no one will
gainsay the statement that the " organic " extracts de-
pend for any activity that they may possess on their
chemical constitution. And when introduced into the
system they act and can only act just as analogous chemi-
cal substances obtained from other sources do.
No analogy between the use of the thyroid in myxe-
dema or the use of the thymus in pseudohypertrophic
paralysis can be advanced to explain the use of cerebrine
in epilepsy. The brain is not a secretory organ, as are
the thyroid and thymus, and its constituents are easily
separable by the chemist. These chemical constituents,
or as many of them as are not inert, are responsible for
any change that the patient has in his symptoms while
being subject to treatment by these extracts.
The report of cases of epilepsy treated by this method
by Babes is so glowing and enthusiastic, and the state-
ment of his results are so indefinite that one need make
no comment.
Gibier has published two articles in which he details
the results that he has obtained. A careful examination
of his report will show that the results barely warrant
him in his conclusion, a very modest one, " That the
method is beneficial in adding to the favorable effects
derivable from other therapeutic agents."
Everyone who has much to do with the handling of
epileptics knows how susceptible they are to new, and
especially novel, methods of treatment and how frequently
the attacks are for quite long periods amenable to such
procedures. The personal factor in the handling of the
cases reported by Gibier will probably account to a con-
siderable degree for the amelioration of symptoms that
they present. Further it may be said that there is
scarcely a remedy that has been advocated for epilepsy
that has not, in the hands of its advocate, given far better
results than has brain injections. I do not wish, how-
ever, to criticise it harshly, but merely to express an opin-
ion as to its entire worthlessness and uselessness.
The various combinations of bromine, such as bromide
of camphor, of nickel, of lithium, of strontium, of arsenic,
ethyl bromate, rubidium-ammonium bromide, etc., have
had their advocates and are in many cases of great ser-
vice, not only as adjuvants to other plans of treatment
but as exchange materials for the bromide of potash and
soda when the system does not well tolerate the continued
tenancy of the latter.
Fer6 has recommended the bromide of strontium, but
others, with the exception of Deny,1 who have utilized
this suggestion, have not been able to corroborate his good
opinion of the drug. Halsted, however, reports with
some favor his use of this salt. The bromide of zinc and
the bromide of nickel have both been extensively used.
The latter, originally recommended by Dr. Costa, was
found to be quite useless by Bourneville,* who gave it a
very extensive trial. Bromide of zinc has been given by
Hammond, Charcot, Bourneville and other clinicians,
but there is so much uncertainty about this salt, both in re-
gard to its dose and its action, that it would be better not
to consider its use at all. For instance, it has been recom-
mended by the writers mentioned above in doses varying
from 5 to 30 grains, while a recent number of the Phar-
maceutical Gazette stated its dose to be from one half to
one grain. Ethyl bromate has been recommended by Do-
nath * in doses from 30 to 40 drops three times daily and
increased to twice this amount if the stomach will stand
it. He recommends its administration with oil of pep-
permint or in capsules.
1 Semaine Medicale. August 10, 1892.
2 Progrbs Medicale, No. 26, 1889.
• Therapeutische Monatschrift, June, 1F91.
September 22, 1894]
MEDICAL RECORD.
357
Corroborative evidence of Donath's estimate of the
value of ethylene bromate is given by Olah,1 who finds
that the attacks are milder and less frequent, and that it
does not produce bromism. The objections to its use
are its extreme volatility and unstableness.
The less important measures against epilepsy that have
been enumerated above may be disposed of very rapidly.
If our conception of the pathology of epilepsy is correct,
or anything approaching correctness, it is an insult to our
intelligence to speak of the curative effects of hypnotism
in this disease.
The use of hydrastinine, as recommended by Arkhan-
gelsky,3 has not been successful in the hands of other
physicians.
Whatever virtue the salicylates may have in the treat-
ment of epilepsy should be attributed to their action as
intestinal antifermentatives. A fact that is too well
known to need emphasis is, that frequently attacks of
epilepsy may be diminished nearly fifty per cent, in fre-
quency by treating the alimentary canal exclusively.
Duboisine, picrotoxin, cannabis indica, and bella-
donna should in no sense be considered of sufficient im-
portance to attempt to combat epilepsy by any one of
them alone. They are frequently of use as adjuvants to
the bromides, particularly in combating some untoward
symptom produced by the latter. Amylene hydrate,
which was first recommended by Wildermuth,' has been
found by Dunn * to be entirely useless, and even danger-
ous, in the treatment of epilepsy. This conclusion is
substantiated by Umphenbach 5 and Drews,0 who found
that this drug greatly increased the mental confusion
in epileptics and caused considerable disturbance of
sleep. It should be dropped entirely from the therapeu-
tics of epilepsy.
Osmic acid has likewise been shown to be of absolutely
no use in the treatment of epilepsy. Sclerotinic acid
has been tried by Bourneville and Bricon in twelve cases
of epilepsy, and in some of these the frequency of the at-
tacks was lessened.7 It was noticed that some of the
patients to whom the sclerotinic acid was administered
decreased rapidly in weight. This fact alone would mili-
tate against its use in the treatment of this disease.
Of the non-medicinal ways of treating epilepsy, the
eye treatment has received the most attention. All neu-
rologists are keenly aware of the fact that epilepsy may
be, and frequently is, excited reflexly and that not in-
frequently the source of this pathologic reflex is some er-
ror of refraction, or defect in the eye muscles, and that
the correction of this faulty condition will be followed by
the relief of the trouble which it caused. They are like-
wise aware of the fact that although attacks of epilepsy
may have been excited originally by defective conditions
of the eye, that not infrequently treatment of the eyes
alone will not cure the disease, and this for two reasons
in particular. First, the eye defect may have been
merely the exciting cause in a patient predisposed to epi-
lepsy. That is to say such a patient might have the epi-
leptogenous areas of his brain brought into activity by
many other factors, for instance, by fright, fatigue, over-
eating, over-heating, etc., and the relief of such exciting
factors would not cure the disease, no more does the
relief of the eye defect. In the second place, if a patient
has had a number of epileptic attacks, that is, if the mo-
tor cells of the epileptogenous areas have been subject to
a repetition of explosions, each succeeding one lessens
the chances of recovery, and particularly do they lessen
the chances of spontaneous recovery on the removal of
the cause which excited the first attack. The cessation
of attacks goes hand in hand with the improvement of
nutrition of the cortical motorial cells, and all our efforts
should be in that direction. Not alone the eye but all
1 Wiener Medical Presse, 1891, No. 21.
2 Wratsch, No. ao, 1892.
1 NeuroL Central., 1889, p. 451.
4 Journal of Mental Science, October, 1891.
'" Munch, med. Wochenschr., No. 4, 1891.
■ Therapeutische Monatshefte, No. io, 1890.
7 Arch, de Neurol., xii., xiv., and xv., xvi., 1888.
sources of peripheral irritation should be carefully and in-
telligently examined and re- examined. Especially should
the highly specialized sense organs be examined and any
departure from the norm should be labored with till it is
overcome. After it has been corrected the physician
will find that all his therapeutic resources are still neces-
sary to combating the disease which unfortunately still
continues to exist. It is then that the plan of treatment
seeking the bettered nutrition of the epileptogenous areas
should be employed to its full extent.
The eye plan of treatment of epileptics, even when
looked at with a most charitable critical eye, does not
deserve the laudations of most of its advocates. It can
never be more than a factor in the treatment of the dis-
ease. If we should decide to treat epilepsy on the eye
plan perhaps it would be best to have a symposium of
medical men, each one of whom would combat the fac-
tor which he considered the important one. Then,
«when all are finished, the patient will recover in the
hands of the physician who gives him iron, and arsenic
and the iodides and other measures that will stimulate
hsematogenesis and tissue repair.
When one considers the unsatisfactoriness of the treat-
ment of epilepsy and the futility of so many of the meas-
ures which are periodically lauded as having great and
peculiar virtues, it is not surprising that most ph>sicians
are animated by a wholesome spirit of scepticism in ap-
proaching the trial or consideration of any newly recom-
mended substance. A considerable number are advo-
cated every year, but appeals for their recognition fall on
deafened ears, and the freezing reception exteffded to
them cuts them off at their very inception, and thus
saves much useless work on the part of the physician and
much harmful experience on the part of the patient.
Occasionally, however, a plan of treatment is suggested
that appeals to us in no uncertain way. One based on a
laudable hypothesis, or one that involves no shrivelling
of our intellect to understand how it may act, or one
that has been tried by an observer who from his labors
and reputation deserves to be heard, and who recom-
mends it because he has seen it do good, and offers it to
his fellow-workers without explanation. It is to such a
plan of treatment that I wish to invite your attention.
About a year ago, Professor Flechsig, of Leipsic, pub-
lished a short article on a new method of treating epi-
lepsy which in his hands had given most gratifying
results. It consists in administering opium in the shape
of the extract or pill in large doses for a period of six
weeks. The dose of opium in the beginning is from one-
half to one grain, and this is gradually increased until
the patient is taking fifteen grains or more per day, in
doses of from three to four grains. The maximum dose
is reached by the end of the first week. At the end of
six weeks the opium is suddenly stopped, and for it bro-
mide of potassium or sodium in doses of one-half drachm
four times daily is substituted. After these large doses of
bromide have been kept up for some time the dose is
gradually decreased until the patient is taking less than
two scruples per day. The sudden cessation of admin-
istering the opium and the exhibition of the bromide is
quite essential.
Being cognizant of the fact that opium in small doses
when combined with bromides is frequently of great ser-
vice in lessening the severity of attacks of epilepsy the
plan of treatment suggested by Flechsig appealed to me
and I determined to give it a thorough trial in a large
number of cases selected from private, hospital, and dis-
pensary practice, and examine the results of such treat-
ment at the end of one year. About fifty patients
have been subjected to this plan of treatment. A few
cases I shall detail, and content myself with presenting
the results observed in the others in tabular form.
The twenty cases considered in the first table I had
under almost daily observation, and the conclusions
reached regarding this plan of treatment is based largely
on the facts therein set forth. The sixteen cases con-
sidered in the second table I did not have under such
358
MEDICAL RECORD.
[September 22, 1894
Table I.
No.
Name.
Age. Sex.
14 Fe.
Duration of
Epilepsy.
Frequency oi Fits
under Bromide
Treatment.
Character of Attack.
Cessation of Fits
after Opium.
3 months.
Frequency of Fits
after Relapse.
Once in 3 months.
1 a month.
Remarks.
1 ' F. M.
1 3 years.
Once a week.
Haut and petit mal.
Dispensary patient.
2 1 H. N.
22 ' M.
1 6 "
1 to 2 4|
Haut mal.
5 "
Private patient
3 M. S.
9 Fe.
6 "
1 to 3 ••
Haut and petit mal.
5
No relapse.
Dispensary patient.
4
M. P.
21 M.
1 1 year.
2 to 3 "
Haut mal.
8 "
4l <(
«• "
5
H. B.
16 1 Fe.
6 years.
6
Haut and petit mal.
2 weeks.
Every 4th day.
Private patient.
6
A. F.
22 ' M.
i 8 ••
7
Haut mal.
6 »
1 a month.
Hospital patient
7
e. s!
16 ! M.
1 9 "
9
Haut and petit mal.
4 "
1 a week.
«• i<
8
23 , M.
20 "
6
<• II M (1
7 "
2 a month.
•• **
9
C. F.
27 i M.
, 9 "
2 "
Haut mal.
1 8 "
Every 3 weeks.
..
10
A. S.
26 M.
; 25 "
2 u
1.
1 week.
1 a month.
<•
11
L. M.
21 1 Fe.
7 "
1 "
*• it
5 weeks.
2 a month.
..
12
E. R.
20 j Fe.
l 4 "
3
Haut and petit mal.
1 2 "
Once in 2 weeks.
"
13
t*
27 M.
10
1 ••
Haut mal.
!4 "
3 "
Dispensary patient
14
IS ' Fe.
1 3 *4
3
..
1 7 <.
2 «•
i< **
IS
B. D.
24 Fe.
1 "
1 "
U (1
5 months.
u 4 «.
Private patient.
16
M S.
28 Fe.
11 "
2
• » ••
I 5 weeks.
1 a week.
Hospital patient
17
D. M
21 Fe.
5 "
4
Haut and petit mal.
7 "
3 a month.
..
18
E. H.
27 | M.
i 7 *l
2 "
Haut mal.
! 6 "
3
Private patient.
• Hospital patient
19
M. Mc.
19 Fe.
1 5 "
4
Haut and pelit mal.
3 "
1 a week.
20
J.L.
17 , M.
6 ••
|3
Haut mal.
| 1 month.
2 "
Dispensary patient
Table II.
The following 16 cases have been under observation for four months only.
1
No. , Name.
Age.
Sex.
Duration of
Epilepsy.
Frequency of Fits
under Bromide
Treatment.
Character of Attack.
Cessation of Fits
after Opium.
Frequency of Fits
after Relapse.
Remarks.
I ! D. S.
Us
M.
13 years.
2 daily.
Haut mal.
1 week.
4 a week.
Hospital patient.
2 1 J. K.
3 W. D.
1 26
40
27
M.
M.
M.
1 12 "
20 "
8 ■•
4 a week.
3 l4
1 ■'
Haut and petit mal.
Haut mal.
No improvement.
2 weeks.
•1 <<
4 1 1. L.
5 G. Y.
1 in 2 weeks.
M
38
M,
11 "
5 "
Haut and petit mal.
11 days.
2 a week.
6 1 T. M.
■ <H
M.
i a6 ..
7 4'
«i <<
6 days.
3
** *'
7 S. H.
39
M.
1 I4 "
3 "
11 <i
2 weeks.
3
l<
8 | W. M.
SO
M.
1 18 "
10 «•
Petit mal.
17 days.
2
.1 .1
9 .
. O.
22
M.
, IO ,4
2 *'
Haut and petit mal.
10 "
1 »
" "
IO '
. K.
26
M.
i 7 "
2 "
• 1 u
3 weeks.
3 a month.
**
II i '
. W.
61
M.
22 "
3 "
• 1 (•
13 days.
No improvement.
1 a week.
*• »•
12 ' B. G.
38
M,
1 IS ..
5 "
Haut maL
• • «.
13 1 W. H.
, 46
M,
1 6 »
2 4i
5 days.
2 a week.
"
14 D. M.
45
M.
| 11 «<
3 *4
11 11
15 "
1 M
15 | H. C.
1 55
M.
20 "
6 «•
Haut and petit mal.
9 "
2 •'
ii .1
16 J. D.
5i
M.
1 17 "
.
ii 11
3 weeks.
2 "
close surveillance. They were very old subjects and
my principal desire in subjecting them to the treatment
was to determine whether the results would militate
against, or corroborate the results obtained in the first
twenty cases. In a general way it may be said that the
results were not so satisfactory.
A study of Table I. shows that all the cases with one
exception (Case 5) were benefited. It further shows
that in two cases (Cases 3 and 4) the fits have not re-
turned. The time elapsed in these cases is, however,
not of sufficient length to refer to them in any way as
cured. And I wish to emphasize the point that, although
the attacks have ceased, I do not consider them
cured, and they are still taking four scruples of potassium
bromide a day. In several of the cases the character of
the attack after the relapse was frequently of a different
nature than that before the attack. That is the family
of the patient or the hospital nurse, as the case might be,
would describe them as "mere fainting spells " and
make light of them. I have observed, however, as time
went on that these " spells " gradually become more
severe as the number of attacks increase after the relapse.
Another fact which I would point out is, that in every
case, almost without exception, the maximum dose of
opium was reached and persevered in with comparatively
slight trouble. Some of the patients who were cogni-
zant of what they were taking complained rather
bitterly and rebelled, but particular attention to the
bowels and a good deal of out-door exercise served to
keep them moderately comfortable. Sometimes it was
necessary to administer strong coffee to combat the drow-
siness, particularly during the first week when the opium
was being increased rapidly.
While the patients were taking opium there was no
marked change in the frequency of the fits. Some of the
patients had a lesser number, particularly toward the
latter end of the six week's period, while others had them
with customary frequency.
Notwithstanding the fact that no sinister results ac-
companied the administration of opium in such large
doses, I feel it incumbent on me to say to any one who
would apply this plan of treatment, that the most watch-
ful and scrutinizing care is necessary, especially during
the first weeks, until the patient becomes accustomed to
the large doses.
The most satisfactory results were obtained in very
chronic epileptics, and particularly those who were not
responsive to large quantities of bromide. In epilepsy
dependent on, or associated with, gross organic lesion of
the brain the treatment seemed to give better results than
in pure idiopathic epilepsy. By gross organic lesion I
mean epilepsy associated with old cerebral hemorrhage
and softening and epilepsy associated with defective de-
velopment.
I can but state my convictions relative to this plan of
treatment in the following conclusions :
1. The plan suggested by Flechsig is not a specific in
the treatment of epilepsy.
2. In almost every case in which this plan of treat-
ment has been tried there has been a cessation of the fits
for a greater or lesser time.
3. A relapse generally occurs in a period varying from
a few weeks to a few months.
4. The frequency of fits after the exhibition of opium
is, for the first year at least, lessened more than one half.
5. The attacks occurring after the relapse are much less
severe in character than those that the patient has been
accustomed to having.
6. This plan of treatment is particularly valuable in
ancient and intractable cases.
September 22, 1894]
MEDICAL RECORD.
359
7. In recent cases of idiopathic epilepsy it cannot be
recommended.
8. The opium plan of treatment is an important ad-
juvant to the bromide plan as ordinarily applied.
9. The opium acts symptomatically, and merely pre-
pares the way for and enhances the activity of the brom-
ides and other therapeutic measures.
10. This plan of treatment permits the use ot any
other substances which are known to have a beneficial
action in epilepsy.
I will cite briefly the history of a few unselected cases
taken from hospital, dispensary, and private case-books,
showing the effect of the treatment I may say that all
of these patients were handled with bromides for a
longer or shorter time previous to being put on the
Flechsig plan.
Case I. Dispensary. — F. M , female, colored,
aged fourteen. Family history tubercular ; personal his-
tory good. Never had convulsions when a child ; was
always bright, vivacious, and smart ; talked early and
walked early. First attack when eleven years of age ;
cause unknown; character of attack, haut mal. Fre-
quency of attacks about three a month and getting more
frequent. Character of aura, headache for some hours.
Physical condition, good ; mental condition, backward ;
she has a great many evidences of mental deterioration.
Head symmetrical ; no other somatic evidences of de-
generacy.
Put on opium treatment September 20th. Reached
thirteen grains a day at end of first week. At this time
took thirteen pills at one time and suffered from toxic
effect, but recovered without difficulty. Put on kalium
bromide, 3ss 4. i. d., November 1st. Patient reported
once a week till January, then stopped for two weeks.
Returned February 8th and said she had had a fainting
spell, while the medicine had been stopped. Bromide
in 20 gr. doses 4 i. d. continued. No attacks since that
time. Result : one attack of petit mal in six months,
Mental condition about the same.
Case II. Private.— H. N , male, aged twenty-
two, salesman. Maternal side of family neurotic heri-
tage. Paternal great uncle had epilepsy. Attacks be-
gan when he was sixteen years of age. Cause, not attrib-
utable. Had one spasm when a child, caused by
eating unripe fruit. Was bright mentally and strong
physically, as a boy. Character of attack, haut mal.
Time of occurrence, always at night. Frequency, in
the beginning they occurred about once in six months ;
now they come once or twice a week. Mentally he is
deteriorating, forgetful, depressed; cannot concentrate
his mind. Physically not robust.
Put on opium treatment April 30th. Maximum dose,
fifteen grains, reached in eight days, and continued till
June 1 6th. No change in attacks in point of form or
frequency while taking opium.
June 15th. — Substituted bromide of potassium, 3 ij.
per diem, for opium. Reports once a week.
November 28th. — Three attacks in succession the
same night. Had not been taking medicine for five
days.
December 18th. — Nocturnal attack.
March 27, 1894. — Reports one attack since Decem-
ber.
Result : Four attacks in nine months. Physical and
mental improvement.
Case III. — M. S female, nine years of age.
One sister died of hydrocephalus. She did not walk till
two years of age, and began to talk when six. Attacks
first began at the age of three years. They were then
of the petit mal character, and gradually increased in fre-
quency until her eighth year, when they were occurring
once or twice a week. From her eighth year she has
had both petit mal and grand mal. Mentally the pa-
tient is quite defective. Evidence of somatic degen-
eracy well marked.
Patient put on opium, gr. j., t.i.d. for three weeks;
then on double the quantity for the next three weeks ;
then on triple the quantity for the next four weeks.
Middle of November put on potassium bromide, 30
grains four times a day.
It is necessary to mention that this little patient was
the only one of the entire number that developed symp-
toms of the opium habit. On substituting the bromides
for the opium, such symptoms of the opium habit as
diarrhoea, anorexia, restlessness, irritability, and sleep-
lessness showed themselves, but were easily ccmbafed
with hydrotherapy and small doses of chloral. She has
had no attacks for upward of five months. Mentally
there is some gratifying improvement. She helps her
mother about the house ; can be trusted to go errands
and the like. During the administration of the bromide
she has had restoratives, such as iron and cod- liver oil,
in such quantities as she could dispose of.
Case IV.— M. P male, twenty- one years of age;
heavy drinker. One brother had attacks for upward of
twelve years and recovered at the end of that time.
One year ago after a heavy drinking bout he had an
attack of pneumonia and while convalescing from this
he had his first epileptic attack. After this they oc-
curred two to three times a week, and both in the day
and in the night. Has an aura starting from the stomach
accompanied by cardiac palpitation. Mental condition
good.
Put on opium August 2 2d and continued for six
weeks. Then bromide in 30-grain doses four times a
day. Result, no attacks since cessation of opium.
Case V. — H. B female, sixteen years of age.
Mother died of tuberculosis. Had convulsion's *hen
three and a half years of age. Then was quite free from
attacks till ten years of age. Talked and walked early
and learned easily until her tenth year, when she bad
severe attacks of haut mal. Three or four months later
she had a second attack and since that time they have
increased in frequency. Concomitant with the increase
in the number of attacks has been mental deterioration,
so that now she is quite demented. Three yeais ago
she had an attack of chorea, and while ailing with this,
she had a left side hemiplegia which disappeared in
about a fortnight. Her mind has been gradually gettirg
weaker, and for the past six months she has bad visual
and auditory hallucinations. Always before an attack
she complains that her eyes hurt her. Evidence of
somatic degeneracy, such as stunted stature, torsus pala-
tinus, over exposure of gums, defective lobulation of
ears, crowding of teeth, broad, flat nasal arch very ap-
parent. For the past six months she has had at least
six attacks a week, for two or three hours after an attack
she is entirely non compos mentis.
Put on opium January 10, 1894, and for the next six
weeks while on opium the attacks were not so frequent
as formerly.
February 28th. — Put on kalium bromide. No attacks
for two weeks, since then an attack about every fourth
day.
Case VI.— A. F male, aged twenty- two, of neu-
ropathic heritage. First attack of epilepsy when four-
teen years of age. Attributing cause, a severe fright.
The fits occurred about every three weeks for the next
four years. Since that time the attacks have been get-
ting more frequent, although he has been under con-
tinual treatment. In the month previous to the begin-
ning of the opium treatment he had twenty-seven attacks
—seventeen day attacks and ten night attacks, all of tfce
haut mal type. Patient put an opium May 25, 1893.
The following is a record of his attacks while taking
the opium r May 25th, six attacks; June 10th, two at-
tacks; June nth, one attack, followed by a maniacal
outbreak. Rectal injection of 30 grains of chloral
hydrate and 60 grains of bromide of potassium, hypoder-
matic injection of yfa- grain hyoscy amine hydrobro-
matis, and ice cap to the head.
June 1 2th. — Patient rational.
July 1 8th.— Opium stopped and given instead bromide
of potassium, 30 grains four times a day.
36o
MEDICAL RECORD.
[September 22, 1894
August 27th. — Two " fainting " spells.
October 24th. — Petit mal
October 25th. — Petit mal.
November 3d. — Petit mal.
December 2d. — Two attacks of petit mal.
January — No attacks. Patient left the hospital.
Case VII. — J. N , male, sixteen years of age, no
family history. Has had fits since seventh year. Cause,
severe fright. The form that the attacks take is vari-
able, occasionally they are of procursive type, some-
times petit mal and sometimes very severe attacks of
haut mal. In the month preceding the opium treat-
ment he had thirty-eight fits. Mentally, patient is en-
tirely demented. Opium stopped and bromides substi-
tuted July 25 th.
The following is the record of attacks for the re-
mainder of the year : August, four attacks ; September,
one attack; October, three attacks, all of petit mal
type ; November, five attacks ; December, three attacks,
one of the haut mal type. Patient transferred to the
asylum.
Case VIII. — E. S , male, twenty-three years of
age. Negative family history. Has had fits since child-
hood. Attributable cause, fright. Mentally the patient
is morose, stupid, wrathy, and scarcely ever speaks unless
angered. In month previous to establishing the opium
treatment he had twenty-four attacks. Opium stopped
July 25th and bromides substituted. The following is
the record: September, 1893, two attacks; October,
two attacks; January, 1894, two attacks; February,
one attack ; March, three attacks.
This patient has undergone a remarkable mental
change for the better, is now cheerful and bright and
works continually about the ward.
Case IX. — C. F , male, twenty seven years of age.
Negative family history. Has had fits since he was
eighteen years of age. At first they occurred at night,
but for some years past he has had both night and day
attacks. He has about eight attacks a month, in each
one of which more than an hour elapses before he re-
covers consciousness. Mentally the patient is deranged,
and spends most of the time praying. He received the
opium in the regular way and was put on bromides Au
gust 2, 1893. He suffered no attack up to October 1st,
when he was transferred to the surgical ward that he
might be operated on for a malignant growth of the
cheek. Since then he has had a few light attacks.
Mentally he is greatly improved.
Case X — A. S , male, twenty-six years of age.
Paternal uocle has epilepsy. This patient had convul
sions when a child after an attack of scarlet fever.
When ten years of age had his first severe fit. He has
been under almost continual treatment in this country
and Germany since his boyhood, but the attacks have be-
come more frequent and severe. Sometimes he will have
three or four attacks in a day and then will not have a
repetition for a week. Most of the attacks are in the
day. Mentally and physically the patient is in fairly
good condition. Patient put on opium June 10th and
stopped August 2d.
The record from that tim; is, August 6th, two "faint-
ing " spells; November 28th, two attacks of petit mal ;
Februarys, 1894, one haut mal; February 10th, petit
mal ; March 7th, petit mal.
In conclusion it gives me great pleasure to acknowl-
edge the many valuable suggestions received from Dr. C.
L. Dana relative to the prosecution of this trial, and to
thank him for placing at my disposal the extensive ma
terial of his clinic at the New York Post Graduate Medi-
cal School.
To Dr. E. D. Fisher my best thanks are due also for
allowing me the privilege of his wards at the Alms
Home. Trie valuable and untiring aid rendered me by
my successive house physicians, Drs. Hedges, Grandy,
aud Worth, at the Hospital for Nervous Diseases is grate-
fully acknowledged.
43 W*st Thirty-ninth Street.
A RARE CASE OF SCLERO CORNEAL STAB-
GREAT LOSS OF VITREOUS — COMPLETE
COLLAPSE OF GLOBE — INTRA - OCULAR
HEMORRHAGE — TREATMENT WITHOUT
ANY PAIN— GLOBE SAVED.
By DANIEL R. AMBROSE, M.D.,
KKW YOKK.
This case is interesting not only from its rare character
and result, but also from the novel, yet very simple,
treatment. In his chapter on ' ' Wounds and Injuries of the
Sclerotic/1 Soelberg Wells says: "When the wound is
very extensive and a large portion of the contents of the
globe has escaped, and there is no hope of restoring any
sight, it is better to excise the eyeball at once, more
especially if it is to the patient a matter of great moment
(as among the poorer classes) to be cured as soon as
possible, and to be free from further inflammatory at-
tacks." l
In a large hospital and dispensary practice, extending
over a period of fifteen years, I have never seen an in-
cised wound of the eye so deep, extensive, and appar-
ently hopeless as the following :
M. W , aged twenty nine, butcher, came to my
office, Sunday afternoon, February 7, 1886, with his right
eye covered with cloths, over which was tied a handker-
chief. After removing these the lids were closed and
sunken as in a case of extreme phthisis bulbi. After
separating the lids the eyeball appeared not more than
one fourth its normal size, so great was the collapse from
an incised wound commencing on nasal side of sclera,
apparently one- fourth of an inch from the limbus con-
junctivalis, near the horizontal diameter, and extending
forward and slightly upward to one eighth of an inch
from the temporal limbus conjunctivalis, cutting through
sclera, choroid, and retina, and extending through cor-
nea, iris, ciliary processes, zonula, and splitting or dis-
placing the lens, which in all probability escaped with
the gush of the vitreous. The iris was divided through-
out the entire extent of the corneal portion of the wound.
There is intraocular hemorrhage, and very probably de-
tachment of the retina. A portion of vitreous had lodged
in the scleral portion of the wound, occupying about
one fourth of its extent, which I did not disturb. The
iris prolapsed through the entire length of the corneal
portion of the wound, and with the convex surface of
Daviel's spoon I gently pushed it back within the corneal
margins. He is a strong, muscular man, but very pale
and nervous from anxiety, and said that while in a
stooping position gathering up the entrails of a hog, a
drunken companion, who was scraping down an adjoining
animal with a knife, recklessly thrust the point of the
instrument upward into his eye, with the above result.
In consequence of the sudden and unexpected blow
between the involuntary contractions of the lids, these
escaped entirely and the eyeball received the whole force
of the blow. My first thought was to close the scleral
portion of the wound with a suture. My second thought
was not to do so. Why ? No one could surely predict
firm union of the corneal margins in such an extensive
wound within forty-eight hours. And in a strong man
like this, in such a state of nervous depression, there fbust
surely follow within forty-eight hours, and probably
within twenty-four hours, a vigorous reaction, with a
reformation of vitreous and aqueous humors, which, in
rapidity and force, would cause an intra- ocular pressure
similar to that in glaucoma fulminans, which a so exten-
sive corneal incision in almost the horizontal diameter,
where little or no support could be obtained from the
lids, and with but a weak adhesion, would hardly be able
to resist ; and if the corneal adhesion, which I hoped to
obtain, should give way, all would be inevitably lost.
I told the patient that he might be prepared for total
loss of sight in that eye, and that there was a strong prob-
ability that the wounded eye would have to be removed,
but at the same time I hoped, with care and regular at-
1 Page 214, Soelberg Wells.
September 22, 1894]
MEDICAL RECORD.
361
tention to be able to save the eyeball. By leaving the
scleral portion of the wound open as a safety-valve, and
giving firm but comfortable support to the cornea with
compress and bandage, I hoped to prevent a reprolapse
of iris and obtain primary union of the corneal portion of
the wound and save a globe which would disfigure but
little, if any, and save him the annoyance and expense
of an artificial eye every eighteen months or two years.
So I carefully and gently cleansed the eye with soft
cloths and lukewarm water, put in two drops of a four-
grain solution of atropine, and repeated this four times
at intervals of about five minutes, and then applied a firm
bat comfortable compress and bandage, and sent him
home with an injunction to send for me if he had any
pain.
The first layer of cotton in contact with the eye was
saturated with glycerine. About 7 p m. he sent a boy
for medicine. I did not send anything, but went to his
rooms in a tenement-house, where I found him sitting
with a bright lamp directly in front of him, with a room-
ful of people, who were talking rather excitedly from the
effects of stimulants. All, except his own family, were
immediately directed to leave the room, and he was in-
structed to have the lamp behind him and to keep quiet.
He said he did not have any pain, but only a slight sore
feeling and feared it might get worse during the night,
and therefore sent for medicine to have it ready in case
of necessity. After he had been quiet about half an
hour he said he felt quite comfortable, so I gave him
nothing and did not disturb the bandage, and, after di-
rections to sleep with his head and shoulders well raised,
I left him.
February 8th. — Twenty-four hours after his first visit
he returned to my office, a distance of nine blocks, and
said he had passed a very comfortable night, and had not
had the slightest pain or sore feeling since I left him.
After cautioning him to keep his eyes closed I removed
the dressing. The eyeball had filled out considerably,
but not quite equal in size to the fellow-eye ; the lids are
natural, there not being the slightest appearance of in-
flammation at the margins. After gently washing the
lids with a soft cloth and lukewarm water, and slightly
pulling down the inner corner of lower lid and dropping
a four grain solution of atropine four times, about five
minutes apart, into the eye, I reapplied compress and
bandage as before.
February 9th. — Returned and says he has not had any
pain, and rested quite comfortably the night before;
dressing removed ; the eyeball has filled out equal to its
fellow, and the lids appear quite natural. Eye gently
washed ; atropine, compress and bandage as before.
February 10th. — Has had no pain, though the eye is
now fuller and more prominent than its fellow, and
margin of the upper lid is slightly red and swollen.
After directing him to make no effort to open his eyes,
I gently and slightly raised the upper lid and was much
gratified to find thorough primary corneal union all
along the line. The vitreous which had lodged in the
scleral wound has entirely disappeared; treatment the
same.
February nth. — The upper lid is more swollen than
yesterday, but he says he has not had the slightest pain ;
treatment the same.
February 1 ath. — The swelling of lids is more extensive
than yesterday, and they bulge forward considerably, are
red and glazed and have all the appearances of a severe
panophthalmitis in full bloom, except the pain, which
is entirely absent; treatment the same. For the last
two days the cotton compress has been quite wet with
water, but only a trace of muco-pus.
February 13th. — Has had no pain. Appearances the
same as yesterday ; treatment same.
February 14th. — Has had no pain. Appearances
about the same as yesterday, except that the lids do not
appear quite so tense, and there is a little more pus to be
seen when the margins of the lids are separated ; treat-
ment the same. Without recording the monotonous
daily details, from this time on there was a gradual sub-
sidence of the inflammatory action, without any pain
and without the slightest change in treatment. It was a
noticeable feature of this case throughout the treatment
that there was less suppuration than I had ever before
seen in an inflammation of such a violent degree.
Nothing occurred worthy of special note until February
28, 1886, when, the eye having much improved, the
swelling and redness of the lids having entirely disap-
peared, but there being still a slight degree of conjuncti-
vitis, with marked injection of the superficial and deep
ciliary vessels extending all around the cornea, but most
marked near the seat of the scleral wound, he attended
church, which had not been warmed, at 7 a.m., while
the thermometer, as reported by morning papers, was at
ten degrees above zero. While at his devotions he felt
a chill run through his body, and his eye felt as though
something was in it ; he said he thought a portion of the
cotton compress had gotten into the eye. I removed
the dressing, but there was nothing in the eye, and the
symptom he described was caused by increase of con-
junctivitis brought on by cold while at church. I then
directed him to remain in his room until the weather
became warmer, and there I gave him the same daily
attention without the slightest change in treatment.
This increase of conjunctivitis, with its accompanying
symptom, as though something was in the eye, was re-
lieved in forty- eight hours; but I confined him to his
rooms and continued the same daily treatment for one
week until the cold wave had passed and the weather
had become milder.
March 15th. — He can distinguish a white shirt bosom,
a white hat with a black band around it, and my hand
at about three feet, but he cannot count fingers at any
distance. As he had to return to work and would be
daily exposed to a varied atmosphere, and also dust, and
as the injection of the deep and superficial ciliary vessels
continued, I thought it safer to continue the treatment
at intervals of every second day until May 10, 1886,
when the bandage was removed and the eye protected
with a light pad of cotton, over which was placed a
paste- board covered with black silk.
The small margin of the scleral wound, of one-six-
teenth of an inch beyond the ciliary zone, healed much
more quickly and kindly than that part running directly
through the ciliary zone, which healed very slowly and
was long marked by the injection of the superficial and
deep ciliary vessels. The paste-board with dark silk ard
slight pad of cotton was, in consequence of his occupa-
tion and frequent exposure to variable temperature, con-
tinued until June 26, 1886, when all appearance of in-
flammation and irritation about the eye had entirely
disappeared, and the ciliary vessel*', both shallow and deep,
had regained their normal condition, and there were
neither perceptible bulging nor depression of the sclera,
one of which is almost the invariable result of wounds ex-
tending through the ciliary zone. The scleral portion of
the scar, which can be easily seen, measures six thirty-
seconds of an inch from the limbus conjunctiva lis. The
direction of the line of the incision iuns from a point on
the nasal side of the sclera six thirty-seconds of an inch
from the limbus, and about five degrees below the hori-
zontal diameter, and extends to a point on the cornea
one-eighth of an inch from the temporal limbus cor juncti-
valis and about five degrees above the horizontal diameter.
There is anterior synechia to both lips of corneal incision
throughout its entire length, except a small portion at
the lower margin of the pupil about the size of the head
of a small pin, which is perceptible when under the influ-
ence of atropine. The globe appears of full size and
good shape, but the cornea is flattened.
During a large dispensary and hospital service extend-
ing over a period of more than fifteen years I have seen
a great variety of ir juries and deformities of the cornea,
but have never before seen a case like this resulting from
a wound, the cornea markedly flattened, yet apparently
equal in ail of its diameters to that of the unir jured eye.
362
MEDICAL RECORD.
[September 22, 1894
Neither can I remember of ever having read of such a case.
[Flattening of the cornea without any diminution of its
diameters may, and often does, exist as the result of old
age, and may be caused by glaucoma as the result of
long and marked increase of the intra ocular pressure,
which, while it causes the globe to approach the spherical
shape, stretches the ciliary nerves which run between the
sclerotic and choroid, and paralyzes them to a greater or
less degree.]
The flattening of the cornea in this case is due to one,
or both, of two causes : 1st. The oblique course of the
knife through the ciliary region not only divided the
ciliary muscle and ligament, but also some of the ciliary
nerves, causing paralysis of the former. [Although the
system of ciliary nerves are mainly derived from one (the
ophthalmic) of the sensory branches of the fifth pair, it
receives motor power, through the medium of the ciliary
ganglion, by a branch derived from the third nerve.] 2d.
The extensive anterior synechia along both lips of the
corneal incision very probably exerts some influence in
producing this flattened condition of the cornea. There
is a slight depression without any discoloration along the
line of the scleral portion of the scar. This reminds me
of a ditch which has been filled up almost to the surface
with the surface portion of the soil through which it had
been dug in consequence of the long neglect of a lazy
farmer.
What does it indicate ? That union by retina, con-
nective tissue, and conjunctiva has taken place ; there
being no direct adhesion of the edges of the sclera. Of
what importance is that ? Remember the last question,
for under the head of Suggestions this very shallow ditch
will be again alluded to and its importance will there be
pointed out.
November 6, 1886. — He can distinguish my hand
from one to three feet, but he cannot see fingers at any
distance. The image of the hand, or other objects, is,
after a few seconds, lost. It may be asked, Why not per-
form an iridectomy and give this man a larger pupil and
more light in that eye ? At first this may seem very
plausible, but very probably there is detachment of the
retina to a considerable extent (and it would be miracu-
lous if there were not some degree of detachment of the
retina after such a sudden evacuation of almost, if not
quite, the entire contents of the vitreous chamber), and
an iridectomy, at best, could give very slight, if any, im-
provement where there is detachment of the retina;
while the risk of starting an irido-choroiditis by doing
an iridectomy where there is such an extensive anterior
synechia, and very probably degeneration of the iris, which
might not only destroy the faint vision he now has but
also cause atrophy of the globe, is considerable. There-
fore, for the best interest of the patient I deem it wiser to
let well enough alone.
Dr. J. F. Gray saw this patient with me during and at
the termination of the treatment, June 16, 1888. It is
now over two years and four months since the accident
occurred, and there is not the slightest symptom of irri-
tation in either eye. The tension is normal, being the
same as that of the fellow eye. The horizontal diameter
of the right, or injured cornea, from limbus to limbus is
-fourteen thirty-seconds of an inch, while the correspond-
ing diameter of the left cornea is fifteen thirty- seconds of
an inch. The vertical diameter of the left cornea from
limbus to limbus is fourteen thirty-seconds of an inch, and
the vertical diameter of the right or injured cornea is
also fourteen thirty- seconds of an inch. Measurement of
palpebral fissures directly over the centres of pupils,
while patient is looking straight forward, shows the fol-
lowing results : When the measure approaches the left
eye, as near as possible without contact, he can, after a
few trials, control the involuntary contractions of the
lids, and then, while looking straightforward, the fissure
over the centre of the pupil is fourteen thirty-seconds of
an inch ; but after several trials, as with the left, the lids
of the right, or injured eye, in spite of strong efforts to
control them, will contract as the measure approaches,
and during this contraction the palpebral fissure of the
right, or injured eye, is eleven thirty-seconds of an
inch — three thirty- seconds of an inch less than that
of the good eye. But when I wave my finger up and
down several times commanding him to follow the
finger with his eyes and look at nothing else, and then
suddenly bring my finger to a rest on my right eyebrow,
I can then approach his injured eye with the measure
without any apparent contraction of the lids, and
then the palpebral fissure of that eye is twelve thirty-
seconds of an inch over the centre of the pupil — or only
two thirty seconds of an inch less than that of the good
eye. This temporary exercise of the eyes and mental
diversion removed that nervousness shown a few moments
before in the injured eye, and which had caused the con-
traction of the lids as the measure approached them, in
spite of his efforts to control them. I remarked that the
lids of the injured eye were not much nearer to each
other than those of the good eye, to which his wife re-
plied, " Oh ! I didn't think anything of that, for I have
always noticed that the lids of the right eye were a little
contracted ; " and the patient said, " That is so, the lids
of the wounded eye have been contracted almost as long
as I can remember." According to these statements the
result is better than I at first supposed. He has per-
ception of shadows at two feet. There is a white film
occupying the space of the small pupil.
October 25, 1890. — It is now over four years and eight
months since the accident occurred, and the eye remains
in the same condition as noted June 16, 1888.
November 26, 1893. — It is now seven years and nine
months since the accident occurred, and his wife says,
when he remains sober his eye looks as well as it did
June 16, 1888.
In this case no antiseptic, except cotton saturated with
glycerine as an external dressing, was used. Several
years ago I obtained primary union in cases not favored
with good hygienic surroundings where the flesh had not
only been torn, but dragged from its attachment by ma-
chinery and the glancing force of some instrument, by
gently cleansing and carefully adjusting the related parts
and dressing the wound with cotton saturated with glyc-
erine and the patient's blood.
Under what more unpropitious circumstances can it be
imagined that an eye will ever be operated on than ex-
isted in the above case, which was cut in the roughest man-
ner possible, with a coarse and filthy knife, and almost
directly through the horizontal diameter of the cornea,
where the least support could be obtained from the lids,
dividing it into two equal parts ; and in the foul, moist,
and comparatively warm atmosphere of a slaughter-house
for hogs, reputed the most filthy of all animals, whence he
had to go over half a mile — twelve and a half blocks —
before his eye was cleansed and dressed.
There was no suppuration within the eye nor in the
margins of the wound. The conjunctiva was the only
tissue from which pus could be seen to issue, and it was
markedly less than I had ever before seen in a case of so
violent reaction, and this yielded in due time to atro-
pine and unadorned cleanliness. And he did not have
pain enough throughout the whole time of treatment to
deprive him of one moment's sleep. The mouth of the
scleral wound was daily exposed to pus from the con-
junctiva for about two weeks, but this gave me no anxiety
after I saw firm corneal union had taken place, because
a full and boiling- over capsule effectually prevented the
entrance and accumulation of any foreign liquid.
The earnest attention of the ophthalmic surgeon is re-
quested to the last sentence above, for in the class of
cases to which I believe much good may be done by the
timely use of the operation which will be described fur-
ther on, there will always be some degree of conjunctival
suppuration, and however much, he may be impressed
with its utility in relieving intra-ocular tension, and in
promoting free circulation through the eye, and thereby
preserving its nutrition, he may still be deterred from
giving his patient the benefit of it for fear that the con-
September 22, 1894]
MEDICAL RECORD.
363
junctival pus might enter the scleral incision and accu-
mulate within the eye, and more than counteract all the
benefit that might otherwise be derived from the opera-
tion. My chief anxiety, therefore, in this case, was that
the scleral opening might unite before the inflammatory
reaction could be checked, or had spent its force, and in
consequence of its speedy union the circulation through
the globe might become obstructed, and its nutrition, as
well as that of the cornea, become impaired, and thereby
defeat the purpose for which I had intentionally left the
scleral portion of the incision open.
The favorable features of this case may be fairly attrib-
uted to simple cleanliness, firm and comfortable support
to the cornea, atropine, and more than all else, to the
continued relief of intra-ocular pressure until the inflam-
matory reaction had spent its force. The intra-ocular
pressure was kept continually relieved by keeping the
scleral portion of the wound continually open as a safety-
valve, free circulation through the globe being thereby
permitted, and its nutrition, as well as that of the cornea,
preserved, and suppuration within the eye prevented, and
lessened to a considerable degree from the conjunctiva.
It may be supposed that these happy results were due to
the age and vigor of the patient and to an unusual vital-
ity of the tissues of his eye. But to such an hypothesis I
would reply that the best results I have had after opera-
tions for cataract, or seen in the practice of others, have
been in elderly and moderately emaciated people who
did not seem to have vigor and vitality enough to get up
a forceful reaction; while the worst results that I have
witnessed have been in stout and vigorous- looking people.
It should, however, be borne in mind that an opposite
extreme may exist where the vitality is so low and the
reparative lymph so deteriorated that union of the cor-
neal incision after extraction may not take place, and
then may follow sloughing of the cornea, panophthalmitis,
and atrophy of the globe, in spite of all that can be done.
For many years I have watched with much interest the
results of cataract extraction, in the practice of others as
well as my own, and have seen in several cases, after the
most skilful extraction by different operators and the
most careful after-treatment, the eyelids become swollen,
red, and glazed, with much pain in the globe and radiat-
ing along the course of the supra-trochlear, infra-troch-
lear, nasal, and temporo-malar nerves ; and in spite of the
careful use of all known remedies the patient would pass
sleepless nights and wearisome days, and the sight, which
was obtained immediately after the operation, and which
so cheered the despondent mind, gradually, and some-
times rapidly, become dimmed until no object could be
distinguished, and his hopes sink away never to return.
I do not know anything, except the dying, which has
caused me more melancholy feelings than the watching
of these unfortunate cases.
Some years ago it occurred to me that something be-
yond the routine treatment— some secondary operation
which would relieve tension, and keep it relieved until
the inflammatory reaction had been checked, or had
spent its force — should be tried early in these violent
cases; but operative procedures, except paracentesis of
the cornea, in the acute stages of such cases, have been
objected to by some of the most eminent ophthalmic sur-
geons, and countenanced by none that I am aware of,
on the ground of increased irritation which would inevi-
tably follow. This objection is perfectly valid and well
taken so far as the old and long used method of relieving
tension — by paracentesis of the cornea — is concerned.
For, although by the use of cocaine complete anaes-
thesia of the conjunctiva and cornea may be obtained,
and the former rendered insensible to the grasp of the
forceps, and the latter to the cut of the knife, the iris
is bat little, if at all, affected by it; and although an
expert surgeon may avoid tearing or pricking the iris
he cannot prevent it bulging forward when the aque-
ous escapes. And this slight displacement, and possibly
rubbing against the knife of so sensitive a tissue as the
inflamed iris, must cause some degree of irritation.
However, if the relief of tension temporarily obtained
by paracentesis of the cornea could be safely made con-
tinuous at the surgeon's will, without the necessity of
repetition, it might in a great measure compensate for
the irritation produced by it. But, unfortunately,
there is no way at present known by which that desirable
result can be safely accomplished. The corneal incision
will primarily unite within twenty-four or forty- eight
hours ; the inflammatory process of the iris and choroid
is not checked ; the aqueous and vitreous humors, which
are incompressible substances, rapidly reform ; the cap-
sule, if possible, is still further distended until it has per-
haps lost all of its resiliency, and this factor in the pro-
motion of the intra-ocular circulation is lost; the
circulation becomes obstructed and consequently the nu-
trition becomes impaired, and then follows the formation
of pus within the eye. Leeches, ice-cloths, warm douches,
and other remedies, have for many years been used to check
this inflammation, and when it is of a mild nature and of
but moderate force are sufficient to subdue it. But I
have seen several cases under the care of different sur-
geons which, after the timely and assiduous application
of the usual remedies, were but slightly, if at all, relieved
by them ; the inflammation continued until suppuration
within the eye occurred ; the sight became greatly im-
paired; nay, totally lost To meet and prevent such
emergencies I would suggest sclerotomy before any de-
struction of tissue had taken place, if possible. It is not
here claimed that sclerotomy is a new operation, for, on
the contrary, it is quite ancient ; but the method, pur-
pose, and regard for neighboring parts, as will be further
on described, I have never seen nor even heard sug-
gested.
Under the head of " Treatment of Glaucoma,1' Stellwag
says : "The paracentesis of the sclera, moreover, in con-
nection with the emptying of a portion of the vitreous, has
been recommended for a long time as a means of lessen-
ing the hardness of the globe (Mackenzie). Since, how-
ever, the technical performance of the operation was not
adapted to produce a permanent relaxation of the scle-
rotic, it could only obtain transient, and therefore un-
satisfactory results." Its union with the iridenkleisis
(Critchett, Coccius) has theoretically very much to be said
for itself, but is to be avoided on account of favoring
cystoid cicatrices, and subsequent threatening irritation.
The proposal to draw out the iris very much in iridec-
tomy, in order to rupture the zonula, and thus to establish
a connection between the vitreous and aqueous humors
(Coccius), should find few friends, in consideration of the
dangers which can accrue to the nutrition of the lens,
and even of the entire globe, from a partial rupture of the
ciliary body." *
From the above it may be seen that, in addition to
the fact that the operator " could only obtain transient,
and therefore unsatisfactory results " for one purpose for
which the paracentesis of the sclera had been employed,
there was also another important cause why the operation
had been followed by not only unsatisfactory results, but
also even worse, by its " favoring cystoid cicatrices and
subsequent threatening irritation," and " in considera-
tion of the dangers which can accrue to the nutrition of
the lens, and even of the entire globe, from a partial
rupture of the ciliary body," viz., that the paracentesis
of the sclera had been done through the ciliary zone.
Suggestion 1— Method of Operating.— The patient
having been placed on his back and anaesthetized, the
surgeon, with fixation-forceps, grasps a fold of conjunctiva
near the cornea, midway between the external and infe-
rior recti muscles, and gently turns the eye downward
and slightly outward. An assistant raises the upper lid
with his finger. A thin Graefe knife, well sharpened
and thoroughly cleansed, and with its cutting edge di-
rected toward the posterior extremity of the eye, and its
sides parallel with the longitudinal axis of the globe,
so as to guard as much as possible against cutting any
of the ciliary nerves, is inserted in the point midway
1 Stellwag-: Fourth edition, p. 318.
364
MEDICAL RECORD.
[September 22, 1894
between the superior and internal recti muscles and five
thirty seconds of an inch from the limbus conjunctival,
and passed directly through all the coats to the vitreous,
the blade being pushed inward only far enough for its
point to pass through the retina, lest damage be done to
the vitreous, when the incision is extended backward six
thirty- seconds of an inch. The length of the scar in the
above case from the limbus conjunctival backward on
the sclera is six thirty-seconds of an inch, and the poste-
rior two thirty seconds of an inch of the incision healed
very much more rapidly and kindly than the anterior
four thirty-seconds of an inch of the scleral portion of
the wound did ; and this fact indicates that in the hori-
zontal diameter four thirty seconds of an inch from the
limbus backward cover all those sublime structures lying
within the Ciliary zone, the wounding of which by acci-
dent or design has always disappointed the hopes of the
surgeon and terminated so disastrously to the patient.
Argument. — Gray says: "The larger processes are
each about one-tenth of an inch in length and hemi-
spherical in shape, their periphery being attached to the
ciliary ligament and continuous with the layers of the
choroid ; the opposite margin is free and rests upon
the circumference of the lens. . . . The ciliary
muscle . . . forms a . . . circular band, about
one-eighth of an inch broad, on the outer surface of the
fore put of the choroid. It consists of two sets of fibres,
radiating and circular. The former . . . arise at
the point of junction of the cornea and sclerotic, and,
passing backward, are attached to the choroid opposite
to the ciliary processes. The circular fibres are internal
to the radiating, . . . and have a circular course
around the insertion of the iris." l Of the sclerotic,
Gray says: "In front the sclerotic is continuous with
the cornea by direct continuity of tissue, but the opaque
sclerotic overlaps the cornea rather more on its outer
than on its inner surface. " Of the cornea, Gray says :
" It is not quite circular, being a little broader in the
transverse than in the vertical direction, in consequence
of the sclerotic overlapping the margin above and be-
low." 2
^ From this eminent authority it will be seen that one*
eighth of an inch from the corneo -sclerotic junction ex-
tending backward covers those very important parts ly-
ing within the ciliary zone ; and from the last quotation
that the cornea is " a little broader in the transverse
than in the vertical direction, in consequence of the
sclerotic overlapping its margin above and below. "
Gray says the eyeball in its antero posterior diameter is
"about nine-tenths of an inch," which, reduced, is
28*
equal to- - - of an inch. The average height of the
normal cornea from limbus to apex, measured in the
horizontal diameter, from thirty to forty years of age, is,
2A
so far as I have examined, about — of an inch ; while at
3-
about sixty years of age it is about A of an inch. In the
following estimate I will calculate from the greater height
because the shortening of the eyeball in old age is due, so
far as is at present known, solely to the flattening of the
cornea.
Therefore — J _ — ? = |j of an inch, which represents
the average length of the eyeball of the adult from the
corneo scleral junction to its posterior end. Now from
|| take fa of an inch in the location proposed for this
operation, and there will remain $£ of an inch; at the
point of five thirty-seconds of an inch from the limbus
backward, the scleral incision begins and extends back-
ward six thirty-seconds of an inch and then there will re-
main fifteen thirty seconds of an inch of the posterior
part of the eyeball, or more than half of the twenty-six
thirty seconds of an inch, which represents the average
length of the eyeball from the corneoscleral junction
to its posterior extremity; and therefore the posterior
1 Gray : Eleventh edition, pp. 810-812.
■ Ibid., pp. 806, 807.
extremity of the incision will be above the equatorial di-
ameter of the vitreous chamber when the patient is on
his back. Under no circumstances should the knife be
passed into the vitreous chamber at a point less than five
thirty-seconds of an inch from the limbus conjunctival,
except for the removal of a foreign body.
The incision made as above described, will not muti-
late the iris, ciliary muscle, ligament, processes, or zon-
ula, all of which should be carefully avoided.
In the location above described the incision, when
the patient is lying on his back, is above the equatorial
diameter of the vitreous chamber ; and when lying on the
side of the operated eye, as, when not otherwise directed
patients instinctively and almost invariably do, the in-
cision will be above the vertical diameter ; and when in
the erect position it will be above the horizontal diame-
ter. In either of these positions which the patient is
most likely to assume, and to which by special instruc-
tions he should be confined during treatment, the open-
ing is always above the corresponding diameter of the
vitreous chamber, and excessive leakage cannot occur
even should the vitreous have degenerated to a liquid
condition. While at the same time the open incision
permits sufficient leakage of the constantly forming se-
rous vitreous, caused by the inflammation, to prevent in-
crease of intra-ocular pressure, and thereby not only pre*
serves the resiliency of the capsule, but also permits free
circulation through the globe and preserves its nutrition
as well as that of the cornea until the inflammatory ac-
tion is checked, or has spent its force. The scleral mar-
gins will not unite directly, and when treated by com*
press and bandage, as further on directed, the opening
through all the coats will remain slightly ajar, and pre-
vent its closing too soon by retina, connective tissue,
and conjunctiva. Should this open suggestion excite the
amazement of the reader he may restrain his astonishment
and bear in mind that the location designated for the
incision is, from its complete covering by the upper lid
under ordinary circumstances, but more especially when
the eye is turned upward, as patients involuntarily do
when there is much inflammation, almost if not quite as
secure from the atmosphere as though it were a subcuta-
neous tenotomy. As soon as the incision is completed,
carefully remove forceps without making any pressure on
the globe, drop in atropine on inside of lower lid,
cleanse and close the lids, and apply a clean soft cloth
saturated with vaseline or pure glycerine, and carefully
apply compress of clean cotton by filling up the inequal-
ities about the orbit until the cotton is well raised above
the] supraorbital ridge, and over this apply firmly, but
comfortably, a flannel bandage one and a half inch wide
and four yards long, carrying a layer of bandage over
the operated eye four times, and pin it carefully that it
will not slip. When compress and bandage are care-
fully applied, they are comfortable and almost as firm as
a plaster-of -Paris dressing, and will remain so for twenty-
four hours, when they should be removed, the eye genu
ly bathed with soft cloth and lukewarm water, and fresh
dressings applied. The patient should be directed to lie
with head and shoulders elevated at an angle of thirty or
forty degrees.
The advantages claimed for this operation, when per-
formed within the prescribed limits, purposes, and after-
treatment, are : 1. Quick relief of pain. 2. Instead of in-
creasing irritation it will relieve that which already
exists. 3. It will relax tension and permit free circula-
tion through the globe. 4. It will preserve the nutrition
of the globe and cornea more than any other remedy at
present known.
From the history and result of this case I believe
three valuable lessons may be learned.
1. That in extensive incised wounds of the eyeball, even
when the sclerotic is involved, and when a " large por-
tion of the contents of the globe has escaped and there
is no hope of restoring any sight," even " among the
poorer classes," the surgeon should not at once jump to
the conclusion that the destructive operation of enuclea-
September 22, 1894]
MEDICAL RECORD.
365
tion of the eyeball is inevitable, but he should by meas-
ures, not necessarily drugs, reasonably adapted to the
circumstances of the case, endeavor to at least preserve
the globe. When the globe is preserved without any ir-
ritation, although the sight may be lost, it is far more
comfortable and economical for the poor man than an
artificial eye, which has to be removed, cleansed, and re-
inserted every night and morning, and renewed every
eighteen months or two years ; to say nothing of the ir-
ritation often caused by an improperly fitted artificial
eye and consequent atrophy of conjunctiva. Unless
there be ciliary irritation long after the inflammation of
the globe has disappeared, the danger of sympathetic
ophthalmia, according to my experience, has been largely
exaggerated.
2. That the surgeon should not waste time in a severe
case, except it be syphilitic, in the delusive effort to cure
suppuration in the eye with drugs, and especially if the
patient be one of " the poorer classes," to whom it is a
-matter of great moment to be cured as soon as possible,"
and with die greatest amount of preservation of his nat-
ural organ.
3. That if so good a result can be obtained in a case
with the cornea split into two equal parts, and under
such unfavorable conditions, by the aid of a sclerotic
safety-valve, it is reasonable to hope for far better results
under more propitious circumstances where the surgeon
may perform a timely sclerotomy in a location where
neither the cornea nor any of those important parts lying
within the ciliary zone can be injured.
Suggestion a. — To mention sclerotomy at any part
where the instrument must enter the vitreous chamber as
a probable cure for glaucoma in the face of its past his-
tory, and of what some of the most eminent men in the
medical world have written about it, and especially at an
age when there is an operation for glaucoma which has
been in unrivalled use for about a quarter of a century,
and which has in many cases given very fair results, may
appear like a reckless suggestion. In presenting its
claims to the profession it will therefore be needful to
compare its advantages and disadvantages with those of
the operation now in use, viz., the broad paracentesis of
the sclera through its most anterior zone into the aque-
ous chamber, combined with an iridectomy. The ad-
vantages of the last- mentioned operation are : 1. That the
instrument pierces only the anterior scleral zone and
does not enter the vitreous chamber. 2. When early and
skilfully performed it has in many cases given very fair
results, that is, complete relief of pain and a fair amount
of vision. Its disadvantages are : 1. That it necessitates
the destruction of a large portion — about one-fifth— of
the iris ; not because the destruction of this tissue is
essential to the cure of the disease, but because of
the danger of its prolapse if not destroyed, and the dif-
ficulty of restoring it when prolapsed, and its great lia-
bility to lead to dangerous irritation. 2. Its location is
not only favorable for the prolapse of the iris when a
large portion of it is not excised, but even after such ex-
cision the margins of the wounded iris are very liable to be
caught in the lips of the scleral incision and lead to dan-
gerous and irreparable irritation. 3. The excision of the
segment of iris, as is required in its performance, close up
to its ciliary attachment, may, in the hands of an inex-
pert operator, cause a rupture of the zonula and endanger
the safety of the globe. 4. Cataract may be caused by
the point of the instrument piercing the capsule of the
lens during the performance of the operation, and this
accident is quite probable in the hands of an inexpert
operator. 5. The more or less dazzling caused by the
greater volume of light admitted through the coloboma
formed by the iridectomy. 6. The increased danger of
hemorrhage, in the hemorrhagic diathesis, from the cut-
ting of so many blood-vessels in the excision of the seg-
ment of iris. 7. The increased risk of sympathetic glau-
coma in the fellow-eye as the early result, upon an already
existing predisposition, of the shock from the wounding
of so many ciliary nerves in making the broad incision
through the anterior scleral zone and the excision of so
large a portion of iris; this increased irritation in a
weakened nervous system, conveyed through the ciliary
branches derived from the ophthalmic division of the fifth
pair to the ciliary ganglion, and thence by its sympathetic
root to the cavernous plexus, and thence through "the
filaments prolonged on to the anterior communicating
artery form a small ganglion, the ganglion of Ribes,
which serves, as mentioned above, to connect the s>m-
pathetic nerves of the right and left sides " 1 to the other
eye, causing or increasing the secretion of serous vitre-
ous and an increase of intraocular tension. 8. " It also
exceptionally occurs that directly after the iridectomy
the resistance of the globe increases markedly, the globe
even becomes of a stony hardness. Such cases always
run an unfavorable course, according to previous expe-
rience" (Liebreich •). 9. "In cases of glaucomatous
degeneration, iridectomy is apt to make the disease
worse, as it usually causes extensive intra- ocular hemor-
rhage." ■
The advantages of sclerotomy into the vitreous cham-
ber, when performed in the location and within the
limits above prescribed for the relief of intra- ocular
tension in panophthalmitis or glaucoma are: 1. There
is no destruction of iris or of any other tissue. 2. It
is performed in a position where the iris cannot prolapse
and cannot be caught between the lips of the scleral in-
cision, and therefore no subsequent irritation can arise
from that source. 3. There being no iridectomy in
this operation there is not the slightest danger, with the
most ordinary care, of disturbing the continuity of the
zonula or ciliary processes. 4. With ordinary care
there is no danger of causing cataract by the point of
the instrument piercing the capsule of the lens. 5.
There can be no dazzling from an increased volume of
light because there will be no coloboma of iris. 6. The
danger from hemorrhage, in a hemorrhagic diathesis,
will be less because there is no destruction of tissue and
a much smaller number of blood-vessels divided. 7.
There will be much less risk of sympathetic glaucoma
in the fellow- eye because there will be much less injury
done to the ciliary nerves; not more than one, and
probably none, of these nerves will be wounded if the
operator is careful to make the incision in a straight
line, parallel with the longitudinal axis of the globe. 8.
The firm compress and bandage, as already prescribed
for use after the operation for the relief of intra-ocular
tension in panophthalmitis, will help to keep the in-
cision open and to promptly afford relief to any increase
of tension which may be caused by hemorrhage, and
will be an aid in checking hemorrhage in glaucomatous
degeneration, which is so liable to be made worse by an
iridectomy.
The chief disadvantages of sclerotomy into the vitreous
chamber are two long standing objections which have
disappointed the hopes and baffled the skilful efforts of
some of the most eminent surgeons throughout the
civilized world for over a quarter of a century, viz., 1.
" Since, however, the technical performance of the opera-
tion was not adapted to produce a permanent relaxation
of the sclerotic, it could only obtain transient and there-
fore unsatisfactory results : " * 2. "Its union with the
iridenkleisis (Critchett, Coccius^) has theoretically very
much to. be said for itself, but is to be avoided on ac-
count of favoring cystoid cicatrices, and subsequent
threatening irritation.'1 *
The result of the foregoing case, upon which these
suggestions are based, clearly proves that these last two
objections can be avoided ; for there is not the slightest
show of a cystoid cicatrix, and the very shallow ditch
along the line of the scleral incision, which has been
covered over and nearly filled to the surface by a nor-
mal conjunctiva — the surface soil through which it had
been dug — proves without a doubt that there is perma-
nent relaxation of the sclerotic. I believe these last two
1 Gray : Eleventh edition, p. 789.
* Stellwag : Fourth edition, p. 323. * Ibid., p. 324. < Ibid., p. 318.
368
MEDICAL RECORD.
[September 22, 1894
parts of the body. These cases are, of course, not
classed as rheumatic in the list given above.
Eight of the cases were evidently directly due to ex-
posure to wet and cold, such exposure as might readily
induce an attack of inflammatory rheumatism,
Nine cases occurred in connection with phthisis. Was
the pleurisy merely a part of the phthisical process al-
ready established, or was it an intercurrent affection?
The patients almost invariably laid the pleuritic process
to exposure to cold. This of course is not the best of
evidence. They got well with remarkable rapidity on
anti-rheumatic treatment Rheumatism "goes to the
weak spot" — in this case to the serous investment
of the lung. The pleurisy was readily cured. The
phthisical process persisted. It is reasonable to sup-
pose that these pleurisies were non tubercular, but due
to rheumatic attacks during the course of a chronic
phthisis.
A few years ago, while engaged in surgical work ex-
clusively, I treated numerous cases of synovitis of the
knee-joint with effusion, due to injury, by means of plas
ter-of-Paris splints and the usual surgical procedures.
Since then I have learned that there is another aspect of
these cases, that a man who sprained his knee severely
did not necessarily get an effusion into the joint ; but,
given a sprained knee and a " touah " of rheumatism, and
you would bs very apt to find it. So with pleurisy oc-
curring in the case of a man who breaks a rib, in the
syphilitic or in the tubercular subject, there may be
more than one element at work.
Looking at it in this light, the necessity for fine points
of differentiation between pleurodynia — the old-fashioned
false pleurisy — and pleurisy proper is not so apparent.
Purely from a practical stand-point it matters little whether
the rheumatism is in the chest-wall, in the costal pleura
lining the same, or in the pulmonary pleura immediately
in contact with the latter. In a case of articular rheu-
matism we do not inquire so particularly as to whether
the external parts only are involved, or whether the
synovial membrane is also inflamed. There are few
cases of pleurisy which do not on careful examination
show strong evidences of pleurodynia or muscular rheu-
matism in the chest- wall, in addition to the signs of
fluid effusion, the pain from pleuritic irritation, and the
other classical symptoms of a full-fledged pleurisy.
Wnen we have a rheumatic joint do we treat the synovial
membrane or the capsular ligament ? Do we not rather
treat the rheumatism as a whole, and the local lesions
when indications call for it.
A disease so widespread as rheumatism, a disease
which is acknowledged to be capable of affecting almost
any portion of the anatomy, is fully capable of producing
pleurisy, and it only remains for a sufficient number of
careful observations, made with the end in view of settling
this point, to establish the truth of this matter.
It may be added here that I find it not uncommon for
a moderate pleural effusion occurring during the course of
an inflammatory rheumatism to be overlooked. Cough
and dyspnoea may be absent, and the pain in the side is
easily accounted for. That it is a more common com-
plication than is usually considered I am fully con-
vinced.
This list of cases attests the value of the salicylates in
promoting absorption of pleural exudates. Compare
and contrast this general plan of treatment with that ad-
vocated by Loomis, who gives opium the most prominent
place ; with Flint, who advises bloodletting, opium, and
aconite ; with Pepper, who says that the " treatment is
symptomatic ; " with the blisterers, the tappers, and the
" vis medicatrix " nihilists.
Can it be that we have something yet to learn in re-
gard to this disease beyond the best way to keep an as-
pirator valve in perfect order, to sterilize a trocar, or to
improve on Estlander's operation of thoracoplasty ? Must
we, on the other hand, go back to blind empiricism and
give salicylate of soda because it is "good " for pleurisy,
or antipyrin because it "absorbs" the effusion? Or
shall we bear in mind the diathesis, the underlying con-
dition, the predisposing cause, the etiological factor ?
A theory of some sort is better than empiricism. Let
this stand or fall as it deserves.
NEPHRITIS OF PREGNANCY AND ITS SE-
QUELS.
By EDWARD NICHOLAS LIELL, M.D.,
NEW YORK.
LECTURER M GYNECOLOGY, NEW YORK POLYCLINIC.
In proportion as our knowledge of the nature of disease
and the action of remedies increases, the practice of
medicine becomes more rational and its basis more
sound.
Though aware of the dangers not infrequently attend-
ing the nephritis of pregnancy, especially so in relation
to complicating eclampsia, we are still far from being
enlightened, definitely, as to the reason why albumi-
nuria so frequently attends pregnancy. It is immaterial,
in its clinical aspect, whether a distinct nephritis exists
previous to or follows upon the pregnant state, or
whether the condition existing during pregnancy be a
distinct nephritis or a simple albuminuria, the compli-
cations arising are practically of equal importance.
Many theories have been advanced to account for the
development of a nephritis or albuminuria, but their
value is unfortified when applied to etiology as a whole.
That which has gained considerable ground, and
which has been strengthened post-mortem, is pressure
of the lower uterine segment upon the ureters, causing
compression with subsequent dilatation of the latter;
more especially is this so in primipare, where the ab-
dominal walls are comparatively tense.
As the gravid uterus gradually enlarges, there is an
added pressure upon the various adjacent vessels, causing
a venous stasis. As regards the value of this pressure
theory, it may be well to state that record has been
made of various cases of ovarian tumors of large size, as
also uterine fibroids, which were complicated with albu-
minuria, in which, after operation, the albumin disap-
peared almost immediately.
In this connection, I would offer the query: May not
the reflex phenomena of nerve irritation, which so often
accompanies the pregnant state, prove a prominent factor
in the etiology ? The state of the general nutrition, oc-
cupation, and habits of life of pregnant women, have
little, if any, apparent influence in the etiology — a rather
remarkable feet.
Having in mind pregnancy in its early stage, there
can be no question of the substantial gain derived from
a more careful attention to the state of the kidneys;
especially in primipare, we should ever recognize the
importance of early and repeated examination of the
urine, enabling us generally to forestall any impending
renal complication.
In a nephritis existing previous to pregnancy, exam-
ination of the urine should be made at the outset and
continued during pregnancy.
Taking a known case of nephritis, existing either pre-
vious to or consequent upon pregnancy, we should bear
in mind the fact that the management of such case is
of prime importance ; it should have reference particu-
larly to three things : The relative amount of albumin
present, the presence of casts, and as to their number,
and a fair amount of urine excreted daily.
Very rarely we may find that examination of the urine
will prove negative as to albumin, yet the microscope
will detect an occasional cast ; such a case demands our
closest attention.
The presence of casts in the urine, a warning only too
significant, would lead us to surmise a lurking danger of
eclampsia during the final stage of pregnancy, during
labor, or subsequent thereto.
A few words here on the subject of eclampsia. To
enumerate the various explanations that have been given
September 22, 1894]
MEDICAL RECORD.
&7
for any length of time. When the stomach would toler-
ate it the fluid subsided rapidly. As soon as the remedy
had to be omitted it reaccumulated. This occurred
several times during the first week or ten days, and fur-
nishes strong proof of the efficacy of the salicylate in pro-
moting absorption of the pleural exudate. Eventually,
on account of the irritable condition of the stomach, it
was abandoned, and salol with antipyrin substituted.
This case has still some dulness at the base of the
pleural cavity, not due, however, to the presence of
fluid but to pleuritic thickening. The same condition
is observed to a slight degree in two other cases of like
character.
No claim is made that salicylate of soda is a specific in
pleurisy with effusion, or in dry pleurisies. But that it
will reduce the effusion, abate the cough, relieve the pain,
and cure the patient more rapidly and effectually than
any other remedy with which I am acquainted, this much
I am certain of.
Neither is there any claim for priority in the use of
this remedy, as I am well aware that Germain S6e, Au-
frecht, and many others have advocated its use. But
some three years ago, without the knowledge that it was
used by others in this disease, I began the use of this
remedy in pleurisies of rheumatic origin, and was so
well pleased with the results that I had no hesitation in
extending its use to cases which were not obviously rheu-
matic, using it since then persistently in all cases which
were non-purulent. It would be, of course, as absurd to
rely on the use of this remedy in empyema as to treat a
suppurative knee-joint on the alkaline plan.
In cases Nos. 24 and 33 two distinct attacks of pleurisy
occurred, with an interval of about one year. The pa-
tient was on anti-syphilitic treatment, and when the effu-
sion took place the only modification of the treatment
was the addition of full doses of the salicylate.
Nine cases occurred in connection with phthisis. In
no case was a pleurisy the starting-point of a phthisis.
Two cases occurred during convalescence from measles —
one as a complication of scarlet fever ; five followed or
were coincident with the various forms of pneumonia, but
in these cases the pneumonia played a secondary part
where the two were present at the same time.
Are the results noted due solely to chance — to the
happy use of a so-called specific? Or is the secret of
success in these cases due to the recognition of the under-
lying factor — the rheumatic diathesis ?
Pleurisy is not a fatal disease. Under any ordinary
plan of treatment the vast majority of cases eventually
recover. A few develop extensive pleuritic adhesions
and thickening, some empyemas, and still others run
into phthisis or interstitial pneumonia. As previously
noted, three of the cases cited developed pleuritic thick-
ening. As these cases were severe, as the disease had
existed in each instance for some length of time before
treatment was instituted, and as they were the kind of
cases which, according to my previous experience, usually
developed pus, I have reason to be satisfied that they re-
covered with no further trouble than the pleural thicken-
ing.
Is pleurisy rheumatic in its origin? Practically I
have found that the average run of cases is purely rheu-
matic.
Loomis says " the etiology of acute pleurisy is some-
times very obscure." He states that it occurs in con-
nection with injuries, pyaemia, the exanthematous fevers,
acute and chronic alcoholism, acute rheumatism, Bright's
disease, pneumonia, etc. Flint, giving practically the
same causes, mentions that " it is developed occasionally
in connection with acute articular rheumatism." Wil-
son, in " Pepper's Practice of Medicine,1' makes no men-
tion of it as a cause of dry pleurisy, and mentions it
merely as occasionally associated with pleurisy with effu-
sion. Other writers lay especial stress on tuberculosis as
the usual causative factor. Still others advocate the mi-
crobic origin. In fact, the list of possible causes is so
long and so indefinite as to resemble in its length and
uncertainty, at least, a chapter on the etiology of acute
rheumatism.
If these writers represent the profession as a whole, if
this is the generally accepted view of the causation of
pleurisy, then I am compelled to take issue with them.
I believe that the most prominent cause of pleurisy is
rheumatism. I wish it distinctly understood that I do
not hold that every case of pleurisy is rheumatic. That
the suppurative pleurisies are due to infection by the di-
plococcus of Fraenkel, by streptococci, or by staphylo-
cocci is admitted. That simple pleurisies may arise in
other ways is conceded. But that the commonest cause
is rheumatism I am convinced — rheumatism pure and
simple, rheumatism as an intercurrent affection, or
rheumatism engrafted upon some chronic tubercular or
other previously existing disease.
In reviewing the reasons which led me to arrive at this
conclusion I find that they are numerous.
To properly appreciate them a careful comparison of the
two diseases is necessary. The reader will bear in mind
that it is but fair to contrast the pleuritic inflammation
with the purely synovial inflammation in joint rheuma-
tism. The pleura is a serous membrane, a gliding joint
if you will, or an enlarged bursa, between the lung and
the chest-wall. Its function is to allow full movement
and to prevent friction, and it is lubricated with a serous
fluid. In other words, it is a modified joint, not be-
tween two bones, but between the lung and the thoracic
wall. Gray says that the synovial membrane " resem-
bles the serous membranes in structure, but differs in the
nature of its secretion, which is thick, viscid, and glairy."
This is a difference in degree, not in kind. We do not
use successfully the same lubricant for a lumber-wagon
and for the delicate mechanism of a watch, yet the prin-
ciple is identical. That the joint surface and the pleural
surface, or perhaps, more properly, the joint cavity and
the pleural cavity, are similar in structure, in secretion, in
function, and in the character of their inflammatory af-
fections, is evident. That slight variations are found is
but to be expected.
Pleurisy may be acute, subacute, or chronic. So also
a rheumatic joint. Pleurisy may result in the formation
of fibrin, serum and fibrin, serum, fibrin and pus, or
new connective tissue. It may be dry or wet, suppura-
tive or adhesive. Compare this with the changes which
occur in the synovial membrane of the knee-joint, for in-
stance. Have we not all seen a " dry " rheumatic joint
with distinct crepitus like that of pleurisy ; joints with
effusion from rheumatism ; joints with fibrous anchylosis
from this cause, and, though more rarely, abscess in the
knee-joint from a neglected rheumatic effusion which be-
came infected with pyogenic germs ?
A comparison of the statements of the majority of our
writers in regard to the etiology of pericarditis and of
pleurisy might be instructive. Wilson, in "Pepper's
Practice,1' states that "by far the most important cause of
pericarditis is acute articular rheumatism," yet he merely
gives passing mention of rheumatism as a possible cause
of pleurisy. Other writers take practically the same stand .
Yet in what essential does the one closed sac of serous
membrane differ from the other either in structure or in
function ? Why should rheumatism patronize the one
exclusively and boycott the other? Surely such par-
tiality is unfair ! Let rheumatism attack something of
its size, and not pitch solely into the smaller neigh-
bor.
An analysis of the forty- four cases in the list throws
some light on the subject. Sixteen cases occurred in
connection with acute rheumatic attacks, one with ton-
sillitis of a rheumatic nature (?), and one with severe
rheumatoid arthritis. This is in itself a strong argument.
A personal acquaintance with these cases and the mem-
bers of their immediate families shows something which
does not appear from the list of cases — that the rheu-
matic diathesis played an important part in many of
the cases which could not be classed as directly due to,
or associated with, distinct rheumatic attacks in other
37°
MEDICAL RECORD.
[September 22, 1894
tion has been relieved. The great prevalence of ear dis-
ease everywhere is also well understood, and the con-
nection between diseases of the nose, ear, pharynx, and
larynx. In diseases of the ear and upper air passages, as
I see them, there is always two main considerations, the
local and the constitutional, or the condition of the nose
and the condition of the apices of the lungs.
You often see cases in which both conditions exist.
The question to decide then is which condition, the local
or the constitutional, is the one which has most to do in
causing the disease of the ear, pharynx, tonsil, or larynx.
These two conditions do not account for everything, I am
well aware, and yet they claim consideration always as
regards prognosis and treatment.
The importance of apex catarrh in ear disease was
forcibly impressed upon me three years ago, when I was
in general practice and a visiting physician to one of
the hospitals. A boy, aged twenty, whose language no
one could understand, was brought to the hospital. The
only history we could obtain was that he had been sick
for six weeks and had had no medical attention. He
had a large accumulation of pus in the mastoid region,
and the house surgeon had lanced the abscess before my
morning visit, at which time I saw the case with one of the
surgeons. The ordinary local treatment in such cases
was proposed, and also it was suggested that calomel and
rhubarb should be given because of the marked gastro-
intestinal disturbance. I was not at all convinced that
the local condition accounted altogether for the boy's
condition, but thought it wisest to make no suggestion
as to apices. A few days later he died from a profuse
hemorrhage of the lungs.
Nearly one half of all the cases of ear disease in
patients from eight to forty years of age that pass
under my observation have also apex catarrh. Many
have hypertrophic rhinitis. Both conditions require
attention. While the increased susceptibility to colds
accounts for the acute inflammations of the middle
ear that are so often seen in patients with apex catarrh,
I have been repeatedly surprised at the number of cases
of chronic middle- ear inflammation that present them-
selves on account of their increased suffering under a
similar constitutional condition. These patients are often
people who have suffered for years from marked loss of
hearing, and who have ceased to believe that there was
any hope of relief. Upon the development of an apex
catarrh they begin to suffer more from catarrh of the
upper air- passages and to complain more from the sub-
jective symptoms. The examination of the ear often
reveals simply marked changes from an old inflammation,
and yet no trace of any acute trouble. Such cases under
creosote, without any local treatment, very soon regain
their usual amount of hearing. Even cases of posterior
adenoids in children over eight years of age are often as-
sociated with an apex catarrh. There is, of course, no
connection between the diseases. Whether chronic catar-
rhal conditions of the nose, naso-pharynx, or pharynx
predisposes a patient to an apex catarrh is an open ques-
tion. For my part I do not believe it. I can under-
stand how such conditions might be responsible for an
ordinary chronic bronchitis, but not how an apex catarrh
— a localized capillary bronchitis — could be dependent
upon any such cause. Posterior adenoids in many cases
cause few symptoms. If an apex catarrh occurs in such
a patient, the posterior adenoids become more trouble-
some because of repeated fresh colds, and the patient pre-
sents himself for relief. The statement made as to pos-
terior adenoids applies equally to chronic nasal catarrh.
The course of an acute follicular tonsillitis may be very
greatly modified when occurring in a patient with an apex
catarrh. The first few days there is nothing different
from the ordinary symptoms. At the time, however, at
which one expects the swelling of the tonsil to begin to
subside, and the tenderness to diminish, they are found
to be as marked as in the first two days of the disease.
In some cases the swelling subsides about as fully as in
the uncomplicated case, and yet the tenderness upon
swallowing is entirely out of proportion to anything
one can see in the throat.
Two years ago in February a girl, aged sixteen, pre-
sented herself at the clinic. She had been under obser-
vation three months before, for three or four weeks, with
an apex catarrh. After improving upon creosote she had
discontinued her visits. Three weeks before coming
under observation the second time she had had an acute
sore throat, from which she had not yet recovered. Dur-
ing this time she had been able to swallow only liquid
food. The swelling of the tonsils had largely passed
away, but the reddening was marked and the tenderness
upon swallowing very great A re examination of her chest
revealed a well marked apex catarrh still present. She
was given drop doses of creosote every hour. Within
twenty-four hours she swallowed solid food. The local
condition rapidly recovered, but the girl continued her
constitutional treatment for a number of months.
This is simply one of many cases that have passed
under my observation. They are by no means rare.
Three such cases consulted me last week. A large num-
ber of the cases of subacute or chronic laryngitis in people
in middle life are associated with an apex catarrh. Many
of these cases have also a hypertrophic rhinitis. Both
conditions have an influence upon the larynx. Both
ought to be treated of course. What to promise such a
patient as to the improvement of the throat for the first
three months is a difficult question. Every such case
improves in many ways when the course of the apex
catarrh is a hopeful one. The great majority of cases
recover of the laryngeal trouble within a few weeks after
cauterization of the nasal hypertrophies and the adminis-
tration of creosote. In a small proportion of cases,
although the patient improves in every way, the laryngeal
inflammation persists. After a few weeks' local treatment
my rule is to inform such patients that they must not
expect to be entirely relieved of the throat symptoms
until they have regained their general health — until the
disturbances in the mucous membranes, of which the in-
flammation of the larynx is only a part, shall have passed
away. It is recommended that stubborn cases of chronic
laryngitis be painted with increasing strengths of nitrate
of silver solution. •
I have never considered it advisable to pursue such a
course in a laryngitis of this kind. If one failed to con-
sider the constitutional condition of his patient, or did
not know that exceptionally a laryngitis might pursue
such a course, the local condition might receive over-
treatment. There is, to my knowledge, no way of deter-
mining which case will promptly recover, and which
case will persist, it may be, for months.
If the practitioner overlooks the constitutional condi-
tion, he fails to accomplish for the local condition what
he otherwise might do. This statement I realize because
I have only learned it from many a humiliation. I shall
never forget a child, aged six, that I had treated for
nasal catarrh for a number of weeks, and could not un-
derstand why the catarrh was not relieved. There was
nothing in her appearance to make me suspicious of an
apex catarrh. Finally, I examined her chest and found
the key to the situation at one apex. Under bcnzosol
her nasal condition passed away, almost at once. If
either condition must be overlooked, the local is of lesser
importance, and unless the specialist looks beyond
the local condition the patient had better be in the hands
of the sensible general practitioner. The local condition
is easy of diagnosis, the patient has made the diagnosis
himself, and will always insist on attaching undue impor-
tance to it. He has not as yet found out that his vitality
is below par. It is useless to say much to such a patient
in the beginning of his treatment. I aim to say enough
to impress upon his mind my belief that there is more at
fault than the local conditions. He soon sees for him-
self that my opinion of his case is correct. When this
time has arrived he will accept the statement that he will
be far from well when the local difficulty is relieved. It
is not claimed that the course of the local condition is
September 22, 1894]
MEDICAL RECORD.
37i
especially modified by the knowledge of the catarrhal
condition at the apex, t.e., the catarrhal condition of thfe
mucous membranes of the entire body.
Cases of apex catarrh recover upon any tonic treat-
ment. The specialist who gives iron because his patient
is anaemic, and then treats the local condition, is going to
benefit his patient ; or if he administer stomachics be-
cause there is a disturbance of the gastrointestinal tract,
the results will be satisfactory.
And yet how a specialist can intelligently treat the
ear and upper air-passages without taking into careful
consideration the facts herein stated is a mystery to me.
There is little science in administering iron because a
patient is anaemic The cause of the anaemia ought to
be found. If it is found to be due to an apex catarrh,
creosote is a much more satisfactory remedy.
I might have summed up the entire paper in one or
two sentences, and yet the subject has been treated at this
length in the hope that this view of disease of the upper
air-passages might be helpful. This is the result of years
of study. Such conditions certainly exist in Cleveland.
During 1888 and 1889 it was my privilege to work for a
number of months in the ear, throat, and nose clinics in
Vienna, and yet I never heard anything concerning the
condition I have endeavored to describe in this and a
succeeding paper. I never saw any observation made as
to the pulse and temperature in the out-patients. It has
been no easy matter to attempt to put my ideas on paper.
Whether I have succeeded, the reader must judge.
A FEW WORDS IN REFERENCE TO LIVING
CELLS VERSUS STAINING.
By WILLIAM MOSER, M.D.,
PATHOLOGIST TO ST. CATHARINE'S HOSPITAL, BROOKLYN, N. V.
I recently stated ' that " I was becoming more and more
convinced that Virchow's teaching not to stain tissues
was the best. ' ' Of course this does not apply to bacterio-
logical examinations, but to general pathological work,
such as the examination of tumors, etc. By this state-
ment I did not intend to underestimate the value of re-
cent advances made in processes of staining, such, for
instance, as Golgi's method in the examination of the
nervous system, but rather to draw the attention of the
profession to the fundamental difference between a living
cell and a dead cell — to living tissue and dead tissue —
facts which have not been sufficiently considered. The
great objection to our ordinary laboratory examinations
lies in eliminating artificial products, and in the radical dif-
ference which must and does exist between the living and
the dead cell. My own observations on the blood-cells,
which I have lately published and to which I wish to revert
merely for purpose of illustration, show that the red
blood corpuscle which does not, as a rule, with few ex-
ceptions, stain with methylene -blue by our regular labora-
tory method, will do so when this substance is given in-
ternally. While the red blood-corpuscle will imbibe
methylene-blue when given internally, it does not do this
in all cases alike. I mean that it is influenced by various
factors — by the condition of the cell. In some cases it
will take weeks to become stained, while in pernicious
anaemia it will stain readily. Even on the dead red
blood-corpuscle this tendency in pernicious anaemia to
imbibe not alone methylene-blue, but other stains, has
previously been noted. But it becomes more manifest on
the living cell. It has long been known that the nucleus
of a cell has a special affinity for certain stains, viz. ;
Carmine, haematoxylin, aniline, hence the term " chro-
matin " (nuclein), which Fleming applied to it. During
the process of karyokinesis the mass of threads formed
are chromatic, while certain threads are achromatic (do
not imbibe these stains). My observations on the nuclei
of the white blood- corpuscles in which methylene-blue
had been given internally, that is in dealing with living
cells, prove to me beyond doubt that the term " chroma*
1 St. Catharine's Hospital Report, 1893.
tin" for the nucleus of a cell has not been misplaced.
While it must be admitted that on the living cell the pro-
toplasm imbibes the stain, it rarely does it so markedly
as does the nucleus. It has long since been demonstrated
that certain intra-cellular parasites, such as the Plasmo-
dium malaria, which usually finds its habitat within the
red blood corpuscle, has, like the nucleus of a cell, a
special affinity to imbibe certain stains. This can
readily be seen by our ordinary method of staining this
parasite with methylene blue in the laboratory. Indeed
some writers l regard this affinity of the Plasmodium for
methylene-blue as quite characteristic, and think that
this property will often enable us to distinguish it from
other intracellular parasites. By giving the stain inter-
nally this affinity of the Plasmodium to imbibe it can
readily be demonstrated. And, strange to note, it will,
in a brief space of time, cause the disappearance of the
Plasmodium from the cell, or, in fact, from the blood.
My observations on this point confirm those of Mati-
enzo,a who first made known this fact. It was for that
reason that he recommended methylene-blue in the treat-
ment of malaria in some cases in place of quinine, etc. It
is to be regretted that it does this, because if the living cell
with its parasite retained the stain, like the nucleus or
nuclei of the white blood-corpuscles, what a splendid op-
portunity it would afford us to study the life history of
the Plasmodium malaria ! I believe we may yet find a
stain to do this. I have tried eosine, but was unsuc-
cessful It is possible that we may be more successful
with carmine or haematoxylin. It is apparent that while
we can stain the blood-cells during life we cannot do this
with all cells in the body. If this were so, what a differ-
ence it might produce in histology and pathology !
158 Ross Strbst, Brooklyn, E. D.
TREATMENT OF FRACTURES AND SPRAINS
OF THE ANKLE BY MASSAGE.
Bv ALEXANDER C. WIENER, M.D.,
CHICAGO, ILL.
While there has been great activity in all branches of
operative surgery, and strenuous efforts have been made
to improve present methods and to introduce new ones,
yet in the treatment of fractures there has prevailed a
manifest reluctance to change the old and approved
methods. What else can account for the total disregard
paid to the theses delivered by Lucas Champonni&re at
the Paris Soctet6 de Chirurgie, June 26, 1886, on the
treatment of fractures by massage ? His ideas suggested
a complete revolution in the treatment of fractures, al-
though this method of treatment has nowhere received
such general recognition as in France.
The treatment by massage fulfils in general the three
following conditions : 1. It shortens materially the time
of recovery and lessens the period of ossification. 2. It
gives better results functionally. 3. It lessens the pain
of the treatment.
Since then massage has been recommended for all ar-
ticular and periarticular fractures ; but in no case has it
produced more striking and indisputable results than in
the treatment of fractures of the ankle and the various
sprains of the foot. In such cases this is the classic
treatment. When we consider that the expectant treat-
ment of immobilizing the foot in splints or in plaster re-
quires at least thirteen weeks for the recovery of a fract-
ure of both bones, two-thirds of this time being required
to overcome the stiffness of the joint and the atrophy of
the muscles resulting from the immobilization, a method
of treatment tha^diminishes the time by one-half is
worthy of consideration.
A simple sprain of the foot treated by the expectant
method, that is, by bandages and rest, renders the foot
useless for twenty-five days on (an average, whereas the
patient treated by massage can move about freely after
1 Adler : Protozoa and Their Relation to Carcinoma.
Journal of the Medical Sciences, January, 1894.
9 La Gaceta Medica, 1893.
American
37*
MEDICAL RECORD.
[September 22, 1894
eight days. Twenty-five per cent, of all the fractures
that occur affect the ankle. The sprains to which this
joint is subject are numberless ; and what a wide field this
opens to the physician, who, as a rule, prefers to take an
active part in the process of recovery rather than to ap-
ply a bandage and see himself reduced to the part of a
passive spectator.
The diagnosis of fractures of the ankle offers no diffi-
culties ; but I beg to be permitted to say a few words re-
garding the mechanism of the different fractures, since
an understanding of this is essential to successful treat-
ment. Fracture of the inner malleolus is produced by
the forced lowering of the inner and raising of the outer
margin of the food. The deltoid ligament being the
first to meet the force is, as a rule, not torn, but tears
off the end of the tibia, to which it is attached. The
foot is then allowed to roll around its inner border into a
most pronated position. The outer malleolus is driven
against the outer border of the calcaneus, and in most
cases the end of the fibula breaks off six or seven centi-
metres from its lower end (Pott's fracture). The next
most frequent cause of fracture of the inner malleolus is
dorsal hyperflexion of the foot. The simple fracture of
the outer malleolus (Dupuytren's fracture) is produced
by forcing the foot down on its outer border. In many
cases only the outer ligament, that is, the ligament cal-
caneo-fibulare, is torn in consequence of the supination
of the inner border of the foot, but usually the lower
three centimetres of the fibula are broken off transverse-
ly. The fragments are not usually dislocated, being held
in place by the ligament tibio fibulare. The action of
the force upon the joint affects only the ligaments
immediately. If they are not torn they transmit the
force to their place of attachment to the bone and thus
a solution of continuity is produced. The mechanism
of the simple sprain of the ankle joint and its fracture is
the same, the difference lying only in the intensity of
the force exerted. This difference is still slighter when
we consider the great extravasation of blood in the ankle-
joint which is produced in tearing the ligaments.
Massage has for its object the prevention of the normal
degeneration and the removal of the blood from the
joint and the oedema from the soft parts. The treatment
during the first eight days is of the utmost importance.
The blood must not be allowed to coagulate ; the process
of regeneration in the bone, which begins, at the latest,
a few hours after the injury, must be accelerated by stimu-
lation.1 The pain must, as a rule, be relieved in three or
four sittings. Massage must begin immediately, pro-
vided there is no dislocation of the bone. In fractures
of both bones the astragalus has lost its position, the foot
wabbles about and frequently the astragalus is dislocated
backward. As the bones always consolidate in the posi-
tion which they take of themselves or in which they are
placed, an immediate reposition, if necessary under an
anaesthetic, and retention in this position are indispen-
sable. These are the only cases in which immobilizing
is indicated. The foot is placed with light pressure in a
position perpendicular to the leg, and then placed in a
plaster cast ; a woollen or silk stocking may be used
next to the limb and a three inch plaster- of- Paris band-
age applied. The bandage reaches to the upper third of
the leg and encloses the whole foot except the toes. For
strengthening the cast at the sole of the foot, a strip of
paste-board may be included. After three days a return
to a wrong position need not be feared. The bandage
is removed and treatment by massage begins. If, as
occurs occasionally, the astragalus again becomes dislo-
cated, a paste-board splint may be made, which can be
easily put on or removed. Massage MP recent sprains or
fractures is to be practised under the same aseptic pre-
cautions as for recent wounds. The foot and leg are to
be thoroughly cleaned with warm water, soap, and brush,
the hair removed and the skin then carefully dried. The
physician's hands must also be thoroughly cleaned.
Disinfecting agents must not be used, as they irritate the
1 Formativer Reiz, Virchow.
skin too much. The epidermis always presents minute
openings through which pus-forming agents may pene-
trate and find rich soil in the extravasated blood. The
limb is then well anointed with sweet-oil or vaseline, and
placed on a solid support. If there is a tendency to a
return of the dislocation in the first few days after the re-
moval of the bandage the foot must be held in the proper
position by an assistant. In simple sprains I prefer to
apply massage while seated, the patient's limb being sup-
ported on my knee.
Massage consists in a gentle pressure of the volar sur-
faces of the united fingers moving in a centripetal direc-
tion. At first one must avoid touching the fracture and
must not continue the sitting too long. The first treat-
ment should not exceed ten minutes. From the fourth
sitting on, each one should occupy at least twenty min-
utes. For practical reasons I would have only one sitting
a day and make them somewhat longer. In making the
passage from the periphery toward the centre, the blood
exudate and oedematous fluid are pressed toward the
lymph spaces and urged toward the heart. How power-
fully the lymph currents are stimulated is shown by the
fact that after a few days the lymphatics of the legs and
thigh become visible from the coloring matter of the
blood which they contain. The hyperemia of the veins
and the troublesome throbbing and heat in the joint are
also promptly removed and the rich arterial blood sap-
ply promotes the healing of bones and ligaments. The
muscles preserve their elasticity and the equilibrium of
their metabolism ; their contractions assist the flow of the
blood into the more deeply lying veins. The painful con-
tractions which follow the over-stretching of the muscles
and tendons disappear rapidly. The most immediately
favorable result of the massage for the patient is the fact
that the treatment after three or four painful sittings be-
comes almost painless ; for, with the removal of the ex-
travasation, the pressure on the sensory nerve ceases. At
the end of the sitting the abundant oil on the surface is
removed with alcohol, which has a pleasing, cooling
effect on the stimulated skin. The fractured limb is
wrapped in a cloth moistened with cold water and the
air kept out by a covering of oil-cloth. These coverings
are changed every two or three hours. A little acetate
of lead or witch-hazel may be added to the water. Ice
should never be applied to the fracture ; it coagulates the
extravasated blood too rapidly and produces anaemia; in
short, all the beneficial effects of the massage are undone
by ice. Hot water, 1 oo° to 1 05 ° F. , in form of local baths
applied for half an hour each day assists the massage by
removing the extravasated fluid.
The second essential in treating sprains and fractures
by massage is not to immobilize the joint. All immo-
bilizing of the foot hinders the recovery and lessens the
usefulness of the foot. The only exception to this rule
has already been mentioned. Since in fractures of the
inner malleolus the foot is always inclined to be pronated,
that is, to be flat-footed, especial attention should be given
to the position of the foot. The leg should rest on a solid,
somewhat elevated support. The sole of the foot presses
against a smooth, polished, square board, which is placed
at right angles to the support, and in such a manner that
the inner border of the foot stands higher that the outer.
If the astragalus during the treatment is inclined to be-
come dislocated backward, an elastic cushion should be
placed under the heel, so that the bone will be held in
place by the weight of the leg. The pes valgus position
of the foot is most easily corrected by the application of
an elastic flannel bandage ; but the joint must be left
freely movable. The advantages in not immobilizing
the joint are apparent. The flexors and extensors of the
foot remain in continuous activity and in the perpendic-
ular position of the foot the antagonizing muscles main-
tain their equality. The pressure of the foot against a
fixed surface provokes continuous elastic movements in
the ankle around a transverse axis, which prevents the
formation of synovial adhesions and atrophy of the artic-
ular cartilages. The mobilization of the joint fulfils for
September 22, 1894]
MEDICAL RECORD.
373
the most part the same indications as the massage ; both
are equally important factors in the cure, they combine
and co-operate with each other. The maintenance of
the muscular tonus produces a continuous auto-massage.
The patient himself, not being hindered by any band-
age, is continually tempted to test his progress ; he makes
active movements in the injured joint, even when, as at
first, the sensations are not agreeable ; he is interested
in hastening the progress of the cure by its own activity.
According to my experience, it is not advisable to make
passive movements.
In more serious sprains of the foot, the recovery re-
quires four to eight days ; in simple fractures of the outer
malleolus ten to twenty- one days; in fractures of both
ankles, especially with dislocations of the fragments and
luxation of the astragalus, the time is variable, usually
from four to six weeks. The eight clinical histories which
Lucas Champonni&re gives in his lecture are all cases of
fracture of the outer malleolus. Only once was the inner
malleolus also dislocated. In no case was there disloca-
tion or abnormal mobility in the ankle-joint. They
were all treated with massage from the first day without
immobilizing bandages. Champonntere considers the
first day on which the patient can walk without assistance
as' the day of recovery. The shortest time was twelve
days, the longest twenty- eight, 'average, twenty and two-
tenths days. '^TiT* - > !*'• % -», "?
In the City Hospital in Magdeburg,' sprains and fract-
ures of the foot are treated by massage since the year
1888. I had the honor of proposing the new mode of
treatment to my chief, Dr. Hagedorn, lately deceased,
and we obtained results which were new and surprising
to both of us. The number of cases treated in the years
1888 to 1891 was about one hundred. We considered
the patient cured when he had recovered the use of his
foot. The average duration in sprains was seven days,
in single fractures of the outer malleolus twenty days.
It would take too long to illustrate the simple cases
by clinical histories. I shall limit myself to a few typical
cases and shall give the preference to the severer one.
Cass I. — Man, twenty-eight years of age. Fracture
of the external malleolus without dislocation. Consider-
able extravasation of blood in the ankle-joint. Massage.
No bandages. Got up in ten days and walked without
a cane. In twenty- two days able to work.
Case II. — Strong laborer, forty-two years of age.
Admitted into the hospital November 6, 1888; dis-
charged December 8th ; the time, thirty-two days. Fract-
ure of the left internal malleolus ; dislocation of the
lower fragment, 2ctm.; foot not actively movable, hang-
ing loose at the ankle-joint ; traumatic swelling of the
whole leg below the knee. Careful reposition. Massage
did not remove extravasated blood as rapidly as usual.
Case III. — Blacksmith, twenty-three years of age;
admitted, July 29, 1888 ; discharged cured, August 20th;
time, twenty- two days. Fracture of both malleoli with
considerable dislocation of the fragments. Pes varus
position. After careful reposition, massage ; but as it
caused too great pain, it was discontinued for two days;
limb placed in Volkmann's splint. From August 1st the
pain decreased rapidly. Massage twice a day, ten min-
utes each time. August 8th, the patient was able to
stand on his foot ; foot freely movable in all directions.
Case IV. — Healthy sailor, forty-six years of age, ad-
mitted October 30, 1888; discharged December 13th;
time, forty-four days. Typical Pott's fracture. Foot
hanging loose from the astragalo-tibial articulation ; an
audible sound in making passive movements. Repo-
sition, massage. When discharged had still slight
oedema evenings.
Case V. — Typical Pott's fracture. Admitted Novem-
ber 14, 1889; discharged December 12th; time twenty-
eight days. Foot after reposition inclined to become
dislocated backward, necessitated the use of Volkmann's
splint for the first seven days in connection with the
massage treatment. Tendency to talipes position ; re-
covery complete. Considerable callus on each side.
Case VI. — Fireman, twenty-five years 01 age; ad-
mitted February 10, 1890; discharged March 5, 1890;
time, twenty- three days. Typical Potts' fracture ; great
extravasation of blood in ankle-joint, which could not
be actively moved ; no dislocation. No immobilization ;
massage. February 16th all movements of the ankle-
joint painless ; beginning callus formation.
Case VII. — Laborer, forty-six years of age, admitted
December 6, 1888; discharged February 16, 1889;
seventy-two days. Pott's fracture of the left ankle ; great
dislocation of the foot outward (pronation); coEsid era-
able extravasation of blood into the ankle-joint. Mas-
sage; the foot was held in pes valgus position by
wrapping in flannel ; formation of callus weak at first ;
resorption of the extravasated blood followed promptly.
On the twenty-first day of treatment, the patient got out
of bed contrary to orders and walked about, before the
ends of the fracture were consolidated. The foot as-
sumed in consequence a flat-footed position very difficult
to correct Extensive formation of callus did not begin
until the eighth week. At the time of his discharge, the
ankle-joint was freely movable actively and passively in
all directions; position of the foot normal; walking
without pain.
All these cases were injuries occurring in healthy per-
sons. The period of treatment exceeded six weeks in
only one case. This case is given on account of its
abnormal duration and the lack of sufficient formation of
callus. As a rule, an abundant callus formation is char-
acteristic of the treatment by massage ; the periosteum
reacts to the formative stimulus of the massage so actively
that later on in the treatment the point of fracture had
better be left out of the field of massage. According to
more recent experience it would be better in such cases
to allow the patient to move about with ankle encased
in a well-fitted plaster bandage properly padded with a
thin layer of cotton. At first, from motives of prudence
and because we could not free ourselves entirely from
the immobilizing of the joint, we used Volkmann's
splint, especially at night. Later, in severe dislocations,
as described above, plaster of- Paris and pasteboard band-
ages were used. If the patient is restless or asleep, or if
he has delirium tremens, a light pasteboard bandage may
be used.
The duration of the treatment depends not only on
the severity of the fracture, the amount of the extravasa-
tion and the recurring faulty position of the foot, but
also on the general health of the patient, his determina-
tion and energy, as well as the skill of the physician and
his ability to render the patient able to bear the very
considerable pain of the first few sittings. In general,
treatment requires longer in women than in men. Con-
tra-indications in the treatment of massage are : Psychi-
cal disorders, wasting diseases (tuberculosis, diabetes) as
well as all synchronous acute or chronic, septic and
pyaunic processes. Injuries to the skin over the region
to be treated must be protected against infection by seal-
ing the wound with iodoform collodion and aseptie
absorbent cotton.
When the patient again returns to his work oedema-
tous swelling of the injured joint sometimes occurs, or the
foot, when too severely used, again takes the flat-foot
position. To prevent this the patient must for a few
weeks support the injured limb with a bandage of elastic
flannel or silk, so as to raise the inner margin of the foot.
Leather shoes, not too wide, but comfortable, with a cork
sole on the inner side of the foot, prevent an incorrect
position. For rapid resorption of the superfluous forma-
tion of bone, tepid salt baths may be used and rubbing:
with an ointment containing iodine and iodide of potash.
The treatment of fractures and sprains must undoubt-
edly be conducted by the physician himself, and only
when no more complications need be feared should the
massage be intrusted to a skilful and experienced nurse.
It is to be regretted that massage, the salutary effect of
which on the organism has been recognized by the oldest
civilizations, such as the Chinese, and later the Greeks,.
374
MEDICAL RECORD.
[September 22, 1894
should be degraded to unworthy purposes in our modern
civilization and should be practised by people whose total
ignorance of the human organism and the characteristics
of diseases occasions more harm than good. I am, there-
fore, well aware of the difficulties which have yet to be
overcome before the practice of massage in its various
forms will be taken up by the physician and recognized
by the public as a necessary and desirable accessory of
the conscientious physician in the exercise of his profes-
sion.
^voQvess at f^tjedical jKcience.
Renewed Virulence of Staphylococci after a Long
Period of Latency. — Dr. Schnitzler relates the case of a
patient who, at the age of seven years, received a severe
injury to the right leg, resulting in a localized osteo-
myelitis of the tibia. This subsided in about six
months, after discharge of pus and sequestra (The
British Medical Journal), The patient had been quite
free from symptoms, local or general, for thirty-five
years, when he was suddenly attacked by severe pain in
the former seat of disease, attended by much general
febrile disturbance. The signs of localized osteitis
quickly became manifest ; there was no discharge. On
chiselling through the dense and thickened bone at the
seat of disease, a closed cavity, the size of a walnut, con-
taining granulations and pus, was found. In the granu-
lations staphylococcus pyogenes aureus was present in a
very virulent condition, as shown by inoculation of rab-
bits. Schnitzler adduces reasons for believing that the
cocci had lain dormant in the cavity for the long period
mentioned, being brought once more into activity by cir-
cumstances unknown. He rejects the supposition that
a fresh supply of cocci had been received into the circu
lation and deposited at the diseased spot. He points
out that staphylococcus pyogenes aureus is capable of
existing upon nutrient media under unfavorable condi-
tions for a very long period, and argues that a cavity
containing granulation tissue well supplied with blood,
such as was present in this case, offers a very favorable
prospect for the prolonged existence of micro-organisms.
There is frequent renewal of nutriment and removal of
waste products. The case, in Schnitzler's opinion,
shows that pyogenic cocci are capable of remaining la-
tent in the human body for a great period of time, again
becoming virulent on some chance disturbance of the
normal processes of metabolism. _>
Starting-Points of Tuberculous Disease in Children.
— At a recent meeting of the Medical Society of London,
Dr. J. Walter Carr read a paper based on 120 necropsies
upon children suffering from tuberculous disease, in
which he drew the following conclusions :
1. Tuberculous disease commences usually in the
glands, the liability being at its maximum during infancy
and early childhood, and rapidly decreasing in later
childhood. But, of the 120 cases, the disease had al-
most certainly commenced in the glands in 70, or 58.3
per cent, (including 13 in which glands only were in-
volved), and in 1 7 more, or 14.2 per cent., there was con-
siderable probability at least that the glands were the
primary focus. Including doubtful cases, the glands
formed the primary focus in 64.5 per cent, of those
under five, and in only 37 per cent, of those above that
age.
2. Tuberculous lesions in the cervical glands, as in
the joints, may arise by infection through the blood-
stream, but caseation of the bronchial and mesenteric
glands, when primary, is usually, if not always due to di-
rect infection from the organ with which they are con-
nected, it having been shown that bacilli may pass
through the lungs or the intestinal walls without produc-
ing any recognizable lesion, and that they then enter the
lymphatic channels and not the blood-vessels.
3. Tuberculous disease starts much more frequently
in the thorax than in the abdomen, and certainly far
more often in the thoracic than in the mesenteric
glands. Of the 120 cases, in 79 the disease probably
started in the thorax (in 54 certainly, and in 12 possibly
in the bronchial glands) ; in 20 in the abdomen (in 1 2
certainly and in 2 possibly in the mesenteric glands) ;
and in 6 in either one or the other cavity. In only 2
cases were the cervical glands the probable primary fo-
cus. The conclusion is that, though infection undoubt-
edly does occur through the intestines, and especially
(as experiments on animals have shown) through milk,
yet infection through air is by far the more frequent and
important. The disease is so commonly generalized in
children that figures merely giving the frequency with
which different parts are affected are of little value, the
important point being to ascertain where the disease is
most advanced — that is, where it probably commenced.
4. Caseation of internal glands, from the frequency
with which it is found after death, must often exist alone
and quite unsuspected, being doubtless in many cases
quite impossible of diagnosis, and it is very necessary to
realize its frequency and importance when dealing with
obscure febrile conditions in children.
5. In regard to treatment, prophylaxis is by far the
most important ; and as it is probably impossible to pre-
vent bacilli from obtaining access, we must try to in-
crease the resistive powers of the system to their
entry, aWrve all by keeping the mucous membranes
healthy, by dealing promptly with, and if possible pre-
venting, rickets — the great cause of catarrh in early
childhood — and by taking especial care of children dur-
ing convalescence from acute specific fevers, which so
depress the vitality of the body generally, and the resist-
ant power of the mucous membranes, as well as the filter-
ing power of the glands in particular. — British Medical
Journal,
The Cause of the Mai de Montague Experimentally
Determined. — The Paris correspondent of The Lancet
writes that it is proposed to bore a tunnel or chimney
extending from the base to the summit of the Jungfran.
In this chimney, whose height will be four thousand
metres, it is intended to install a lift destined to convey
passengers to the top of the mountain; but sinister
warnings of the dreaded mat de montagne, which, it is
said, will surely make the tourist repent his temerity,
have brought the project to a standstill. Struck by the
fact that this malaise affects mountain-climbers at an ele-
vation of about three thousand metres, while aeronauts
only suffer when they have reached double that height,
M. Regnard concludes that the difference is explained
by the factor, muscular fatigue, which is present in the
first and absent in the second case. In order to solve
the problem he places under a bell jar two guinea-pigs
equally developed, of whom one has to work a wheel
(the climber) while the other is at rest (the aeronaut).
The air of the bell- jar is then progressively exhausted so
as to reproduce the atmospheric conditions obtaining at
different heights. At a pressure equivalent to three
thousand metres the climbing guinea-pig showed signs
of distress, and at four thousand eight hundred metres
he renounced the struggle and remained lying on his
back. The aeronautic guinea pig, on the other hand,
appeared quite comfortable up to an elevation of six
thousand metres, and his condition became serious only
at a height of eight thousand metres. This experiment
appears to prove that, although some of the symptoms
of the mal de montagne are doubtless due to the rarefac-
tion of the air, the chief determining cause is fatigue,
and the resulting exaggerated consumption of oxygen.
M. Regnard opines that tourists who venture on the
Jungfrau-lift expedition will reach the top in good con-
dition. Should this prognostication be true, it consti-
tutes one more proof of the usefulness to speculators of
the much-maligned experiments conducted in the phys-
iological laboratory. Rabid anti-viyiaectionists cannot
now, however, logically avail themselves of the above*
mentioned mode of transit to the top of the Jungfrau.
September 22, 1894]
MEDICAL RECORD.
375
Medical Record:
A Weekly Journal of Medicine and Surgery.
GEORGE F. SHRADY, A.M., M.D., Editor.
Publishers
WM. WOOD & CO., 43, 45, & 47 East Tenth Street
New York, September 22, 1894.
THE ANTITOXIN TREATMENT OF DIPH-
THERIA.
The report of Dr. Biggs to the New York City Health
Department on the value of the antitoxin treatment of
diphtheria has naturally excited great interest in lay as
well as medical circles. The work in this direction was
not unfamiliar to our readers, for reports of it have been
published from time to time in these columns. It is
rather unfair that Professor Koch should be getting the
credit, since it is not he who has been making the inves-
tigations, but Behring, Aronson, Katz, Surinow and
others. Early in August, Dr. H. U. Walker gave an
account of the results that had been obtained in Berlin
{British Medical Journal, August 18th). Katz's report
of the employment of Aronson's antitoxin in the Berlin
Children's Hospital shows best what the effects of treat-
ment are.
Dr. Ratz states that, " In the last threeyears, 1891 to
1893, 1,081 cases of diphtheria have been treated in the
hospital, of which 421, or 38.9 per cent, died, the mor-
tality in the respective years being 32.5 per cent, in
1 89 1, 35.4 per cent in 1892, and 41.7 per cent, in 1893.
From the commencement of this year up to March 14th,
86 cases have been treated, with 38 deaths, or a mortal-
' ity of 41.8 per cent. On the latter date the antitoxin
treatment was commenced and employed in 128 out of
151 cases admitted to the hospital, 23 cases not being
subjected to it for various reasons. In the 128 cases so
treated only 17 deaths occurred, the mortality thus fall-
ing from 41.7 to 13.2 per cent. In all his clinical ob-
servations Dr. Katz is able to say that on no occasion
could any deleterious effect be ever attributed to the em-
ployment of the antitoxin solution. If renal inflamma-
tion did occur, it followed quite a normal course, no bad
effect could be observed upon the rhythm or tone of the
heart and pulse.
Quite lately Dr. Katz has inoculated 72 children who
had been exposed to the disease. Of these only 8 were
attacked, and they so slightly as to be free from any evil
consequences.
Dr. Thomas Eastes reports, in the British Medical
Journal of August 25th, seven cases of diphtheria suc-
cessfully treated by the new method. He also gives a
description of the technique which we reproduce here.
He says:
" The syringe I have used is Debove's, a beautiful but
complicated and expensive instrument. Any syringe
will do that can be sterilized either by boiling or immer-
sion for a few hours in a five per cent, solution of car-
bolic acid, but it is better if it will hold at least 5 c.c. (85
minims). The skin should be washed, and then cleansed
with absolute alcohol where the injection is to be made.
The dose should be 1 c.c. to produce immunity for any
aged over three, half that for younger children. For
cure during the first two or three days under two years of
age, 2 to 3 c.c. ; from two to ten years of age, 5 c.c. ;
over ten years of age, 10 c.c. j after the third day in a
severe case twice as much. If worse symptoms should
ensue after the injection the dose should be repeated in
twelve hours. It seems doubtful whether any symptoms
whatever are caused by the injection, and in cases of ex-
ceptional severity larger doses still should be used.
Usually there will be distinctly less oedema and a fall in
temperature in from twelve to twenty-four hours, and a
most marked improvement in the general condition in
forty- eight hours. The advantages of this treatment are
many in addition to its efficacy. The injection once for
all into the tissues of the back gives very little pain, and
there is no more interference with the patient required at
all — no more painting, spraying, or swabbing the throat,
no tearing off false membrane — and consequently a most
welcome diminution of suffering and distress."
In this connection it may be stated that simpler
methods of preparing an antitoxin have been described
by Surinow (Ber. Klin. Woch., July 23d). On the
ground of the change from toxin to antitoxin being a
chemical one, he has endeavored to induce, by oxida-
tion or reduction processes, properties in the serum of
healthy or diseased animals like those possessed by im-
mune animals. Positive results were obtained only by
electrolysis. By exposing 100 c.c. of dog's serum to a
current of 120 to 140 milliamperes from three to four
hours, the author obtained a serum which, when inject-
ed into animals, produced a rise of temperature. The
change produced in the serum is due to an alteration in
the albumin. Many animals were infected with diph-
theria, etc., and then treated with this simple electro-
lyzed "serum. They all died, however, notwithstanding
that a high temperature was produced. The author then
took ordinary serum, or its constituents, and inoculated
it with diphtheria culture. After some time toxins were
produced. A globulin culture was also made, but in
this no toxins were developed. The serum or serum al-
bumin cultures were then electrolyzed, and it became
evident that the toxins could then be converted into
antitoxins. Animals were inoculated with diphtheria,
and then treated with the antitoxins thus obtained.
Some of the experiments were not successful, but it was
thought that a more powerful antitoxin could be ob-
tained* It was found out that electrolysis of a bouillon
diphtheria culture also converted the toxins into anti-
toxins. After a certain time a color reaction is devel-
oped in the electrolyzed fluid, and at this time the elec-
trolysis should cease. Some successful experiments are
then recorded where the antitoxins from this electrolyzed
bouillon were used instead of those from electrolyzed
serum or serum albumin. It was found that a single
large dose administered subcutaneously was more effi-
cient than divided doses. The antitoxins were harmless
to the animals, and preserved their properties for a long
time.
376
MEDICAL RECORD.
[September 22, 1894
SARSAPARILLA, CELERY, AND RED CLOVER.
We have at different times referred to the curious popu-
larity of sarsaparilla and its growing rival, celery. It is
abundantly shown that neither of these plants have any
real therapeutic properties. A third candidate for popu-
lar favor is "red clover," and this seems equally defi-
cient in therapeutic or physiological properties*. Ac-
cording to the announcements clover extract has a
" great and growing reputation as a blood-purifier, and
as a specific for cancers." The number of individuals
whose "cancers " are said to have been aborted or dis-
persed by clover-tea is legion. It is not only good for
"cancers," but for other morbid productions, even
"carbuncle" and "scrofula."
It is needless, says the Boston Medical and Surgical
Journal^ to say that no medicinal principle has yet been
obtained from the trifolium. We shall expect next to
see an extract from the potato or turnip vaunted for can-
cer or syphilis ! There is, by the way, still a belief in
certain localities that the tomato is a cause of cancerous
growths ! Our contemporary adds : It is hard to account
for the repute that clover has acquired among the laity
of this country as a remedy for cancer. In many parts
of New England we know it to be almost impossible for
a person to have a suspicious growth of any kind with-
out being urged to take clover, and the urging is per-
sistent. In a certain neighborhood near Boston, one
woman, afflicted with growing scirrhus, is said to have
consumed in extracts and infusions of red clover the
product of a ten acre lot ; but without saving her life.
The fact that the cancers do not disappear, despite the
free use of the antidote, appears to detract in no measure
from the sale or use of the preparation.
There is no sound basis for the reputation which red
clover has acquired, and the only persons who have ever
derived any advantage from the use of clover in cancer,
furuncle, or various " humors," are the venders of cer-
tain extracts, fluid and solid, which are in growing de-
mand.
THE GAS HABIT.
The so called "exposures " made by the daily papers are
often sensational, exaggerated, and unjust. A reporter
of The Herald, however, has done some service by in-
vestigating one of the compound oxygen establishments
in this city. Oxygen is a substance* which to the lay
mind represents all that is fresh and pure and life-sus-
taining in the line of gases. " Compound oxygen " is
a term which gives the impression that it is something
several times better than oxygen. Hence it is a name
that has long been popular with the fakirs. Some ad-
vertised preparations of it have been inhaled, some
taken internally, all with the result of receiving numer-
ous testimonials. The establishment whose methods
have lately been exposed dispensed under the name of
" compound hydrogen " a gaseous mixture of about two
parts nitrous oxide and one part atmospheric air. This
was administered by means of an elaborate apparatus
which enabled the patient to recline at his ease and in-
hale the gas slowly and intermittently. The stimulant
effect of the mixture was thus obtained without inducing
anaesthesia or unconsciousness. Patients describe the
effect as very delightful, and many returned for weeks
and months in order to enjoy this seductive form of
inebriety*
There seems little doubt that a gas hatih or a form of
gas-inebriety can be induced by this promiscuous admin-
istration of the " compound oxygen." One case indeed
is on record (Robert's Intoxications n) in which a per-
son acquired the habit and eventually became insane.
The ether habit and chloroform habit are well known,
and there is no reason to doubt that given the opportu-
nity, the nitrous-oxide habit may be formed also. The
effects of this gas are usually very temporary and it
would require a good deal of time for serious results to
ensue, provided the anaesthetic were given with care.
But it is well known that nitrous oxide is not a perfectly
safe substance. Deaths from its use have occurred, and
cases of serious nervous disorder are reported to have
followed its administration. It is in fact a poison, and
we believe that it should not be administered except un-
der the direction of duly qualified persons. The dis-
penser of the " compound oxygen " is said not to be a
physician, and he certainly is not registered as such.
Establishments for giving nitrous oxide to patients would
come in the same class as establishments for giving chlo-
roform or ether or administering hypodermics of mor-
phine. There is no use for such places; they do not
subserve the public good ; they are, on the contrary,
dangerous, and we should judge entirely unlawful.
It is about time that " compound oxygen " humbugs
were exposed and the people made acquainted with their
true character.
THE TREATMENT OF CHRONIC HEART DIS-
EASE BY BATHS AND MASSAGE.
The mechanical treatment of chronic heart disease has
now been accepted by the profession as having a certain,
though limited, value. This treatment, as oftenest em-
ployed, consists in regular pedestrian exercise over
fixed courses which, as a rule, have a gradual ascent.
Gymnastic exercises at home, and baths, supplement
this.
In addition to this method of cardio- therapy, we hear
periodically of the special method devised by the
brothers Schott, of Nauheim. A pilgrim to that spot.
Dr. W. Bezly Thome, has recently described again the
remarkable efficacy of the Schott treatment, and has re-
ported a number of illustrative cases (Lancet, May 5,
1894). The patients who are treated at Nauheim follow
a method which has been elaborated "after eighteen
years of study," though we doubt if there is much differ-
ence between what is done now and what was done eight
years ago. The measures employed consist of baths
and passive and active movements known as Wider-
standgymnastik. The most frequently employed are
those containing one and a half per cent, of sodium
chloride, one and a half per thousand of calcium chloride
and salts of iron, with a variable proportion of carbonic
acid gas. They possess a natural temperature of 88° to
950 F. The baths are given daily, and are followed by
an hour's repose in the recumbent posture ; while in the
bath the patient is subjected to various movements.
The extremities are slowly flexed, extended, abducted,
adducted, rotated, etc., by the operator, while the patient
breathes slowly and makes resistance.
September 22, 1894]
MEDICAL RECORD.
377
The effects are manifest in a diminution of cardiac'
dilatation and slowing of the pulse rate. The exact
technique, of course, can only be acquired by experience,
but the baths themselves can be artificially prepared, and
there seems to be no reason why physicians in this coun-
try should not be able to apply successfully the treat-
ment.
THE PNEUMATIC CABINET.
Those who have heard that, some four years ago, the last
of the stock of pneumatic cabinets had been sold for old
iron, will perhaps be surprised to know that Dr. C.
E. Quimby, according to a reprint just received, has not
given up his instrument nor allowed this method of treat-
ing phthisis to pass wholly into oblivion. While ac-
knowledging his ignorance of what the cabinet can do
alone in the cure of phthisis, he claims to demonstrate
that, scientifically applied, it must act favorably in con-
junction with other measures of proven value. After six
years' experience, the writer believes that " from seventy-
five to eighty per cent, of localized tuberculosis, if seen
reasonably early in the first stage, can be brought to and
kept in a condition of practical cure by the use of the
pneumatic cabinet and adjuvant measures other than cli-
mate." Disseminated tuberculosis subacute and third
stage cases are found to be correspondingly relieved and
benefited.
The alternation during each respiration of negative
differentiation and negative pressure is, the writer be-
lieves, the most comprehensive motion of the cabinet, and
one which has received little attention. The value of
full inspiration until circulatory equilibrium is estab-
lished and exhalation into the rarefied air of the cabinet,
is explained, and it is shown how the blood is pumped
into and out of the lung in the physiological direction
without increase of vascular tension.
In fine the claim is advanced, that the cabinet acts cur-
atively, to a greater or less degree, upon all the factors of
phthisis except the bacillus itself.
%zws at Xhz WLz&k.
Further Hews About Diphtheria Antitoxin. — In the
Berliner klinische Wochenschrift of September 3d, Bea-
ring publishes a paper, in which, among other points, he
deals with the question of dose. He states that the se-
rum prepared and tested under his own supervision and
that of Ehrlich is now issued in two forms — No. I. and
No. II.; No. II. is two and a half times stronger than No.
I. No. I. is sufficient for the treatment of a case of
diphtheria in a child under ten years of age, if it be seen
on the second or third day. In cases of longer standing,
in those of a very severe type in young children, and in
adults, a repetition of the injection will be necessary.
No. II. serum acts more surely and rapidly in these cases,
but, owing to the difficulty of rendering the animals
sufficiently immune to provide a serum endowed with im-
munizing powers so strong, a constant supply cannot be
insured. The estimation of the exact strength of the
serum is a difficult matter, and it must be recognized that
the strength is liable to vary with the commercial source
from which it is obtained. Behring and Ehrlich have
devised a method of expressing the strength in figures.
Their No. I. (quality and quantity) contains 10 c.c,
which is equal to 600 antitoxin normals, and is sufficient
for one case with the limitations already mentioned.
No. II. contains 11.5 c.c. of a strong serum, and is
equivalent to about 1,500 antitoxin normals. Behring
now estimates that the death-rate of cases treated within
forty-eight hours of the onset of the disease with No. I.
ought not to exceed five per cent. The dose to be in-
jected as a prophylactic in persons liable to be exposed
to diphtheria is set down by Behring at 60 antitoxin
normals, or one-tenth of No. I. After infection, that is
during the incubation stage, he believes that 150 anti-
toxin normals ought to avert the development of the dis-
ease.
M. Crispi will soon be operated upon for cataract.
A Monument to Volkmann was unveiled on Septem-
ber 4th, and one to Dr. Testelin, of- Lith, on the same
day. A monument to Quatrefages has recently been
completed.
Dr. Theophilus Patterson, of Salem, N. J., died at
his residence in that city on September 7 th. He was
born in Salem County in 1827, and was graduated from
the Jefferson Medical College, Philadelphia, in 1848,
being a pupil of Dr. J. K. Mitchell, the father of Dr. S.
Weir Mitchell He almost immediately began practice
in Salem and lived there in the active exercise of his pro-
fession for forty-six years. He was always interested in
educational matters, and was largely instrumental in rais-
ing the standard of the public schools in Salem during
a number of years in which he held the office of city
superintendent. A wife and four children, one of them
also a physician, survive him.
Dr. Horace Ingersoli died a few days ago at Salem,
Mass., at the age of eighty -three. Besides medicine he
also, at different periods, studied and practised theology
and law. He was a friend of Hawthorne, and was cred-
ited by the latter as being the one who suggested the in-
cidents in the " Scarlet Letter.''
Cycling in Paris. — A Paris correspondent writes that
there are over one hundred thousand cyclists in that city,
that nearly all the leading physicians ride, next come
the lawyers, then the deputies, officers, and even the In-
stitute; the family physician prescribes the exercise as
the most health- giving ever devised.
Japanese Nurses. — A corps of trained female nurses
has been despatched from the Tokio Training School to
the military hospital at Seoul, and others are being
trained for this service. Throughout all Japan, it is said,
the women have caught the war fever, and the greatest
enthusiasm prevails. A number of women of high rank
have offered to go to the seat of war as volunteer nurses,
and others have even offered to raise a corps of female
soldiers.
A Quick Answer. — A correspondent sends us a story
told of an old country doctor down East. In the latter
years of his life his ankles became very weak, necessitat-
ing the wearing of a pair of steel braces. One day, as
the old gentleman was shuffling along on Exchange
Street in Bangor, Me., some young wag called out:
"Hi, doctor, hi, you are interfering! " "Not with
other folks business, young man ! " retorted the doctor.
378
MEDICAL RECORD.
[September 22, 1894
Yellow Payor of a malignant type is reported to be
epidemic in the coast regions of Nicaragua.
Traction on the Tongue in Hysteria.— Th. Balade
(Gaz. des H6p. de Toulouse, July 28th) has in two cases
made very violent hysterical attacks cease by traction on
the tongue, the organ being drawn with some force out
of the mouth, and kept in that position for some min-
utes. This procedure was successful when every other
treatment had failed.
Dr. 8. Hembury Smith died on September 12th, in
Brooklyn, N. Y. He was born in England in 1810, and
was graduated in London in 183 1. He studied later and
practised in Stockholm; he came to this country in 1847,
settling in Cincinnati. He afterward came to New York,
where he was engaged for a number of years in the manu-
facture of artificial mineral waters.
To Celebrate the Discovery of Anaesthesia.— Mr.
Charles J. Wells, of Hartford, is announced to be the
only living descendant of Dr. Horace Wells, the discov-
erer of anaesthesia. He is said to be taking a deep
interest in the arrangements now in progress for celebrat-
ing the fiftieth anniversary of his father's great contribu-
tion to surgical practice. Mr. Wells has been consulted
by the committee from the Connecticut Dental Associa-
tion, which has charge of the arrangements in this city,
and is in complete accord with the project for a bronze
tablet to be placed on the site that was occupied fifty
years ago by the discoverer's office.
What a Maniac oan Stomach — One of the medical
officers of the County Asylum, Lancaster, contributes
to The Lancet an account of an operation upon a luna-
tic from whose incoherent statements it was suspected
that he had swallowed some nails. Forceps passed into
the stomach having failed to extract any foreign bodies,
though they could be felt from the outside ; it was de-
cided to attempt to relieve the man by operation. On
incision, the stomach was found to be occupied by a
mass of rusty nails, many of them nearly three inches in
length, and some very sharp, bent, and twisted. Their
removal, naturally, was very tedious, as many of them
could only be extracted one at a time. A piece of
matted hair, nearly two inches in length, was also
found. In all, there were removed from the stomach
one hundred and ninety-two nails (the majority being
two and a half inches in length, and many even longer),
half a screw-nail, a piece of brass wire, a carpet tack,
several small pieces of stick, a button, and the mass of
hair already mentioned. The whole weighed one pound
nine and one- half ounces. Several pieces of wood were
found in the patient's intestines, but no nails.
The Country Doctor and Post-Graduate Study. — The
editor of the Post Graduate has made an interesting
analysis of the place of residence of three thousand eight
hundred and twenty- four matriculates of the New York
school. The students were divided into four classes,
according as they came from large cities, having a popu-
lation of over one hundred and fifty thousand ; medium
cities, having a population of over twenty-five thousand ;
small cities, having a population of over ten thousand ;
finally towns and villages. We find from the figures
that have been furnished us that there is a pretty even
distribution of matriculates in all four classes. The
towns and villages, however, rank at the bottom with
six hundred and ninety- five students, while the medium
cities are at the top of the list with eleven hundred and
four. On the whole, one can see that it is die medium
cities and large towns that furnish the greater number
of matriculates. The number from the large cities is
relatively small. Another interesting fact which is de-
veloped by the study of tables is this : The physicians
from the towns and villages are coming to us in increas-
ing number every year. During the first four years of
the school, not more than twenty- five or thirty came
from this class, but in the last year or two the numbers
have exceeded one hundred, and last year the villages
and towns of the United States furnished as many stu-
dents as the large cities.
This, adds the editor, is certainly an interesting, and
we would add a hopeful, sign. It shows that the doc-
tors in the smaller places are making a living, and a lit-
tle more, and what is still better, it shows that they
possess a desire to keep abreast of the times, and that
this desire is even keener than that which the city phys-
icians have ; for it must be remembered that it requires
no small sacrifice for a country doctor to leave his prac-
tice, turning over his patients to the care of a brother
physician with whom his relations may, perhaps, have
been sometimes a little strained, and of whose experience
and skill he has, perhaps, himself once expressed a slight
amount of doubt. But it is evident that a country doc-
tor is bound to learn, and that he is learning and is
keeping as alert in every direction as his city brother.
The Late Dr. Albert B. Miles, House Surgeon of the
Charity Hospital of New Orleans, left $10,000 each to
the following institutions : Medical Department Tulane
University of Louisiana ; Charity Hospital of New Or-
leans ; and the Hotel Dieu, also of New Orleans.
Fighting the Diploma Trade.— Dr. C. T. Metcalf,
Secretary of the Indiana State Board of Health, has in-
structed the county boards of health to notify clerks of
court to refuse licenses on the diplomas of the " Marion
Physico Medical School of Indiana and Marion."
Physicians' Protective Association. — The first annual
meeting of the Physicians' Protective Association of De-
troit was held September 4th. Reports of officers
showed a prosperous year, $9,916 in outstanding ac-
counts having been collected. Officers for the ensuing
year were elected as follows : President, Dr. L. J. Len-
nox ; Vice President, Dr. R. H. Stevens ; Secretary,
Dr. P. M. Hickey ; Ireasurer, Dr. S. H. Knight.
The Office of Coroner to be Abolished. — The Consti-
tutional Convention at Albany has adopted the first
amendment abolishing the office of coroner in this State
as a constitutional office. The purpose of the amend-
ment is said to be to make it possible for the Legislature
to provide that only physicians shall exercise the duties
now performed by elected coroners.
The Medical Society of the Missouri Valley held
its seventh annual meeting in Council Bluffs, Iowa, on
Thursday, September 20th. The programme contained
the titles of twenty- five papers presented by members of
the Society from Missouri, Jowa, and Nebraska. Dr.
A. F. Jonas, of Omaha, was President, and Dr. F. S.
Thomas, of Council Bluffs, Secretary.
September 22, 1894]
MEDICAL RECORD.
379
BEAVEN NEAVE RAKE, M.D.,
TRINIDAD, WIST INDIES.
With profound regret we notice the death of Dr.
Beaven Neave Rake. A cablegram received in London
announced the sad event. He died in Port of Spain,
Trinidad, British West Indies, August 24th, of fever —
presumably, yellow fever, as it has prevailed there in epi-
demic form for several months past.
Dr. Rake was one of the world's recognized specialists
in leprosy. He had made its study the work of his life.
2 he Lancet^ London, September 1st, referred to him as
having been " one of the greatest authorities " on that
disease.
Ere entering on the study of medicine and surgery he
had received a thorough classical education. He be-
came a member of the Royal College of Surgeons of
England in 1879, a Licentiate of the Royal College of
Physicians of London in 1880, a Bachelor of Medicine,
University of London, 1881, and a Doctor of Medicine
of the same in 1882. He had had seven years' hospital
experience in London, one year on the Continent, one
year in the East Indies, studying leprosy, and nearly ten
years as Chief Medical Officer at the Trinidad Lepers'
Asylum.
He was a member of the Pathological Society of Lon-
don, the British Medical Association, Pan-American
Medical Congress, Washington, 1893, Trinidad Medical
Society, etc., etc.
He was a faithful and indefatigable worker, a man of
keen perceptive powers and sound judgment. His early
training had eminently fitted him for the government
appointment at Trinidad. He was an able and prolific
writer. His original observations have been published
in England in The Lancet In America the Medical
Record published his last paper — being a concise sum-
mary of his observations. That paper, specially pre-
pared, appeared in its columns a few months ago.
All students of leprosy will remain profoundly grateful
for the veritable "arsenal of facts" that he has left on
record. His name will ever rank as an original worker
and thinker.
While on the Anglo-Indian Commission he and his
associates examined the histories of over two thousand
cases of leprosy ; in but two instances could contagion
have been a factor ; sensationalism in medicine he dep-
recated. For twenty-eight years past the Sisters of Char-
ity have had exclusive charge of the Trinidad Lepers'
Asylum ; not an instance can be cited where they have
become infected.
At the Pan-American Medical Congress he read a
paper on leprosy before the Section on Dermatology,
and addressed the Sections of Hygiene and Climatology
on the same.
Death, in selecting him at the early age of thirty-six,
has taken from us a bright and shining light; but " his
good works will live after him." He died like a brave
soldier, fighting disease during an epidemic. He had
warm friends the world over. The warm shake of the
hand, the frank, manly glance of the eye, will be re-
membered. He was one of God's greatest works — " a
true man." His genial manners and quiet dignified
way have left a living impress on his time and profession.
He leaves a widow and three little sons. The highest
compliment that can be paid a member of our profession
is his first due—" He did his duty."
A Comfortable Ailment Desired Lady medicals
are at times hard pressed for patients, as the following
little wail will show: " Wanted — the care of an invalid
lady of means (comfortably ill), who will appreciate best
of medical skill and competent nursing ; with kindly,
sympathetic attention. Address Lady Physician, Herald
Agency, 708 Columbus Av."
QPlittixal gjqrartmettt
TABES DORSALIS IN A WOMAN TWENTY-
THREE YEARS OLD.
By L. PIERCE CLARK, M.D.,
MIDDLBTOWN, COKN.
This case of tabes dorsalis in a woman but twenty-
three years old, came under my observation when I was
house physician at the workhouse hospital, on Black-
well's Island. She was admitted to the hospital and re-
mained there for four weeks, during which time she made
little or no improvement.
Five years previous to her admission she contracted
syphilis in a very severe form, and its treatment was al-
most entirely neglected until the tertiary symptoms
made their appearance, when she took the baths at
Hot Springs, Ark., for six months. But they gave her
little relief. For seven years she had used alcoholic
stimulants, taking sometimes twenty or thirty drinks a
day. The remainder of her history is as follows :
Name A. D ; aged twenty- three ; single ; had been
a prostitute for six years ; family history good. She had
never been sick before her present illness ; at least not
sufficient to incapacitate her for her abnormal* occupa-
tion. The present attack began about eight months
prior to her admission to the hospital. After one of her
usual debauches, lasting four days, she complained of
faint and dizzy sensations, which came on every three
or four days, and lasting only an hour or so. These
attacks gradually increased until they were of almost
daily occurrence, lasting three or four hours each time.
One month from these first symptoms of dizziness, etc. ,
vomiting and sharp lancinating pains in the epigastrium
began. The vomiting was projectile in character, and
the pains in epigastrium radiated from a central point in
all directions, especially toward the vertebral column.
This attack was also attended by purging. It lasted for
two days, during which time she was obliged to remain
in bed. Notwithstanding the severity of the attack she
recovered, so as to be about on the third day, and was as
well as ever, save the faint and dizzy sensations which
continued to trouble her greatly, when she had taken
considerable exercise. For the next five months she
used stimulants very freely.
At the time of her admission to the workhouse on the
charge of "soliciting," she had the appearance of one
who had been suffering from syphilis and the abuse of
alcohol for a long .time, although she was in fair physical
health. She was unable to walk to any great extent, and
complained constantly of sharp, darting pains in legs,
inability to see clearly, and occasionally saw double.
These eye symptoms had been more or less prominent
for past two months.
Physical examination revealed entire absence of knee-
jerk, immobility of pupils, the right being a little larger
than the left. The girdle sensation was present around
upper and lower abdomen. There was swaying on stand-
ing and the gait was markedly ataxic. There was also
present some inco-ordination of upper extremities. The
feet were numb and cold, and the cutaneous sensation to
pin- prick was perceptibly delayed and diminished over
lower extremities.
On her discharge her symptoms remained about the
same, except the gait, which showed some improvement,
probably because the alcohol had nearly all left the sys-
tem.
This case was diagnosed on admission as one of alco-
holic neuritis, because of her alcoholic condition at the
time of her arrival at the workhouse, and the subjective
symptoms. But upon obtaining a syphilitic history, and
the presence of the effects of syphilis yet remaining,
together with the absence of a great many of the symp-
toms found in alcoholic neuritis, such as diminished
motor power, tenderness along course of nerves, and
38o
MEDICAL RECORD.
[September 22, 1894
atrophy of any of the muscles, we had sufficient evidence
to cause a more careful inquiry into the case, which re
suited in the above diagnosis of tabes dorsalis. No
mental symptoms were present.
It is just possible that a peripheral neuritis of alcoholic
origin was present in this case together with tabes.
The early vomiting, pains in epigastrium, and purging
which came on without any apparent cause and disap
peared entirely in two days, seems to me to be a form of
visceral crisis quite frequently found in tabes. I think
the case is one of considerable interest, as it is an in
stance of tabes dorsalis in a young woman but twenty-
three years old.
Her after history is unknown, as she passed from
under my observation after leaving the hospital.
REMARKABLE USE OF BICARBONATE OF
SODIUM.
Dr. Robert G. Feek, of Hamilton, N. Y., writes:
" William G — —, who resides in the town of Dekalb,
near Hamilton, St. Lawrence County, N. Y. , was suffering
from disease of the Stomach about twenty-five years ago.
He states that he spent all his earnings in doctoring till
about twenty-one years ago, when he tried saleratus, which
gave him relief. Since then he has used it constantly and
is now* using the twenty-second hundred pounds. He
carries it with him wherever he goes. He is sixty one
years of age, father of eleven children, and does all
the work t)f a farm of one hundred and ten acres except
an occasional extra help. He purchases his saleratus by
the barrel. These statements are authentic, as inquiry
•will prove. The saleratus is taken in a dry state. At
first it was taken in small quantities, but now in doses' of
one half ounce, and to the quantity of overtTo pounds a
week."
A FOREIGN BODY IN THE EYE FOR SIX
YEARS.
By THOMAS M. STEWART, M.D.,
CISClNXAri, c.
Cases of foreign bodies in the eye are interesting to eye
surgeons, because of the many important questions that
they involve. The case herewith reported is interesting
because of the length of time the foreign body was re-
tained, with the history of pain and redness, and abso-
lutely no irritation occurring in the sound eye.
The patient was a married man, aged forty yean.
Six years previous to his first visit to me, while watching
miners at work, a piece of coal struck him in the right
eye. He was at once removed to his home, and a sur-
geon summoned. After some weeks he was discharged
from the surgeon's care, but with a blind eye. The iris
was occluded, the small pupillary space presented to
view a cataractous lens. Subsequently, the man sought
medical aid for the relief of severe lightning like pains
in the injured eye. The pains continued from time to
time. I found the eye a little red, no pains on palpa-
tion of the ciliary body, but pressing the eye backward
and a little outward, he complained of severe cutting pain.
He was then taking morphine for the relief of the pain ;
he took several one-fourth grain pills every day, and
when the attacks were very severe he took mare.
From the history of the case, evidence of having been
struck in the eye by a flying missile, the occluded pupil,
cataractous lens, and the history of pain from the time of
injury, I advised enucleation. Two days later he gave
his consent, and the eye was removed in the ordinary
way. Adhesions were cut away at the back of the globe.
Section of the eye showed the adhesion of the iris to the
opaque lens, and the vitreous was dark brown in color.
Close to the optic nerve was found an enlargement, due
to a piece of coal 6 mm. square, ragged at one end.
This pushed the sclera backward, and had become firm-
ly imbedded. A firm adhesion also held it to the
nerve.
The question of enucleation had been considered, but
it was thought that the pain was entirely neuralgic, com-
ing in paroxysms aggravated by change in temperature
and humidity of atmosphere. The sound eye had been
interrogated for recession of the near point, and other
symptoms of sympathetic inflammation. These points
determined his medical advisers upon no interference.
To my mind there was no question as to the necessity
for operation, it was a clear case for the rule to enucleate
an eye subject to attacks of redness and pain, the vision
of which has been destroyed by an injury.
THE SWALLOWING OF A HAT-PIN, AND ITS
SUBSEQUENT EXTRACTION.
By THOMAS B. STEELE, M.D.,
CAMBRIDGE, MD.
I had yesterday, July 15th, the most extraordinary case
of surgery I ever saw, or that has ever occurred in this
part of the country.
About three weeks ago I was called in to see a colored
child (female) a little over three years old.
She complained of severe pain at the inner
extremities of the two lower ribs of the left
side. She kept her body constantly bent over
to that side as far as she could get it, and a
little forward. In this position she was some-
what relieved, but was never entirely free
from pain. She had but very little fever, if
any, and her appetite and digestion were fairly
good.
About ten days ago a protuberance the size
and shape of section of an ordinary hen eggf
made its appearance just over the seat of pain.
As her mother and the rest of the family insisted
so strongly that nothing had occurred to ac-
count for her symptoms, I was forced to the
conclusion that by some forgotten accident the
cartilages at the enlarged spot had been dislo-
cated from the ribs, or a growth of some kind,
most probably an abscess, was forcing its way
there to the surface. Last night I was sent for
in a great hurry to see her, as the sharpened
end of a hat-pin had made its appearance
through the middle of the lump. And such I
found to be the case. By slight pulling the
pin would come out five or six inches, but was
retained by its large bullet shaped end.
The pin penetrated the cartilage of the
eleventh rib, instead of coming out between
the ribs, where there was less resistance, and as
nothing could be done without keeping her
constantly under the influence of chlorofonr,
and I could not do so unassisted, I sent for Dr.
B. W. Goldsborough. After some difficulty he
succeeded in enlarging the opening in the car-
tilage and in extracting the pin.
Last night her mother remembered that
some children told her the child had swal-
lowed, the day before she complained of be-
ing sick, a hat-pin, but she thought it so un-
likely that it had escaped her memory. This
morning she is more comfortable. Rather a
large quantity of water flows from the opening, which
shows that it connects with the stomach.
A Patient in one of the Paris hospitals was recently
scalded to death in a bath through negligence of the
nurse.
Breast Tumors in Women.— A " lump in the breast/'
previously to twenty five years, may often be " severely
let alone ; " one after thirty five can be disregarded only
by the surgeon who is reckless to the verge of criminal-
ity.— Dr. Herbert Snow in The Practitioner, August,
1894.
September 22, 1894]
MEDICAL RECORD.
38i
(&avrzsvon&2ucz.
OUR LONDON LETTER.
(From our Special Correspondent )
VACATION — CHOLERA PROSPECTS — THE OPIUM COMMISSION
— THE REPORT OF THE LUNACY COMMISSIONERS — THEIR
VIEWS ON BEER.
London, September 1, 1894.
London is just now more depleted of her doctors than
daring the brief meeting at Bristol, for a considerable
number have set out on their autumnal holiday. In the
few Bristol days we had scarcely time to miss them, for
those who went — or a large proportion of them — returned
to town before leaving for any length of time. The ap-
pearance of "students' numbers' ' of the journals is an
indication that the opening of the winter session is only
just a month ahead. Then the active teachers will be
obliged to be at home, and even the fashionable consult-
ants will begin to return.
We have passed the first of the two most dangerous
months in respect to cholera ; but September has several
times been a month of invasion, and as the disease is still
epidemic on the Continent the danger is obvious. Hither-
to the weather has been in our favor, but there is now a
prospect of hot, damp days, which, if long continued,
may cause any seeds sown last year to spring up. Whether
we are to escape altogether or suffer from such recrudes
cence, or to be invaded afresh is therefore a favorite topic
of conversation and the speculations indulged in are some-
times more curious than instructive. After a long spell
of cool, wet weather, the last two days have been hot,
yet dull and misty. The ground in the country is no
doubt saturated with moisture enough to give us a damp
atmosphere as the sun pours down its rays. If cholera
invade us it will therefore have a condition favoring its
spread, and with all our sanitarians' efforts it is impossible
to pronounce all our defences to be impregnable. The
Local Government Board are prepared to act with energy.
Inspectors are ready to visit suspicious cases, and provi-
sion is made for a bacteriological examination of faeces
forwarded with a clinical record of the case. Expert ad-
vice and assistance is therefore at the disposal of those
who may have to meet suspicious cases, and in the coun-
try the officers of health seem equally ready with help.
If any port or sanitary authority should be caught nap-
ping the results may be disastrous, but we may still hope
this will not happen.
The report of the Opium Commission will, I under-
stand, not be issued until Christmas, but rumor is pretty
busy as to its contents. Some persons profess to have
precise information — others are evidently guided by their
judgment of the evidence. The former say the report
will be unanimous, and I hope they may be right, for
that would probably deliver us from the " opium ques-
tion " for some time to come. Both former and latter
agree that the report will be conclusive against any inter-
ference by the state with the cultivation and use of
opium. If so, it will be in accord with the evidence ten-
dered by those medical men who have had the best op-
portunity of judging by their residence and official posi-
tions in India.
I may recur for a moment to the Lunacy Report, which
I have previously noticed. In some quarters surprise is
felt at the prepossession of the commissioners in favor of
beer in the dietary. Again and again regret is expressed
in the reports at the absence of beer or something else.
Thus, respecting the Surrey Asylum, the remark, " workers
only have beer," is evidently made in a deprecatory
spirit. At Norwich it is remarked, " One gentleman
complained of the stoppage of the dinner beer, which,
we understand, has been general throughout the hospital. ' '
At Colney Hatch the commissioners observe, " Beer is
not given to the workers, which we regard as a mistake,
as it keeps down the percentage of employed patients."
It is curious that encouragement should thus be given to
the plan of inducing patients to work by paying them
in beer. The commissioners defend their approval ot
intoxicating beverages thus : " The asylum is not a re-
formatory ; and claiming to be advocates of temperance,
which total abstinence is not, we think that the with-
drawal from the temperate of their past life's beverage
irritates, whereas every effort should be made to alleviate
the morbid discontent of the sober patients, in propor-
tion to whom the drunkards are few. These last, if in
the incipient stage of their vice, so soon recover that they
must be discharged too soon for the eradication of that
vice ; if they be old stagers, they come to the asylum
wrecks of humanity, and their condition is too chronic
for discharge, except through death. We deem it our
duty to repeat our colleagues' objections in 1892 to what
is in no sense a proceeding in the cause of true temper-
ance, which is the avoidance of excess." I am not in-
clined to controvert this curious manifestation of the
commissioners' penchant, nor would I go so far as to
assert that a glass of small beef would have an apprecia-
ble effect on the majority of the patients. But I cannot
compliment the commissioners on their logic, and there
are other issues involved, as there are also in the case of
workhouses, as to which the beer question is continually
cropping up. The rate-payers may object to provide
this luxury to persons who in large proportion owe their
distress to too free indulgence in it. Then these very
reports contain a series of tables, some of which show
the predisposing and exciting causes of the patients' lu-
nacy. As may be anticipated these statistics confirm
those with which your readers are familiar, and prove the
terrible idle that alcohol plays in the production of in-
sanity. I think the comissioners would find a difficulty,
in expounding these figures so as to support their views,
which certainly do not seem quite up to date from a sci-
entific point of view. It will therefore not surprise me if
some controversy should be raised on the question.
WHO IS TO BLAME?
To thb Editor op thk Medical Rbcokd.
Sir : One of the great and much admired minds of the
century has emitted the sentiments that,
" Work without hope draws nectar in a sieve,
And hope without an object cannot live."
After a fashion these lines were recalled to my mind by
Dr. McGee's ardent letter published in -to-day's Medi-
cal Record. The lines of the poet- philosopher can be
applied to the evil complained 'of by Doctors Cochran
and McGee, and many other good men, both as to its
cause and its therapeutics.
Dr. McGee would have " one good general law " for
limiting the number of medical colleges, and the number
of medical colleges being limited by law, he would ex-
pect " a better satisfaction to the profession " to follow.
Another blessing flowing from this law of numerical
limitation would be, Doctor McGee says, "at least more
than a show of real protection for the people." May
one not ask why the " better satisfaction " of the pro-
fession needs the protecting hand of the lawyer ? Law
means lost innocence, lost manliness, and as a prohibi-
tive help positive only by negation. What does " real
protection for the people " mean ? Is the profession be-
coming a band of beggars because this very profession
in some sections of the country is developing medical
schools and professors in superabundance? Quite the
contrary. Those medical men who are impoverishing
the profession by making it cheap, and who besides are
committing a sort of wholesale homicide by inundating
the public with medical humbugs very much after their
own pattern find the business profitable. And while
such business pays such men, can any other conclusion
be drawn than that both the public (the people) and the
profession rather like it ? All things thrive by what they
feed on, and the schools and the professors of whom
complaint is made are no exception to this natural law.
382
MEDICAL RECORD.
[September 22, 1894
The people who will have them deserve to have them.
Why do these particular men hurry to establish schools
and make themselves professors? It is because they
hope to gain power thereby, and to turn that power and
eclat — the prestige of a name — into money !
If they are not honorable men, they are ambitious
and they are practical. They do not weave the cloth of
gold from moonbeams. Their hopes are very material,
and their object extremely selfish. They are not idealists.
Indeed they resemble Napoleon I. in their hatred of
idealists. Now the idea of professor is an actual ideal-
ism with the great body of the laity. It is not the legal
conception. It is often an idealism that borders on the
mythical. The professor of medicine (or surgery) to
most layman is a man who knows when the practitioner
does not know. The professor to the layman is the man
who can do when the practitioner fails or is powerless.
The professor to the layman is the man who has done
his best to make the practitioner a capable man. The
people have an ideal doctor in mind when they think of
the medical professor. And it is this ideal that these
would be medical schools and their would be professors
deflower, and make the most of to their own selfish
satisfaction. We must not be too hard in our judg-
ments of the people just because a laudable ideal is
theirs. The people are always right in the end, only it
takes them such a long while sometimes to distinguish
between brass and gold. Then, too, are not the better
elements in and out of the profession parts of the peo-
ple? The making of prohibitive laws, or agitating for
them, are worthy ways of letting loose our altruistic and
philanthropic propensities, when we do not forget our
other and more important social and professional obliga-
tions. It is no more than just that every philanthropist,
altruist, and ameliorist be the model he is clamoring for
some one else to be. And besides clamoring for legis-
lation— which is right in its way— each decent practi-
tioner, as occasion offers, can do a good deal toward
killing away the falsehoods on which the evils under con-
sideration feed, by themselves emulating the lay ideal of
the professor, and by teaching the laity who are and
who are not not legal professors, but real and worthy
professors. Perhaps decent and intelligent practitioners
have contributed more than a mite toward the making
of the layman's myths, and from which they feel ill
effects every now and then.
Adolph Rupp, M.D.
New York, September 8, 1894.
HYDROPHOBIA STATISTICS DESIRED.
To the Editor or thb Medical Record.
Sir : Will you permit me, through your columns, to ask
that my professional brethren will communicate to me
the occurrence of cases of so-called hydrophobia in their
practice for the year 1894, from January 1, and so on
until the end of this year ?
I would like in all cases to learn : 1, The sex and age
of patient ; 2a, the kind of animal that is credited with
the inoculation ; 2d, its state of health ; 2C9 the provo-
cation to bite (if any existed) ; 2d, the reasons why the
animal was (if it was) deemed rabid ; 3, the seat of the
bite (or other mode of inoculation) ; 4, the fact and
method of cauterization (if any); 5, the time between
the inoculation and the outbreak ; 6, the symptoms of
the outbreak, the occurrence of mania or imitation of
dog actions ; 7, the remedies used and doses, with their
seeming effect ; 8, the issue of the case and when death
occurred ; 9, the investigations made to exclude the pres-
ence of disease other than so-called hydrophobia; 10,
the findings on autopsy, if one was held.
I shall, of course, acknowledge in future publications
aid received in continuing my studies in regard to this
subject.
Yours respectfully,
Charles W. Dulles.
4iox Walnut Street, Philadelphia, Pa.
"THE PHONOGRAPH; ITS PHYSICS," ETC.
To the Editor or the Medical Record.
Sir : An article under the above title appeared in your
issue for September 1, 1894, by J. Mount Bleyer, M.D.,
from which I quote the following : " Photographs and
measurements of these tracings of the sound-waves on the
wax cylinders, etc., were recently made by Herman, of
the Konigsberg Physiological Institute, and are of great
interest in the study of the physics of sound." I desire
to call attention to the fact that drawings and measure-
ments of tracings of voice records upon a wax cylinder of a
phonograph were made by me in 1888, and the same, with
an article entitled "A Study in Physiological Acoustics —
Preliminary Notice/' were sent to your journal for publi-
cation.
The article appeared in the Record for November 17,
1888, p. 589, but the graphic representations were not
published because you did not have space. In the article
by me I state : " I have shown the number of vibrations
to inch, entire length of letter or word, total number of
vibrations to each, and also depth of imprint." If there
was a disposition to credit our own countrymen for scien-
tific research and investigation more, and less tendency to
look abroad, it would be better for the profession and
our country as well.
J. A. Maloney, M.D.
1424 Q Struct, N. W., Washington, D. C.
A FALSE REPORT OF PREMATURE BURIAL.
To thx Editob or thb Medical Reoobd.
Sir : Some time ago a patient handed me a slip cut
from one of our daily papers, wherein was related, with
the usual minute detail, a case of "Buried Alive."
The incident was said to have happened near the town
of Lester, Minn., and the victim was said, upon disin-
terment, to have been found completely turned upon the
face, the flesh torn by the finger* nails, and the hands
filled with hair torn from the head. As my patient was
a lady of nervous temperament, who dreaded for herself
or husband a similar terrible fate, I determined to run
the lie to earth, and, accordingly, wrote to the post-
master, inclosing the slip, and asking him to report.
The following is his reply :
Lester, Minn., August 23, 1894.
Dear Sir : In reply to your request will say, that I
have taken time to thoroughly investigate the matter and
find "it is not true.9' It is true he was removed, but,
he was found in the coffin the way he was placed there.
I never heard of the matter until I got your letter.
Respectfully.
C. O. Perusis.
And that is all the foundation there was to this tale.
S. S. J.
A Simple Remedy for Cough. — Dr. Charles E. Page,
of Boston, says that the best remedy for cough he has
ever found is a teaspoonful of moderately hot water,
taken every time a paroxysm of cough comes on.
Intra uterine Injections in Antiquity. — At a recent
meeting of an Edinburgh medical society Dr. Ballantyne
quoted from a paper by Dr. Koromilas, a Greek physi-
cian, in which it was claimed that there was evidence in
the writings of Hippocrates, Oribasius, Paulus ^Egineta,
and Galen to show that these authors were acquainted
with the use of intra- uterine injections. Hippocrates
divided the generative organs into three parts — first, the
external genitals ; second, the genital organ or vagina ;
and third, the uterus. He also used for each a special
kind of substance to be injected : wine with honey for
the external genitals, goose grease for the vagina, and
oil with honey for the uterus. Dr. Koromilas believed
that Hippocrates was the first to make intrauterine in-
jections.
September 22, 1894]
MEDICAL RECORD.
383
IJXMicat Stems.
Contagious Diseases— Weekly Statement— Report of
cues and deaths from contagions diseases reported to the
Sanitary Bureau, Health Department, for the week end-
ing September 15, 1894.
Tuberculosis
Typhoid fever
Scarlet fever
Cerebro-spinal meningitis
Measles
Diphtheria
Small-pox
Cases. Death*.
98
108
26
13
17
2
0
4
14
3
ic6
30
9
2
Unfortunate Fingers. — Dr. George Corrie, of Blossom
Hill, Va., gives the following history, in the Virginia
Medical Monthly, of a family of finger- losers : " George
Williams, negro, had two fingers * hurt by the cars,1 ne-
cessitating amputation (by some other doctor than my-
self). His father is minus an index, I having amputated
it after contact thereof with the proverbial ' buzz saw.1
I have amputated the right digitus auricularis of one of
George's nephews, the hand having been caught in an
apple-giinder. I relieved another of George's nephews
of his left digitus auricularis, the boy having fallen while
carrying a sharp axe, the edge of which severed all tis-
sues, artery, and nerve, and entered the first joint. All
these finger-losers lived at one time in the same house."
The Decline of Marriage. — Mr. Grant Allen has
undertaken to explain why marriage is less common to-
day than it was a century ago : " Thirty or forty years
ago young men used to rush by blind instinct into the
toils of matrimony — because they couldn't help them-
selves. To day they shilly-shally, they pick and choose,
they discuss, they criticise, they say foolish things about
the club and the fiat and the cost of living. They be-
lieve in Malthus. Fancy a young man who believes in
Malthus ! But they don't marry, and it is because they
are less of young men than formerly. Wild animals in
confinement seldom propagate their kind. Only a few
caged birds will continue their species. Whatever up-
sets the balance of the organism in an individual or a
race, tends first of all to affect the rate of reproduction.
Civilize a red man and he begins to decrease at once in
numbers. Is not the same thing true of us ? Civiliza-
tion and its works have come too quickly upon us. The
strain and stress of correlating and co-ordinating the
world we live in are getting too much for us. Railways,
telegraph, the latest edition have played havoc at last
with our nervous system. We are always on the stretch,
rushing and tearing perpetually. We bolt our breakfast,
we catch the train or 'bus by the skin of our teeth. The
tape clicks perpetually in our ears the last quotation in
Eries, the telephone rings us up at inconvenient mo
ments. Something is always happening somewhere to
disturb our equanimity. Life is one turmoil of excite-
ment and bustle. Financially, 'tis a series of dissolving
views; personally, 'tis a rush; socially, 'tis a mosaic of
deftly fitted engagements. Drop out one piece and you
can never replace it. You are full next week from Mon-
day to Saturday — business all day, what calls itself pleas-
ure (save the mark ! ) all evening. Poor old leisure is
dead. We hurry and scurry and flurry eternally. One
whirl of work from morning till night ; then dress and
dine ; one whirl of excitement from night till morning.
A snap of troubled sleep, and again da capo. Not an
hour, not a minute, we can call our own. The first gen-
eration after Stephenson and the Rocket pulled through
with it somehow. They inherited the sound constitu-
tions of the men who sat on rustic seats in the gardens
of the twenties. The second generation — that's you and
me — felt the strain of it more severely. New machines
have come in to make life still more complicated ; tele-
grams, Bell and Edison, submarine cables, evening pa-
pers, perturbations pouring in from all sides incessantly ;
the suburbs growing, the hubbub increasing, metropoli-
tan railways, trams, bicycles innumerable ; but we still
endured, and presented the world all the same with a
third generation. That third generation — ah, me ! there
comes the pity of it ! One fancies the impulse to many
and rear a family has wholly died out of it. It seems to
have died out most in the class where the strain and
stress are greatest. I don't think young men of that
class to day_have the same feelings toward women of their
sort as formerly. With certain classes and in certain
places a primitive instinct of our race has weakened.
The present crisis in the marriage market is due not to
clubs or the comfort of bachelor quarters, but to cumula-
tive effect of nervous over-excitement."
' Taking His Telephone to Bed. — A Pittsburgh physi-
cian has devised a way of taking his telephone to bed,
so that he can answer calls without rising. He has his
telephone hung upon hooks, in his office, the connections
being made by the telephone coming in contact with an
electric board which he has had constructed. He also
has wires run to his bedroom, where another electric
board has been placed. The doctor may be said to take
his telephone to bed with him every night. He takes it
from the hooks in his office, carries it under his arm up
to his bedroom, and places it upon the hooks there.
Should any calls come during the night, he can answer
them without leaving his room, thereby getting the use
of two telephones for the price of one.
Morphinism in Medical Men. — It is a fact — striking
though sad — that more cases of morphinism aie met with
among medical men than in all other professions com-
bined. It is too true that a very large proportion of
cases in general are found in our own fraternity. In a
paper, "Opium Addiction among Medical Men," pre-
sented in the Medical Record eleven years ago — June
9, 1883 — reference was made to the dismissal within a
week of a half-dozen doctors recovered from this disease,
and attention called to the surprising frequency with
which it occurs in this particular class. Another decade
of professional work exclusively given to the betterment
of such patients has brought no decrease in this number;
indeed the reverse has quite steadily obtained, so that in
a paper, " The Ethics of Opium Habitues," Medical and
Surgical Reporter, September 8, 1888, in a r&sumi of
300 cases, we noted 118 doctors, and of 125 most re-
cently under my care 62 were medical men ; and the
latest reference to my record shows a still larger propor-
tion, being more than seventy per cent. — Dr. J. B. Mat-
tison in the Journal of the American Medical Associa-
tion, August 4, 1894.
Migraine in Infancy. — Intelligent observation and ac-
cumulating experience show that infancy does not es-
cape many of the neuroses (perhaps we may learn to say
none of the neuroses) observed in mature life. The
diagnosis is obviously embarrassed by the difficulties at-
tendant upon the elicitation of symptoms. Thus, it has
been conclusively demonstrated that infants and young
children may be unequivocally hysterical, and there is
reason to believe that they may be similarly affected with
migraine. Evidence in support of the latter proposition
is furnished by the report by Dr. Betz of the case of a
female infant, thirteen months old, that, at a time when
influenza was prevalent, was seized with an attack of fe-
brile gastrointestinal catarrh, attended with diarrhoea.
In the course of this illness the infant was seized with
twitching, affecting principally the hands and arms, oc-
curring intermittently and also during sleep. It further
indicated by gesture its complaint of pain in the head.
Consciousness was perverted, but not lost. It was ob-
served that the child manifested a tendency to grasp the
left side of its head and to lie upon its left side, and on
examination the left side of the head was found to be
somewhat smaller in size than the right, while further
investigation disclosed the fact that an elder sister and
384
MEDICAL RECORD.
[September 22, 1894
the mother both presented a similar asymmetry and suf-
fered from attacks of migraine. The interesting features
of the case are the age, the sex/ the heredity, and the
asymmetry of the face. In a diagnostic connection it is
pointed out that on palpation the temperature may be
found higher on the affected side than upon the opposite
side, and that during the attack of pain the upper lid
upon the affected side displays a tendency to droop.
Therapeutically, general rather than special measures are
indicated. Diathetic and hereditary tendencies, as well
as complicating conditions, are as far as possible to be
corrected or removed. Opium may be used internally
and topically with caution ; ice-water compresses, topi-
cal applications of menthol, cocaine, or ether may aid in
the relief of pain. — Medical News.
Diseases of the Heart in Typhoid, Scarlatina, and
Diphtheria. — Dr. Rhomberg points out that the paren-
chymatous and interstitial processes are not closely con-
nected in the tissues of the heart. In typhoid the higher
grade of parenchymatous degeneration advances rapidly
to the end of the second week ; but later this morbid
change is not so great. Interstitial myocarditis, on the
other hand, only makes its appearance at the end of the
second week, when the parenchymatous has run its
course. In scarlet fever the interstitial myocarditis may
begin to make its appearance on the fourth day, but its
intensity is not reached till the end of the second week.
Diphtheritic myocarditis makes its appearance later than
scarlet fever, usually about the seventh or ninth day, and
its intensity is reached about the beginning of the third
week, and is continued even into convalescence. Rhom-
berg has seen myocarditic bands from diphtheria in the
third week. Leyden has recorded several in the fourth
week well advanced. In typhoid, Rhomberg has met
with these in the third week. The symptoms during the
fever period are — great weakness of heart, irregularity
and smallness of the pulse, probably with dilatation.
The best sign of dilatation of the left ventricle with ir-
regular contractions is, according to Leyden, galopp-
rhythmus. Traube considered sudden sinking of the pulse
" frequenz " an ominous sign in diphtheria. Leiber-
meister considered the pathological increase of tissue
fluid, as oedema of the ankles, a dangerous symptom.
Dilatation is frequently met with in typhus by the mid-
dle of the second week ; observable by the soft and empty
pulse. In diphtheria Rhomberg can only relate one case
of dilatation occurring in the first week. On the other
hand, he has found it after a few days in scarlet fever,
continuing two or four weeks. — Medical Press.
Intestinal Toxins. — Two cases were related at the
Clinical Society recently, one by Dr. Lauder Brunton
and Mr. Watson Cheyne, the other by Mr. Silcock,
which illustrates well the important role played by the
toxins developed by decomposition of the intestinal
contents in some cases of intestinal obstruction. The
first was one in which, after repeated attacks of ap-
pendicitis, a somewhat gradual obstruction developed,
without tenderness or local signs of recent inflamma-
tion. On laparotomy being performed it was dis-
covered that the caecum was matted and tied down by
general adhesions, but not strangulated by a band.
After separating the adhesions it became possible to
squeeze the contents of the small intestines into the
colon, showing that the constriction was removed. Be-
fore the operation the patient had been in a state
of the most absolute collapse; after it he improved
somewhat for a time, but soon again relapsed, and
seemed as bad as ever, until, after discharging a couple
of very offensive motions, his condition rapidly im-
proved, and he recovered without any further trouble.
Mr. Silcock's case was apparently one of acute obstruc-
tion from, or at any rate accompanied by, peritonitis.
Laparotomy was done, but from the matting of the in-
testines it was impossible to discover the exact cause, or
in fact the position, of the obstruction. Ultimately,
however, the distended small intestine was attached to
the abdominal wall, and a large amount of offensive
faecal matter was drained away. In this case, also, the
collapse was profound, so that during the operation he
was thought to be dead ; but after the discharge of the
offensive intestinal accumulation rapid recovery took
place, the natural action of the bowels was restored, and
the wound healed, although apparently the only thing
the operation did was to empty the bowels of their con-
tents. These cases put in striking light the fact, which
is perhaps not so constantly borne in mind as it might
be, that the fatal results of intestinal obstruction are not
entirely due to the local mischief at the seat of the block,
the strangulation, the volvulus, or the intussusception,
but depend largely upon the absorption by the intestines
above it of the toxins produced by the decomposition of
their contents. These symptoms of sapraemic intoxica-
tion are no doubt often absent, but where they exist,
where with low temperature there is thready pulse and
general failure, the emptying of the bowel may clearly
be as important a means of saving life as the relief of
the strangulation. — The British Medical Journal.
Prostitution in Berlin is increasing very rapidly. Ac-
cording to a recent report of a committee of the Berlin
Medical Society, the members of the demi monde were
estimated to number from 40,000 to 50,000. In 1886
the number of professional prostitutes, those recognized
as such by the police, was 3,006, and this had increased
in 1 89 1 to 4,364.
Death of an Aged Priest. — A Greek priest died re-
cently in Trikhala, Thessaly, at the reputed age of one
hundred and twenty years. He had had charge of the
parish in which he died for ninety- nine years.
Cure of Deafness. — Dr. Barclay reports in the St. Louis
Courier of Medicine for June a case of deafness from
chronic aural catarrh almost entirely relieved by an opera
tion setting free the anchylosed ossicles.
Dr. d'Arsonval has been elected to the Paris Academy
of Sciences to fill the vacancy caused by the death of
Dr. Brown Sequard. M. d'Arsonval was long associated
with his predecessor- in the latter's experiments with ani-
mal extracts.
BOOKS RECEIVED.
Practical Manual of Mental Medicine. By Dr. E. Regis.
Translated by Dr. H. M. Bannister. i2mo, 692 pages. Press of
the American Journal of Insanity, Utica, N. Y.
Chemistry, Medical and Pharmaceutical. By John Att-
field. 8vo, 794 pages. Illustrated. Published by Lea Bros. & Co.
Philadelphia, Pa.
A Practical Treatise on Orthopedic Surgery. By Jas.
K. Young. M.D. 8vo, 446 pages. Illustrated. Published by Lee
Bros. & Co., Philadelphia, Pa.
A Manual of Hygiene. By Mary Taylor Bissell, M.D. 8vo,
3.}8 pages. Illustrated. The Baker & Taylor Col, New York City.
Price, $2.00.
A Text- Book of Practical Therapeutics, with Special
Reference to the Application of Remedial Measures to
Disease and their Employment upon a Rational Basis. By
Hobart Armory Hare, M.D. 8vo, 740 pages. Published by Lea
Bros. & Co., Philadelphia, Pa.
Transactions of the Forty-Ninth Annual Meeting of
the Ohio State Medical Society. Held at Zanesville, 0.
8vo, 488 pages. Published by Order of the Society.
A Treatise of the Principles and Practice of Medicine.
By Austin Flint, M.D. 8vo, 1143 pages. Published by Lea Bros.
& Co., Philadelphia, Pa.
Antiseptic Surgical Technique By Hunter Robb, M.D.
8vo, 264 pages. Illustrated. Published by J. B. Lippincott,
Philadelphia, Pa. Price, $2.00.
Transactions of the Michigan State Medical Society,
for the year 1894. Vol. 18. Published by the Society. Dciroit,
Mich.
Myxedema; Cretinism, and the Goitres, with some of
their Relations. By Edward T. Blake, M.D. 8vo. 89 pages.
Illustrated. Price, 3s. 6d. Published by John Wright & Co.: Bris-
tol, England.
The Insanity of Over-Exertion of the Brain. By J.
Batty Tuke, M.D. 8vo, 66 pages. Illustrated. Price, 6d. Pub-
lished by Oliver & Boyd, Edinburgh, Scotland.
SUPPLEMENT TO THE MEDICAL RECORD. September 29, ISM.
-F*F**gri|
#
^f'
w.
''Km-'-
w
vy^*&^W--*?$m:;\
^•^\
Diphtheria colonies. Diphtheria colonies. Luxuriant growth.
COLONIES OF BACILLI, 20 HOURS GROWTH ON AGAR, X 124 DIAM.
<5&
Pseudo-diphtheria colonies.
$«?$fri
J±> i\Jkr.-
6^ 5*4 .?*
1- * ■ ' *
v *■_,$*•
Diphtheria colonies.
Actual size.
S
*
s
\
Diphtheria bacilli
Rather even stain.
► # •♦
+
• - 1
•
•" <
^
0
• -
•*- .
&
J?
Diphtheria bacilli.
Diphtheria bacilli.
Pseudo-diphtheria
bacilli and a few cocci.
40
- *
#
**
^*-w - -
»
* /
- * *
1
*>»
s*
->•-'* .
^*
<
r
1
** - *.....'
Diphtheria bacilli. Showing unequal staining.
Not characteristic diphtheria bacilli.
Pseudo-diphtheria bacilli.
Mixed cocci and streptococci from pseudo or
INDIVIDUAL BACILLI AND COCCI GROWN ON BLOOD SERUM, X IOOO DIAM. false diphtheria
Small wooden box holding culture tube and sterile cotton swab. Actual size.
PHOTOGRAPHS OF DIPHTHERIA AND PSEUDO-DIPHTHERIA BACILLI.— PARK & LEAMING.
Medical Record
A Weekly yonrnal of Medicine and Surgery
Vol. 46, No. 13.
Whole No. 1247.
New York, September 29, 1894.
$5.00 Per Annum.
Single Copies, ioc.
®vigfaml Articles.
DIPHTHERIA AND PSEUDO-DIPHTHERIA.
A Report to Hermann M. Biggs, M.D., Pathologist
and Director of the Bacteriological Laboratory,
on the Bacteriological Examination of 5,611
Cases of Suspected Diphtheria, with the Results
of Other Investigations on the Diphtheria and
the Pseudo diphtheria Bacillus. From the Bac-
teriological Laboratory of the Health Depart-
ment of New York City.
By WILLIAM HALLOCK PARK, M.D.,
BACTERIOLOGICAL DIAGNOSTICIAN AND INSPECTOR OF DIPHTHERIA, FELLOW IN
FA7H0TOGY, COLLEGE PHYSICIANS AND SURGEONS, COLUMBIA COLLEGE, NEW
YORK,
AND
ALFRED L. BEEBE, Ph.B.,
INSPECTOR OF BACTERIOLOGY,
NEW YORK.
From May 4, 1893, to May 4, 1894, there were 5,611
cases of suspected diphtheria subjected to bacteriological
examination. In 31255 of these the Loeffler bacilli (the
bacilli of true diphtheria) were found to be present, and
these cases were thus proven to be true diphtheria. In
1,540 no diphtheria bacilli were present in the cultures,
and as these had been carefully made at an early period
of the disease, the cases from which they were taken may
be considered as proven not to have been true diphtheria.
In 816 cases, although no diphtheria bacilli were found
in the cultures, yet, for various reasons (either because
they were made after the fourth day of the disease, or
the exudate was imperfectly obtained from the throat, or
the culture media had become contaminated or were too
dry), the cases from which the cultures were obtained
were considered to be of a doubtful nature, so far as the
bacteriological examination was concerned, although
they were probably not diphtheria.
Thus we find in 5,611 cases of suspected diphtheria
that about fifty-eight per cent, were proven to be true
diphtheria, twenty seven per cent, to be false or pseudo-
diphtheria, and fifteen per cent, to be of somewhat doubtful
character. It would probably be just to consider that sixty
per cent, were true and forty per cent, were false diph-
theria.
Bex, Age, and Mortality in the Cases of True Diph-
theria.— In a large percentage of the cases the sex was
given, and in these there were fifty- four per cent, females
and forty-six per cent, males, a fairly even division.
The statistics reveal some interesting facts as to the influ-
ence of age on the occurrence of true diphtheria, as well
as on the mortality of the disease. The ages of persons
attacked ranged between three weeks and seventy years.
The ages and mortality were determined in ^625 cases
and were as follows :
Age.
1 st 13 mos.
No
Mortal-
Cases ,*£**.
Age
No.
Cases.
'No. Cases! *£
5ve^ I *?'
Average. I Cem>
ad
3i
5th
Ith ••
7th
«4
109
%
193
163
u
t"
7th to xoth year
10th to 15th year.
15th to 20th year,
aoth to 30th year.
30th to 50th year. ,
992
117
4«
13
97 +
«3 +
Ml
»5
5
The number of cases increased with each twelve months
of life up to the fourth year and then gradually dimin-
ished. The mortality was highest in the first two years
of life, and then steadily diminished until adult life was
reached, when it again slowly increased.
Scarlet fever was associated with diphtheria in about
five of every thousand cases. Exact figures cannot be
given.
Age and Mortality in False or Pseudo-diphtheria. —
It has been the general rule of the Department to take
no further cognizance of cases of false diphtheria after
the culture has demonstrated the absence of the diph-
theria bacilli.
In order, however, to compare the mortality and the
communicability of false diphtheria with that of true
diphtheria, 450 cases of the false were carefully inves-
tigated by sanitary inspectors detailed for this work*
These cases comprised 300 occurring in the fall months
and 150 occurring in the following spring. The cases
were taken in consecutive order and are believed to be
average cases.
Age.
Age.
*3
<8.
1 st 12 mos.
2d "
3d 44
4th »
5th '•
6th "
7th »
1 2 i ° 1
1 17 s» \y 7
47 °. P
\ 16 ' 29 ! ..
34 ! 0 ! V a
3« 1 ° )
7th to xoth year.
10th to 15th year.
15th to 20th year,
soth to 30th year.
30th to 50th year.
Over 50 years.
63
63
44
63
'7
2
21
12 +
9-
6 +
1 —
H
'■.\
*f
Total mortality in all cases
1 Two deaths due to scarlet fever. * One death due to scarlet fever.
* One death due to scarlet fever.
In the 450 cases investigated there weie 1 1 deaths, or
about two and one- half per cent, mortality. Of the 450
cases 42 were complicated by scarlet fever, and of
these 42 4 died. In six of the 450 cases measles
occurred as a complication, and these all recovered.
Of the two deaths which occurred among the adults,
one was of a man of seventy years who was suffering
from a serious valvular lesion of the heart, and the
other was of a young adult female * who died of sep-
ticaemia.
The five deaths occurring in uncomplicated pseudo-
diphtheria in children under five years of age were all in
cases in which the larynx was affected, and in three,
more or less broncho- pneumonia developed as a compli-
cation.
True and Pseudo-diphtheria of the Larynx (Mem-
branous Croup). — The statistics gathered of the location
of the disease in the true and false cases are of special
interest. There were 286 of the cases examined in
which the disease was entirely or chiefly confined to the
larynx or bronchi, and of these, 283 were in children
and 3 in adults. In the cultures of 229 of the 286,
characteristic Loeffler bacilli were found, and the cases
were thus proven to be true diphtheria. Of the 229
cases in which the Loe filer bacilli were found, 167
showed no pseudo membrane or exudate above the
larynx, while in the remaining 62, although the larynx
* The history in brief of the second case was as follows : Three
weeks before death the disease began with a swelling of one tonsil
and its surrounding tissues. A week later, the tonsil was incised but
no pus obtained, and about the incision a dirty brown pseudo mem-
brane formed. Later, the tonsil and surrounding tissue became
necrotic and sloughed off, then the ulceration extended to the phar) nz
and the other tonsil, and was still progressing when the patient died
of sepsis and exhaustion.
386
MEDICAL RECORD.
[September 29, 1894
was mainly involved, there was also some membrane or
exudate present on the tonsils or in the pharynx. In 57
out of the 286 examined, no diphtheria bacilli were
found, but in 17 of these the cultures were unsatisfactory.
Excluding the 17 doubtful cases, there were 40 cases
of pseudo-diphtheria in which the diphtheria bacilli were
certainly absent. The disease was confined to the
larynx or bronchi in 27 of the 40, while more or less
exudate or membrane was present on the tonsils or in
the pharynx in 13.
Table of Results ok Examinations of Cases of " Mem-
branous Croup."
Cases.
Diphtheria
Bacilli
found.
Diphtheria
Bacilli not
found.
167
a?
6a
*3
Cases in which the exudate was confined to the larynx
or bronchi
Cases in which the exudate was chiefly confined to
the larynx or bronchi, but other parts somewhat
involved.
Cases in which satisfactory cultures were not
obtained 17
Total cases examined 286
Diphtheria 229
Pseudo-diphtheria 40
Doubtful 17
We find, therefore, that of the cases of acute laryn-
gitis in children which have been subjected to bacterio-
logical examination in the laboratory of the Health
Department during the past twelve months, about
eighty per cent, have proved to be undoubtedly cases of
diphtheria, and of the remaining twenty per cent, only
fourteen per cent, were certainly not diphtheritic.
Not only have the bacteriological examinations shown
that a large proportion of the cases of acute croupous
laryngitis in children (commonly designated by the
name membranous croup) are diphtheria, but the De-
partment inspectors have frequently found that these
cases were apparently the cause of characteristic pharyn-
geal diphtheria in others.
Th» comparatively small number of laryngeal cases
examined is partially due to the fact that membranous
croup has not been considered a contagious disease, and
reports of such cases have not been required by the
Health Department;* and partially to the custom of
Department Inspectors to not make cultures in cases
which have been intubated, or which seem so sick that
the family may think injury had been done by in-
serting the swab in the throat. The cases in which
no cultures are made are treated as cases of true diph-
theria.
The Kelation Between the Length of the Bacillus
and Its Virulence. — Some investigators have believed
the degree of virulence possessed by the diphtheria ba-
cilli could, to a certain extent, be judged by their
length. The longest bacilli were supposed to be the
most virulent ; those of medium length less so, and the
shortest little, if at all, virulent. By observing this
characteristic it was thought cultures might become help-
ful in prognosis. Very careful notes have been made on
this point in the examination of the bacteria from the
original serum tubes in 1,613 cases.
The results of the examinations are shown in the fol-
lowing table:
* An Amendment to the Sanitary Code was adopted by the Board of
Health on June 6, 1894, by virtue of which membranous croup is re-
garded as laryngeal diphtheria, and hereafter physicians will be re-
quired to report such cases to the Health Department.
Notk — Many experienced physicians still find difficulty in believ-
ing that cases in which the exudate or pseudo-membrane is entirely
absent from the pharynx and tonsils are those of true diphtheria It
is also often difficult to persuade parents that such cases are diph-
theria, as, for instance, a child, agel five, subject to attacks of bron-
chitis and slight laryngitis, developed a croupy cough. For diagnos-
tic purposes a culture was made and the diphtheria bacilli were
found to be present. It was with the greatest difficulty that the
parents could bi made to consider the case a serious one and to
quarantine the child. Under suitable treatment, on the fifth day the
child ssemed nsarly recovered, and now the parents became sure it
was not a case of diphtheria, stopped all precautions, allowed the
child to go out, etc. A relapse followed, the laryngeal symptoms in-
creased, and the child died in thirty-eight hours, of asphyxia, intuba-
tion being refused.
Bacilli of average size found in 1*368
'* longer than average found in 8a
41 shorter'* •• •» 67
** short, not characteristic in shape and evenly
stained, of which many were pseudo-diphtheria
bacilli 66
Total cases examined 1.613
Mortality
Per Cent.
26
*7
35
The results obtained from this examination of 1,613
cultures therefore indicate that in New York the great
majority of cases of diphtheria yield in cultures bacilli of
medium size, which are characteristic in shape and man
ner of staining. In a moderate number of cases the
bacilli found are much longer, and in about an equal
number they are much shorter. Both the clinical histo-
ries and the animal experiments show that whenever in
their shape and in the way in which they take the stain-
ing fluid the bacilli are characteristic, no information as
to their virulence, either in men or animals, can be
gathered from their length. Those bacilli, on the other
hand, which are short and stain uniformly with methyl-
blue, usually prove to be of the pseudo diphtheria type,
and have no virulence in animals.
The Bacteriology of Diphtheria — So many inquiries
have been sent to the Department regarding the methods
employed for the general bacteriological examinations of
suspected cases of diphtheria, that it has been thought
desirable to include in this report a condensed account
of the facts which have been brought out in the various
bacteriological investigations of diphtheria, together
with a description of the characteristics of the diph-
theria bacilli which must be known in order to make
bacteriological examinations for diagnostic purposes.
It is hoped that with these additions this report may be .
of greater practical assistance to many who have begun
or are about to begin similar work.
Successive Investigations Showing the Specific Causal
Relation of the Diphtheria Bacillus of Klebs and Loeffler
to Diphtheria. — In the year 1883, bacilli, which were
very peculiar and striking in appearance, were shown by
Klebs l to be of constant occurrence in the pseudo mem-
branes from the throats of those dying of true epidemic
diphtheria. One year later Loeffler2 published the re-
sults of a very thorough and extensive series of investiga-
tions on this subject. He found the bacillus described
by Klebs in most, but not in all, cases of throat inflamma-
tions which had been diagnosticated as diphtheria. He
separated these bacilli from the other bacteria present
and obtained them in pure culture. When he inoculated
these bacilli upon the abraded mucous membrane of sus-
ceptible animals, pseudo-membranes were produced, and
frequently death followed. If a certain amount of a
bouillon culture was injected subcutaneously into guinea-
pigs, death was caused with characteristic lesions. Loef-
fler's failure to find the bacilli in every case examined is
now explained by the fact that certain varieties of pseudo-
membranous inflammation not due to the diphtheria ba-
cillus, such as occur especially in scarlet fever, were then
wrongly considered to be true diphtheria.
In 1887/ further studies by Loeffler added to the
oroof of the dependence of diphtheria on the diphtheria
bacilli. In 1888, D'Espine found the bacilli in fourteen
cases of characteristic diphtheria, and proved them to be
absent in twenty-f jut cases of mild sore-throats which,
clinically, were believed not to be cases of diphtheria. In
the same year, the first report of the results of the very
important investigations of Roux * and Yersin was pub-
lished, and the dependence of diphtheria on the diph-
theria bacilli may be considered to have been established.
Roux and Yersin found that diphtheria bacilli were pres-
ent in all characteristic cases of diphtheria, and that
these bacilli possessed the cultural and pathogenic quali-
ties of those described by Loeffler. They found, too,
when the bacilli were inoculated upon the healthy mu-
cous membrane of the trachea of the rabbit, no result
September 39, 1894]
MEDICAL RECORD.
3*7
followed; but if the inoculation was made on the
abraded membrane, phenomena occurred which strikingly
resembled those present in membranous laryngitis in
man, i.e., congestion of the mucous membrane followed
by the formation of a pseudo membrane, oedematous
swelling of the tissues, and of the glands of the neck,
dyspnoea, stridulous breathing, and asphyxia. Injections
of cultures beneath the skin of rabbits and guinea pigs in
sufficient quantity caused their death in from thirty six
hours to five days, the period varying in ratio to the sus-
ceptibility of the animal, and the number and the viru-
lence of the bacteria introduced. The same results fol-
lowed the i ejections of filtered cultures, showing the
products formed by the growth of the bacilli were by
themselves capable of causing the general lesions.
Roux and Yersin were also able to produce in animals
characteristic diphtheritic paralysis. They produced
this in many cases where the inoculated animals did not
succumb to a too rapid intoxication. Paralysis com-
menced in a pigeon three weeks after the inoculation of
the pharynx, and after all membrane had disappeared
and the animal seemed to have completely recovered.
In rabbits, the paralysis usually commenced in the pos-
terior extremities, and then gradually extended to the
whole body, causing death by paralysis of the heart or
respiration. In rare instances the muscles of the neck
or of the larynx were first paralyzed, and thus character-
istic symptoms were caused. The authors conclude:
" The occurrence of these paralyses, following the intro-
duction of the bacilli of Klebs and LoefHer, completes
the resemblance of the experimental disease to the natu-
ral malady, and establishes with certainty the specific
rdleoi this bacillus.1'
Finally, the microscopical changes in the internal or-
gans of animals dying of experimental diphtheria pro
d'iced by the bacilli have been shown by Welch and
Flexner,* and by Babes * and others, to be essentially the
same a? those produced by diphtheria in man, and thus
a still further proof is afforded of the specific rdle of this
bacillus.
The results of the various observations detailed above
have since been confirmed by a great number of com-
bined clinical and bacteriological investigations, so that
all who have studied the bacteriology of diphtheria would
now agree with the following statement made by Welch 7
in an address on diphtheria: "All the conditions have
been fulfilled for diphtheria which are necessary to the
most rigid proof of the dependence of an infective dis-
ease upon a given micro-organism, viz., the constant
presence of this organism in the lesions of the disease,
the isolation of the organism in pure culture, the repro-
duction of the disease by inoculations of pure cultures,
and similar distribution of the organism in the experi-
mental and in the natural disease. In view of these
facts, we must agree with Prudden,8 that we are now jus-
tified in saying that the name diphtheria, or at least,
primary diphtheria, should be applied, and exclusively
applied, to that acute infectious disease usually associated
with a pseudo-membranous affection of the mucous mem-
brane, which is primarily caused by thq bacillus called
the bacillus diphtheria? of LoefHer.11
Pseudo or False Diphtheria. — Under this general title
are included all cases of pseudo membranous or exuda-
tive inflammation of the mucous membranes in which the
diphtheria bacillus is absent. The thorough considera-
tion of the bacteriology of this form of inflammation is
to be reserved for a later report, but it is necessary to
touch on a few points here.
Since LoefHer 2 in 1889 first described a class of pseudo-
membranous inflammations of the throat in which the
diphtheria bacilli were absent and cocci present, it has
been established that a certain proportion of the inflam-
mations of the respiratory mucous membranes, which
closely resemble the less characteristic cases of diphtheria,
are not due to the diphtheria bacilli but to cocci, espe-
cially to streptococci.
. It has been found that streptococci are commonly
present in the throats ot healthy persons, or at least in
the throats of persons living in large cities, and that
other forms of cocci, especially the pneumococci and sta-
phylococci, are apt to be associated with them. These
germs seem to live in the throat without creating any
disturbance there so long as the mucous membranes are
healthy, but under certain conditions, as when the mucous
membrane has been made vulnerable by exposure to cold
or other deleterious influences, or by the poison of scarlet
fever, measles, or some other disease, the streptococci,
alone or associated with other cocci, are able to attack
the mucous membrane and to cause an inflammation*
This may be of any degree of intensity from a simple
inflammatory hyperemia to an inflammation with the
extensive production of pseudo membrane or with ulcer-
ation. Such inflammations, when associated with the
formation of a pseudo-membrane, are known as pseudc-
diphtheria. The exudate, or pseudo membrane, in pseudo-
diphtheria is usually confined to the tonsils, but other
parts, such as the larynx, pharnyx, and nostrils, may be
invaded.
It has been found that the percentage of mortality in
tfiese cases is far less than in diphtheria, and that the
disease is seldom, if ever, communicated to others.
The Proportion of Cases of Suspected Diphtheria which
upon Examination Prove to be True Diphtheria. — As
soon as careful investigation had demonstrated it was pos-
sible, with proper precautions, to separate by bacterio-
logical examination the cases of true from the cases of
fake diphtheria, large numbers of cases suspected to be
diphtheria were examined bacteriologically. The re-
ports from hospitals in which all cases of diphtheria and
oi suspected diphtheria were examined, are of especial
interest as showing the proportion of cases of true to
false diphtheria. The results from these hospitals are
all the more valuable because the cases came from all
parts of the various cities in which the respective hospi-
tals were located, and hence special local conditions were
not likely to greatly influence the general results ob-
tained. Thus Baginsky,8 in Berlin, found the diphtheria
bacilli in 120 out of 154 suspected cases; Martin,10 in
Paris, in 126 out of 200 ; Park,11 in New York, in 127 out
of 244 ; Janson,12 in Switzerland, in 63 out of 100 ; and
Morse,1* in Boston, in 239 out of 400. Thus from twenty
to fifty per cent, of the cases sent to diphtheria hospitals
did not have diphtheria.
If we examine the reports of examinations made under
some special conditions, as during an outbreak of some
contagious disease in a hospital for children we find the
results may differ in a striking manner.
Thus in 1889 Prudden14 made bacteriological exami-
nations of 24 fatal cases of pseudo-membranous inflam-
mation of the tonsils, pharynx, and larynx. In none of
these were the LoefHer bacilli found to be present. These
cases occurred in two hospitals for children in New York,
in which both scarlet fever and measles were at the time
prevalent. During the past year we have examined the
exudate from 46 fatal cases of suspected diphtheria oc-
curring in the same institutions and found the bacilli
present in 44 of them.
If scarlet fever and measles (but not true diphtheria)
were prevailing in an institution, it is evident the bacilu
would be absent from the pseudo- membranes occasionally
occurring in the throat as a complication of these diseases.
The Mortality in True Diphtheria and in Pseudo*
Diphtheria. — All observers have found the mortality was
far higher in those cases in which the diphtheria bacilli
were present than in those in which they were absent.
In true diphtheria the mortality has been found to vary
from 25 per cent, to 70 per cent., while in pseudo diph-
theria it varies from o per cent, to 20 per cent.
The death-rate in cases of pseudo- diphtheria occurring
in hospitals averages far higher than the death rate out-
side of such institutions. The reason for this is chiefly
to be found in the fact that it is mainly the graver cases,
especially those suffering from laryngeal obstruction,
which are removed to the hospitals.
388
MEDICAL RECORD.
[September 29, 1894
Laboratory Technique. Collection of the Blood-serum
and its Preparation for Use in Cultures. — A covered
glass jar, which has been thoroughly cleansed with hot
water, is taken to the slaughterhouse and filled with
freshly shed blood from a calf or sheep. The blood is
received directly in the jar as it spurts from the cut in
the throat of the animal. After wiping the edge of the
jar, it is covered with the lid and set aside where it may
stand quietly until the blood has thoroughly clotted.
The jar is then carried to the laboratory and placed in
an-ice chest. If the jar containing the blood is carried
about before the latter has dotted, very imperfect separa-
tion of the serum will take place. It is well to inspect
the blood in the jar after it has been standing a few
hours, and if the clot is found adhering to the sides, to
separate it by a rod. The blood is allowed to remain
twenty-four hours on the ice, and then the serum which
surrounds the clot is siphoned off by a rubber tube and
mixed with one- third its quantity of nutrient beef broth,
to which one per cent, glucose has been added. This
constitutes the Loe filer blood-serum mixture. The
broth used to mix with the serum is prepared as follows :
One pound of finely chopped lean beef is allowed to
soak in one litre of water in a cool place for at least
twelve hours. The meat and fluid arc now dumped into
a cheese cloth or towel, and the fluid squeezed out. To
this solution one per cent, of peptone, one per cent, of
glucose, and one- half per cent, of common salt are added.
It is well to test the reaction of the mixture, and if it is
found to be acid, to render it neutral by adding a few
drops of a solution of caustic soda or carbonate of soda.
The whole is now boiled for half an hour, and filtered
through absorbent cotton or filter-paper. If the broth
is to be kept it should be placed in flasks and then steril-
ized. The Loeffter blood-serum mixture when ready is
poured into tubes, which should be about four inches in
length and two thirds of an inch in diameter. These
tubes should first be plugged with cotton, and sterilized
by dry heat at 1500 C. for one hour. Care should be
taken in filling the tubes to avoid the formation of air-
bubbles, as they leave a permanently uneven surface
. when the serum has been coagulated by heat. To pre-
vent this, the end of the pipette or funnel which contains
the serum should be inserted well into the test-tube.
About 2 c.c. are sufficient for each tube. The tubes
having been filled, are now to be coagulated and steril-
ized. The tubes are placed at the proper angle and then
kept for two hours at a temperature just below the boil-
ing point. For this purpose a Koch serum-coagulator
or a double boiler serves best, though a steam sterilizer
will suffice. If the latter is used, a wire frame must be
arranged to hold the tubes at the proper inclination, and
the degree of heat must be carefully watched, as other-
wise the temperature may go too high, the serum actually
boiled, and the culture medium thus spoiled. After ster-
ilization by this process the tubes containing the sterile,
solidified blood-serum can be placed in covered tin-boxes
and kept for months. The serum thus prepared is quite
opaque and firm. A mixture of blood-cells renders the
serum darker, but it is not less useful.
The Swab for Inoculating Culture-tubes. — The swab
to inoculate the serum is made as follows : A stiff, thin
steel rod, six inches in length, is roughened at one
end by a few blows of a hammer, and about this end a
little absorbent cotton is firmly wound. Each swab is
then placed in a separate glass tube, and the mouths of
the tubes are plugged with cotton. The tubes and rods
are then sterilized by dry heat at about 1500 C. for one
hour, and stored for future use. These cotton swabs
have proved much more serviceable for making inocula-
tions than platinum-wire needles, especially in young
children and in laryngeal cases. It is easier to use the
cotton swab in such cases, and it gathers up so much more
material for the inoculation that it has seemed more re-
liable.
For convenience and safety in transportation " a cult*
ure outfit" has been devised which consists of a small
wooden box containing a tube of blood serum, a tube
holding a swab, and a record blank. These " culture
outfits " may be carried or sent by messenger or express
to any place desired, and are kept at stations scattered
throughout the city for the free use of physicians.
Directions for Inoculating Culture- tubes with the Ex-
udate in Cases of Suspected Diphtheria. — The patient
should be placed in a good light, and, if a child,
properly held. The swab is removed from its tube, and
while the tongue is depressed with a spoon it is passed
into the pharynx (if possible without touching the
tongue) and is rubbed gently but firmly against any
visible membrane on the tonsils or in the pharynx, and
then, without laying the swab down, it is immediately in-
serted in the blood serum tube, and the portion which
has been previously in contact with the exudate is rubbed
a number of times back and forth t>ver the whole surface
of the serum. This should be thoroughly done, but it is
to be gently done, so as not to break the surface of the
serum. The swab is replaced in its tube and both tubes, (
their cotton plugs having been inserted, are returned to '
the box and sent to the collecting station. The blank
forms of report which accompany each outfit should be
completely filled out and forwarded to the station with
the tubes.
Where there is no visible membrane (it may be present
in the nose or larynx) the swab should be thoroughly
rubbed over the mucous membrane of the pharynx and
tonsils, and in nasal cases, when possible, a culture
should also be made from the nose. In little children
care should be taken not to use the swab when the throat
contains food or vomited matter, as then the bacterial
examination is rendered more difficult. Under no con-
ditions should any attempt be made to collect the mate-
rial shortly after the application of disinfectants (espe-
cially solutions of corrosive sublimate) to the throat. If
any of these instructions have not been carried out, the
fact should be carefully noted on the record blanks.
The Examination of Cultures. — The culture tubes
which have been inoculated as described above, are kept
in an incubator at 370 C. for twelve hours, and are then
ready for examination. On inspection it will be seen
the surface of the blood- serum is dotted with very numer-
ous colonies, which are just visible. At this time no
diagnosis can be made from simple inspection. (If,
however, the serum is found liquefied, or shows other
evidences of contamination, the examination will prob-
ably be unsatisfactory.) A microscopical preparation is
now made by placing a tiny drop of water upon a clean
cover-glass, and then a platinum needle is inserted in the
tube, and quite a large number of colonics are swept with
it from the surface of the culture medium. The bacteria
adherent to the needle are washed off in the drop of
water previously placed on the cover glass and smeared
over its surface. The bacteria on the glass are then al-
lowed to dry in the air. The cover-glass is then passed
quickly through the flame of a Bunsen burner or alcohol
lamp three times in the usual way, covered with a few
drops of Loeffler's solution of alkaline methyl blue, and
left without heading for ten minutes. It is then rinsed
off in clean water, dried, and mounted in balsam. ^
In the great majority of cases one of two pictures
will be seen with the -fa oil immersion lens ; either an
enormous number of characteristic Lex filer bacilli with a
moderate number of cocci, or a pure culture of cocci
mostly in pairs or short chains (see photographs). In
a few cases there will be an approximately even mixt-
ure of Loeffler bacilli and cocci, and in others a great
excess of cocci. Besides these, there will be occasion-
ally met preparations in which, with the cocci, there are
mingled bacilli more or less resembling the Loeffler
bacilli, but not characteristic. These bacilli, which may
be either the less characteristic diphtheria bacilli or the
pseudo-diphtheria bacilli (see photographs), are especially
frequent in cultures from the nose.
In not more than one case in twenty will there be any
serious difficulty in making the diagnosis, if the serum-
September 29, 1894]
MEDICAL RECORD.
389
tube has been properly inoculated. In such a case an-
other culture may clear up the doubt, or it may be neces-
sary to obtain the bacilli in pure culture.
The Direct Microscopical Examination of the Exudate.
— An immediate diagnosis,, without the use of cultures,
is often possible from a microscopical examination of the
exudate. This is made by smearing a cover glass with a
little exudate from the swab, drying, staining, and ex-
amining it microscopically. This examination, however,
is much more difficult and the results more uncertain
than when the covers are prepared from cultures. The
bacilli from the membrane are usually less typical in
appearance than those found in cultures, and they are
mixed with fibrin, pus, and epithelial cells. They may
also be very few in number in the parts reached by the
swab, or bacilli may be met which closely resemble the
Lceffljr bacilli in appearance, but which differ greatly in
growth and In other characteristics. When in a smear
containing mostly cocci a few of these doubtful bacilli
are present, it is impossible either to certainly exclude or
make the diagnosis of diphtheria. Although in certain
cases this immediate examination may be of the greatest
value, it is not a method suitable for general use.
Characteristics of the Diphtheria Bacillus. — When
cover-glass preparations made from the blood serum
tubes are examined, the diphtheria bacilli are found to
possess the following characteristics :
The diameter of the bacilli varies from 0.3 to 0.8 m.,
and the length from 1.5 to 6 m. They occur singly
and in pairs, and very infrequently in chains of three
or four. The rods are straight or slightly curved, and
usually are not uniformly cylindrical throughout their
entire length, but are swollen at the ends, or pointed
at the ends and swollen in the middle portion. Even
from the same culture different bacilli differ greatly
in their size and shape. The two bacilli of a pair may
lie with their long diameter in the same axis, or at an
obtuse or an acute angle. The bacilli possess no spores,
but have in them highly refractile bodies. They stain
readily with the ordinary aniline dyes, and retain their
color after staining by Gram's method. With an alkaline
solution of methyl-blue, the bacilli, from blood-serum
cultures especially, and from other media less constantly,
stain in an irregular and extremely characteristic way.
The bacilli do not stain uniformly. Certain oval bodies,
situated in the ends or in the central portion, stain much
more intensely than the rest of the bacillus. Sometimes
these highly stained bodies are thicker than the rest of
the bacillus ; again they are thinner and surrounded by a
more slightly stained portion. The bacilli seem to stain
in this peculiar way at a certain period in their growth,
so that only a portion of the organisms taken from a
culture at any one time will show the characteristic stain-
ing. In old cultures it is often difficult to stain the ba-
cilli, and the staining, when it does occur, is frequently
not at all characteristic.
Growth on Blood-serum. — If we examine the growth
of the diphtheria bacillus in pure culture on blood serum
we will find at the end often to twelve hours little colo-
nies of bacilli, which appear as pearl gray or whitish
gray slightly raised points. The colonies when separated
from each other may increase in forty-eight hours so that
the diameters may be a quarter of an inch. The borders
are usually somewhat uneven. Those colonies lying to-
gether fuse into one mass, especially if the serum is
rather moist. During the first twelve hours, the colonies
of the diphtheria bacilli about equal in size those of the
streptococci ; but after this time the diphtheria colonies
become larger than those of the streptococci, nearly
equalling those of the staphylococci. The diphtheria
bacilli in their growth never liquefy the blood serum.
Growth on One Per Cent. Alkaline Glycerine-agar,
and Method of Obtaining Pure Cultures. — It is frequently
desired to obtain the diptheria bacillus in pure culture.
This is most readily accomplished by removing with a
platinum needle a portion of the mixed growth of bac-
teria in a serum tube and lightly streaking it over
the surface of the nutrient agar* contained in a Petri
dish.
Though the growth of the diphtheria bacilli upon agar
is less certain and luxuriant than upon serum, the appear-
ance of the colonies when examined under the microscope
is more characteristic.
If the diphtheria colonies develop deep in the substance
of the agar, they are usually round or oval, and, as a rule,
present no extensions, but if near the surface, commonly
from one, but sometimes from both sides, they spread
out an apron -like extension which exceeds in surface area
the rest of the colony. When the colonies develop en-
tirely on the surface, they are more or less coarsely granu-
lar, are nearly translucent, and usually have a darker
centre. The edges are sometimes jagged, and frequently
shade off into a delicate lace-like fringe ; at other times
the margins are more even and the colonies are nearly
circular. With a high power lens the edges show sprout-
ing bacilli (see photographs). The colonies are grayish
or grayish white by reflected light, and pure gray or with
olive tint by transmitted light.
The growth of the diphtheria bacillus upon agar pre-
sents certain peculiarities which are of the utmost prac-
tical importance. While the bacilli from the majority of
cases grow rather feebly, some grow luxuriantly. If a
large number of the bacilli from a recent culture are im-
planted upon a properly prepared agar plate, a certain
and fairly vigorous growth will always take place. If,
however, the agar is inoculated with the exudate of a
throat which contains but few Loeffler bacilli, no
growth whatever of the bacilli may occur; while the
tubes of coagulated blood- serum inoculated with the same
exudate contain them abundantly. Again, agar prepared
from broth made from different specimens of beef, or to
to which different peptones have been added, varies some-
what as to its suitability for the growth of the bacilli.
Because of the uncertainty of obtaining a growth by the
inoculation of agar with a few bacilli, or with bacilli
of diminished vigor, agar is a far less reliable medium
than blood serum for use in cultures made for diagnostic
purposes, and is therefore not to be recommended. All
agar should be tested by means of a pure culture of the
diphtheria bacillus before being used experimentally.
Growth in Broth. — All the varieties of the Loeffler
bacillus experimented with have grown in slightly alka-
line broth with or without the addition of one per cent
glucose. The characteristic growth is one showing fine
grains. These deposit along the sides and bottom of the
tube, leaving the broth nearly clear. In some cultures
for twenty-four to forty- eight hours there is a more or
less diffuse cloudiness, and exceptionally a film forms
over the surface of the broth. On shaking the tube this
film breaks up and slowly sinks to the bottom. All the
varieties tested caused the alkaline broth to become acid,
or, at least, distinctly less alkaline, within forty-eight
hours.
Animal Inoculations as a Test of Virulence. — Animal
experiments form the only reliable method of determining
with certainty the virulence of the diphtheria bacillus.
For this purpose alkaline glucose-broth cultures of forty-
eight hours1 growth should be used for the subcutaneous
inoculation of guinea pigs. The amount injected may
vary from one-fourth to one-half per cent, of the body-
weight of the animal inoculated. In the great majority
of cases, when the bacilli are virulent, this amount causes
death within seventy-two hours. In the autopsy the
characteristic lesions .described by Loeffler are found ;
namely, at the seat of inoculation there is a grayish focus
surrounded by an area of congestion ; the subcutaneous
The agar is prepared by adding one per cent, of agar to the re-
quired quantity of broth. This broth is prepared in the same way as
that used in the blood-serum mixture already described, except that
it contains no glucose. The agar must be thoroughly dissolved in
the broth, and to accomplish this it is necessary to boil the mixture
for from three to six hours. Before filtering, sufficient alkali must be
added to make the agar slightly but distinctly alkaline. Finally, six
per cent, of glycerine is added, and the mixture sterilized in flasks.
When needed it is melted and poured into sterilized Petri dishes in a
thin layer.
390
MEDICAL RECORD.
[September 29, 1894
tissues for an extensive area around are congested, and at
times very oedematous; the adjacent lymph nodes are
swollen and the serous cavities — especially the pleural —
frequently contain an excess of fluid, usually clear, but at
times turbid; the lungs are usually congested. If the
organs are subjected to microscopical examinations, the
lesions described by Welch and Flexner,* Babes/ and
others are found. There are numerous smaller and larger
masses of necrotic cells which are permeated by leuco-
cytes. The heart and the voluntary muscular fibres
usually show degenerative changes. The number of leu-
cocytes in the blood is increased. From the area sur-
rounding the point of injection virulent bacilli may be
obtained, but in distant areas and organs they are only
ocasionally found.
Bacilli, which in cultures and in animal experiments
have shown themselves to be characteristic, may be re-
garded as certainly true diphtheria bacilli, and as capa-
ble of producing diphtheria in man under favorable con-
ditions.
Original Investigations.— A large portion of the daily
work in the laboratory has consisted in the routine ex-
amination of the cultures received each day. Besides
this, however, a number of important questions have
been studied experimentally, of which the most important
are the following :
1. How much reliance can be placed on the bacterio-
logical diagnosis made from the examination of a cult-
ure inoculated with the exudations in the throat of a
case of suspected diphtheria ?
2. If in cultures bacilli are found which possess the
shape, size, and staining characteristics of the diphtheria
bacillus, can they, without further cultural or animal
experiments, be considered as virulent diphtheria ba-
cilli?
3. What is the period of time during which virulent
diphtheria bacilli remain in the throat after the disap-
pearance of the exudate or pseudo-membrane ?
4. (a) What relation has the pseudo- and the non-
virulent diphtheria bacillus to the true virulent bacillus ?
(b) Are virulent diphtheria bacilli ever present in
the throats of healthy persons who have been in contact
with diphtheria ?
5. To what degree is pseudo- diphtheria communica-
ble?
6. What are the means by which diphtheria is trans-
mitted ?
1. How much Reliance can be Placed on the Bacterio-
logical Diagnosis made from the Examination of a Culture
Inoculated with the Exudations in the Throat of a Case
of Suspected Diphtheria ? — During the first few months, in
order to test the results of the examinations and to make
the liability to error as slight as possible, the following
plan was adopted :
All cases in which the cultures yielded no diphtheria
bacilli were turned over to special inspectors, who made,
whenever possible, a second culture, and followed up the
case during the illness, and for some time even after its
recovery.
By means of the information thus obtained the bacte-
riologists of the Department were able more and more
surely to decide how far they could base absolute diag-
noses on cultures, especially when made by others.
Many physicians, as well as the inspectors, gradually be-
came so skilled in making inoculations that it was possi-
ble to rely certainly on the results obtained from the ex-
amination of their cultures ; while, on the other hand, it
was found that caution was necessary in accepting the
inoculations of others, and in such cases a second culture
was requested.
After a year's trial the following conclusions have
been arrived at : The examination by a competent bac-
teriologist of the bacterial growth in a blood-serum tube
which has been properly inoculated and kept for four-
teen hours at the body temperature, can be thoroughly
relied on in cases where there is visible membrane in the
throat, if the culture is made during the period in which
the membrane is forming, and no antiseptic, especially
no mercurial solution, has lately been applied.
In cases in which the disease is confined to the larynx
or bronchi, and where, therefore, there is no visible exu-
date against which the swab can be rubbed, surprisingly
accurate results can be obtained from the examination cf
cultures, but in a certain proportion of cases no diph-
theria bacilli will be found in the first culture, and yet
will be abundantly present in later ones, the bacilli hav-
ing probably been coughed up more freely as the disease
progressed. We believe, therefore, that absolute reliance
for a diagnosis cannot be placed on a negative result in a
single culture from 'the pharynx in purely laryngeal
cases.
In nasal diphtheria a negative result may be obtained
from a culture made from the throat, and yet the bacilli
be found in cultures from the nose.
In making a diagnosis from the examination of a cult-
ure it is essential to know the duration of the disease in
the case from which it was made, because although ba-
cilli may remain present and alive in some throats for
many weeks, it is nevertheless important to remember
they may vanish early and suddenly, and that, therefore,
the cultures cannot be certainly relied on after the mem-
brane begins to disappear.
The use of antiseptics shortly before making the inoc-
ulation of a culture tube may render the culture useless
for diagnosis. It has been found in a few instances that
a culture made from a case of diphtheria shortly after a
thorough irrigation with a 1 to 4,000 solution of bichlo-
ride of mercury gave no diphtheria bacilli, though one
made just before, and one made some time later, gave
them abundantly. It is a curious fact that under such
circumstances a vigorous growth of other organisms may
take place.
The above conclusions are true only when the inocu-
lations have been properly made, and in judging cultures
received from physicians in general, the greatest care
must be taken. Some cultures are made carelessly, and
some evidently without taking the pains to even read the
instructions, or to glance at the condition of the coagu-
lated serum in the tube. If, therefore, when no diph-
theria bacilli are found, the bacterial growth is scanty,
the media dry or contaminated, or the inoculation in any
way faulty, the case must be referred back for another
culture. The second culture in these cases not infre-
quently contains the bacilli when the first did not
The absence of the bacilli in a culture proves the case
to be one of false diphtheria only when it has been possi-
ble to make it under the proper conditions.
2. If in Cultures Bacilli are found which Possess the
Shape* Size, and Staining Characteristics of the Diphtheria
Bacillus, can they, without Further Cultural or Animal
Experiments, be Considered as Virulent Diphtheria Ba-
cilli?— Since it is the custom in the laboratory of the
Health Department to make a bacteriological diagnosis
in suspected cases of diphtheria from the examination of
the growth upon the original blood serum tube, without
waiting for further cultural or animal experiments, it
is of the greatest practical importance to ascertain to
what extent bacilli appearing upon the serum in every
way characteristic of the diphtheria bacilli can be as-
sumed to be virulent.
To test the virulence of bacilli it is necessary to ob-
tain them in pure culture, for otherwise it would be im-
possible to determine whether the changes produced in
the inoculated animal were due to the supposed diphtheria
bacilli or to other micro-organisms injected with them.
It is further necessary to grow the bacilli in proper media
and to inoculate susceptible animals at a period when the
growth of the bacilli in the media has reached its maxi-
mum. It is only when these precautions have been fol-
lowed that accurate results will be obtained. The pres-
ent almost uniform practice is to inoculate half grown
guinea-pigs with from one- quarter to one half per cent,
of their body- weight of a forty-eight hours' culture of the
bacilli grown at 37° C. in simple nutrient or glucose alka-
September 29, 1894]
MEDICAL RECORD.
39i
line broth. It is important to remember that it is not
safe to decide because the growth derived from one ba-
cillus is not virulent that all the bacilli from that throat
are not virulent. The cultures from several bacilli must
be tried. The majority of those who have inoculated
bacilli derived from pseudo membranes and possessing
the characteristics of the Loeffter bacilli have found, as
Loeffler did, that they were always virulent. The re*
searches of Hofmann,15 Beck/6 and others, however, show-
ing that in a certain number of healthy throats there
were bacilli which closely resembled the Loeffler bacillus
and yet were not virulent, stimulated others to subject
the bacilli from large numbers of cases of suspected diph-
theria to the test of animal inoculation.
In 1890 Roux and Yersin17 published the results of
some examinations as to the virulence of the bacilli ob-
tained from 100 cases of diphtheria. Fifty- five of these
were fatal cases, and in all of them virulent bacilli were
found, although in a few, together with many virulent
bacilli, there were a few non- virulent ores. Among the
45 cases which recovered, many were very mild, and in
10 of them they found no bacilli of sufficient virulence
to cause the death of guinea pigs, when injected in
moderate amount. From all of them, however, they ob-
tained bacilli capable of causing inflammation in the
guinea-pig at the point of injection. This varied from
slight, transient oedema to extensive necrosis. From
further experiments they proved similar bacilli were
able, under proper conditions, to regain their virulence.
They further showed in these milder cases, among many
non virulent or slightly virulent bacilli, there were usually
a few virulent ones ; therefore they believed in most of
these ten cases fully virulent bacilli may have been present
in the throat with the slightly virulent ones, which by
chance were used for the inoculations. In similar inves-
tigations carried on in a different locality somewhat dif-
ferent results were obtained. Escherich 18 was unable to
obtain, from a large number of diphtheria cases studied,
any bacilli having the characteristics of the Loeffler ba-
cillus which were not virulent, and only a few which, in
injections of one-quarter per cent, of the body weight of
a forty eight-hour bouillon culture, did not kill guinea-
pigs within forty-eight hours. Koplik,19 in New York,
in testing the virulence of bacilli from mild cases of ton-
sillar diphtheria, found them in every case fully virulent.
In Baltimore Welch*0 and Abbott in eight cases of
diphtheria found the bacilli in every case fully virulent.
In a later investigation, in which a large number of
healthy and slightly inflamed throats were examined,
Abbott M found in the cultures from three, bacilli resem-
bling the Klebs- Loeffler bacilli, but lacking virulence.
These will be considered bacteriologically in connection
with the pseudo diphtheria bacilli, but the cases are of
sufficient interest to be briefly quoted in the present con-
sideration of the virulence of bacilli obtained from throats
in which inflammatory lesions have appeared which more
or less resemble diphtheria.
Case I. — Adult, aged fifty- nine, while in hospital de-
veloped a laryngitis and pharyngitis. The uvula, tonsils,
and faucial pillars became swollen and (Edematous, of an
intense crimson red color, and covered with a thin, gray-
ish-white, slightly adherent exudate. In five days the
patient completely recovered. Bacteriological examina-
tion showed abundant, apparently characteristic diph-
theria bacilli, which, when inoculated, proved not to be
virulent.
Case II. — Adult, similar lesions to last ; well on ninth
day. Bacteriological examination : Abundant bacilli, in
appearance similar to Klebs-Lceffler bacillus, but not
virulent.
Case III. — Girl, aged eleven ; acute tonsillitis, with
small white plug in one crypt. Quick recovery. Bac-
teriological examination : Apparently characteristic Loef-
fler bacilli, but not virulent.
It must remain a matter of doubt whether some colo-
nies from these cases would have been found to possess
virulence if more had been tested as to this characteristic.
These cases, as well as those of Roux and Yersin, show
that now and then the bacilli from cases suspected to be
diphtheria have little or no virulence.
Original Investigations. — In order to determine the
virulence of the bacilli obtained in the ordinary routine
examinations from suspected cases of diphtheria, blood-
serum cultures from twenty cases were selected in which
bacilli were found having the characteristic appearance
of the virulent diphtheria bacilli. The cultures tested
were selected before any information was possessed of
the severity of the case from which they were obtained
and were used for experiments on animals.
Virulence of the Bacilli found in Twenty Cases of
Throat Inflammations of such a Character as to
arouse a Suspicion of the Existence of Diphtheria.
Sevei ity.
•Very mild case. Sick only
four or five days
Moderately severe case. Sub
sequendy contracted scar-
let fever
Mild case
Mild case
Mild case
Very mild case. Culture
taken after disappearance
of membrane
Very mild case ,
Fatal case, and cause of se-j
vcre case in mother |
Mild case
Mild case. Adult ; never in I
bed
Removed to Diphthetia Hos-
pital. Severe case
Rather mild case
Very mild case
Fatal case- Croup
Fairly severe case, followed
by measles
Moderately severe case
Moderately severe case . . .
Fatal case. Croup
Very mild case
Contracted from a mild case.
No membrane present
458
305
350
goo
405
430
4x0
435
390
40 hours. 14-19 days.
ra days.
! 45 hours.
40 horn ?.
40 hours.
34-32 days.
6 days.
i-5
i.5
T.33
i-33
40 hours. 13 days.
I 40 hours. 1
• 40 hours.
' 40 hours.
P. 16 days.
P. 38-41 days
210
0.5
2*b
620
479
675
o.5
3-33
2
i-5
443
435
510
475
500
''•33
1.C6
x.66
250
«
50 hours. P. 44 days.
40 hours.
25 hours. P. 42 day?.
40 hours. P. 20-74 days.
40 hours.
40 hours. P. 1 5-23 days.
4 days . P. 15-19 days.
40 hours.
40 hours. I
40 hours.
40 hours, j
We find, therefore, that the bacilli obtained from
twenty cases of suspected diphtheria, two- thirds of *hich
were very mild cases, proved in every case to be virulent,
and in all but three fully so. If these results are con-
sidered in connection with those obtained by other
American and European observers, we must conclude
that for diagnostic purposes all bacilli found in throat
inflammations suspected to be diphtheria, which possess
the morphological and cultural characteristics of the
Lceffler bacilli must be regarded as virulent unless ani-
mal inoculations prove otherwise. Further, it should be
remembered (as shown by Roux and Yersin, and as con-
firmed by others and by ourselves) that the absence of
virulence in a culture derived from one bacillus is not
sufficient to prove that cultures from other bacilli from
the same case would not be virulent.
In three of the above cases the cultures from the first
colony selected were not virulent, while from others they
were fully so.
3. What is the Period of Time during which Virulent
Diphtheria Bacilli Remain in the Throat after the Dis-
appearance of the Exudate or Pseudo-membrane ? — If a
piece of membrane be removed from a throat during the
period of invasion of diphtheria and examined micro-
scopically or by cultures, the presence of abundant diph-
theria bacilli will be noted. If, a few days later, *hen
the membrane has begun to loosen, another bit be exam-
ined the diphtheria bacilli will be found to be partly or at
times wholly replaced by other micro organisms, mostly
cocci. If, several days after the complete disappearance
of the membrane, cultures be made from the mucus of
the throat, it will be found the bacilli of diphtheria in
many cases will have disappeared from the throat.
This rule is not, however, without many exceptions, for
it will be frequently found— days after the complete dis-
appearance of the membrane and after the return of the
392
MEDICAL RECORD.
[September 29, 1894
throat to a healthy condition — fully virulent bacilli lin-
ger in the throat.
If we examine the researches of others regarding this
matter we find the following facts :
Severity of the Diph-
theria in the Case. |
I LengthofTime dur- 1
I ing which the Ba-J
I cilTi had persisted
^fii!?? *"£ Results obtained from the Inocula-
tion of Guinea-pigs.
pearance of the
Exudate when
they were tested
as to their Vim-'
lence.
Roux and Yersin : ' '
Mild case.
Mild case. j
3 Severelaryngealcase.
4! Severe case.
5 Mild case.
6* Mild case. I
7' Laryngeal case.
I
8 Severe case. I
I
^Koplik : »»
9 Mild case.
10 Mild case.
|Loeffler : « \
11 Moderate case.
3 days. Guinea-pig died in twenty four
hours.
3 days. I Fully virulent. Killed in a few
I hours,
x 1 days. Guinea-pig died in three days.
14 days. Guinea-pig. Fully virulent.
9 days. Some colonies virulent, some not
I virulent. For one week more,
I non- virulent bacilli were found.
7 days. Virulent and non-virulent colonies.
I For four days more only non-vir-
ulent bacilli found.
15 days. I On the twelfth day, all virulent.
On the fifteenth, some virulent tnd
some not virulent.
2 months. I Produced a slight local oedema only
. when injected into guinea-pigs.
j Fully virulent.
14 days. Virulent. A week later the bacilli
7 days. ' obtained were not virulent.
Fully virulent. (This was twenty-
8 days. fourth day of the disease.)
Eicherich : 1S In a number of cases the Loeffter bacilli
were found to persist after the disappearance of the mem-
brane. In all of these the bacilli were as virulent as
those obtained at the height of the disease.
Morse " in twenty- five cases found the average length
of time the Loeffbr bacillus remained in the throat after
the disappearance of the membrane was ten days.
The average duration was the same for both nose and
throat, although in some cases the bacilli were found in
the throat much longer than in the nose, and vice versa.
The bacilli disappeared in one case the day after the
throat was clear, in another three days after, and in an-
other four days after. The longest periods during which
they persisted were twenty-two and twenty-seven days.
The bacilli were tested from only one case, and these
were fully virulent ten days after the disappearance of
the membrane from the throat.
Tobiesen28 found virulent diphtheria bacilli in the
throats of 24 out of 46 patients at the time of their dis-
charge from the hospital. The majority were children
between six and twelve years of age. The following
table gives the length of time after convalescence that
the diphtheria bacilli were found :
Severity of Case.
I Number of
Persistence of Bacilli after
Disappearance of Membrane
at Time of Examination
at Discharge.
Days.
Mild 1 4
Moderate 5 4
Moderate 4 5
Moderate 4 6
Mild x I 8
Moderate ! x I 8
Moderate x , 9
Severe [ 1 I 9
Moderate ' x xo
Mild x , xo
Moderate x xi
Severe x 16
Moderate x aa
Moderate [ x , 31
j 24 214 Average, 8JJ
In the twenty-two in which the bacilli were not found
the length of stay in hospital of the patients after conva-
lescence was about the same. Tobiesen 's studies indicate
that the existence of throat lesions rendered the condi-
tions more favorable for the persistence of bacilli. The
virulence of the bacilli was proven in 19 out of the 24.
In 16 cases the guinea-pigs died within a period of fifty
hours, and the autopsies showed typical lesions ; in 2,
local necrosis developed, followed by death in one ani-
mal and recovery in the other. In the last case the ani-
mal developed paralysis five weeks after the local symp-
toms had disappeared. From these results he draws the
following conclusions :
In 19 out of the 24 persistent cases the Loeffler bacilli
proved virulent, and the probability is, they were also
virulent in the 5 not tested. In other words, one half of
the patients who are allowed to leave the hospital under
the usual conditions carry virulent bacilli in their throats,
and are capable of giving diphtheria to others. Clinical
investigation alone can decide the frequency with which
these convalescent cases infect others. This investiga-
tion must be carried on with great caution. In the 24
investigated by Tobiesen he excluded those where nu-
merous cases had occurred in the house besides the ones
under investigation. Among those remaining he dis-
covered one where the convalescent child was the almost
certain cause of diphtheria in another.
Original Investigations. — In order to test the virulence
of the bacilli in the throats of convalescent cases they
were obtained in pure culture from the healthy throats
of sixteen convalescent diphtheria cases and used for the
inoculation of guinea-pigs. The following table gives
the results of these experiments :
fc I
Severity of Diph-
theria in the Case.
M
1 - ' "i
Dav
1 .Rather severe case. . 8
JMild case xo
Mild case la
Severe case x8
, Moderate case 6
Mild case ' 33
1 Very mild case 12
I Mild case ' 8
, Very mild case 35
Very mild case (na-
sal) 10
Mild case 1 6
MUd case 8
Mild case I xa
Virulence.
**-
Life of Guinea-
2**
pig after
<*
Injection.
*
<
c.c.
30a
1.33 60-70 hours.
250
0.50 8 days.
290
x.25 13 days.
229
1. 00 0 days.
549
x.25 14 days.
226
x .00 ( Extensive necro-
sis with filial re-
covery).
440
x.50 ( 40 hours.
310
2.00 40 hours.
505
x.66
40 hours.
Persistence
from Incep-
tion of
Disease.
i*
Fairly severe case
Mild case 50
»53
490
45*
3°>
347
4x0
2.00
x.66
x.33
«-33
i-33
3 00
40 hours.
40 hours.
40 hours.
40 hours.
5 days.
2 days.
Days. Days.
13 17
f 14
16
30
»4
«3
«9
In each case, in testing the virulence of the bacilli de-
rived from it, we employed the last culture or the next
to the last culture made from it in which the bacilli were
found to be present. The results in the sixteen cases
tested, as well as in those before recorded by others,
prove conclusively that the bacilli, which in a certain
proportion of cases persist in the throat after an attack of
diphtheria, are always virulent for some time. In the
exceptional cases in which the bacilli persist for a very
long time, it is found they occasionally lose their viru-
lence a few days before their final disappearance; while
in other cases they retain their virulence to the end.
That the cases themselves are not so liable to spread
diphtheria is probably because of the relatively small
number of bacilli present in convalescent throats as com-
pared with the number found in those showing the lesions
of diphtheria.
During the last year 2,566 cultures have been made
from the throats of convalescent cases of diphtheria in
order to determine the length of time during which the
Loeffler bacilli persisted. The cultures were made at
short intervals after the complete disappearance of the
exudate, until the throat was found to be free of diph-
theria bacilli. The custom was to make the second
culture three days after the complete disappearance of
the membrane, and then, when necessary, to make
further cultures about every fourth or fifth day. Com-
pleted observations in 605 consecutive recovered cases
give the following facts : In 304 of these 605 cases the
diphtheria bacilli disappeared within three days after the
complete disappearance of the exudate; in 301 cases
the diphtheria bacilli persisted for a longer time, viz., in
September 29, 1894]
MEDICAL RECORD.
393
176 cases for seven days ; in 64 cases for twelve days ;
in 36 cases for fifteen days; in 12 cases for three
weeks ; in 4 cases for four weeks ; in 4 cases for five
weeks ; and in 2 cases for nine weeks after the time when
the exudate had to all appearances completely disap-
peared from the upper air-passages.
4. (a) What Relation has the Pseudo- and Non-viru-
lent Diphtheria Bacillus to the True Virulent Bacillus?
— In 1888 Hofmann published the results of the bacteri-
ological examinations of a number of diseased and healthy
throats, which for a time threw doubt on the specific
character of the Loeffler diphtheria bacillus. Further re-
search has entirely dispelled the confusion which his dis-
coveries seemed to make, but the results of these studies
and of similar ones on the virulent and non- virulent
bacilli are of such practical importance in relation to the
bacteriological diagnosis of cases of suspected diphtheria
that a detailed account of the work of die subsequent in-
vestigators, as well as that of the Health Department, will
be presented.
Hofmann's 16 results were similar to those of Loeffler,
in that he found the virulent bacillus in all of eight cases
of true diphtheria, but in further search he was surprised
to find in the throats of twenty-six out of forty-five per-
sons, none of whom was suffering from diphtheria, a
bacillus which very closely resembled the Loeffler bacillus.
Some of these persons were suffering from scarlet fever,
measles, or some other disease, while many were entirely
healthy. The bacilli from a number of these healthy
throats were obtained in pure culture and inoculated into
animals. The majority had no virulence whatever. The
bacilli from the different cases varied somewhat in their
characteristics. Some in appearance, manner of staining,
and growth on media seemed identical with the Loeffler
bacillus, while others presented slight but constant differ-
ences. Between the extremes were many gradations.
Those bacilli which did not possess all the character-
istics of the virulent bacillus differed in the following re-
spects: They were shorter, thicker, and more uniform
in size. On agar they grew in whiter and thicker colo-
nies whose circumference was more circular and less
notched. They also grew at a lower temperature than
the virulent bacilli (200 to 220 C).
Hofmann was undecided whether all of these bacilli
were really Loeffler diphtheria bacilli, which had lost
their virulence, or whether they were a different species
of bacteria and of a saprophytic nature. He was also
undecided whether, even among these non-virulent ba-
cilli, there might not be included different species. Hof-
mann's death prevented further attempts on his part to
solve this problem, and different investigators since that
time have been divided in their opinions ; some taking
the view that these bacilli were derived from true Loeffler
bacilli, having merely lost their virulence; others that
they were a different species, having no connection with
the Loeffler bacillus ; and still others consider the matter
as undecided. The results of two other important series
of investigations should be considered here, those of
Roux and Yersin, and those of Escherich.
Roux and Yersin found in a hospital for children in
Paris, where cases of diphtheria occurred from time to
time, that fifteen out of forty five children contained in
their healthy throats non-virulent bacilli resembling the
Loeffler bacillus. In a French village where no diph-
theria had been present for a long time they made cult-
ures from the healthy throats of fifty-nine children living
in a school. In twenty-six of these non virulent bacilli
were found.
In an examination of the throats of ten attendants in a
diphtheria hospital, non-virulent bacilli were found once.
Thus, in one hundred and fourteen healthy throats the
non virulent bacilli were found forty-two times. In all
of these throats the bacilli were present in very small
numbers. They found the same bacilli twice in six
children with mild sore throats, and five times in seven
children sick with measles. It should be noted that
these examinations were made chiefly in a hospital and
in a school, both for children, and in both of these the
children were confined together for considerable periods
of time, and the direct transmission of the bacilli from
one throat to another would be likely to occur. The
unusually large percentage of children in which they
were found might thus be accounted for.
The bacilli found, when studied in pure culture,
differed somewhat from each other. The majority were
identical in all their characteristics with the Loeffler ba-
cillus, except as to their lack of virulence. The minority
resembles those described by Hofmann, being shorter
and thicker and growing at a lower temperature than the
characteristic Loeffler bacilli. They made the important
observation that non-virulent bacilli, which they tested,
when grown in broth, caused the same changes in the re-
action as the virulent forms, namely, from alkaline to
acid in forty-sight to seventy-two hours, and later back
again to alkaline in the course of some weeks. These
changes were found to occur even more rapidly in the
cultures of the non-virulent than of the virulent bacilli.
Roux and Yersin regarded the occasional sb'ght differ-
ences in growth, shape, and staining, as too slight and
inconstant to distinguish the virulent from the non-vir-
ulent bacilli. Animal experiments alone sufficed to
determine the question of virulence, and they regarded as
arbitrary a division founded on the reaction of the guinea-
pig to inoculation ; since they found bacilli from cases of
diphtheria may possess every degree of virulence, from
those which cause death within twenty-four hours to those
which cause only a temporary oedema. With such varia-
tions it is a difficult matter to determine what should be
the proper line of division between the virulent and the
non-virulent bacilli.
To fully prove these bacilli belong to the same species
they believe it is necessary to derive non-virulent bacilli
from the virulent ones, and to give virulence to those
entirely lacking it.
They found it was possible to produce an attenua-
tion of the virulence of the bacilli in a number of ways.
For instance, if a current of sterile air is kept passing
through a broth culture of diphtheria bacilli, maintained
at a temperature of 39^° C, after about two weeks some
of the bacilli begin to lose their virulence, and at the end
of about four weeks all of the bacilli have lost all of their
virulence and produce non-virulent cultures. A little
while after losing their virulence the bacilli remaining in
the culture died.
They also found that if from time to time cultures were
made from dried bits of membrane, a period finally came
when the bacilli, although alive, had become non-viru-
lent. Thus they had fulfilled the first condition.
The attempt to restore to bacilli the virulence which
they had entirely lost was not so successful. They found
it possible to greatly increase the virulence of bacilli by
injecting them together with a virulent culture of the
streptococcus of erysipelas. The bacilli obtained from
animals which had succumbed to this double inoculation
were found to have fully regained their virulence. Roux
and Yersin were unable, on the other hand, to give back
virulence to those bacilli which had been completely
robbed of their virulence by the above methods, or to those
which had no virulence originally when obtained from
the throat. Thus of the two proofs necessary to establish
the identity of the virulent and the non- virulent forms,
they had obtained the first fully, the second only par-
tially.
As additional proof of the identity of the virulent and
non-virulent bacilli, they brought forward the fact that
they found the latter more frequently in patients recently
convalescent from true diphtheria than in those who had
never- had the disease, and that the bacilli which had ar-
tificially been deprived of their virulence frequently were
changed in other respects, so as to resemble in all ways
the bacilli which were originally lacking in virulence.
From their studies they concluded the non-virulent atd
virulent bacilli were one and the same species of bacteria.
If we now turn to the work of Escherich we find results
394
MEDICAL RECORD.
[September 29, 1894
which tend to show the virulent and some of the non-
virulent bacilli are different species of bacteria.
He first lays stress on the methods to be employed in
testing the virulence. He advises that the animal inocula
tions be made always from broth cultures, which have been
grown for forty-eight hours at zilA° C., and that the
amount of the culture be regulated by the size of the ani-
mal. Under these precautions he found the bacilli from
every case of diphtheria examined to be fully virulent,
and in a few cases, where he obtained characteristic ba-
cilli from the healthy throats of persons exposed to diph-
theria, he found them also to be virulent.
Escherich did indeed find in a moderate number of
throats of persons not suffering from diphtheria a non-
virulent bacillus similar to those described by Hofmann.
Thus in Munich he found this non-virulent bacillus in
2 throats out of 70, and in Graz in n out of 250, or 13
times in 320 cases. These bacilli, however, all possessed
certain cultural and morphological characteristics which
were sufficient to separate them from the virulent bacilli.
They were, as in some described by Hofmann, plumper
and shorter than the Loeffler bacilli and more uniform
in size. The growth on agar was more luxuriant and
whiter than is the case with the diphtheria bacilli. He
noticed two new points of difference which seemed to him
important. The non-virulent or pseudo- diphtheria ba-
cilli, when spread on a cover- glass, lie in parallel rows,
while the virulent diphtheria bacilli lie at every angle and
in the most varied positions. The second difference was
still more marked. He found, as had all others who had
noticed this point, that the virulent bacilli in their growth
in alkaline bouillon changed the reaction of the bouillon
to acid in the course of forty-eight hours. The amount
of acid formed differed in different cultures, and had no
relation to the degree of virulence. He then noticed the
pseudo diphtheria bacilli always made the bouillon more
alkaline instead of acid. Therefore, if at the end of
forty-eight hours litmus was added to the different bouil-
lon-cultures it turned red in the virulent ones, and blue
in the pseudo-diphtheritic non-virulent ones. Although
this will be referred to again it should be noticed that
this difference in reaction was not found by Roux and
Yersin in the cultures of the non-virulent bacilli tested
by them.
Escherich, in conclusion, states his position as follows :
" Since we have found constant cultural differences be-
tween the true and the pseudo-diphtheria bacilli we can
give the pseudo diphtheria bacilli no diagnostic value.
We do not find it to be a frequent inhabitant of the
mouth. Chronic throat inflammations and measles seem
to render the throat more liable to its invasion.1'
He did not find, as Roux and Yersin and Fraenkel had,
that it was possible to determine from the abundance of
the colonies of bacilli present whether they were com-
posed of virulent or non-virulent bacilli.
Up to the present time the results, so far as they are
known to the writers, are given in the following tables :
ESCHSKICH."
VON HOWAXN.1*
LoEFFLB*V
Some bacilli identical with those Somewhat larger than virulent
of Loeffler, others were' bacilli, and more tendency to
shorter, thicker, and morej produce swollen ends,
uniform in size. i
Similar to virulent. | Similar to virulent.
Sometimes identical with Loef- Similar to virulent.
fler bacilli ; again found ( in
larger and somewhat whiter t
colonies. I
Growth on agar. Grows more luxuriantly and Colonies had less iagged edges
spreads more on the surface. ! and were of a whiter hue.
May become of a dirty brown
color in central part of col-
onies. '
In 45 throats, comprising some Once with virulent bacilli from
healthy and some the scat of a case of diphtheria.
non - diphtheritic innamma-j
tions, they were found in a6. :
« ....... • \v
Morphology.
Growth in bout!
Ion and reac- 1
tion.
Growth on blood-
serum.
Frequency met
with.
Opinion as to the Is doubtful whether these non Believes them to be of a differ
nature of the
bacilli.
virulent bacilli belong to thel ent species, but only to be
same species as the virulent separated by animal cultures,
diphtheria bacilli, or whether
they are of a different species.
Morphology.
BaocJ*
Shorter, plumper bacilli as a
rule, but some more like viru-
lent bacilli.
Quicker and
growth.
more luxuriant in
Bacilli shorter, plumper, and
more uniform in size. When
a drop of bouillon-culture is
smeared on a cover-glass the
I bacilli are found to lie in par-
allel rows.
Growth in bouil- : More luxuriant growths, with
Ion and reac- tendency to cause cloudiness;
tion. when grown in neutral litmus
I bouillon the litmus turns bluej
after a or 3 days. .
Growth on blood- Fairly characteristic, but apt to' Somewhat more luxuriant and
serum. j be a more luxuriant andj of a more yellow color,
whiter growth.
Growth on agar. Grows more luxuriantly and
I spreads more on surface ; may
become brow nish in color
' after some days,
met In Munich in a out of 70. '
In Graz in 11 out of 250
1 healthy throats and
those the seat of non-
I diphtheritic lesions ex-
1 amined.
to Believes that they have no rela-
of tion to the virulent diphtheria
, bacilli, and that they can be
separated pretty accurately
I by cultural differences.
Frequency
with.
Opinion as
the nature
the bacilli.
t ?3
3»o
Colonies less jagged on margin
and more yellow in hue.
In 66 well children found in 23; m
41 non-diphtheritic affections
in 14, or in a total of 107 found
them in 36. Also along with
virulent bacilli in true diph-
theria.
Believed that the non- virulent
forms found by him were of a
different species from the vir-
ulent, and were saprophytic in
nature.
Kofuk," 1ST Paper.
Kopuk," »d Pates.
Morphology.
Short, plump, uniform in size.
Take a more uniform stain.
Growth in bouil- More luxuriant, cloudy at first,
Ion and reac- afterward clearing, with
tion. abundant deposit; bouillon
acid after forty-eight hours.
Growth on blood- More luxuriant and spreading.
serum.
Growth on agar. More luxuriant and spreading.
Frequency met In 4 mild throat inflammations,
with.
Opinion a s t o Are of a different species from
the nature of Loeffler bacilli
the bacilli.
Identical in form and size with
virulent and characteristic
stain.
Cloudy ; less abundant ,
in bouillon to which j
has been added;
alkaline after forty -eight
1 hours.
More luxuriant, opaque, and
j whiter growth.
1 More luxuriant, opaque, and
I whiter growth.
I In a following true attack of
I diphtheria. For first three
! weeks found virulent bacilli;
then for two weeks there were
non-virulent forms.
Morphology.
Growth In bouil
Ion and reac
tion.
Growth on blood
ROUX AMD YbKSXN.4
Abbott.11
Majority identical with virulent Bacilli from 3 cases were identi-
bacilh. The m i n o r it y of cal with virulent forms ; from
shorter, plumper, and morel 1 they were larger than the
uniform variety. virulent average.
Characteristic, except for slight .Growth in bouillon same as in
cloudiness. Changes of broth; virulent forms, except the
were same as in virulent changes from alkaline to acid,
forms, but somewhat more and later back again to alka-
rapid. ' line were more rapid than in
case of virulent bacilli.
Same as in virulent .Characteristic,
serum.
Growth on agar. Same as in virulent, varying Two of 4 characteristic, x more
, within the limits noticed in: luxuriant in growth, and 1
different virulent cultures. giving colonies with darker
I I central portion.
Frequency met, In 104 healthy children's throats Four times in 53 throats. Some
with. found 41 times ; 10 adults healthy, others the seat of
j once. In 6 mild throat in- moderately severe inflamma-
I nammations twice; in 7 sick tions.
with measles 5 times,
t o, Believed the non-virulent to be Non-virulent bacilli having; all
of the same species as the other characteristics of viru-
virulent ; they were simply an lent bacilli to be of same spe-
attenuated form. cies.
.Pseudo diphtheria bacilli to
show constant cultural difler-
Opinion as
the nature of
the bacilli. |
Note.
I
Frabnkbl."
Maxtin."
Morphology.
Growth in bouil-
lon and reac-
tion.
Growth on blood-
serum.
Growth on agar.
Frequency met
with.
Opinion as to.
the nature of
bacilli.
Identical with virulent forms. Short, plump bacilli.
Characteristic I
.Characteristic.
Characteristic.
More moisu luxuriant, and
whiter. Grow at room tem-
peratuie.
In quite a number of diphtheria
cases running a mi* M
In number of healthy conjunc
tiva; and in some cases of mild
tonsillitis, and with viiulent
bacilli in diphtheria. Figures
not given.
Believes the virulent and non- An attenuated form of the viru-
virulent to be of the same lent diphtheria bacillus.
species and includes under
non-virulent, some causing!
local reaction. I
September 29, 1894]
MEDICAL RECORD.
395
If we review the remaining literature of this subject
we find some investigators have been led by their results
to adopt views similar to those of Roux and Yersin,
others to those of Escherich, and still others have been
forced to content themselves with the position of Hof-
mann, viz., that we are not yet in a position to affirm
whether all these bacilli are of one or of different species
of bacteria.
If we inspect closely the descriptions of the non- viru-
lent bacilli, we find there seem to be two forms which
stand out distinctly as separate varieties with which the
others can be grouped :
1st. Bacilli which are in all respects, except that they
lack virulence, identical with the Loeffler bacillus, and
which, like it, produce an acid in their growth in broth-
cultures.
2d. Bacilli which are shorter, plumper, and more uni-
form in size than the (characteristic) Loeffler bacilli, and
which produce an alkali in their growth in broth- cult-
ures.
As we look over the tables we see that some observers
have chanced to find one of these varieties, some the
other, and some both. This has led to the present con-
fusion.
Table Showing Results of Cultures Made from the
Throats of Healthy Persons where there has been
no History Obtained of Direct Contact with Diph-
theria.
From Where.
Virulent
Total Casev Characteri s-
N. Y. Dispensary (by Dr.
JohnH. Huddkston)....
Northern Dispensary
VanderbUt Clinic
Throughout the City
College Phys. and Surg.
(Students)
N. Y. F. H. Dispensary. ..
Orthopedic Hospital :
Female Ward
Male Ward (through kind-
ness of Dr. Chappeil). .
N. Y. Foundb'ng Hospital,
(by Dr. Adams)
Totals.
Non-viru-
ilent Charac-
Non-viru-
lent Pseudo-
<u leases, ^naraciens- L«j.»:„n:«i. ;ienc rseuao
Nos. ,tic Diph«he-,ten*^Ph- diphtheiia
ria Bacilli,
theria
Bacilli.
Bacilli.
x to 151 ,
15a to 163
264 to 189 !
190 to "93 |
294 to 34a !
343 to 857
358 to 167
268 to 275
27610330
330
27
A Comparative Table of Non-virulent and Pseudo-diph-
theria Bacilli.
NON-VIXDLBMT DlPHTHBRIA BACILLI.
Pseudo-diphtheria Bacilli.
Case No. and New York, 66. New York, 7a.! ^,£52! ™d . New York, iox.
Source. j CThroat) (Throat.) I (JE^tf* (Throat.).
Examination of Abundant Abundant Abundant short, Abundant short,
bacilli in pri- large charac- characteris-, even- stained even - stained
mary cult-
ure.
tenstic diph-
theria bacilli.
I
tic diphthe-1 bacilli. (See
ria bacilli. photograph of I
pseudo - diph-
theria bacilli.)
bacilli (pseudo-
diphtheria).
Growth in pure, Characteristic Characteristic. Fairly character- Character is tic
istic appear-: appearance of
ance of colo-l colonies,
nies. I
Coarsely granu- Fairly typical,
lar colonies,! More heavily
with jagged, pigmented and
rough borders,,
ana of aboutj
equal thickness
culture on j
serum at
37*° C.
Agar.
appearance
of colonies.
Fairly typical ; Not typical col-
colonies.
u n i f o r mly
thicker than is
characteristic
of the virulent
bacilli. Colo-
nies nearly cir-
cular, with even
borders.
Growth in neu- Characteristic Not character- Typical growth Formation of thin
tral glucosei acid at end istic Broth in rather coarse pellicle and
broth. j of forty-two cloudy for,
hoars. j two a a y s ; 1
acid at end
I ' of forty eight
' j hours. m _
Virulence _ i n Guinea -pig, Guinea -pig, Guinea - pig, 405 Guinea « pig, 400
guinea-pigs. 2x6 g m s . ; 164 g m s . ; I gnu. ; 3 c. c. gms. ; 2 c. c
3.33 c\ c- *-33 c«. c-| No reaction. , No reaction.
No reaction. No reaction.
Omkal notes. B rone hit is. 1 Intestinal ca- Healthy throat. Bronchitis. No
Diphtheria tarrh. No | history of con-
in house' history off ' tagion.
three weeks1 contagion. 1
previously.
Female. {Female. Male.
throughout ;
brownish hue
by transmitted'
light ;
grains. Alka-'
fine reaction at
end of forty-
eight hours.
slight diffuse
cloudiness. Al-
kaline reaction
at end of forty-
eight hours.
Sex....
Age 1 year.
15 months. 37 years.
xo years.
Original Investigations — In order to study these vari-
ous bacilli and to clear up, if possible, some of the .ques-
tions connected with their classification, cultures were
made upon blood serum from 330 healthy throats (chil-
dren 280, adults 50).
When any of the varieties of bacilli described above
were discovered in the cultures they weie isolated, and
in the great majority of cases tested, as to their virulence,
on guinea-pigs. The results of these studies are given
in the tables above. The bacilli formed may be divided
into three groups.
1. Virulent Loeffler' s diphtheria bacilli, characteristic
in growth, producing acid in bouillon.
2. Bacilli identical with Loeffler's diphtheria bacillus
in growth, producing acid in bouillon, but having no
virulence.
3. Bacilli not having all the characteristics of the
Loeffler bacillus in growth, producing alkali in bouillon,
and having no virulence.
In the above table we find bacilli possessing the
characteristics of the virulent diphtheria bacilli except
that of virulence were found in 24 cases, namely :
Nos. 7> 33* 52> 63» 66> 72> io3> io5> "o, 114, 124,
132, 188, 189, 190, 191, 192, 193, 198, 212, 258, 259,
260, 297.
These bacilli were abundant in the primary cultures
from 17 cases, and present in small numbers only in the
cultures from 7.
They were on the average a little longer than the viru-
lent bacilli from the cases of suspected diphtheria ex-
amined on the same days. In broth the bacilli from 13
of the 24 cases grew characteristically, while from 6 they
caused a more or less dense cloudiness. It was found,
however, that sometimes the virulent bacilli produced
the same effect, though never to the same degree, as the
bacilli from case 191. In 5 cases the bacilli were not
grown in broth. In all the cases in'which broth cult-
ures were made (19) the bacilli produced acid in their
growth. When their acid-producing power was com-
pared with that of an equal number of virulent cultures
no marked difference could be noted. Some virulent ba-
cilli were found to produce more acid than the non- viru-
lent ones, while others produced less.
Upon blood-serum the bacilli grew in a manner char-
acteristic of the Loeffler bacillus.
Upon agar the bacilli from 1 1 cases grew as the viru-
lent bacilli usually grow, while from 7 they grew in a
less typical manner, but always in ways seen exceptionally
in the virulent form. Guinea-pigs were inoculated with
the bacilli from 15 cases. The lack of virulence in the
bacilli from the remaining 9 cases was taken for granted
from their close association with the 15 tested. Half-
grown guinea-pigs were employed, and they were in-
oculated under die skin with from one- half to three-
fourths per cent, of their weight of a forty-eight hour
broth - culture. In only one animal was there any
appreciable reaction, and in this the local induration
caused passed away within four days. A very slight
degree of immunity was given to some of the pigs by the
injection.
The bacilli persisted in 4 of the throats for four weeks,
in 1 for three weeks, in 3 for two weeks, and in some of
the others for shorter periods.
Column three of the table shows that in 27 cases
pseudo-diphtheria bacilli were found corresponding to
those described by Hofmann and Escherich and photo-
graphed by Koplik.19 Upon agar some of the bacilli
grew in a similar manner to the diphtheria bacilli, while
others grew as described in the table given opposite.
The bacilli were smaller, shorter, thicker, and more uni-
form in size than the Loeffler bacilli and always formed
alkali in their growth in broth. These bacilli were
never virulent in animals.
Guinea-pigs were inoculated with large amounts — one-
half to one per cent, of their weight — of broth cultures
of bacilli obtained from 8 cases without showing any re-
action.
39«
MEDICAL RECORD.
[September 29, 1894
As is shown in column one of the table, virulent
diphtheria bacilli were found in 8 of the 330 cases.
They were in all probability derived from mild cases
of unrecognized diphtheria, or from healthy children who
were carrying the bacilli in their throats. The number
of such infected children is indicated by the results of
studies described in the following pages.
4. (b) Are Virulent Diphtheria Bacilli ever Present in
the Throats of Healthy Persons who have been brought in
Contact with Diphtheria t — The search for the origin of
obscure cases of diphtheria has revealed the fact that it is
possible for the human throat to become the habitat of
the virulent Loeffler bacillus without any visible lesions
resulting. Thus Loeffler1 found the virulent bacillus
once, Fraenkel ,4 twice, and Escherich tt found it in sev-
eral cases. In one of Escherich's cases the history is so
significant as to be worth repeating. It was noticed
among the children coming under the care of a certain
apparently healthy nurse a number of cases of diphtheria
were developing. A bacteriological examination being
made, her throat was found to contain very numerous
virulent diphtheria bacilli. These remained present and
virulent for weeks. A similar and interesting case is re-
ported by Feer." In a diphtheria epidemic occurring in
a hospital ward, due to a single infection, the throats of
seven children became infected. The infection caused
fatal diphtheria in four, an acute angina without mem-
brane in two, and no symptoms whatever in one. In all
of these the bacilli were abundant and equally virulent.
Many similar examples have been met with by us.
A very interesting investigation has been carried on to
determine how frequently the throats of healthy children
became infected in families where one is sick with diph-
theria, and where little or no isolation is possible.
As will be seen by the following tables, the throats of
the healthy children of fourteen families, in which one or
more of the other members had diphtheria, were exam-
ined. There were in all forty-eight healthy children.
In fifty per cent, of these diphtheria bacilli were found ;
forty per cent, developed later, to a greater or less extent,
the lesions of diphtheria.
No. of Cases ex-
amined aside
L. Bacilli
found in —
L. Bacilli
MILY.
from the Original
not
Remarks.
Case of Diph-
found in —
theria.
A.
X
0
x Isolation partial.
B.
3
3
0 No isolation ; all three cases
subsequently developed
diphtheria.
C.
a
X
1 No isolation
D.
X
X
0 No isolation
£.
3
X
a No isolation.
F.
A
I
3 ' Isolation partial.
G.
5
3
a Isolation partial.
H.
4
3
x No isolation.
I.
4
X
3 Isolation partial.
k.
8
3
5 Isolation partial.
4
X
3
Isolation partial.
L.
3
X
X
Isolation partial.
M.
5
3
a
Isolation partial.
N.
1
X
0
»4
No isolation.
-
48
84
Of the above cultures in which the Loeffler bacilli were
found, in six the virulence was tested in the usual way.
The results are stated in the following table :
2 Amount
v I Bouillon-
m cult. inoc.
Guinea-
pig-.
Weight
B.'
G.
H.
K.
M.
N.
t
x.33
1-33
x.66
337 gm.
205 gin.
332 gin.
300 gin.
490 gm.
950 gm.
Virulence.
Clinical History.
day
Died in 40 hrs. I Developed fatal diph.
I after cult was taken.
Died in 44 hrs.: Developed tonsillar diph. 2 days
after cult was taken.
Died in 48 hrs. No subsequent development of
diphtheria.
Died in 40 hrs.' No subsequent development of
diphtheria.
No subsequent development of
diphtheria.
No subsequent development of
diphtheria.
Died in 40 hrs.
Died in 40 hrs.
In considering the high percentage of cases in which
the virulent Loeffler bacillus was found, it must be re-
membered in these families the conditions were the best
possible for the transmission of the contagium.
In numerous instances cultures have been made from
the throats of healthy children in families where the
diphtheria case was well isolated ; in such cases the ba-
cilli have been found in less than ten per cent, of the
children.
It may be interesting to detail here two instances out
of many observed in which the virulent bacilli of diph-
theria derived from healthy throats have been the cause
of diphtheria in others.
1. A child was admitted into a hospital ward in an
anaemic condition and with a chronic coryza. Five days
later four children in his neighborhood developed diph-
theria. Two of these died. In seeking the cause of the
diphtheria suspicion was directed to the child by a slight
nasal discharge. Bacteriological examination showed
this secretion contained many diphtheria bacilli. On
further examination it was found the child came from a
family in which three weeks before there had been a case
of diphtheria.
2. In a family of eight children one child sickened
with diphtheria ; and a second child, a baby, was sent to
a neighbor. The next day cultures showed this baby, as
well as two of the other children, all of whom were ap-
parently healthy, were infected with diphtheria bacilli.
The three apparently healthy but infected children, as
well as the sick one, were at once quarantined, but al-
ready one of the family to which the baby had been sent
had contracted diphtheria from it
The practical value of bacteriological examinations of
the throats of healthy children in families where isolation
has not been carried out in the first days is further shown
by the fact that those children in whom the bacilli are
found are extremely apt to develop diphtheria in the
course of a few days, when no cleansing treatment is
adopted, while they seem much less liable to do so if kept
under treatment.
The detection of the virulent bacilli in throats prevents
the dissemination of diphtheria by allowing us to isolate
those infected. A very striking instance of this was the
following: In a family of four children one was sick
with diphtheria. The Department Inspector found three
other children in the same bed with the sick one, who
was constantly spitting upon and soiling the bedclothes.
He made cultures from these three children, whose
throats appeared healthy, as well as from the sick one ; all
contained abundant characteristic Loeffler bacilli. (These
were later shown to be virulent by the inoculation of
guinea-pigs.) When the Inspector visited the same
family three days later, he found two of the previously
healthy children had meanwhile sickened and died, and
that the third was severely ill. This child finally re-
covered.
From the observations detailed above we cannot es-
cape the conclusion that all members of an infected
household should be regarded as under suspicion, and in
those cases where isolation is not enforced, the healthy
as well as the sick should be prevented from mingling
with others until cultures from the throat have shown
the absence of bacilli or a sufficient lapse of time gives the
presumption that they are not carriers of the contagium.
Summary and Conclusions on Diphtheria Bacilli in
Healthy Throats. — We have found that children, and
to a less extent adults, who are brought in direct contact
with true cases of diphtheria very often receive the diph-
theria bacilli into their throats, and that these bacilli
may persist and develop in these throats for days or
weeks. In some cases we have found that true diph-
theria followed the appearance of the bacilli in the res-
piratory passages, while in others no disease developed,
though they might be the source of diphtheria in others.
The examination of the throats of three hundred and
thirty healthy persons in whom no contact with diph-
theria was known, revealed the presence of virulent
bacilli in but eight persons, two of whom later developed
diphtheria.
September 29, 1894]
MEDICAL RECORD.
397
We must conclude, then, that virulent diphtheria
bacilli are to be found in the throats of a small propor-
tion of healthy persons throughout the city, and that
they have been derived either directly from diphtheria
cases or from those who have been in contact with them.
The examinations of the throats of the three hundred
and thirty healthy persons showed that in twenty- four
bacilli existed in every way identical with the Locffler
bacillus, except that they were not virulent in animals.
As the bacilli in cases of true diphtheria are known to
gradually lose their virulence, and as this loss of viru-
lence can be caused artificially, it seems to the writers
that these bacilli, characteristic except as to virulence,
should be regarded as true diphtheria bacilli which have
lost their virulence.
The examination of the same throats showed that, in
twenty-seven there were bacilli present which were so
uniform in their peculiarities as to staining, size, shape,
and the production of an alkali instead of an acid, that
there seems to us to be even more reason to separate
them from the diphtheria bacillus than there is, for ex-
ample, to separate the colon bacillus from that of ty-
phoid.
Table I.— False Diphtheria.
Table II.— False Diphtheria.
!
*• £ Z
£.6 i=3
•<
H
r
•! 4
4 years
iz years
a years
1* yew
8 years
6 years
3 years
6 years
9 years
I Mild
Severe
Mild
to a 12 6> years
11 3 < *3 [ 3 years
«3
M
15
16
17
18
"9
3
15
4
16
z
4
2
4
«9
3
ao
4
ax
a
as
3 i »3
a **
a years
xz years
15 years
ai years
9 years j
3 years (
5 years ,
xo years '
8 years
4 years
I
I
7 days
a days
30 days
5 days
1
Recov.
7 days
5 days
3 days
9 days
5 days
zo days
7 days
5 days
days
days
days
days
days
days
days
days
days
days
*3 o
»4 5
•5 5
«7 ©
a8 a
«9 3
30 o
3*| a
3»! 1
33 3
34 a
35 4
36 3
37! 3
3« 3
39 3
40
4X
43
as [ 3i years ••
96 j 31 years i "
37 ' 7 years •»
*8 ' 4 years | Severe
29 9 years Mild
xi year Severe
ai years < Mild
35 years
6 years
x+year
xo years
a 1 years
Severe
Mild
37 *9 years
38 7 years
39 a years
a years
1
41 a years
4a ao years
43 30 years
44 3 years
a days t
xa days <
3 days ;
14 days
a days '
45
46
47
4»:
1
45
46
49
SO
5*
5«
i 53
54
3 years I
19 years
2} years
6 years j
a years |
z8 years
ai years
3r years
24 years
8 years
Severe
MUd
Severe
Mild
7 days I
7 days I
5 days i
7 days
7 days
6 days '
a days I
l
4 days
a days
4 days '
9 days
7 days
3 days
x day
7 days
4 days
xo days <
xo days
7 days I
7 days
5 days
jo o , 55 , a years '
Severe I xo days
Mild ' 3 days
a I 4 2ayS
** j 30 days
10 days
History of Contagion, etc.
Came from a house where
diphtheria was present.
None.
Complicated by pneumonia.
None.
These two cases occurred
together.
These two out of the four
children attacked nearly
together ; one with simple
tonsillitis, the other with
suppurative tonsillitis.
Complicated by scarlet
fever.
None.
The child was first taken
sick ; a few days later the
servant developed sore
throat.
None.
Another mild sore throat in
house.
None.
These cases occurred at
same time in family. No
others developed in house.
Complicated by pneumonia
None.
Exposed to scarlet fever.
None.
Case of true diphtheria in
another family in house.
Scarlet fever in family.
None.
Scarlet fever in house one
month before.
Scarlet fever in house one
month before.
None.
The mother in the first case
was never really sick : the
child had very slight ton-
sillitis.
None.
Another case in house.
None.
Scarlet fever as compli-
cation. Other cases of
scarlet fever in house.
None.
J.9
g (s.
9 '3
il 4 i
2
E
3
Z
8
«7
rt
M
U
<
16
17
18
»3
«4
as
I
26
a7
«3
3 I M
X5
x6
17
18
>9
3 I 20
*9 3
to I 3 as 9 years
8 years
5 years
1
Mild
Histoiy of
Contagiousness.
30 years '*
3a years "
ix years *•
16 years '*
19 years "
X9 years ( Severe
19 years
Mild
a years
Severe
16 years
MUd
12 years
4 years
**
a years
3t years
tt
4 years
a years
8 years
11
3 years
xa vears
»,
6 years Severe
33 1 4 years Mild
1 34 ' ai years i "
4 1 as 5 years
1 36 9 years ,4
4 I 27 20 years ■•
I
I
4 38 j 2a years Severe 7 days
32 3
33
34I
35
36
3!
39
40
4»
4«
45
46,
JO>
29 6 years j Mild
30 1 5 years '• Severe
31 ' 3 years Mild
3a as years u
33 »3 years "
34 4i years ; «c
35 26 years . *•
i
36 ' 8 mos. . Severe
37 5 years 1
54 I x6 years 1
55 I 6 years ,
56 I X5 years ,
57 j 7 years j
xa days
ax days
5 days
1
xo days {
6 days 1
xo days I
5 days
14 days :
30 days '
9 years :
Mild
x day
30 years !
Severe
5 days
a years '
MUd
4 days
37 years
Severe
14 days
4 years
MUd
4 days
so years >
;;
4 days
9 years 1
x day
ax years >
•*
7 days
20 years 1
5 days
x year ,
Fatal
7 days
5t years u
ai years r Mild
ijyear 1 Fatal
xiyear | '•
19 years , Mild
30 years [ *'
7 days
7 days
5 days
3 days
6 days
7 days
4 days
3 days
Recov. First case one week pre-
»* I vious to second. No
I others in house.
'• None.
Died
Scarlet fever in house.
Followed surgical opera-
tion on throat.
Scarlet fever in house.
None.
i Scarlet fever in house.
<4 *i It It
' None.
These tv<o children were
taken sick together ; one
with mild "croup," the
other with tonsillitis.
None.
Scarlet fever as complica-
tion.
j Scarlet fever previously in
; house.
Scarlet fever as complica-
tion.
I None.
Measles in house.
This and following case oc-
curred in same house,
one week apart.
These three children slept
together. Two had very
I mud sore throats, while
the third had a more se-
vere attack, complicated
by mumps.
None.
These two cases, mother
and child, had sore
throats within three days
of each other.
Complicated by scarlet
fever. Other cases in
family.
Scarlet fever as complica-
tion.
A sister had scarlet fever.
None.
•1
None. m Suppurative ton-
Recov.
None.
Complicated by erysipelas.
Membraneous laryngitis
and scarlet fever.
Scarlet fever from preced-
ing.
None.
Complicated by scarlet fev-
er contracted from sister.
None.
These two cases occurred
in the same house a few
days apart.
None.
I
We have never found bacilli possessing these peculi-
arities to be virulent, nor have they seemed to have any
connection with diphtheria. It seems to us that to these
bacilli alone the name pseudo-diphtheria bacillus should
be given. The few bacilli which do not seem to come
under either of these divisions must await further study
before being classified.
5 . To what Degree is Pseudo-diphtheria Communicable f
— In the general circular issued by the Department, it
was announced that cases which bacteriologically proved
to be false diphtheria would not be kept under the super-
vision of the Department. Some who approve heartily
of the rest of the work of the Board in its dealings with
diphtheria believe in this step it has made a mistake,
and that the pseudo-diphtheria cases, though less con-
tagious than the true, are yet sufficiently so as to render
isolation necessary. From the experience obtained in
the diphtheria hospital; it was believed these cases were
398
MEDICAL RECORD.
[September 29, 1894
so little, if at all, contagious, that visiting by the De-
partment inspectors was unnecessary. Nevertheless, to
investigate this question thoroughly, four hundred and
fifty cases of false diphtheria, as nearly consecutive as
possible, were investigated, all sources of contagion
sought for, and the cases followed up for two weeks
after complete convalescence. In none of these was
isolation or disinfection enforced by the Health De-
partment.
Table I II. —True Diphtheria Cases from the same Dis-
trict as the False Diphtheria in Table I.
Summary of Tabulated Cases.
J. I
I
^
*, 5
al 4
3 x
4 4
5 1
6 3
12.
39
4o,
41
4»|
43
44
45
46
47
48
49
50
I
I 4 years Moderate
xi years • "
3 years I Severe
a years . Slight
xo years I "
1 3 years Moderate
1
Poor Recov.
History of Contagion, etc.
75 years f
I 8 5 years **
1 9 ■ 6 years Slight
a years
3 years
x J 10 j
V'!
4 I xa I xo years
13 I 8 years
14 I 7 years
15 4r years
16 ' xiyear
I
Slight
Severe
Slight
Severe
Good Died
None Recov.
Good "
1 None "
Good
None *•
Poor ,
Good Died
NTone Recov.
Good
19
a years ( Moderate
5 years ■ **
9 years . "
1
3 years ' Severe
4 years I *•
6 years j Slight
33 ' 5 years Severe
, 94 ' 3 y«*r» I "
25 : 8 years I Mild
87'
a8
99
30
3»
3a
6 36
x 97
x , a8
x 99
4 30
3»
1 3a
33
34
a years Moderate
4 years
3 years
5 years
5 years
6 years
9 years
if year
5 years
Slight
Moderate
»»
Severe
Moderate
a 35 - 3 years ' Slight
36 j 3 years Malignant
37 ' 6 years '
' Slight
, Malign
Poor
Good
Poor
None
Good
Poor
Good
Poor
Died
Recov.
33 » 38 I 4 years Moderate Good
Severe
Moderate
No
1
I 39 a years
x 40 i s years
4 41 7 years
42 3 years
( 43 8 years ' Severe
a I 44 7 years I "
45 , 30 years Moderate
x 46 , a years Malignant
a 47 4 years Severe
48 a years Slight
Poor
1 ««
Good
<4
I None
49 ,
50 1
3 years _ "
5 years ! Severe
51 I a years *'
5a i 5 years ■•
53 8 years j Slight
54 9 years Severe
55 ! 7 years "
56 6 years Moderate
57 I 8 years Slight
58 4 years Severe
59 18 years ! Moderate
60 ' K vMrc ! "
I _w ^
3 60 " s years J
Poor
Good
None
Poor
Good
Died
Recov.
Died
j Recov.
Died
it
Recov.
Died
Recov.
Died
Recov.
Died
Recov.
Died
Recov.
None.
Previous case four weeks
before.
None.
•t
' Other cases in school.
Two days before two chil-
dren in same family died
of •• diphtheria." At
time of culture child was
not sick, but developed
diphtheria later.
I N°ne*
Two children had just died
' of diphtheria in family.
1 None.
From Case 3. which was in
I adjacent room.
None.
Sent away for safety from
family in which there
was a case of diphtheria.
Fatal case previously in
family.
Servant had just come
from Case 9, where there
had been three cases in
family.
None.
Case of diphtheria on floor
below.
j Two fatal cases just pre-
vious to this case.
I Other cases in school.
■ None.
From a candy store. The
I proprietor's child had
diphtheria. This store
seemed the cause of sev-
eral cases in street, and
' in a school.
Previous case in house.
None.
' A case six weeks before in
house.
• None.
I From cases in school
From brother,
»« *•
■ None.
• From school
' None.
I From brother.
From school or from a case
next door three weeks
before.
From family.
j From a case in school.
This and following case
1 had symptoms of a cold
only.
From family.
I From school.
I From family.
None.
' Had had a previous case
one week before in fami-
ly. Had just moved to
new house.
I None,
i From Case 14, originating
from school.
None.
Prom case next door, or
from school.
From school
None.
Table I. (50 Fam- Table II (50
ilies) Pseudo-
diphtheria.
Families (Pseu-
do diphtheria.
Table III. (50
Families) True
Diphtheria.
Total number cases ! 56
History of contact with other
cases 7
No history of contact 49
Families in which more than !
one case developed j 5
Recovered I 56
Died o
Cases complicated by scarlet
fever I 4
7
50
41
53
4»
33
»7
3
17
» Two had scarlet fever.
* Three of which had scarlet fever.
* Six others had been in contact with scarlet fever, but
acteristic rash.
showed any char-
This is such an important question that the results of the
investigation of one hundred consecutive cases are given
here in tabular form. As a comparison, a similar table
is given of fifty consecutive cases of true diphtheria
which were taken from the same district and at the same
time of the year as the first fifty cases of pseudo-diph-
theria.
We find, therefore, in 113 cases of false or pseudo-
diphtheria, occurring in 100 families, that 14 occurred
at the same time with, or shortly after, some other case,
and that it is possible to assume the disease had been di-
rectly communicated to them. In 9 of the 100 families
more than one case developed. In these, as in the other
350 cases of pseudo diphtheria investigated, it did not
seem secondary cases were any less liable to occur where
the primary case was isolated, than when it was not. In
this connection we must remember mild throat inflam-
mations are very frequent, especially in the early spring
months, and that it is quite possible where two cases
occurred in a family together, or within a short period
of each other, that they may have both been due to ex-
posure to some common condition rather than to direct
transmission. The presence in nearly all healthy throats
in New York City of streptococci renders this assumption
almost a probability. The presence of the same germs
in healthy throats as in those of patients suffering from
pseudo diphtheria prevents us from deciding the point
by bacteriological examinations. A good illustration
of the difficulty in determining whether these cases are
communicable is the following :
In a family of eight there were, a mother, aged forty-
five, six children whose ages ranged from twenty- five to
ten, and a grandchild aged two. The family lived on
the top floor of a tenement. Two days before being
visited by the Inspector of Diphtheria a heavy, wet snow
had fallen, which, as the roof leaked, caused the walls to
become very damp. The next morning four of the chil-
dren were attacked by more or less severe tonsillitis,
which later developed follicular deposits or croupous
patches. On the following day the baby had an attack
of croup. All recovered and no further cases developed
in the tenement. Here the exposure to dampness cer-
tainly seems to be the explanation of the first four cases
of tonsillitis, but the occurrence of laryngitis in the baby
might with equal justice be considered as due to the
dampness, or as the result of communication from the
others.
Even if further investigation should seem to prove the
14 cases of pseudo-diphtheria out of 113 tabulated which
were found to have had some connection with other
mild sore throats, were due to contagion and not to the
simultaneous effects of atmospheric or other deleterious
conditions, there would still be an important practical
objection to sanitary supervision or enforced isolation.
All of the 14 cases, except 3 who had scarlet fever, were
mild, and, indeed, leaving out of consideration the cases
which occurred as complications of scarlet fever, there
was only 1 death in 103 cases of pseudo-diphtheria, and
in this case, as has been said, there was no history of in-
fection or contact with other cases.
6. What are the Means by which Diphtheria is Trans-
September 29, 1894]
MEDICAL RECORD.
399
milted? — The facts brought out by the investigations of
the Department throw important light on the manner in
which diphtheria is transmitted.
As related to this question let us first consider very
briefly what is known of the duration of life of the Lcef-
fler bacillus outside of the body.
In actual experiments the Lceffler bacillus has been
found to live for long periods of time, namely : by Hof-
mann,on blood serum, for one hundred and fifty- five days;
by Lceffler and by one of us (Park) for seven months ;
and in gelatine by Klein, for eighteen months. The
bacilli have been found to live in bits of dried membrane
by Lceffler for fourteen weeks, by us for seventeen, and
by Roux and Yersin for twenty weeks. Dried on silk
threads, Abel " reports they may sometimes live for one
hundred and seventy two days, and upon a child's play-
thing, which had been kept in a dark place, they lived
for five months.
As examples of the manner in which diphtheria may
be contracted, he gives the following from Johannes-
sen:"
A teacher developed diphtheria from passing the night
in a room in which three weeks before a fatal case had
occurred.
A child developed diphtheria after putting on the
clothing worn by a child which had died of diphtheria
two months before.
In a number of isolated dwellings diphtheria devel-
oped nearly a year after previous outbreaks, without
there being any apparent possibility of a new infection
taking place from outside.
We ourselves have met with a number of cases where
the infected bedding or clothing has undoubtedly been
the source of the infection.
Sources from which Virulent Bacilli may be Received.
— 1. From the pseudo membranes, exudate, or discharges
from diphtheria patients. 2. From the secretions of the
nose and throat of convalescent cases of diphtheria in
which the virulent bacilli persist. 3. From the throats
of healthy individuals who have acquired the bacilli from
being in contact with others having virulent germs on
their person or clothing. In such cases the bacilli may
sometimes live and develop for days* or weeks in the
throat without causing any lesion.
When we consider it is only the severe types of diph-
theria that remain isolated during their actual illness the
wonder is, not that so many, but that so few persons con-
tract the disease. This seems to be more remarkable
when we observe that, in a city like New York, the whole
tenement-house district at least is an infected area. This
has become evident from the observations made by the
Department.
It has been the practice of the Department during the
last year to plat upon a city map the location and date
of every case of diphtheria in which the diagnosis had
been settled by bacteriological examination. After sev-
eral months the map presented a very striking appearance.
Wherever the densely crowded tenements were located,
there the marks were very numerous, while in the dis-
tricts occupied by private residences very few cases were
indicated as having occurred. It was also apparent the
cases were far less abundant, as a rule, where the tene-
ments were in small groups, than in the regions of the
city where they covered large sections. At the end of
six months there were square miles in which nearly every
block occupied by tenement- houses contained marks
indicating the occurrence of one or more cases of diph-
theria; and in some blocks many cases (fifteen to twenty-
five) had occurred.
As the platting went on from time to time the map
showed the infection of a new area of the city, and often
the subsequent appearance of a local epidemic. It was
interesting to note two varieties of these local epidemics ;
in one the subsequent cases evidently were from neigh-
borhood infection, while in the second variety the infec-
tion was as evidently derived from schools, since a whole
school district would suddenly become the seat of scat-
tered cases. At times in a certain area of the city, from
which several schools drew their scholars, all the cases of
diphtheria would occur (as investigation showed) in fam-
ilies whose children attended one school, the children of
the other schools being for the time exempt.
Another fact noted — perhaps as important as the fore-
going— was that with the most careful inquiry it was
impossible to find, in about one-half of the cases of diph-
theria which first occurred in a house, any connection
with preceding cases of diphtheria.
An Average Section of the City in which each Dot indicates where a Case of
Diphtheria Occurred during a Period of Six Months.
The two following histories are instructive as showing
that special conditions, which are largely unknown to us,
determine in every individual the occurrence or escape
from diphtheria under exposure. Two children in a family
were taken sick with diphtheria and removed to the hos-
pital. The servant who was, and remained apparently,
healthy went to another family, where the youngest child
developed diphtheria a week later. In the meantime a
case developed in the family living in the next apartment.
There were in this latter family three other children
which were not isolated at all from the sick child, yet
none of these developed diphtheria.
The child of a man who kept a candy store developed
diphtheria ; there were four other children in the family
and these were in no way isolated from the sick, yet none
of them developed diphtheria, but children who bought
candy at the store, and other children coming in contact
with these in school developed diphtheria. The second-
ary cases ceased to develop so soon as the candy store
had been closed.
Many similar histories could be given to illustrate the
fact that the majority of persons, and even perhaps the
majority of children, are not ordinarily very susceptible
to diphtheria, and that in addition to receiving the germs
of the disease into the respiratory passages they must
be in a condition favorable to the development of the
disease, and their mucous membranes must be vulner-
able.
It seems to be generally true that the more malignant
a case of diphtheria is, the more likely it is to cause diph-
theria in others. This may be due to the high grade of
virulence possessed by the bacilli or to the peculiar asso-
ciation of other micro-organisms in the membrane, or to
400
MEDICAL RECORD.
[September 29, 1894
the wider dissemination of the infectious matter through
the discharges.
It is also well known that young children are much more
susceptible to diphtheria than older persons. It is com-
paratively rare for the parents of children sick with diph-
theria to contract the disease, although in nearly every
case they must at some time receive the germs into their
throats.
Conclusions. — 1. All inflammations of the mucous
membranes due to the diphtheria bacillus of Loeffler
should be included under the name diphtheria, and in
this report they have been so included. An acute hyper-
emia of the mucous membrane, caused by the Loeffler
bacilli, is considered as truly diphtheria as an inflamma-
tion with pseudo-membrane or exudate, and a case in
which the lesions are confined to the larynx or bronchi
as truly diphtheria as one in which the tonsils and phar-
ynx are involved.
2. Under pseudo diphtheria should be included all in-
flammations of the mucous membranes which simulate
true diphtheria and which are due to streptococci, or,
more rarely, other cocci.
3. The name croup, or membranous croup, should be
regarded as a term merely indicating that the location
of the pseudo-membranous or exudative lesion is in the
larynx, and not as describing the nature of the disease,
whether diphtheritic or pseudo-diphtheritic. In New
York City at the present time eighty per cent, of the
cases of " croup " are diphtheria.
4. The examination of cultures made upon solidified
blood-serum under the conditions insisted on by the
Department form a reliable method for determining
whether the diphtheria bacillus is present or absent in a
throat For diagnostic purposes cultures should be made
before the pseudo membranes or exudate begins to dis-
appear.
5. Virulent diphtheria bacilli were apparently present
in about one per cent, of the healthy throats in New
York City at the time of these examinations. Diphtheria
was, however, rather prevalent at this time. Most of the
persons in whose throats they existed had been in direct
contact with cases of diphtheria. Very many of those
whose throats contained the virulent bacilli never develop
diphtheria. We must therefore conclude that the mem-
bers of a household in which a case of diphtheria exists
should bs regarded as sources of danger, unless cultures
from their throats show the absence of virulent diphtheria
bacilli.
6. The bacilli found in the original serum cultures,
which in appearance and staining are identical with the
typical Loeffler diphtheria bacillus, may be regarded, for
diagnostic purposes, as virulent diphtheria bacilli, if the
cultures have been made either from throats containing
exudate, or from those of persons who have been in con-
tact with true diphtheria, for investigation has shown that
over ninety-five per cent, of such bacilli are virulent.
Bacilli, on the other hand, which resemble the pseudo-
diphtheria type must be subjected to both cultural and
animal experiments before their nature or virulence can
be judged.
7. All bacilli which are identical with the virulent
Loeffler diphtheria bacillus, morphologically, biologi-
cally, and in staining by reagents, should be classed with
the diphtheria bacilli, whether they have much, little, or
no virulence when tested on guinea-pigs. Bacilli which
have entirely lost their virulence rarely, if ever, regain
it. They probably are incapable of causing diphtheria,
for the twenty-four cases in which they were found by
us never developed any lesions, nor were they the
original of any case of diphtheria, so far as could be
ascertained.
8. The name pseudo-diphtheria bacillus should be re-
garded as applying to those bacilli found in the throat
which, though resembling the diphtheria bacilli in many
respects, yet differ constantly in others equally impor-
tant. These bacilli are rather short, and are more uni-
form in size and shape than the typical Loeffler bacillus.
They stain equally throughout with the alkaline methyl-
blue solution, and produce alkali in their growths in bouil-
lon. They are found in about one per cent, of tke healthy
throats in New York City, and seem to have no connec-
tion with diphtheria. They are never virulent.
9. One or more varieties both of streptococci and of
other forms of cocci exist in the great majority, and
possibly in all, of the healthy throats in New York City.
Cultures from the throat in cases of pseudo-diphtheria
contain more cocci, especially more streptococci, than
those from healthy throats, but otherwise do not seem to
differ.
10. The investigations of the Health Department have
given striking evidence of the marked difference in mor-
tality between true and pseudo diphtheria, for while it
was twenty-seven per cent, in diphtheria, it was under
two per cent, in pseudo diphtheria.
n. The combined clinical and bacteriological inves-
tigation of over five thousand cases has demonstrated
clearly the fact that many of the less characteristic cases
of diphtheria and pseudo diphtheria are so similar in
appearance, symptoms, and duration, that it is impossi-
ble to separate them, except by bacteriological examina-
tions. In the more severe cases, and after the disease
, has fully developed, cultures are less necessary, although
their systematic use is desirable.
12. Persons who have suffered from diphtheria should
be kept isolated until cultures prove the bacilli have
disappeared from the throat, for not only are the bacilli
which persist in the throat virulent, but they are not
infrequently the cause of diphtheria in others. Where
cultures cannot be made, isolation should be continued
for at least three weeks after the disappearance of the
membranes, for our experience has shown that it is not
unusual for the bacilli to persist that length of time.
13. In pharyngeal cases in which thorough irrigation
of the nostrils and throat with 1 to 4,000 bichloride of
mercury solution has been practised every few hours,
the bacilli have not remained in the throat for as long a
time after the complete disappearance of the pseudo-mem-
brane as when no antiseptic has been employed. Other
antiseptic and cleansing solutions may be also useful.
14. Inflammation of the mucous membranes due to
streptococci, either alone or associated with other cocci,
are usually mild in character. These inflammations may
be more serious when the lesion is located in the larynx,
or when they are complicated by scarlet fever or measles.
15. While the streptococci, and perhaps other forms of
cocci, may be considered as the primary etiological factor
in pseudo • diphtheria, yet, in die majority of cases at
least, certain predisposing factors, such as exposure to
cold or other deleterious influences, or the presence of
certain infectious diseases, appear to be of great impor-
tance in determining the occurrence of the disease.
The streptococci which under these conditions ap-
parently cause the disease are probably those which had
for a long time existed in the throat, and not those
freshly derived through communication with other cases
of pseudo-diphtheria. In a small number of cases, in-
deed, the histories suggest a direct communication, but
the causation may be equally well explained by the sup-
position that the second case shared with the original
one the same predisposing cause.
16. The slight mortality and the usual mildness of the
cases of pseudo-diphtheria do not warrant us in enforc-
ing isolation, even if further investigation produce posi-
tive proof that this disease is directly communicable.
With the results of these investigations before us we
can appreciate the difficulty of exterminating diphtheria
from a city like New York. On the one hand, we have
cases of diphtheria scattered all through the city, many
of which are so mild as to be unrecognized, and on the
other hand, we have the crowded tenements with their
ignorant and shifting population, where proper isolation
of the patient from other members of the family, or of
the family from other inmates of the building, is usu-
ally impossible unless harsher measures are adopted than
September 29, 1894]
MEDICAL RECORD.
401
are now customary. With stricter isolation of patients,
and intelligent and systematic supervision of the schools
and tenements, we can certainly reduce the number of
cases of diphtheria in the city, but the total extermina-
tion of the disease, under the existing conditions of life
here, does not seem probable unless one can acquire new
means to combat the disease.
Bibliography.
I Klebs : VerhandL des Zweiten Congress, f. In. Medicin, 1883.
* Loeffler : Mitth. aus d. Kais. Gesundheitsamte, Bd. 2, 1884.
» Loeffler : Berlin. Klin. Wochen. , 1890, No. 39.
* Roux and Yersin : Ann ales de l'lnst. Pasteur, ii., 1888, p. 620.
« Welch and Flexnor : Bulletin of the Johns Hopkins Hospital, Oc-
tober, 1891.
* Babes : Virch., Archiv., Bd. 119, S. 463.
▼ Welch : Medical News, May 16, 1801.
* Prudden : Medical Record, April 18, 1891.
* Baginsky : Berlin. Klin. Wochen. , February 29, 1892.
" Martin : Annales de d'Inst. Pasteur, May, 1892.
II Park: Medical Record, July 30, and August 6, 1882 ; Febru-
ary 11, 1893.
w Janson : Hygiea, April, 1891.
"Morse: Boston Medical and Surgical Journal, 1894, and Medical
and Surgical Reports of the Boston City Hospital, 1894.
i« Pipdden : American Journal Medical Sciences, April, 1889.
" Hofmann : Wiener Medicin. Wochenschrift, No. 3, 1888.
" Beck: Zeitschr. f. Hygiene, Bd. viii., 1890
17 Roux and Yersin : Annales de l'lnst. Pasteur, 1890.
" Escberich: Berlin. Klin. Wochen., 1893. Nos. 21-23.
» Koplik : New York Medical Journal, August 27, 1892 ; March
xo, 1894.
» Welch and Abbott: Bulletin of Johns Hopkins Hospital, Febru-
ary and March, 1892.
*l Abbott: Bulletin of Johns Hopkins Hospital, August, October,
and November, 1891.
*» Loeffler: Deutsche Med. Woch., 1890, Nos. 5 and 6.
« Tobiesen : Centralbl. fur Bakt., 1892. Bd. xiiM No. 17.
* Fraenkel : Berlin. Klin. Wochen., 1893, No. 11.
» Feer : Mitth. aus Klin. u. Med. Inst, der Schweiz, Hefte, 7, 1894.
* Abel : Berlin. Klin. Wochen., 1894.
*7 Johannesen : Difterius forekomst i Norge, 1888, p. 204.
THE AFFINITY OF GOUT AND RHEUMA-
TISM.
By R. SHAWE TYRRELL, M.D., L.R.C.P. Lond.,
TORONTO, CANADA.
The time, no doubt, is rapidly drawing to a close when
retention of excess of excrementitious matter will any
longer be tolerated daring the treatment of diseases in
general.
Not a score of years ago the practice in London was,
as everybody knows, to lock up the bowels for a fort-
night or more during the course of enteric fever, and this
mode of treatment was instituted by the very man, viz.,
Murchison, who enlightened the medical world on the
subject of lithaemia, and as his custom in typhoid fever
has long since been abandoned, so also has his theory
regarding the production of lithaemia been brought into
question. The object, however, of this paper is to en-
deavor to show the close relation which exists between
gout and rheumatism. And if the cause of gout is, and
has been for some time quite apparent and beyond dis-
pute, viz., uric acid in excess in the system; and if, on
the other hand, the cause of rheumatism is still in doubt,
may it not be justifiable to draw attention to this close
resemblance between these diseases, and, if possible, to
explain why their effects are somewhat different.
I well remember the late Dr. Murchison diagnosing a
case of severe inflammatory affection of the elbow joint,
which was not preceded by a local injury, as a first at-
tack of gout, and his opinion was corroborated by subse-
quent events. This case, I need hardly say, occurring
on one of the larger joints as a primary attack, would
probably suggest die conviction to many minds of so-
called rheumatic origin. And Garrod says, " It is not
uncommon to hear a patient call the disease gout as long
as it is confined to the feet, but rheumatism or rheumatic
gout when the upper extremities become attacked, al-
though the same condition of the system which causes the
one gives rise to the other.11 One naturally infers that
the patient referred to above calls his disease what his
physician does, and that a certain amount of doubt is in
many cases manifest in regard to its etiology, particularly
if the disease be of a chronic character or situated in the
muscles; many aches and pains and neuralgias which
were formerly designated rheumatic are now held to be
lithaemic, and give way under an eliminative mode of
treatment. It is, I say, in the chronic forms of rheuma-
tism and gout that one notices the resemblance is the
most marked. I think that lumbago, which is consid-
ered a form of muscular rheumatism, is always lithaemic
in origin, and certainly purgation and diaphoresis have,
in my hands, given more satisfactory results than the ac-
cepted mode of treatment by acupuncture. Osier says,
"persons of a rheumatic or gouty habit are certainly
more prone to this affection.9 ' Here again we have an
uncertainty expressed.
Dr. Beverley Robinson, of New York, has stated that in
his hay- fever patients he has frequently noticed a rheu-
matic habit, while Dr. Bishop, of Chicago, and I have
independently proved, at least to our own satisfaction,
that the affection is lithaemic in origin. There is, no
doubt, in that pronounced form of gout occasioned by
an excess of alcohol some characteristic appearances
which frequently stamp it as a distinct affection from
acute rheumatism, caused, I will state, by a loaded con-
dition of the system due to inactive organs, plus some
exciting cause ; but in many cases the physician is severely
taxed before he arrives at any definite conclusions, pos-
sibly because there has been noticed not only an alco-
holic habit, but also defective elimination ; with expos-
ure. In the one case the attack has been occasioned
solely by the effects of an excess of alcohol or its
products circulating through the blood. In the other
case the supply of alcohol or food may not have been in
excess, but due to faulty elimination — the effete products
circulate through the blood and give rise to the inflam-
matory condition known as rheumatism. The hypothe-
sis which I rely upon is, that both gout and rheumatism
are due to inefficient elimination ; if in the one case the
kidneys, bowels, and skin could be made to do excessive
duty we would have no gout, and if this same activity
could be constantly kept up we would have no rheuma-
tism. If this be tenable I think we are approaching
the cause of rheumatism, and may possibly class it with
gout under the term "Lithaemia." Now in regard to
the results of these affections Garrod says that in all
cases of gout you have a diseased condition of the kid-
neys, and it is well known that one finds a small amount
of uric -acid and urates in the urine in cases of gout
due to this diseased condition, and consequently one
naturally expects that this uric acid and urates will make
their appearance somewhere, which always occurs fre-
quently, but not always, in the joints ; but in the case of
rheumatism the kidneys are not diseased, and hence you
do not have a deficiency of uric acid and urates in the
urine, but an excess, and consequently you would not
look for uric acid in the blood or deposits of urates or
biurates in the joints or elsewhere, because the kidneys
being active and healthy are able in time to carry them
off, so that this distinction between gout and rheumatism,
in regard to uric acid in the blood, and biurates of soda
in the joints, is explained by the condition of the kid-
neys. I have had many cases of so-called rheumatism
which have in after-years developed the usual symptoms
of gout, and I explain the fact in this way, that at first
the kidneys were active and healthy and afterward be-
came diseased.
Again, youth is the special time for rheumatism, when
the kidneys are liable to be healthy. Middle age is the
choice time for gout, when these organs are more prone
to disease. And in this connection I may say that expe-
rience has taught me that there is a transitional stage be-
tween healthy and diseased kidneys when chemical and
microscopical examinations of the urine is of small prac-
tical value.
I have stated that rheumatism is caused by a loaded
condition of the system (by this I mean an excess ot
uric acid and urates), plus an exciting cause, viz., cold
and dampness ; this exciting cause occasions an explo-
sion, as it were, in this way. That it not only shuts off
402
MEDICAL RECORD.
[September 29, 1894
all excretion by the skin, but also causes a congested
condition of the internal organs which interferes with
their eliminative action, particularly that of the liver,
and hence you have the system suddenly charged with
waste products, so that cold is essentially the exciting
cause in producing this congested condition which pre-
vents elimination as is evidenced from the fact that in
tropical climates we find no rheumatism. Do you not
always find a state of constipation in acute rheumatism,
and is not purgation combined with diaphoresis the most
satisfactory mode of dealing with this disease ? as it is
also, in my experience, the most efficient way of cutting
short an attack of gout, and it is hardly necessary to say
that the large class of dyspeptics which we come across
daily are relieved most effectually by purgation; in fact,
elimination by the bowels and skin probably relieves
more suffering and avoids more acute attacks of illness
than all other forms of treatment combined. I have
been in the habit for several years of advocating the the-
ory that in order to enjoy good health it is, as a rule,
not only necessary that the bowels should be moved
daily, but that they should be freely moved daily, and I
think that if this principle were urged to a greater extent
than it is we would have much less rheumatism and gout,
or, as I will take the liberty of saying, a marked diminu-
tion in cases of Hthaemia in general.
KLEBS - LOEFFLER BACILLUS IN HEALTHY
THROATS AND IN MEASLES THROATS.
By ROBERT S. ADAMS, M.D.,
KBSIDRNT PHYSICIAN NEW YORK FOUNDLING HOSPITAL. NMW YORK.
As the present belief in this city is that the Klebs- Loef-
fler bacillus in nose or throat is diagnostic of true diph-
theria, and its absence characterizes false diphtheria,
and that until the bacilli are absent from the nose or
throat, no matter how long after the disappearance of a
pseudo-membrane, the case is to be considered as one
of true diphtheria, the following account of a series of in-
vestigations made at the New York Foundling Hospital,
in March of this year, Dr. J. J. Reid attending, may
prove of interest :
Seventy- nine cultures in all were made. All cultures
were sent to the Board of Health and examined by the
inspector of diphtheria, Dr. Park. Of these 79 tultures
51 were made from throats that appeared, clinically
speaking, perfectly healthy, while 28 were made from
throats of children during or shortly after the eruption
of measles. Of the 51 clinically healthy throats 10 were
in perfect health and in a nursery entirely free from dis-
ease, and 12 were convalescent or surgical cases in hos-
pital, but able to be about, and enjoying in general ex-
cellent health. Nineteen were made from throats of
children coming to the Outdoor Department. In these
5 1 healthy throats the Klebs-Loeffler bacillus was found
in 7 cases, while 1 had suspicious bacilli which in sub-
sequent cultures seemed to be pseudo-diphtheritic ba-
cilli. Only one of these cases has since developed any
clinical symptoms of diphtheria, viz., laryngeal diph-
theria and stenosis requiring intubation. He recovered,
but died of pneumonia one month after stenosis had dis-
appeared.
In the 28 measles throats Klebs-Loeffler bacilli were
found in 9 cases, pseudo-diphtheritic bacilli in 3 cases,
and suspicious bacilli in 2 more, one of which proved to
be genuine Klebs-Loeffler. Of these 10 cases of Klebs-
Loeffler bacilli in measles throats none showed any clin-
ical manifestations of diphtheria, while the one showing
at first suspicious bacilli, and afterward true Klebs Loef-
fler, died of bronchopneumonia, but showed no mem-
brane in air- passages post mortem. The pneumonia was
the typical catarrhal pneumonia of measles. Almost all
the cultures were made from children of three to four
years of age, and were made with the greatest care. In
many cases extra cultures were made subsequently for
greater certainty. To take up the cases somewhat more
in detail : Cases I. to X. were made on one floor of the
hospital proper from convalescent children who were al-
lowed to eat at the same little table in an adjoining
room and play together. When the reports of Klebt-
Loeffler in two of the cases were received, they were
promptly isolated and treated.
Case I. (Culture No. 3). — Eugene W , aged three,
suffering from anaemia, well nourished, no cough, called .
" doll baby " from his perfect face and pettish actions.
Soft blowing murmur, generally heard best over pulmon-
ary interspace, which disappeared entirely under treat-
ment until at the time culture was made it could no longer
be heard and child seemed perfectly well. Three days
after culture was made laryngeal diphtheria developed,
and intubation became necessary ; tube removed on fifth
day, reinserted on sixth day, and finally removed four
days later; patient gradually improved, but remained in
weakly condition and died of broncho-pneumonia a
month after first intubation. Culture of this case proved
virulent in guinea pigs.
Case II. (Culture No. 1). — Denny C , aged four,
convalescent from croupous pneumonia for two weeks
and playing around with the other children. Throat
appeared perfectly normal, culture contained many typi-
cal Klebs-Loeffler bacilli, which proved virulent in
guinea- pigs. No membrane or further manifestations of
diphtheria appeared, and a little treatment soon removed
bacilli. Has been perfectly well since. An interesting
point in connection with these two histories is that three
days later No. 4 developed typical diphtheritic patches
on both tonsils, and cultures showed abundant Klebs-
Loeffler. She recovered nicely under treatment, and
culture about a week later showed no Klebs Loeffler,
none having been found in her original culture.
Culture No. 2. — Maggie W , a child suffering from
marked rachitis showed two well-marked patches of
pseudo-membrane a few days after original cultures;
some temperature, enlarged glands, prostration, etc.,
but no Klebs Loeffler were found in original or two later
cultures. Hers was an obstinate case, but she recovered
after vigorous treatment. Now here were ten children
not having been exposed to diphtheria, in good general
condition, with apparently perfectly healthy throats, no
enlarged tonsils, nor adenoids, nor nasal catarrh, one of
whom developed laryngeal diphtheria, apparently giving
diphtheria to another, and infecting one with true and
another with false diphtheria.
Culture No. 7, who had suspicious bacilli at first cult-
ure, showed pseudo-diphtheritic bacilli, but no further
manifestations of diphtheria, and the bacilli disappeared
with treatment.
The following cases were in other wards :
Case III. — Stephen , aged five, tubercular osteo-
arthritis ankle, showed Klebs-Loeffler typical, but no
further sign of diphtheria, and treatment begun shortly
after isolation. Showed no further bacilli.
Case IV. — Thomas C , granular conjunctivitis,
showed typical Klebs-Loeffler. No further manifestations
of diphtheria.
Case V. — Annie W , talipes equino varus, with
special shoe fitted. Klebs-Loeffler found, but no subse-
quent diphtheria.
The two cases from the Out-patient Department showed
true Klebs-Loeffler, but treatment removed bacilli, and
no further symptoms appeared.
Of the 28 measles cases, in which cultures were made
in all but 6 at time of eruption, typical Klebs-Loeffler
were found in 10 cases. Four of these had croupy
coughs, but only one of them had Klebs-Loeffler, while
one had pseudo-diphtheritic bacilli. None showed any
further trouble with the throats, the peculiar cough
doubtless being due to a greater degree of catarrhal in-
flammation of the larynx. Two of these cases died of
pneumonia, but no membrane was found post mortem.
From these cases, to sum up, we note :
1. Of 51 healthy throats, Klebs-Loeffler bacilli in 7;
that is, 28 healthy throats in hospital, 5 Klebs-Loeffler;
September 29, 1894]
MEDICAL RECORD.
403
19 healthy throats in Out-patient Department, 2 Klebs-
Loeffler. Nearly one in seven is the proportion of Klebs-
Loeffler in healthy throats.
2. Probable infection of a case from the Klebs-Loeffler
bacilli in a throat in which at time of culture they were
doing apparently no harm.
3. Occurrence of severe pseudo-diphtheria in a throat
which contained no Klebs-Loeffler.
4. Cases of pseudo - diphtheritic bacilli in healthy
throats.
5. The occurrence of Klebs-Loeffler bacilli in 10 out
of 28 cases of measles throats, or in about one-third of
cases examined, but apparently not adding clinical man-
ifestations of diphtheria at a time when they should
have found it easiest, i e.f in inflamed measles throats.
The bacilli were removed with much greater difficulty
from half of the measles throats, they apparently finding
the inflamed mucous membrane a good habitat. As all
of these cases were promptly isolated and treated as soon
as bacilli were found, no idea of the virulence of the
bacilli can be obtained other than the few cultures inoc-
ulated in animals. All of these children have been under
observation for the past three months, and none of them,
save the single case requiring intubation, have since
showed any sequelae or further manifestation of diphthe-
ria.
THE CERVICAL GANGLION OF THE UTERUS.
By BYRON ROBINSON, M.D.,
CHICAGO, ILL,
It would astonish any student to know how little has
been published in regard to the nervous system of the
female genitals which is of an original character. The
reason for this is at once apparent when one pursues the
study for several years. Of course, the simplest and easi-
est way is to dissect the genitals of man and animals.
Bat few do that. And besides, to dissect with value and
discrimination requires time, experience, and patience.
The best way is to secure an infant cadaver and drop it
in alcohol for several weeks, and for comparison secure
some six to eight weeks' foetal pigs from the slaughter-
house and treat them likewise.
To get at the parts most readily, open the infant's ab-
domen and take away the hip-bone. Unjoint it at the
sacro-iliac joint, then cut it away at the tip of the ischial
spine, and then saw through the pubic rami at the centre
of the obturator foramen. The field is now clear. Next,
observe the course of the hypogastric plexus just beneath
the peritoneum at the promontory of the sacrum. It
will show itself like white threads shining through the
peritoneum. The white lines are the hypogastric plexus
and should be carefully followed by a sharp-pointed
scissors as far as the region of the cervix. Now, with
gentle care, clear away the various tissues from the roots
of the first, second, third, and fourth sacral nerves. It
will, by this time, be clear to the sight that the lower
end of the hypogastric plexus and the branches from the
sacral nerves (especially the third and fourth) converge
near the cervix into a mass of white tissue. This mass
of whitish-gray tissue is the ganglion of the cervix uteri.
So far as I can ascertain, this ganglion was first described
by a physician named Walter. The existence of the
ganglion has been denied by Snowbeck, of the English,
and by Kilian, of the French. The defenders of the
ganglion are chiefly Lee (1842) and Frankenhausen
(1867). The names of those who have worked at this
ganglion are very few even to this day. The only work-
er on this ganglion that I know of in the last generation
is Dr. Jastrobef, of St. Petersburg, in the clinic of
Professor Slavjansky. Dr. Jastrobef used thirty bodies
to secure anatomical and pathological knowledge. I
have been working at the nervous system of the female
genitals for some Ave years, and I did not become aware
of Dr. Jastrobefs labors until August, 1894. Nearly
every worker in this subject comes to essentially the
same conclusions, but some little manifestations arise
which induce said observer to think every other investi-
gator overlooked. Lee and Frankenhauser showed with
anatomical positiveness the largeness and solidity of the
cervical ganglion ; while Snowbeck and Kilian tried to
belittle its size, and even its existence. Jastrobei's short
account simply sides with the idea that the cervical gan-
glion is a mere plexus of nerves.
After careful dissecting (man and animals) I must say
that the cervical ganglion is a veritable ganglion, just as
the superior cervical ganglion is. The cervical ganglion
is a real ganglion. It is true it varies in shape and size,
as all sympathetic ganglia do. But it i§ constant and
real. I shall carry on this investigation for the next few
years in man and animals and prove its constancy. The
last cadaver which I dissected for the purpose of identi-
fying the ganglia for study was that of a woman about
seventy years old. " The ganglion was fully three-fourths
of an inch long, and over one-fourth of an inch wide.
It was a thick, hard, irregularly shaped mass of nerve- tis-
sue receiving the hypogastric plexuses and the branches
of the sacral nerves, and sending out many small nerves
to the uterus, bladder, and rectum. The ganglion in this
special case received all the branches of the sacral nerves
before they entered the uterus, and all the nerves of the
hypogastric plexus, except two or three, before they were
sent to the uterus. It appears, then, that the cervical
ganglion is the distributor of nerves to the uterus. It is
no doubt the ganglion of the uterus. Its business is to
control the uterus. Leashes of nerves start out of this
ganglia to the uterus, bladder, and vagina. The vagina
was, next to the uterus, the favored organ for numerous
strands. The ganglia lie near the cervix, one on each
side. In the above case the right cervical ganglion was
much more solid and compact than the left. More than
a dozen branches could be counted going to the uterus,
to the vagina, and to the rectum, in the order of abund-
ance. In this case of a woman seventy years of age the
ganglion was perfect and distinct, as it is in an infant
cadaver. The wonderfully intimate nervous connection
of the uterus to both rectum and bladder should be a les-
son to the gynecologist. The uterus, rectum, and blad-
der are richly supplied by many strands from the same
great trunk (hypogastric plexus). It is almost impossible
to irritate one organ without the other two being brought
directly into the disturbed field.
During the last five years I have had many subjects
(man and animals) to study the sympathetic nervous sys-
tem, and one fact has, time and time again, impressed me.
This fact is the widespread and profoundly intimate
nervous connection of the kidney and genitals. So far
as the nerve connection is concerned the organs should
be written genito-urinary, with a distinct hyphen. The
explanation arises in embryology, where both genital and
urinary organs arise from the same source — the Wolfian
body. I wish to give credit for this same idea to Dr.
Frankenhauser, whose work I was able to secure only a
few months ago, as it is out of print. A glance at a well-
dissected sympathetic nervous system lying in situ would
enable a physician to cast aside forever an error long
propagated in obstetrics, and to my own knowledge
taught even to this day from obstetric chairs. It con-
cerns pressure over the sacral promontory to stop post-
partum hemorrhage. It is taught that pressure com-
presses the aorta so that the blood is checked from going
to the uterus. A few actual trials in obstructing the aorta
by pressure will soon dispel the delusion. The facts in
the case are that the irritation of the hypogastric plexus
(in attempting to compress the aorta) induces the uterus
to contract. The more pressure and vigorous irritation
applied to the sacral promontory the more vigorous and
certain will be the uterine contractions, so that the ex-
planation of how post-partum hemorrhage is checked by
compressing the aorta is certainly wrong. The mechan-
ism is accomplished by the irritation of the hypogastric
plexus. So far I have not had the opportunity of dissect-
ing a pregnant uterus, to determine whether the cervical
ganglia enlarge, but both Lee and Frankenhauser say
404
MEDICAL RECORD.
[September 29, 1894
they do. It is probable, however, that John Hunter is
correct in his suggestion that it is the connective tissue,
and not the nerves themselves, which enlarges in preg-
nancy. Almost every investigator of the uterine nerves
has come to the opinion that it is the infant cadaver
which serves the best purpose. The nervous system of
the infant is disproportionately large and is plain to the
eye, and it can easily be separated from the delicate con-
nective tissue. The cervical ganglia are very plain in
the infant. Two to four nerve-branches pass along with
the ovarian vein and artery to the ovaries. At the
junction of the tube and uterus (i.e., at the origin of the
round ligament) the ovarian and uterine nerves join —
anastomose. The cervical ganglion , of course, shrink after
the menopause, but its shrinkage must be limited, as
many of its branches supply the rectum and bladder, or-
gans which persist in further use. Yet it appears to me
that the rectum and bladder in old female cadavers are
considerably atrophied as well as the uterus.
Jastrobef in his short article notes that in disease of
the genitals on one side the ganglion of the same side is
affected. He reports two cases where the ganglion and
the genitals of the same side were both diseased. As a
considerable portion of the cervical ganglia rests on the
vagina, even total extirpation of the uterus would include
but a very small part of the ganglia, for the cervical
ganglia are situated too low down to be included in the
extirpated uterus. These few remarks may call attention
to the cervical ganglion of the uterus, its limited litera-
ture, the varied opinions as to its existence, shape, and
size, as well as the slight records of its functions and
pathology.
grograsB of Igftedical Science.
The Significance of the Venous Pulse.— Dr. James
Mackenzie divides the venous pulse into two forms, the
auricular and the ventricular. The former, he says,
presents distinct evidence of the functional activity of
the right auricle. In this form there is also a wave due
to the ventricle, and as it increases the auricular wave
decreases and finally disappears, and thus the ventricular
venous pulse is developed. The latter form is a more
advanced stage than the auricular, and, as during its
development there is a gradual fading of the auricular
wave, there is a period when such terms do not sufficiently
denote the character of the pulse; but the terms are
convenient for descriptive purposes. The ventricular
venous pulse appears only when there is organic disease
of the heart itself (most commonly in valvular disease).
When failure of the heart is functional and not due to
organic disease of the valves, the auricular pulse persists
to the end. Similar types of pulse may be recognized
in the liver. Here the pulse appears only when there is
organic disease of the heart. In many respects, says
Dr. Mackenzie, more information regarding the various
cavities of the heart can be obtained from the study of
the venous pulse than from that of the arterial pulse.
Thus, during a cardiac revolution the arterial pulse is in
free communication with but one chamber, the left
ventricle, only a portion of the time, whereas in the
venous pulse the effects of the right auricle during its
systole and its diastole may be observed, while the time
of the appearance of the ventricular wave gives informa-
tion regarding the degree of incompetence of the tricus-
pid orifice. Information may be gathered regarding the
exact time of closure of the pulmonary valves, and the
persistence of the ventricle in systole for a short time
after the outflow through the arterial orifices has ceased
may be noted. There is also distinct evidence of the
diastole of the right ventricle in the venous pulse. In
heart failure the venous pulse affords information of a
kind entirely different from that supplied by other
means. Its appearance, increase, decrease, and disap-
pearance may give evidences of changes in the blood-
pressure quite inappreciable by any signs given by the
arterial pulse. While, as a general rule, an increase of
the venous pressure implies a diminution of the arterial
pressure, that, nevertheless, is not always the case. Al-
though in some cases the disappearance of the venous
pulse is a sign of the restoration of the body to a health-
ier condition, yet in other cases it may precede a fatal
termination. In these last cases there is also a failure of
arterial pressure. In pulse irregularities no true knowl-
edge of the action of the different chambers of the heart
can be obtained except by the study of the venous pulse,
and this study, says the author, throws a new light upon
the heart's movements, and reveals a variety of them
hitherto unsuspected. — New York Medical Journal.
Obliteration of the Superior Vena Cava. — According
to the Paris correspondent of The Lancet, Dr. Merlin has
published the details of a case of plugging of the superi-
or vena cava — a very rare phenomenon ; but what con-
stitutes a still greater rarity is the recovery of Dr. Mer-
lin's patient, who has since (a space of four years)
remained well. His patient was a man, aged thirty four,
who, after an effort, was affected with a swelling of the
face which, spreading to the whole head, rendered it of
an enormous size. The cheeks were puffed out, oedema-
tous, the eyes bulging out of the orbits, the lips (espe-
cially the lower) double the normal volume, the tongue
swollen so that the mouth could hardly contain #it, and
articulation was difficult. The oedema of the neck was
great, the circumference having increased from thirty-
nine to fifty-six centimetres. The jugular veins were
dilated, and the establishment of collateral circulation
was apparent from the presence of varicosities at the
base of the neck. The oedema was marked as low down
as the base of the thorax, and the patient had attacks of
dyspnoea. The voice was cavernous, cough was frequent,
and deafness was complete. The upper extremities were
much less swollen than the face or trunk. Below the
umbilicus there was no oedema. The patient denied
having had syphilis. He was, nevertheless, ordered one
drachm of potassium iodide per diem, with the result
that considerable improvement began as early as the
second day. The improvement continued progressively,
and he was discharged in a month cured. As above
mentioned, the recovery has been since (for four years)
maintained.
Suprarenal Tumor. — According to the Berlin corre-
spondent of the Medical Press Dr. Lazarus showed a
preparation before the Gesellschaft taken from a child,
aged three and a half, which had been received into hos-
pital in the middle of February. According to the
mother's story the disease commenced with pain in the
body, which soon began to swell. In the right upper
part of the abdomen a firm, hard swelling was found, which
was taken for disease of the liver. The lungs, heart, and
kidneys appeared to be healthy ; the child became feeble
and pale, the haemoglobin of the blood fifty per cent.,
and at no time in the history of the case was there fever.
Repeated punctures from the margin of the ribs to the
umbilicus, over the region of the swelling, emitted very
little fluid, of which the microscopical examination gave no
confirmation of a malignant character. Closer diagnosis
revealed a renal tumor. The child rapidly emaciated,
while the weight of the body as quickly increased, till,
eight days after admission, it died. On section the ab-
domen was found to be filled with a tumor ; the total
weight of the child was thirty-seven pounds, the tumor
alone twelve pounds, which originated from the left supra-
renal body, which was firmly adherent to the cortical sur-
face of the kidney. The small bowel was pressed upward
and backward, the stomach and large intestine were
crushed into a small space on the right side of the dia-
phragm. During life no discoloration of the skin was
present. Over the surface of the tumor small nodules
were found rising in knots, which, on examination, proved
to be sarcomatous degeneration. The liver appeared as a
sheet of paper enveloping the tumor.
September 29, 1894]
MEDICAL RECORD.
405
Medical Record:
A Weekly Journal of Medicine and Surgery.
GEORGE F. SHRADY, A.M., M.D., Editor.
Publishers
WM. WOOD & CO., 43, 45, & 47 East Tenth Street
New York, September 29, 1894.
TYPHUS AND TUBERCULOSIS.
At a recent congress of hygiene in France, two impor-
tant subjects received special attention : the spread of
contagious diseases, especially typhus and small-pox, by
tramps and other vagabonds ; and the social as distin-
guished from the hereditary causes of tubercular con-
sumption, this disease being probably the greatest physi-
cal evil known to humanity.
Typhus had been practically absent from Paris for
seventy years, until last year, when tramps brought it
into a night refuge at Amiens. It soon spread to other
institutions and to the soldiers1 barracks, in spite of ener-
getic disinfection and segregation. This year it has ap-
peared as virulently as ever, and is tending to become
endemic in France. Deschamps read the first paper on
the subject of typhus, stating that, unlike most epidemic
diseases, this is one which easily attacks persons in per-
fect health and without physical defect or predisposition,
ending mortally with them oftener than with those of
weakened or inferior constitutions. The tramp who has
not as yet the slightest exterior or visible symptom of
typhus may already give it to those with whom he comes
in contact or leave it behind him in the night refuge, es-
pecially during the ten or twelve days before he finally
comes down with the disease. Contagion is ever to be
feared when cure seems to be complete. Dronineau
spoke of the tendency of typhus to fix itself permanently
in a region to which it once gains admittance. It was
thought best, however, by others, not to suppress the
night refuges, as these combine public safety with public
charity. Constructed of brick or stone, with framework
and furniture exclusively of iron, such refuges could each
morning be thoroughly disinfected and the straw of the
floor and beds be burned. In concluding, the associa-
tion decided to ask the ministers of the interior and of
agriculture, that sanitary inspectors, both of men and
beasts, might enjoy permanently the powers now granted
them only during a period of a declared epidemic. Re-
* publican France accepts the duty of sheltering its vaga-
bonds, and should also have the right of preventing the
contagion of disease to its citizens.
An interesting feature of the meetings was a paper by
Tison on pulmonary tuberculosis, to which he attributes
one quarter of the whole number of deaths in Paris and
in other large cities everywhere. At once infections and
contagious, very difficult to expel when it has once in-
vaded the organism, tuberculosis remains the cause of
death that science has least succeeded in mastering.
The preventive measures that might be taken by society,
correspond to the three great social causes of tuberculosis
as distinguished from hereditary predisposition. These
are " troglodytism," alcoholism, and excessive labor,
three influences most at work between the ages of
eighteen and forty-five. Troglodytism is that condition
of modern society that lodges human beings in small
rooms, insufficiently supplied with pure air and light, simi-
lar to the cave dwellings of the prehistoric troglodytes,
with advantages on the side of the cave dwellers. They
crept into their holes only to sleep or to shelter them-
selves from storm or attack, spending most of their time
hunting and fishing in the open air. The modern cave-
dweller spends most of his time in a luxurious hole or
apartment house, and but little, comparatively, outside
in the open. Alcoholism, as a cause of pulmonary tuber-
culosis, must not be confounded with drunkenness, which
is uncommon in France. By alcoholism, Tison means
that light but constant sipping of liquors and brandy,
especially before and after meals, which daily comes
more and more to prevail among the men and women of
France. In nearly all of these drinks there is from fifty
to seventy per cent, of pure alcohol ; and even when
water dilutes them, more alcohol enters the system than
can well be borne. Modern chemists find that alcohol
does little more than pass through the system without
change or assimilation, remaining as a clog to liver or
brain when not eliminated. Even when it has disap-
peared, a morbid condition of the organs by which it is
eliminated remains. The forced elimination of alcohol
by the lungs is a direct cause of pulmonary tuberculosis.
The physiological impoverishment resulting from insuffi-
cient nourishment, Tison states with much bitterness, is
due largely to the adulteration of important articles of
food and drink. In ordinary canned goods there is only
a trace of genuine food. Modern legislation allows the
counterfeiting of food and drink, and punishes severely
the counterfeiting of money. When the public health is
considered as important as the public purse, there will
be less pulmonary consumption.
A PRIVATE AMBULANCE SERVICE.
In this city all the ambulance service has been furnished
by the public or private hospitals. The city is divided
into districts, and connection with the hospitals and
police stations is established by telegraph and telephone.
The system works well, though at times the service is
slow. When a* person who is very ill needs some con-
veyance to his home or a private hospital he has usually
to go to some of the large hospitals and hire an ambu-
lance for his purpose. This is expensive, and often slow
and annoying. There are, we believe, some specially
arranged carriages by which an invalid can be conveyed
from the ferry or a train to his destination. Recently
an enterprising firm has undertaken to establish a private
ambulance service which may be called upon at any
hour of the night or day for the convenience of small
institutions or physicians in private practice. Already
we are informed that some of the private hospitals are
using this service, and as its rates are much more reason-
able than those of the public ambulances, it seems as
though it would supply a demand.
406
MEDICAL RECORD.
[September 29, 1894
SNAKE-POISON A TOXIC PROTEID.
In Science Progress for September, W. Halliburton has
a most interesting paper on snake-poison. Not the least
strange of the many puzzling facts in connection with
the proteids, says the author, is that many of them are
poisonous. The proteids are the most important class
of chemical substances, forming the most essential of the
. constituents of a diet, and are the most constant and
abundant of the materials obtainable from protoplasm
and living structures generally. Yet practically nothing
is known of their chemical constitution. The poisonous
proteids are not distinguishable by any well-marked or
physical properties from the non-poisonous or food pro-
teids. Both animals and vegetables furnish poisonous
proteids; notably jcquirity seeds and the yellow lupin
in the vegetable kingdom, and snake-poison among ani-
mals, together with the proteids in the serum of the
conger-eel and other fish, and the proteid poisons found
in certain spiders. Proteid poisons are also formed
during ordinary digestive processes in the human ali-
mentary canal, from the proteids taken as food. Nor-
mally animals are protected from this poison by the
lining membrane of the alimentary tract, so that no
proteose or peptone is found in blood or lymph during
the most active periods of digestion. The cells of this
membrane possess many remarkable properties, but one
of the most important is this power of regenerating
albumin from peptone.
Allied to the albumoses of ordinary gastric activity are
the similar products produced by bacteria. In some
cases poisons produced by the growth of micro-organ-
isms are alkaloidal in nature. In by far the greater
number the toxic product is a proteid. There is still an-
other important class of proteid poisons, the nucleo-
albumins obtained by suitable methods from most 'of the
cellular organs of the body. Out of all the work neces-
sary to make the foregoing discoveries, the practical
recognition of the alezines or protective proteids has
been reached. These alexines appear to belong to the
nucleoalbumin class also. In small doses they confer
immunity on animals to large doses of similar poisons.
The long hidden secret of the modus operandi of vaccin-
ation and other forms of protective inoculation begins at
last to be revealed.
The small quantity of poisonous proteid that the snake
secretes is atoned for by its quality. One thousandth
part of a grain of the Australian black snake's poison in-
variably kills a rabbit five pounds in weight in about a
hundred seconds. And this deadly proteid is as yet un-
distinguishable by chemical methods from those in daily
use as foods !
In the researches on the venom of the Australian black
snake, Martin and Smith found it necessary to exclude
various classes of poisons, as well as to determine posi-
tively the nature of the venom. They excluded in the
first place by appropriate experiments the presence of
micro-organisms, ferments, alkaloids, ptomaines, and
crystalline acids. Next they showed that the poison it-
self was a proteid mixture, containing three distinct
proteids, one an albumin, and the other two albumoses.
The albumin is not virulent, but the two albumoses (cor-
responding to proto- and hetero-albumoses of Kilhne)
are extremely poisonous. They each have the same
physiological action, and this is the same as that pro-
duced by the venom itself. Momentary boiling of the
venom does not impair its activity, but prolonged boil-
ing for days destroys its virulence.
The most marked local effect of serpent proteid poi-
son is oedema. The general symptoms consist of twitch-
ing and convulsions in non lethal doses. Continued
fluidity of the blood has been noted by numerous ob-
servers in the case of various snake-poisons. Martin
found that different doses produced different results;
and these results show a great resemblance between the
action of the venom and that of tissue-fibrogen and
nucleo albumin. Does the poison contain nucleo-albu-
min, which itself is a proteid united to a substance rich
in phosphorus called nuclein? Snake- venom contains
no nucleo albumin ; and its action not only opens up a
novel aspect of the subject of snake-poisoning, but also
sheds light on the vexed question of blood coagulation.
GRIEF, EMOTION, AND INFECTION.
Many violent maladies have been supposed to have been
produced under the operation of moral influences. Fear
has been considered capable of provoking erysipelas.
Laennec believed that griefs and annoyances were im-
portant constituents in the frequency of tuberculosis in
large cities. Reproaches and agitation have been known
to be shortly followed by puerperal infection, in cases
that were doing perfectly well up to the untimely inter-
ference of parents or relatives. Many observers, ac-
cording to FM9 in the Popular Science Monthly, for
January, attribute an important part in the etiology of
the diseases of women in child-bed to moral affections.
Theories recently put forth to explain contagion and
immunity from infectious disease seem to agree with the
facts in the case. One, that mesodermic cells are
charged with the protection of the organism, explains
why diminutions of circulation and decrease in the cali-
bre of the blood-vessels is necessarily unfavorable to the
sally of protective cells and phagocytosis. Asthenic
emotions, from this point of view, lead to the same
condition as traumatism, fatigue (Charcot, Boyen);
chill (Pasteur, Wagner, Platania, Chairin) ; ' inanition,
(Canalis, Morpurge) ; loss of blood (Serafini) ; and ner-
vous sections (Ruffer, Roger, Herman).
That grief prostrates, often causing physical disease
and sometimes death, has long been a matter of every-
day knowledge. The way in which such effects are
brought about has been the subject of careful study by
an investigator named Bassi, who has recorded observa-
tions on animals which apparently died in consequence
of capture. Birds, moles, and a dog, finally succumbed
to conditions that correspond in the human animal to
acute nostalgia and a "broken heart." These humble
cousins of the human race were examined post mortem.
Generally there was hyperemia, says The Lancet% some-
times associated with capillary hemorrhages of the ab-
dominal organs, more especially of the liver, with fatty
and granular degeneration of their elements, and some-
times bile was found in the stomach with or without a
catarrhal condition. The clinical symptoms were at
first those of excitement, especially in the birds, and fol-
lowed by depression and persistent anorexia. The theory
suggested by Dr. Bassi is that the nervous disturbance in-
September 29, 1894]
MEDICAL RECORD.
407
terferes with the proper nutrition of the tissues in such a
way as to give rise to poisonous substances — ptomaines —
which set up acute degeneration of the parenchymatous
^elements similar to that which occurs in consequence of
the action of certain poisonous substances, as phosphorus,
or to that met with in some infectious disease. In sup-
port of this view, it may be remembered that Schule ear-
lier found parenchymatous degeneration in persons dead
from acute delirium, and that Zenker found hemorrhages
into the pancreas in persons who had died suddenly.
MENTAL SEDATIVES.
Thousands of men and women, says the London Specta-
tor, use novels as mental sedatives, read them to steady
their nerves. Busy brain-workers, or those who other-
wise exhaust their nervous energies, want some form of
mental sedative. They cannot rest while doing nothing.
In order to quiet the thinking machine, it must be kept
gently at work. The easier and more mechanical that
work is the better, but the mental powers must just be
kept running. A douche of fiction quiets them, so
novels are poured over the weary in a gentle easy
stream. This physical need creates the novel market.
To one accustomed to use fiction to soothe his mind,
there comes a positive craving for novels, like the crav-
ing for any other sedative. Hence the demand for
fiction, good or bad, of a kind that does not obtain in
other forms of literature. And if the novel is in a for-
eign language, be it said in passing, the sedative effect is
complete.
%txos of ttxe WStesk.
The Progress of Medicine in China. — The Viceroy Li
Hung Chang has established in Tientsin an imperial
medical college, with a staff of western (English) medical
men who assist native Chinese in teaching. A four years'
graduated course is required and a well-equipped hospi-
tal has been built.
Cesario's Body. — Professor Lacassagne applied to have
Cesario's body, in order to make a post-mortem examina-
tion. Menacing letters, it appears, were sent to the
medical faculty, and the body has been buried. Thus
probably interesting pathological and physiological data
have been lost, and it is shown that the anarchist does
not favor scientific any more than he does social prog-
ress.
On the Use of Cinnamon and Other " Cures " for
Cancer.— Mr. J. W. Hulke writes to The Lancet that a
regulation of the Middlesex Hospital respecting its in-
patient cancer wards requires the surgeons in charge of
these to try every alleged remedy the composition of
which is not " secret " and for which obviously there are
not sufficient grounds for judging that its effect, if any,
will be injurious. A letter from Dr. J. Carne Ross hav-
ing been published in The Lancet on the great value of
cinnamon in cancer, it was agreed to. try the drug in the
way recommended. Five cases were chosen as best ful-
filling the conditions under which Dr. Ross had obtained
the best results. Three were uterine cases, one was rec-
tal, and one was a case of recurrent masses in the neck
everywhere covered with sound skin. The preparation
used was made by slowly boiling one pound of Ceylon
sticks with three pints of water till the bulk was reduced
to one pint. Half a pint was drunk daily. Four of the
patients were under observation in the hospital the whole
time ; the fifth patient was treated for part of the time
as an out-patient. In four of the cases administration
was continued for between two and three weeks, after
which the drug became intolerable to the patient and was
vomited. The patient in the fifth case continued to take
it for a month before he begged to have it changed. In
three of the cases there was definite evidence of increase
of the growth during the administration. In none was
there any evidence of relief of the pain, and in no case
was it possible to diminish the dose of morphia or opium,
but rather this had to be increased with the increase of
the growth or as the drug lost its power from custom.
Mr. Hulke adds : " It has fallen to me to make trial of
various remedial measures, suggested here and abroad for
the relief and cure of sufferers from cancer, in the course
of some twenty-five years or thereabouts. Of such " phar-
maka" I may mention " Fells' paste M (the active in-
gredient in which is zinc chloride colored with red snake-
root), slow injection of acetic acid through a capillary
tube, sundry escharotic pastes and powders having arse-
nic as their essential component, condurango, and more
recently Chian turpentine ; also besides these the dietetic
treatment laid down by Beneke, without and with the
association of arsenic administered internally recom-
mended by Esmarch. Several years ago the conjecture
that cancer might have a parasitic origin induced me to
try cinnamon, being influenced in the selection of this
by the common ascription of germicidal properties to
aromatic oils, and by my recollection that my old teacher,
Dr. A. Farre, held strongly that cinnamon had something
like a specific or particular influence over some uterine
functions, a belief which led him to prescribe large doses
of the tincture in certain cases of dysmenorrhcea. I gave
cinnamon a long trial, chiefly in cases of cancer of the
uterus, but also in that of other organs. The result was
wholly negative.
The Craig Epileptic Colony. — Dr. Frederick Peter-
son, President of the Board of Managers of Craig Col-
ony, writes that our informant was in error in the state-
ment, recently published in these columns, that the
epileptic colony would not be opened under two or three
years. The colony will be opened for actual work, he
says, next spring. ''There are six hundred patients
eagerly waiting in the almshouses of the State to patron-
ize the colony; besides which the managers are receiving
daily letters from numberless unfortunates, not in alms-
houses, anxious to enter the colony as soon as they can
be received."
Dr. George W. Davis, of Holyoke, Mass., died in
that city, on September 18th. He was born on March
26, 1847, aQd was graduated in medicine from the Ver-
mont University in 1868. He began practice in Crafts-
bury, Vt, but removed to Holyoke in 1871 where he
resided continuously up to the time of his death. The
cause of his death was disease of the heart following an
attack of influenza in 1892.
A New Charity has been organized at Brooklyn,
known as the Non-Sectarian Hospital and Home for
Epileptics, having accommodations for forty inmates.
4o8
MEDICAL RECORD.
[September 29. 1894
The New Tork State Association of Railway Sur-
geons.— The annual meeting of this Association will be
held at the Academy of Medicine, in this city, on No-
vember 15th next All railway surgeons of the State
are invited to be present. The Secretary of the Associ-
ation is Dr. J. B. Hulett, of Middletown, N. Y.
The Southern Surgical and Gynecological Associa-
tion.— The Seventh Annual Session of this Association
will be held in Charleston, S. C, on November 13th,
14th, and 15th. Papers will be presented by a number
of the leading surgeons and gynecologists of the South.
The medical profession is cordially invited to attend.
The President of the Association is Dr. Cornelius Kol-
lock, of Cheraw, S. C.
Dr. Albert H. Buck, of No. 14 East 45th Street, New
York, writes: "On page 810 of the Medical Record
(issue of June 30, 1894), I speak of Dr. Frederic Lange,
the distinguished surgeon of this city, as Dr. Theodore
Lange. You will do me a favor if you will insert a suit-
able correction of this error in one of the next issues of
the Medical Record.
The Malarial Organism in the Blood Plaque.— Dr.
George J. Preston, of Baltimore, writes: "In- examin-
ing the blood of a considerable number of malarial cases
this summer, I observed quite frequently a speck of pig-
ment in the blood plaques. Careful observation
showed beyond any doubt that this pigment possessed
motile properties. Generally there was but one clump
of pigment, occasionally two or three granules. At first
the single granule was mistaken for a nucleus, but it was
soon noted that the supposed nucleus moved from one
part of the plaque to another. The movement is not the
rapid zigzag motion of the free malarial organism, but
a much slower motion. The pigment can be seen to
slowly change its place in the plaque, now in the centre,
now at the periphery. In patients taking methyl blue
the pigment was slightly stained. The organism was
observed most frequently in the blood of patients taken
during the chill or a few hours before or after the par-
oxysm. It was seen, however, sometimes in the inter-
paroxysmal period. The physiology of the blood plaque
is still so uncertain that this note is recorded in the hope
that further observation may confirm the presence of the
malarial organism in this structure. "
The American Medical Publisher's Association. — The
first annual meeting occurred at Hot Springs, Va., on
August 13th and 14th. After the transaction of the usual
routine business, the president, Dr. Landon B. Edwards,
read a paper on "Advertising and Advertising Agen-
cies. " Upon motion, it was decided that all annual
meetings hereafter should be held just prior to the ses-
sions of the American Medical Association, the next
meeting being set for Monday, June 5, 1895, at 9 A*M>
in the Utah House, Baltimore.
Dr. Oharles H. Dare, of Bridgeton, N. J., died on
August 25th. He was for seventeen years County Phy-
sician, and was Surgeon of the Fourth New Jersey Na-
tional Guard.
A Worm Specialist on Third Avenue advertises to re-
move the worm, head and all, in two hours. This hard-
ly gives taenia Solaris, which is naturally a slow animal,
a fair show.
Dr. Jacob Newkirk, of Binghamton, N. Y., died
August 13th, aged eighty- nine.
Dr. Charles H. Williamson, formerly a surgeon in the
United States Navy, died at St. John's Hospital, Brook-
lyn, N. Y., in the sixty-ninth year of his age. He was
a native of Portsmouth, Va., and a graduate in medicine
from the University of Pennsylvania.
Railway Accidents. — From the advance sheets of the
Statistics of Railways in the United States prepared by
the Interstate Commerce Commission for the year end-
ing June 30, 1893, the following statistics are prepared
and published in the Railway Surgeon.
Comparative Summary op Railway Accidents for the
Years Ending June 30, 1893, 1892, 1891, 1890, 1889*
AND 1888:
Year.
Employers.
Passengers.
Other Persons.
Total.
|
|
Killed.
3,727
Injured.
Killed. | Injured.
Killed.
injured.
5*435
Killed.
7.346
Injured.
1893..
3L729
299
3,229
4»3»o
«^393
1892...
a. 554
28,267
376
3i»*7
4,a»7
• 5iX58
7.147
36,65*
1891...
2,660
26,140
293
a,97*
4,076
I 4.769
7.©»9
, 3*«»
1890...
a.45«
22,396
286
a,4»5
5,598
4,206
6.335
1 *9»<«T
1889...
1888...
1,972
20,0*8
3x0
2,146
3.54X
I 4.X35
5.8*3
26,300
t »5»*w
1 8,070
20,148
3X5
2,138
8,897
3.63a
5.282
A Hopeful Candidate. — A late applicant before the
Texas Examining Board was asked : " What is histol-
ogy ? " " Histology is the history of medicine."
" What system of medicine do you practise ? " " The
Vanderbilt and St. Louis systems, and sometimes the
homeopath system."
"What is the homeopath system, as you call it?'*
"Sweatin' the patient."
The Abuse of the Reprint. — It is a courteous and
commendable custom for an author who has written an
article of real value to send reprints thereof to libraries
for reference, to his friends for preservation, and to those
pursuing the same line of investigation, who might not
otherwise become so soon acquainted with his researches.
When, however, the reprint is used merely to advertise
the fact that the writer is peculiarly skilful in a certain
specialty it is less commendable ; and when it is used to
advertise Messrs. Enterprise & Paywell's Panacea, or
some similar substance, it becomes anything but com-
mendable. These thoughts are suggested by the receipt
of a pamphlet, reprinted from a journal published in a
neighboring city, and bearing the title " Functional
," by X. Y. Z., M.D., Professor of in the
, etc., which publication, although ostensibly
coming to us from the author, is quite evidently circu-
lated as an advertisement by, and at the expense of, the
firm whose "trade-mark" product is therein recom-
mended (no doubt honestly) as a sovereign remedy for
the affection in question. Apart from all questions of
propriety, men who permit their names thus to be mis-
used are very shortsighted. Their advice, however un-
justly, comes to be looked upon with suspicion, as not
wholly scientific and disinterested ; and their reputation
becomes upon a par with that of the " advance-agents "
of theatrical notorieties — an honorable reputation when
one does not pretend to be other than an advance-agent.
The advertising-reprint and the reading-notice are twin
growths of the same poisonous root, and should be
utterly condemned by thinking, self respecting physi-
cians.— Medical News.
September 29, 1894]
MEDICAL RECORD.
409
©liuital gejrartroenk
SECONDARY SUTURE OF THE SCIATIC
NERVE.
By LEONARD FREEMAN, M.D.,
PATHOLOGIST CINCINNATI HOSPITAL ; SURGEON TO CHRIST'S HOSPITAL, CINCIN-
NATI, O.
On July 19, 1889, a colored boy, aged nineteen, was
brought to the Cincinnati Hospital suffering from a cut
across the left thigh. The incision, which reached to
the bone, began about two inches below the trochanter
major and extended backward and downward for a dis-
tance of about fire inches. The wound soon healed,
but, according to the history of the case, sensation re-
mained absent in the foot and the limb could not be
used freely.
On August 15, 189 1, he again entered the hospital,
about twenty-fire months after the original injury.
Paralysis and atrophy of the muscles of the leg and foot
were present, with some atrophy of the thigh. Sensa-
tion was absent on the entire outer side of the leg and
on the sole and dorsum of the foot, except in a line
about one and one-half inch broad along its- upper and
inner aspect. The anaesthetic area was dry and covered
with a scaly, whitish epithelium, and was separated in a
beautifully distinct manner from the adjacent soft, dark,
and moist skin. There was oedema of the foot, and the
nails of two or three toes were missing. A large, deep,
trophic ulcer occupied the under surface of the heel.
It was difficult to make the man understand that there
could be any connection between the injury to his thigh
above and the trouble in the foot below ; he suspected
that we wished to "experiment" on him. Finally he
consented to an operation, and about twenty -seven
months after its division the sciatic nerve was reunited
with sutures.
A longitudinal incision six inches in length was made,
with the line of the old cicatrix as a centre. The infe-
rior segment of the nerve, owing partially to its atrophy,
was found with some difficulty. The superior segment
revealed itself at once by the spindle-shaped bulbous en-
largement, the size of an English walnut, which occu-
pied its extremity. This was removed by a wedge-
shaped incision with its apex well within the normal
nerve above. Below the old injury the nerve was much
atrophied, its fibres spreading out and losing themselves
in the cicatrix. These stringy fibres were separated as
thoroughly as possible from the surrounding tissues, and
the end of the nerve resected. The distal and proxi-
mal nerve-sections were then repeatedly and forcibly
stretched with as much force as was considered safe, in
order to bring them closer together.
On flexing the knee and extending the hip it was pos-
sible to approximate the ends of the divided nerve, the
separation between which had at first been at least four
inches. Catgut sutures were employed, some being tied
to portions of the neurilemma and others introduced
through the body of the nerve itself, the end of the distal
segment being dove-tailed into the Y-shaped incision in
the end of the proximal segment.
The operation and subsequent dressings being con-
ducted with aseptic and antiseptic precautions, the
wound healed by first intention, the knee being re-
tained in flexion and the hip in extension by plaster of
Paris.
On the third day following the operation, wishing to
demonstrate the absence of sensation in my patient's
leg, I suddenly stuck a pin into the part. The result
was startling; the man gave a yell, and raised very
pointed objections to a repetition of the experiment.
This was the first intimation which we obtained of re-
turning sensation.
On the eighth day, quoting from the history, " sensa-
tion is greatly increased/1 and " the scaly appearance of
the skin over the entire leg is disappearing, and the cuti-
cle approaching more nearly its normal condition. The
ulcer on the foot is healing steadily."
In two weeks, during which time sensation gradually
returned to the leg, the plaster splint was removed and
the patient instructed to straighten his limb slowly and
carefully, a little each day. On the outer surface of the
foot, and more especially about the little toe, the power
of feeling remained markedly deficient.
In seventeen or eighteen days the history reads,
" sensation is gradually passing to the foot, and now
deep prickings with a pin can be felt in the little toe."
In about three weeks the patient was walking about on
crutches. In a month from the date of the operation
the skin of the leg had recovered its softness and smooth-
ness, and had almost returned to the normal, while the
ulcer was nearly healed. Sensation having become even
abnormally acute in places.
At the end of about five weeks the patient insisted on
leaving the hospital. He could walk well without the
use of crutch or cane, the ulcer was healed, and the skin
of the leg nearly normal. There was some sensation in
the foot, although very deficient on the outer border,
but sensation in the leg was nearly what it should be.
The muscular paralysis, however, had improved little if
any.
In July, 1892, nearly a year after the operation, the
patient was again in the hospital. The ulcer on the
foot was present, although, as near as could be ascer-
tained, it had healed and broken out several times.
Unfortunately nothing was mentioned in the history as
to sensation or motion in the foot.
On May 24, 1894, the patient was again examined.
The leg above the ankle was perfectly normal ; the skin
being soft and moist and the sensation perfect. The
foot, however, was in bad condition — a large and deep
ulcer occupied the posterior surface, while another
smaller ulcer had appeared on the outer edge of the foot
near the little toe. In fact, the condition of the foot
was such that amputation was resorted to in order to rid
the patient of his incumbrance.
After a careful search of all the literature at my dis-
posal, I have been able to find but three other cases of
secondary suture of the sciatic nerve — although there
have probably been others — one by Welhouse and one by
Langenbeck, in 1876, and one by Weir, in 1882. Wy-
eth, although he did not suture the sciatic itself, re-
united to that nerve the severed internal and external
popliteals.
Langenbeck's operation was made two and a half years
after the injury to the nerve ; and, similarly to my own,
was followed by a return of sensation on the third day.
The patient, a man, aged nineteen, had motor paralysis in
the leg and foot, together with anaesthesia of the area sup-
plied by the sciatic. A large, deep ulcer existed near the
base of the fifth metatarsal bone. The operation- wound
healed by second intention. The ulcer filled up rapidly,
and sensation returned steadily to the parts, some portion
even becoming hypersesthetic.
At the end of a year the patient was again seen. Motor
paralysis was still as complete as before the operation.
Considerable of the sensation which had been gained
was found to have again disappeared, although a certain
amount of improvement remained, and the ulcer had not
broken down.
In Wyeth's case the popliteal nerves were sutured to
the sciatic ten weeks after the injury. Sensation began
to return in five days, and was almost fully restored at the
end of twenty two days. The ulcers which had appeared
on the foot healed rapidly. After two months, sensation
still existed in the part, accompanied by considerable pain.
The subsequent history is not given.
In Welhouse's case complete paralysis of the sciatic
followed an injury to the left thigh just below the gluteal
mass. He operated nine months after the injury, the
wound healing in two or three weeks. The first few
signs of returning sensation and motion did not occur for
three months, and it required two years for the leg to
4io
MEDICAL RECORD.
[September 29, 1894
regain its original usefulness. At the end of that time
only a slight oedema and a subnormal temperature
remained of the original disturbance.
Weir sutured the sciatic nine years after its division.
There was no gain in motility, but some in sensation, and
great improvement in the trophic changes, which had
progressed to ulceration.
It strikes one in this connection that too much stress
should not be laid on the healing of ulcers, because con-
finement to bed after an operation must have a tendency
in itself to produce improvement.
Considering the history of my own case and that of
Langenbeck, it seems reasonable to suppose that the ul-
timate disappearance of sensation which had reappeared
following the operation might have been due to pressure
on the nerve from cicatricial contraction. This view is
strengthened by a case reported by Tillaux, in which
suture of the median was followed by restoration of func-
tion which subsequently disappeared. A second opera-
tion revealed a cicatricial mass pressing on the nerve, the
removal of which rapidly restored the lost functions.
Pye describes a similar case. I have myself seen in a
case operated upon by Dr. Dandridge the removal of a
cicatricial band, which pressed upon a nerve, greatly ben-
efit the motor and sensory disturbances which had resulted.
Where there is much danger of such cicatricial con-
traction, might it not be practicable, at least in regard
to the deep-seated sciatic, to conduct the sutured neive
over the dangerous region through a suitable aluminum
or other light, non absorbable, non- compressible cylin-
der? Aseptic bodies, such as drainage-tubes, bullets,
gauze, wire, etc., heal into the tissues without any diffi-
culty or irritation, even splinters of wood sometimes do
this, and there seems to be no reason why an aluminum
cylinder should not do the same. In addition, Gluck
asserts that nerves regenerate more rapidly over long dis-
tances when their severed ends are connected by a bone
drainage-tube. Vaulair mentions a case in which a
regeneration of two inches was thus obtained after a lapse
of four months, the new nerve-substance originating by a
process of proliferation from the end of the proximal
segment alone.
The suturing of nerves, although rather a recent surgi-
cal procedure, has been done a great number of times,
especially in connection with the median and ulnar; and
the results, particularly if the operation is undertaken at
the time of the injury, or soon afterwards, are generally
excellent. But in cases where weeks, months, or even
years have elapsed the chances ot success are not so good.
Successful cases have been recorded, however, after a great
lapse of time. Jessup, for instance, operated on the
median nerve nine years after it had been divided, and
succeeded in obtaining restoration of function.
F. J. Hodges has collected 108 cases of secondary
nerve-suturing, including Bran's 33 cases, with eighty-
eight per cent, of successes. This percentage is probably
too high. There are a number of reasons why it is easy
to be mistaken in the assumption that reunion of a di-
vided nerve has taken place. It must be remembered
that there is such a thing as anastomosis of nerves as well
as of arteries, and that these anastomotic filaments may
take on the sensory functions of the injured nerve. The
areas of innervation of nerves also at times overlap each
other to a greater or lesser extent, so that sensation is
only slightly or temporarily interrupted by division of a
nerve-trunk. It has been asserted by Brown S6quard
that irritation of the proximal end of a divided nerve,
such as would result from an operation, would so stimu-
late the spinal centres that a reflex and heightened sensi-
bility would be communicated to alien filaments going to
the anaesthetic area, leading the operator to think that
the nerve operated upon had been reunited.
It is of course possible that something of this sort may
have taken place in either of the cases described above.
In such a process as that just mentioned motion is not
apt to return to any marked extent, even though the
restoration of sensation be complete. As regards mo-
tion, deception is easy. Patients become, in the course
of time, quite expert in overcoming the loss of power in
a set of muscles, by the use of others. Also the natural
elasticity of the tissues, especially when aided by con-
tractures, may cause movements which seem as if pro-
duced by nerve action. For instance, if the flexors of
the hand are paralyzed, the opposing muscles will extend
the fingers, which may partially flex themselves again
simply from elastic contraction of the muscles and ten-
dons. A reliable sign of nerve regeneration is probably
the return of the faradic excitability of the muscles.
It is a common thing for sensation to return first, fol-
lowed after a time by motion. Motion may not appear
at all, or only after the lapse of weeks, months, or eren
years, and then it may be but partial. The case may
improve for a time, and then grow progressively worse ;
which may be due occasionally, as I have stated, to
cicatricial contraction. Absolute failure cannot be de-
clared, however, until two or three years have elapsed.
It is truly astonishing how soon sensation will some-
times reappear. Tillaux states that following suture of
the median four years after its division all the functions
of the nerve reappeared in three hours ; and we read of
cases of immediate suture in which recovery of taction
took place within fifteen minutes, or even as soon as the
nerve ends were approximated (Segond).
Catgut is probably the best material to employ, al-
though silk and even silver wire have been used. The
suture may pass directly through the substance of the
nerve, in which case, for obvious reasons, a Hagadorn
needle is better than one with sharp edges ; or they may
include only the neurolemma. In the latter method a
small portion of the sheath may advantageously be
caught in a knot on either side, so as to prevent tearing
out of the thread. Or both these methods may be em-
ployed in conjunction, which seems to be ordinarily
preferable, as it permits of accurate adjustment of the
divided surfaces, and at the same time gives considerable
strength to the union.
In case the ends of the divided nerve have contracted
too far to be easily brought together, one of several ex-
pedients may be adopted : Gluck has suggested that the
extremities of the segments be connected by a section of
decalcified bone drainage tube, in order that the nerve
may regenerate along its lumen. By use of this proced-
ure Vaulair succeeded in obtaining a regeneration of two
inches after four months.
Experiments have been carried out on animals which
show that sections of nerves may be grafted from one
animal to another, and probably from animals to man.
Nerves have occasionally been successfully spliced — a
flap turned down from one segment being joined to a
flap from the opposing segment, similarly to the way in
which tendons are spliced.
The distal portion of a divided nerve may also be
grafted into the side of an adjacent nerve, or onto the
proximal end of a second nerve if it be likewise divided.
Good results have been thus obtained. Again, both the
proximal and distal ends may be grafted onto another
nerve at different levels, so as to use the latter as a con-
ducting medium for a short distance. Billroth resected
a portion of the humerus in crder to bring the ends of
the divided nerve closer together.
Explosive Power of Modern Bullets. — Dr. Du Bois
Reymond has been making experiments to record the
effect of the modern German rifle-bullet, and finds it
very destructive. The bullet of the old style rifle, he
says, bored only a comparatively small hole through the
portions of the body through which it passed, whereas
the new bullet has an astonishing explosive effect. If,
for instance, the ball passes through the head of the
corpse, the skull is burst asunder in all directions, and
very little of the head remains. The speed of the bullet
is so great that when it meets an obstacle it explodes like
a Prince Rupert's drop and destroys all the tissues
around it.
September 29, 1894]
MEDICAL RECORD.
411
TUBERCULOSIS OF THE LARYNX AND
PHARYNX.1
By FRED. S. CROSSFIELD, M.D.,
HARTFORD, CT.
I do not propose in the present paper to bring forward
new ideas respecting the theory or treatment of this
form of laryngeal disease. My purpose is rather to state
my experience with it, and to outline the course of
treatment I have adopted, and the results that have
followed.
I have selected two cases entirely unlike in their gen-
eral features, and I shall give the histories of these cases
in detail.
The first case is that of a young woman, aged twenty-
three, American, unmarried, of slight build, employed
in a silk mill. She was brought up amid the most
favorable hygienic surroundings, and her health had
always been good. There was nothing unfavorable in
the family history. Her father, mother, brother, and
two sisters were living, and in good health.
She came to me with the following history : In the
month of May, r886, at the age of eighteen, she was
injured by a runaway horse. She was thrown some dis-
tance, striking upon the side of her head ; the injury
caused concussion of the brain and meningitis followed.
This sickness lasted three months, at the end of which
time, having regained her health, she went back to her
work in the mill. About three months afterward she
took a severe cold, and from that time her health failed.
Aside from a sense of continued fatigue, she complained
only of her throat, where she felt a constant burning
irritation with a desire to cough, but no expectoration.
Deglutition produced but slight discomfort. Her throat
was not examined at this time. Her physician told her
she was overworked and run down, and advised her to
go to Vermont for a change. She deferred the trip,
however, until June of the following year, 1887. Mean-
while the discomfort in the throat increased, dysphagia
being added. She remained in Vermont thirteen
months. Soon after her arrival improvement began,
and it continued during her stay. Her weight in-
creased from 88 pounds to io8# pounds. The throat
difficulty entirely disappeared, and she says she felt per-
fectly well.
Three months after returning to her home she resumed
her position in the mill and worked steadily until June,
1 89 1 — three years. At this time there was a recurrence
of the throat trouble.
I first saw her in October of the same year. Up to
this time there had never been an examination of the
throat, nor had she received any local treatment. Her
condition was as follows: Pale, emaciated, easily fa-
tigued, no appetite, slight rise in temperature in the
latter part of the day. Deglutition was painful and a
troublesome cough interfered with sleep and with the
taking of proper nourishment ; the expectoration at this
time was muco-purulent. The voice was husky and at
times lost. The lungs were repeatedly examined, but
were always found free from disease.
On examination the pharynx was found to be reddened
and covered over the entire surface with a thick, tena-
cious, ropy mucus, streaked with blood. This mucus
being wiped away, several small ulcerations were no-
ticed upon the posterior wall, hardly deeper than the
mucous membrane. The larynx presented the same
appearance but without ulceration. The epiglottis and
vocal cords were reddened and slightly oedematous.
The patient was placed upon a nutritious diet, and
cod-liver oil, iron, and wine were administered. The
local treatment consisted of thoroughly cleansing the
surface, and afterward applying lactic acid, twenty- five
per cent, every second day.
In three weeks the ulcerations had healed, the parts
had assumed their natural color, and what little oedema
1 Read Jn the Section of Laryngology, New York Academy of
Medicine, May 24, 1893.
there was had disappeared. The voice regained its nor-
mal quality, and the appetite and strength returned*
The secretions frcm the pharynx and larynx were exam-
ined microscopically, but no tubercle bacilli were found.
I therefore considered the condition one of simple
catarrhal ulceration. The existence of s) philitic taint
was considered highly improbable, as the local condi-
tions were wholly unlike those found in syphilitic lesions
of the larynx. Furthermore, the social position of the
family would not warrant any such supposition.
I did not see this patient again until four months later,
in February, 1892. The old trouble had apparently
reappeared with increased intensity. She was pale and
had grown rapidly weak and emaciated. She had night-
sweats, and coughed constantly, the expectoration being
tenacious mucus. The voice was now entirely lost.
The pain in swallowing was severe, and her sleep much
disturbed. In fact, the general condition was discourag-
ing in the extreme. The pharynx was one mass of
ulceration, from a point a little below the uvula down
and into the larynx. The ulceration was shallow — but
little below the surface— and covered with a grajfeh,
tenacious mucus. The epiglottis was enlarged by infil-
tration to twice its normal size, and ulcerated nearly its
whole length. The arytenoids were also infiltrated and
ulcerated. An imperfect view only could be had of the
vocal cords. Though oedematous, I do not think they
were ulcerated. The entire surface of pharynx and
larynx had a peculiarly blanched and sodden appearance.
The lungs were examined carefully at different times,
always with the same negative results ; but microscopical
examination of the secretion from the pharynx now
showed unmistakable signs of tuberculosis. Cod liver
oil and iron were administered as before, and inhalations
of oxygen were given frequently. The surfaces were
thoroughly cleansed, and the ulceratiois were curetted
after applying a ten per cent, solution of cocaine.
Lactic acid, fifty per cent., at first, and afterward undi-
luted, was nibbed into the surface. Several applications
were required. Improvement began right away. The
ulcers healed rapidly, so that at the end of six weeks
healthy cicatrices marked their former location. The
oedema gradually subsided and the membrane throughout
resumed its normal condition and function. At the
same time her general health improved.
It is now a year since cicatrization was completed, and
she continues well and says she is stronger than she has
been for several years. I have recently examined the
throat, and could find no evidence of there having been
such wide-spread destruction. I hope to be able to re-
port favorably upon this case at some future time.
It was to me an extremely interesting case, both be-
cause the whole progress was unusual, and because it was
a case of primary tuberculosis of the larynx and pharynx
of extreme severity, and demonstrated what can be done,
even in what would seem to be a hopeless case, toward
alleviating the distress, if not absolutely producing a
cure.
The second case that I shall describe was that of a
printer, twenty- seven years of age, American, married.
His father, brother, and one sister died of consumption,
and he had had general tuberculosis himself for a year and
a half previous to his coming under my care, in November,
1889, and at that time he had also been suffering for
three months with throat complications.
I saw the patient at his home, he being too weak to
come to my office. I found him pale, emaciated, very
weak, and able to sit up only a few moments at a time.
The cough was constant and painful ; respirations, 40 ;
pulse, 120; temperature, io2^°F.; voice entirely lost ;
dysphagia marked. The pain on swallowing was so se-
vere that he could take no nourishment, nor even swallow
the secretions from the mouth. The pharynx and larynx
on inspection presented the characteristic pale, sodden
appearance, and large superficial ulcers were found upon
the posterior wall of the pharynx and upon the soft palate.
Infiltration was everywhere present. The larynx was
412
MEDICAL RECORD.
[September 29, 1894
cedematous and ulcerated. The epiglottis was nearly
covered with ulcerations, and was so much enlarged by
infiltration that no satisfactory view of the larynx and
vocal cords could be had. A rhinoscopic examination
showed a large ulcer upon the posterior wall of the phar-
ynx on a level with the Eustachian orifices, and ulcers
were also found upon the septum, and on the middle and
inferior turbinated bodies on both sides.
Several small nodules were also seen upon both sides
of the septum, but none upon the outer walls of the
nose.
The prostration of the patient was so great that I did
not dare to resort at once to curettement, indeed I had
grave doubts that such treatment would be warranted at
all. A five per cent, solution of cocaine was sprayed
into the nasal cavities, pharynx, and larynx every three
hours for four days, and whiskey and oxygen were ad-
ministered freely. On the fifth day there was an evident
improvement in his general condition, and he had taken
considerable nourishment I then ventured, after applying
a ten per cent, solution of cocaine, to curette the pharynx,
afterward rubbing well into the surface undiluted lactic
acid. Liter the ulcerations in the nasal cavities and the
larynx were similarly treated. Though this procedure is
usually very painful, it was not especially so in this case.
Improvement began immediately, and the patient said
he felt much relieved. Cicatrization was everywhere ap-
parent, and nourishment was taken in sufficient amount,
without difficulty, and with relish. He slept well and
awoke refreshed. He increased in strength and was
able to be up and about the house most of the day.
Within four weeks the ulcerations had all healed, and
the epiglottis had nearly resumed its usual size. The
vocal chords were slightly oedematous, however, and the
voice remained husky.
The patient gradually failed, and died from general
tuberculosis five months after local treatment was begun.
There was no return of the discomfort in the throat, and
an examination of the throat and nose a week before
death showed the membrane very free from ulceration,
bat in a pale, slightly ceiematous condition throughout.
This caie presents one especially interesting feature —
the appearance of ulcers and nodules within the nasal
cavities. I have never seen this condition before.
B jsworth, in his work on " Diseases of the Nose and
Throat," vol. i., states that twenty-seven cases with this
complication are reported in medical literature, and
these, from lack of positive evidence, he reduces to
twenty.
There can be no doubt regarding my second case, be*
c mse abundant evidence of tuberculosis was found micro-
scopically.
This case also demonstrates the efficacy of curettement
and lactic acid, even in hopeless cases of general tubercu-
losis with laryngeal complication, in relieving the distress
referable to the throat, and giving comparative comfort
to th; sufferer during the few remaining weeks of his life.
It has been said that it is only by looking backward
that we can wisely look forward. It is certainly interest-
ing to note the progress which has been made during the
pait few years in the theory and treatment of this disease.
Some of the older writers make no mention of the tuber-
cular form of laryngitis as a primary disease. Quoting
from an article written upon this subject in 1883, it says,
"Primary laryngeal tuberculosis may possibly occur,
but the few claimed cases of its occurrence are at least
open to doubt as to correctness in diagnosis." Another
writer says : " Neither the catarrh nor the ulceration of
phthisical subjects present any characteristic signs by
which they could be recognized as such." Heinze, writ-
ing in 1879, states that of 1,226 deaths from phthisis
51.3 per cent, had laryngeal ulcerations. He also says
that ulcerations were never found with tuberculosis of
other organs when the lungs were intact.
The microscope and the demonstration' of a specific
bacillus make the diagnosis much less obscure. The
advancement along these lines, and the knowledge de-
rived from experimental investigation, now place these
cases in the list of remediable diseases.
February 1, 1894. — The patient in the first case re-
ported is still in good health, with no indications of a
return of the laryngeal trouble.
THE RELATIONSHIP BETWEEN BOVINE AND
HUMAN TUBERCULOSIS, WITH THE RE-
PORT OF A CASE.
By W. H. SHERMAN, M.D.,
ATTENDING SUXGZOM TO ST. JOHN** KIVBSSIDB HOSPITAL, YONKOtt, K. T.
Veterinary Report,
By J. S. LAMKIN, D.V.S.,
YJNKXKS, N. Y.
GBADUATS OF AM SKI CAN VSTSRINABY COLLEGX.
The following case deserves, in my opinion, to go on
record as a contribution to the important subject of the
etiological relationship between human and bovine tuber-
culosis. The brief history herewith given is sufficient to
thoroughly establish the diagnosis, and the veterinary
report, in connection with that of the pathologist, would
seem to indicate that the disease of the cattle bore a
causative relationship to that of the young patient.
B. H , male, aged four. Well nourished and of aver-
age size. Maternal grandfather died of phthisis some years
ago. Mother died as the result of an accident. Family
history otherwise entirely negative. His nurse had,
about a year previously, attended her daughter who died
of consumption. She did not contract the disease, how-
ever, nor did any of the servants in the house have tu-
berculosis in any form. The boy's previous history is
good. He has slight adenoid vegetations in the vault
of the pharynx, which render him prone to attacks of
bronchitis. Two years ago he had a mild attack of
pneumonia, and one year ago a second attack; from
both of these he recovered entirely, and for one year has
had no cough nor illness of any kind. His development
has been good, and his growth and dentition normal.
His uncooked food has all been raised on the place, and
it is believed that he has never eaten raw fruit from
market until thoroughly peeled.
I was called to see him on February 21, 1894, as it
was observed that he walked with a spastic gait, on his
toes, and that he would frequently tumble. From this
time on he gradually but progressively developed the
classical symptoms of meningitis, namely, spastic con-
traction, thickness in speech, difficulty in deglutition, loss
of power to protrude the tongue, lack of co-ordination,
opisthotonos, etc. On March 5th Dr. M. Allen Starr,
Professor of Neurology at the College of Physicians and
Surgeons, New York City, saw him in consultation, and
confirmed the diagnosis of meningitis, probably tuber-
cular.
Treatment — Iodides and bromides. In spite of
treatment the disease progressed in the usual way until
death occurred on March 27 th. No autopsy was allowed.
During the latter part of the boy's illness, having some
suspicion in regard to his milk supply, I requested Dr.
J. S. Lamkin, Veterinary Surgeon, to inspect and exam-
ine the cows on the place, with the result as shown in his
report hereto appended.
Veterinary Report.
On March 22, 1894, 1 was requested by Dr. W. H.
Sherman to visit and examine three cows, which were
stabled on the place of Mr. B , Yonkers, N. Y., with
a view of determining whether they were the subjects of
tuberculosis. Two of these animals were the property
of Mr. B , and the third was owned by his son in-
law. The mixed milk was consumed by all the members
of the household, including B. H , a boy four years
of age, who was at this time suffering from tubercular
meningitis. A short time previous to my first visit the
cows had been examined by a local veterinarian who
gave them a "clean bill of health.'1 The attending
September 29, 1894]
MEDICAL RECORD.
4i3
physician, Dr. Sherman, being dissatisfied with this ex-
amination, as by physical examination alone it is some-
times impossible to detect tuberculosis in cattle, asked
me to see the animals and express my opinion as to the
presence or absence of tuberculosis.
Inspection showed that they were thoroughly well-
housed, well cared for, and well-nourished.
Physical examination failed to disclose anything which
could lead to any suspicion that they were other than
perfectly healthy, except an enlargement and thickening
of one section of the udder of one cow (No. 3). None.
of them were (or had been) suffering from cough, dysp-
noea, or respiratory disturbances of any kind. After a
consultation with the family and the attending physician
it was decided to employ the tuberculin test, the writer
being thoroughly impressed with its value as a diagnostic
agent. Accordingly, on March 23d, the temperatures
of the three animals were taken at 8.30 and 10.30 p.m.
At 1 1 p m., in each case, 2*4 c.c. of a ten per cent, solu-
tion of tuberculin in one per cent, solution of carbolic
acid was injecled hypodermatically after the hair over the
shoulder had been removed and the hide rendered
aseptic.
The following morning (March 24th) at 6 a.m. the
temperatures were again taken, and every three hours
thereafter until 9 p.m.
The following table shows the results obtained :
« o.-= a «
§5 ! §* £2 ' §3
Dei
s
DcK.
Fah.
Deg. Deg. , Deg.
Fab. , Fah. Fah.
Com No. 1. — Five - 101.0 Tuberculin 101.2 ' 101.2 101.4 ' 101.4
Tears of age. 1 ■ injection I
Pale red Alder- | 2} c.c. of
nev. Not in 'ten per ,
caff. I j cent solu- '
I ' lion.
Cow No. 2.— Six 101.4 Tuberculin 101.4 104.2
years of age. > injection
Brown Jersey , 2} c.c. of
or Alderney. , ten per
Aborted 1 a s t ( ' cent, solu-
Angusk Due> tion.
to calve in May . (
Cow No. 3.— Ten ; 100.6 , Tuberculin
years of age. ! injection
Cream - colored , 24 c.c. of
y. Aborted ten per
nber. 1 cent, solu-
Not in calf. tion.
<v a.
4
■8,
De*.
Fah.
101.9
Fa£
xo6.o X04.2 104.2 104.4
100.3 1 102.2
I
105.8
104- 2 , 103.4
March 95, 9 a.m., temperatures all normal.
These results seemed to prove that two of the three
cows (Nos. 2 and 3) were the victims of tuberculosis, al-
though this seemed difficult to believe in the case of Cow
No. a, who showed every other evidence of the most
robust health. In view of the results of this test the
writer communicated with the Secretary of the New York
State Board of Health requesting that the Board send an
inspector to condemn and destroy the two cows which
reacted to the test, and recompense their owner.
As there was considerable delay in obtaining the de-
sired permission to destroy and examine the animals
post mortem, it was decided to retest all three of them.
This second test was conducted in the same manner as
before, except that the injection was given at 9 p.m.
April 1st.
The following table shows the results obtained :
, April 1,
April 1,
April it
April 7,
April a,
.April a,
' 12 M.
0 P.M.
to. 30 P.M.
9 A.M.
12 M.
1 3 P.M.
1
Deg.F
Deg.F.
Deg.F.
Deg.F.
i Deg.F.
Cow No. 1.— Pate 102. a
xoi.2
Tuberculin injec-
101.6
101.8
! 101.5
red Alderney.
tion a} c.c of ten
,
percent solution.
<
CowNo.3. — Brown
xox.6
101.4
Tuberculin injec-
103.2
, »°5-8
■ X04.0
Jersey or Al-
tion 2} c.c. of ten
derney.
per cent, solution.
1
CowNo.x, — Cream
colored jersey.
103.8
xox.6
Tuberculin injec-
tion af c.c. of ten
per cent, solution.
xoi.2
t
102.4
i
ioa.2
It will be noticed from this table that Cow No. 3 did
not present the characteristic reaction as in the original
test
On April 16th the two cows which responded to the
test were slaughtered and a post-mortem examination was
conducted by Dr. £. F. Brush, of Mount Vernon, Professor
of Cattle Pathology in the American Veterinary College,
and the writer, in the presence of several physicians and
veterinarians, with the following results :
Cow No. 3 (White Cow) — The thickened mass from
the udder was first removed. It apparently consisted of
fibrous tissue, a few small cysts, and a little caseous mat-
ter, but no gross appearance of tuberculosis wss observed.
The mediastinal glands were markedly involved, rang-
ing from the size of a marble to that of a lemon, with
cheesy degeneration well advanced. There were also
tubercular masses of various sizes in the lung substance
beneath the pleura.
Cow No. 2 (Black Cow) — Mediastinal glands en
larged, but not to so great an extent as in Cow No. 3, the
largest mass being about the size of a large marble —
caseous degeneration well under way.
Small nodular masses in lung under pleura with cheesy
centres. On section the lungs were found to be studded
with tubercles in various stages of development. Liver
and kidneys not involved in either cow. Specimens from
the mediastinal glands and lungs of both animals, and a
portion of the mass from the udder of No. 3, were sub-
mitted to Dr. George A. Tuttle, of New York, Patholo-
gist to the Colored Home and Hospital, for microscopical
examination.
His report is here appended.
"New York, May 1, 1894.
" Dear Doctor : — The examinations of the pieces of
tissue from the two cows resulted as follows :
" White Cow, No. 3. — Lung : A cluster of tubercles
about the size of large peas in and beneath the pleura.
The centres of these tubercles consisted of soft cheesy
material. Microscopic examination showed mirute tu-
bercles in various stages of development. Tubercles
consisting of epithelioid cells and giant cells. Older
tubercles with considerable fibrous tissue and with tubercle
tissue and giant cells around the edges ; and others with
cheesy centres and tubercle tissue and giant cells around
the edges. Tubercle bacilli found in moderate num-
bers.
" Mediastinal gland, about the size of an egg, consisted
of a thickened capsule containing a mass of soft, yellow,
cheesy material. Sections of the capsule showed tuber-
cular inflammation, tubercles with cheesy centres, and
epithelioid cells and giant cells. Not examined for tu-
bercle bacilli.
" Udder contained several cheesy nodules. Sections
through these showed considerable diffuse inflammation
and infiltration with leucocytes, also a number of minute
tubercles of epithelioid cells, but no giant cells. Not ex-
amined for tubercle bacilli.
"Black Cow, No. 2. — Lung tissue: Result of exami-
nation identical with that of lung of White Cow, No. 3.
" Bronchial gland found in the piece of lung showed
characteristic changes of tubercular inflammation, cheesy
degeneration, tubercle tissue, and giant cells.
" Respectfully,
(Signed) "George A. Tuttle, M.D.
"936 West Forty-fourth Stkebt.''
April 3, temperatures not taken.
April 4, temperatures normal, except Cow No. 2 — ioa.6° F.
Large Families in tforth Carolina. — Dr. J. M. Hays,
of Greensboro1, N. C, writes : " A proposoi arecent item
in your columns in regard to the fecundity of women, I
wish to state that in Granville County, N. C, there
lives a mulatto woman, the wife of Daniel Boone, who is
the mother of twenty seven living children, several of
whom have been my patients. This family belongs to a
rather large class in that section popularly known as the
' issue free,' they and their ancestors for several genera-
tions having never been slaves.'1
4H
MEDICAL RECORD.
[September 29, 1894
METHOD OF TESTING FOR ALBUMINURIA.
By PHILIP JAISOHN, M.D.,
WASHINGTON, D. C.
There are innumerable methods for testing for albu-
minuria, but one must select the best process and use it
constantly in order to be thoroughly familiar with the
msthod, and derive practical benefit therefrom.
Among the commDn methods, the one most frequently
used by the practitioners is : Boil the urine, then add a
few drops of nitric acid to ascertain whether or not the
urine is cloudy. But this method is too inaccurate to be
of any service ; and there 13 another method known as
Heller's te3t, which consists in adding nitric acid care-
fully to the urine contained in a test-tube, and observ- .
ing whether or not a band of cloudiness exists at the
junction between the urine and the acid. This method
is preferable to the former, yet there is a chance of mak-
ing a mistake; because if there should be phosphates
present in the urine, there will be a cloudy band, which,
however, differs from the cloudy* band caused by al
bumin ; but it is sometimes very deceptive to the inex-
perienced eye.
I know another test, which is as follows : First acidu-
late the urine with acetic acid. (Filter it if turbid.)
Fill the test-tube one third to one-half with the reagent
composed of the following ingredients : Bichloride of
mercury, 8 grains ; tartaric acid, 4 grammes ; distilled
water, 200 c.c. ; glycerine, 20 cc. ; and then add the
urine, drop by drop. By this method one can detect
albumin in the urine, when present in the proportion of
1 to 50,000. This is the most delicate test known ;
even more delicate than the trichloracetic- acid method,
which is considered one of the most delicate.
But I have come to the conclusion that these two
methods are of no practical use for clinical purposes, be-
cause by them one can detect albumin in the majority of
cases, whether healthy or unhealthy. This is especially
true of the bichloride of mercury test. I have exam-
ined twenty specimens of healthy urine and have found
albumin in eighteen cases, by the mercurial reagent, which
shows the worthlessness of the test. It is a well known
fact that even healthy people pass a very small quantity
of albumin during certain hours of the day ; especially
during digestion, and there is no pathological signifi-
cance in this.
However, if one applies such a delicate test as the one
I mentioned, the albumin will show plainly, and will
cause unnecessary apprehension to the physician as well
as to the patient.
There is one method I am in the habit of using, and
which I consider the most reliable and practicable. It
is more accurate than the method of boiling the urine
and adding a few drops of nitric acid, and not so deli-
cate as the trichloracetic acid, or the mercurial mixt-
ure.
Put a few drops of liquor potassii in a test-tube full of
urine and filter it. Fill the test-tube one-half with the
filtrate; then add fifteen to eighteen drops of fuming
nitric acid. By this time the clear urine will be some-
what cloudy if it contains albumin. Boil it over an
alcohol lamp or Bunsen flame, and let it stand for one
half hour. There will be a sediment of whitish flakes or
brownish granules. Boil it again and observe whether
or not these will dissolve. If it is albumin they will not
dissolve by the second boiling.
This is a fact of especial importance to medical exam-
iners for insurance companies. It is their duty to
guard against the admission of undesirable persons to the
companies with which they are connected. But, at the
same time, they must not apply too delicate a test in
examining the applicant's urine ; as, by applying such
test, the albumin is apt to be found in most cases, re-
sulting in the rejection of the applicant upon the ground
that he has albuminuria. Of course such rejections by
the medical examiner will be a loss to the company.
On the other hand, the medical examiner makes a
grave mistake who applies such a crude and inaccurate
■method as boiling the urine, and adding* a few drops of
nitric acid, and then declares that there is no albumin ;
and the applicant is accepted, even though he may have
albuminuria. The last-named test will not always bring
out the albumin, unless there be a considerable amount
in the urine.
Admitting applicants to the companies on the strength
of such a test, in my opinion, is running a great risk.
The method I prefer, and already described, is really the
nodification of so-called "heat and nitric acid test."
If albumin shows by this test, it is a case for clinicians
to watch the patient more carefully, and for the examin-
ers of insurance companies to be justified in rejecting the
applicant.
I may add here, that examination of urine should be
required by the army, navy, and marine hospital service,
in connection with physical examination of candidates
for soldiers, officers, and sailors.
There is no other secretion or excretion in the human
body which gives more information about the internal
affairs of the constitution than urine, and it is therefore
a subject deserving a careful study and investigation.
It is hoped that in die near future all the practitioners in
the land will realize the importance of this, and examine
the urine of their patients whenever it is possible. It is
true that most general practitioners have neither time
nor facilities to do the chemical and microscopical exami-
nation of the discharges of their patients ; but it is ad-
visable for them to have this kind of work done by some
one who has experience, skill, and time to do it. It is
a justice to the patient as well as to the attending physi-
cian.
THE DOCTOR'S WIFE.
To ths Editor of th* Mumcal Record.
Sir: Your editorial on "Some Experiences of the
Doctor's Wife," in last week's issue, strikes the key-note
of your innate gallantry, which doubtless will cause
many physicians' help (?) mates to induce, I almost said
compel, their derelict husbands to subscribe to the
Medical Record.
At the risk of appearing less chivalrous than we would
like the entire profession to be, I crave a little space
anent your comments on the Brooklyn physician's wife
who enriched the columns of the Tribune with her ex-
periences.
Ab initio, the tone of discontent which characterizes
the quotations you publish is all too prevalent among
physicians' wives. They should rather be proud to have
been selected by men who sacrifice themselves for the
good of humanity.
Madam says, in connection with her life as a physi-
cian's spouse that " this is a big world and a hard
world. ' ' Big in a sense it is, to those who have travelled
much, eg., from the Bridge to the " L " terminus and
back. But those who voyage from continent to conti-
nent, find distance annihilated and the world made very
small by the people they meet, especially those who find
nothing but cause for complaint in their destinies. The
latter, like your fair writer, find it also a hard world.
They forcibly suggest the woman who, on reaching
heaven was welcomed by her optimistic husband with :
" Well, at least you will say that this is a pleasant
place ! "
" To people of a certain taste, it may be," she sniffed,
"but your professional engagements doubtless left you
no time to select a dry cloud for me. I am consequently
full of rheumatism, and this wretched halo neither sits
straight on me nor has it any pretence to style. Had it
been a fetid ulcer, or a broken bone, or some filthy
disease on some immoral low wretch, you would have
given it attention, but as to me "
September 29, 1894]
MEDICAL RECORD.
415
An anthem by the celestial choir drowned the re-
mainder of her speech.
Madam objects to being "Mrs. Doctor." I once
tried to meet this objection by saying that German
women are very proud of the marital title " Frau Doc-
tor;" the fair objector sneered that this was "too
tonic" (pray remember it was her pun). But would
your, or rather the Tribune's Brooklyn medical spouse
rather be Mrs. Butcher, Mis. Baker, or Mrs. Candlestick-
maker? If so, why did she elect to become "Mrs.
Doctor?" If she made so serious a mistake in her
choice, why does she flaunt it before the world in a
widely circulated medium? Why does she advertise
that intellectual smallness which prevents her appreciat-
ing the exalted position she occupies ?
She says that the certificate she obtained at the marital
altar " has nothing to do with degrees." She is mani-
festly, then, one of that class which cannot be elevated
by association with her husband. What if she has been
asked to " set a broken arm or pull a tooth when the
doctor (with a lower-case initial) was out ? " Would there
be anything degrading in having learned to apply a
temporary dressing, or in cleansing the cavity and for
the time being stuffing the tooth with cotton soaked in
laudanum ? Aside of thus holding the case for her hus-
band— of course I refer to the broken arm — would it not
be better if she gave attention to relieving human suf
fering, rather than to be moaning her lot and incident-
ally trying to besmirch the profession ?
Madam objects to life in a house behind a brass sign.
She correctly explains the cause with " when you stand
in the window you are not a private woman in a private
house." A woman who properly attends to her house
and family has no time to stand in the window.
Madam complains that the physician's wife is not sure
of her evening amusements, and finishes with a pathetic
protest that she must "look after the family caiv-
mg.
What hardships indeed ! While her husband loses the
very entertainments from which, by the way, his wife
does not abstain, he is earning, by the hardest of hard
work, the means for her to enjoy fife and leisurely com-
plain about it. And as to the family carving — a man
who would allow his wife to carve while he goes off to
save a life, is capable of any iniquity, even so vile a one
as to neglect to button her shoes.
When one reaches the age that entitles reminiscences,
one cannot but recall antitheses. I once had occasion
to call on a successful practitioner, whose home life, be-
cause of its happiness, was the object of much comment.
The doctor was not at home. His wife urged me to
wait for the doctor, as she had sent for him a moment
before I explained that I was not a patient, but a
colleague. "I am so glad, Doctor," she responded,
" won't you come in quickly, please. I have a man on
the operating- table with, I think, his posterior tibial
artery cut. I controlled the hemorrhage with an im-
provised tourniquet, but of course would not attempt to
ligate."
I then observed that Mrs. Doctor (with a capital ini-
tial) had stained her elegant dress with blood. Her hat
and gloves were on the floor of the operating-room ; the
patient was lying with his injured leg raised on an in-
verted chair, the trousers and drawers (I blush for the
Brooklyn Madam at their mention) slit, and as neatly
applied a tourniquet as I ever saw controlling the bleed-
ing.
Just then her husband came in. She assisted him at
the ligation ; pride in her husband and in herself gleamed
in her eyes and when all was done, she patted him af-
fectionately on the cheek and said, "Good boy, dar-
ling."
" But, dearest," he said, "you have lost the matinee
in consequence, and your new dress is ruined."
" What is a mating* or a dress to seeing a good oper-
ation performed by a good surgeon, and that surgeon my
husband?"
That woman, whose name may not have been Harris,
was proud to possess her husband; she sought happiness
in b?ing " the wife of Dr. Harris," and did not complain
of the world not calling him "the husband of Mrs.
Harris."
Is it a wonder that such a man succeeds ? He leaves
home with encouragement from her ; he hurries home
when tired, exhausted, and in doubt, to get more en-
couragement and stimulus for study and work from her ;
she is all and everything to him ; both are happy, and
she consequently does not fly into print to proclaim what
.a miserably wretched creature she is — probably because
she fails to wreck her husband's career.
Are these lines too severe for Mrs. Brooklyn Doctor's
Wife? Perhaps. But as she is one of very many who
talk exactly as she writes, the reproof may not be mal-
apropos.
Yet the morbidity she expresses is not her mult. In
reality she should not be blamed. The real culprit is
her husband — he should not have been such an idiot as
to marry her, nor, having married her, so great an ass as
to permit such sentiments to grow in her.
Ferd. C. Valentine, M.D.
'Tub Winchestbh," 1212-1348 Broadway, Nhw Yokic
"AS OTHERS SEE US."
To thb Editor of the Mbdical Rkoosd.
Sir: Having read the leading article entitled "As
Others See Us," in the Medical Record for September
15, 1894, which article treats on Dr. Polaczek's book,
" The Medical Science in the United States," I think it
may interest your readers to learn what another German,
Professor Dr. M. Schdller, of the University of Berlin,
who has visited America, has said on Dr. Polaczek's pub-
lication. He writes in Der atztliche Praktikery No.
32, as follows :
" The book disappoints us in so far as it contains just
the least of that which the title promises to give. The
author confounds science with practical medical arrange-
ments for instruction, with the modes of providing for the
sick in public hospitals, with institutions of public hygiene,
etc. A picture of medical science in the United States,
on account of the part which the Americans have taken,
and which is by no means a small one, in the progress of
medical science, for instance in the field of anatomy,
surgery, pharmacology, and especially operative gyne-
cology, the reader of the book will look for in vain.
What the author gives in his book are treatises on Amer-
ican hospitals, on therapeutic currents, on the caring for
the insane, on the American physician, on American
universities, on the sanitary and hygienic conditions of
the large cities. We find everywhere the intention to
give the German reader a true picture, to do justice.
According to our judgment the author has but succeeded
in the chapters on the Insane, on Quarantine, on Sani-
tary and Hygienic Conditions of the Large Cities, on the
American Physician. The chapters on the American
Hospitals and the American Universities are, it is true,
quite correct in what they give, but they do not by far ex-
haust the subject treated. In regard to the hospitals, we
notice in America, as it is quite natural in such a large
continent with different distant States and cities, and
therefore different climates, considerable variety in re-
gard to architectural plans and inner organization. Be-
sides, some of the arrangements which differ from those
in Germany are not specific American, but originally
English. Especially incomplete, however, appears the
superfi:ially written chapter on American Universities.
We cannot overlook some of those easily recognizable
drawbacks of the specific American University education,
but we should not overlook, either, the fact that just at
present mighty exertions are made in almost every State
to remedy the existing evils, and to make the medical
instruction more profound."
A. Rose, M.D.
New York.
416
MEDICAL RECORD.
[September 29, 1894
IJfceftical items.
Contagious Diseases — Weekly Statement. — Report of
cases and deaths from contagious diseases reported to the
Sanitary Bureau, Health Department, for the week end-
ing September 22, 1894.
Tuberculosis
Typhoid fever
Scarlet fever
Cerebro-spinal meningitis .
Measles
Diphtheria
SmaJl-pox
Case*.
Deaths.
68
84
*7
7
38
5
0
0
24
5
107
«5
5
3
The Anti-tetanic Serum and How to Use it. — In
the treatment of tetanus an anti- tetanic serum, obtained
from the horse and prepared in the dry state and sent out
in tubes each containing four to five grammes, is a little
more than the minimum dose considered curative in the
case of a man. The substance is to be dissolved in dis-
tilled water, and injected subcutaneously. The dose
must vary according to the gravity of the symptoms, and
requires to be repeated in smaller quantity for several
days. In regard to the cases hitherto reported, doubt
has been expressed by some as to the severity of the at-
tack, it being well recognized that the less acute forms of
tetanus by no means partake of the gravity which attaches
to those of more acute onset. These doubts are, how-
ever, in some cases ill-founded, and now that the ma-
terial for the treatment can be stored and kept at hand
we ought quickly to accumulate sufficient evidence to de-
cide on its utility in surgical practice. — British Medical
Journal.
Anarohists, Anti-vacoinators, and Anti-Pastenrists.
— Anarchists, anti-vaccinators, and and Pasteurists ap-
pear to be foregathering just now in a friendly and in-
structive fashion. The anarchists have been assembling
at a friendly meeting at the house of the president of the
Anti- vivisection League in Paris, and a little outdoor
gathering, including a quaint collection of " Anti V
generally, to protest against the British Institute of Pre-
ventive Medicine has had its little innings and is reported
in all the papers. It is just as well that these wild people
should have their silly say unanswered and without com-
ment. But it is rather painfully comical to find a min-
ister and a man of Mr. G. W. Russell's culture writing
to them to announce that he detests Pasteurism — and of
course also Listerism. Why not add that he has a con-
tempt for the equator and grave doubts about gravita-
tion ? It reads oddly at this moment when the whole
world has been meeting to do honor at every quarter of
the globe to its two greatest benefactors — Pasteur and
Lister, and on the day after Lord Salisbury's eulogy
urbi et orbi of the Listerian conquests as among the few
great positive victories of modern science on which he
could definitely congratulate mankind. But oddity is
the badge of the anti- party, who delight in posing as
"against all science'1 and "agin all government," and
appear to think that there is something progressive,
emancipated, and metaphysical in this attitude. To be
logical, Mr. Russell should add the inevitable converse
of his proposition, and declare that he loves small- pox,
is much attached to hydrophobia, and adores blood-poi-
soning and high hospital mortality. This would put him
quite in sympathy with his friends, the orators in the cart
to whom he addressed this interesting missive. — British
Medical Journal.
A Monument to Semmelweiss. — During the session of
the Congress of Hygiene and Demography at Budapest,
a monument was unveiled to Semmelweiss, the precursor
of Lister. As long ago as 1847 he urged the necessity
of washing of their hands in an antiseptic solution by
surgeons prior to undertaking an operation.
The Sterilization of Bread.— At the meeting of the
British Medical Association, on August 3d, the investi-
gations of Mr. Walsh, of London, and Dr. Waldo, of
Southwark, as to whether baking sterilizes a loaf of bread,
were the subject of an interesting discussion. Mr. Walsh
read a paper based on a large series of experiments. Its
main conclusion was that baking does not necessarily
destroy the vitality of micro organisms contained in
dough. With regard to temperature, they had found
that the average maximum temperature in the centre of a
large loaf varies from 163. 40 to 1860 F , and in a small
loaf from 186. 8° to 2030 F. As the heat increases
steadily in the centre of a loaf, any organisms present
are exposed for a short time only to the maximum tem-
perature reached. The average microorganism will
withstand a prolonged exposure to a much higher tem-
perature without being destroyed. Spores are much
more resistant again, so that on theoretical grounds
alone, having ascertained the maximum temperatures in
the centre of the loaf during baking to be those men-
tioned, they might venture to predict that organisms (or
their spores) would not be destroyed by the process of
baking. By the method of plate cultivations they suc-
ceeded in obtaining thirteen different species of micro-
organisms from the centre of recently baked (a few hours
after baking) loaves. The latter were obtained from
bakeries in different parts of London, rich and poor.
Numerous experiments were carried out for them by Mr.
Walter Severn on sixty- two loaves. It was clearly
shown, if the results were trustworthy, that certain non-
pathogenic organisms are able to survive the process of
baking.
Some Carious Life Insurance Details.— According to
the Medical Press it appears that in Germany a man
who loses both his hands in an accident can claim the
whole of bis life insurance money, if he be insured, on
the grounds that he has lost the means of maintaining
himself. The loss of the right hand reduces the claim
to from seventy to eighty per cent, of the total ; that oi
the left to from sixty to seventy per cent. ; the thumb is
valued at from twenty to thirty per cent. ; the right
index finger at from fourteen to eighteen per cent ; and
so the reduction continues until the little finger is
reached, when the percentage is put down at from nine
to twelve. No figures are given as to the value of the
various segments of the lower extremities.
Cramps in the Legs in Diabetes.— Unschuld calls
attention to an early symptom of diabetes, which is
seldom mentioned by writers on the subject but which
is yet frequently found, and may assist in an early
diagnosis of the affection. This symptom consists in
cramps in the calves of the legs, and is found in about
twenty- six per cent, of all cases. The pains occur with
especial frequence in the morning upon waking, and
occasionally also during the night, when they are usually
accompanied by a desire to urinate. They are rarely
troublesome in the daytime, unless after a nap or a bath.
Cramps of this nature, occurring in a person in feeble
health, should always, Unschuld holds, suggest the ne-
cessity of an examination for sugar.
The Confidential Relations of the Physician. — A
correspondent, " Medicus," writes : " Your view of the
decision of Judge Cole in your editorial of September
1st, is doubtless that of the majority of the medical and
legal professions, but the learned jurist's action must be
based upon the ruling of the Attorney- General of the
United States and Supreme Court, since the Naval
Regulations require medical journals (containing as they
must do, a record oi personal and family secrets ' pa-
tient's confidences' and 'privileged communications9
necessary for diagnosis and for pension claims) to be
' subject at any time to the inspection of the captain
and fleet surgeon.' This violation of the spirit of the
Hippocratic oath is not required in the army nor in the
Marine Hospital Service."
Medical Record
A Weekly Journal of Medicine and Surgery
Vol. 46, No. 14.
Whole No. 1248.
New York, October 6, 1894.
$5.00 Per Annum.
Single Copies, ioc.
<$rijjitial Articles.
THE TREATMENT OF DIPHTHERIA, WITH SPE-
CIAL REFERENCE TO THE EFFICACY OF
ANTITOXIN.
By ADOLF BAGINSKY, M.D.,
A. O. PROPS3SOR OP PEDIATRICS, UNIVERSITY OP BERLIN.
In i 89 i I published, in the"Archiv ftlr Kinderheil-
kunde," a paper on "The Therapeutics of Diphtheria
from die Kaiser and Kaiserin Friedrich Children's Hos-
pital," in which I stated that certain requirements of the
remedy should be formulated : i. The remedy should
be capable of destroying the diphtheria bacillus at the
seat of infection without injuring the surrounding tis-
sues or the body. 2. The remedy should prevent the
formation of pseudo-membranes, which latter might
cause laryngeal stenosis and asphyxia. 3. The remedy
should prevent and neutralize the products of the bacilli
in the blood and lymphatic circulation, possibly also the
septic material in the nerves.
The therapeutic measures consisted in applying local
treatment to the pharynx, and strengthening nourish-
ment, with cardiac tonics. Other remedial agents, when
the diphtheritic process extended to the larynx, threaten-
ing laryngeal stenosis, were tracheotomy and intubation.
The local remedies used were those which had both a
solvent and an antiseptic effect, namely : Acid, salicylic,
1-2 to 1,000 for gargling and irrigation with the syringe ;
acid, boricum, 3 per cent. ; kali hypermanganic, 3 per
cent; iodid. chlorid., 1 to 2,000; auro-natrio-chlorat, 1
per cent., for swabbing. Acidum lacticum, 10 per cent.,
for swabbing ; 2 per cent, for spraying. Acidum car-
bolicum, alcoholic solution of 5 percent., for swabbing;
2 per cent, to 3 per cent, for gargling. HgClt, 1
to 3,000, for gargling ; 1 to 500 for swabbing. Oleum
cirri for spraying; acid, acetic, 2 per cent, to 3 per
cent, for gargling, and 5 per cent, for swabbing. 01.
terebinth, for inhalation. Ichthyol, 2^ per cent., sub-
limat., 1 per cent., watery solution.
Iod-phenyl mercurial preparation by a chemist (Gold-
mann) is at present being tried. Ferric chloride is
applied as an ointment with pledgets of cotton, and
mechanical friction avoided.
Of all remedies mentioned thus far, those containing
bichloride, and after the latter the 3 per cent, (alcoholic)
carbolic solution proved most efficient. Boric acid,
salicylic acid, iod trichlorid., and auro natrio chloratum
were absolutely inefficient and useless. Acetic acid
proved useless. The kali hypermangan. proved bene-
ficial against the fetor, but negative in diphtheria. The
ol. citric, and ol. terebinth, were decidedly inefficient ;
the latter was used in a steam spray. I am decidedly op-
posed to the application of load caustic treatment, hav-
ing always had deleterious results from it. Besides sol-
vent remedies like lactic acid, and aq. calcis, 5 per cent,
to 10 percent, solutions of papayotin were used, and were
applied with cotton swabs ; this did not, however, pre-
vent the extension of the process to the larynx. Besides
the local remedies mentioned, an ice-bag externally and
cracked ice internally were used, until the inflammatory
infiltration of the pharyngeal mucous membrane had
disappeared. Subacute and chronic swellings, rather
late hyperemias in the pharynx, were treated with a
tannin solution, 1 to 80, with twenty parts of glycerine
added.
In two cases treated with submucous injections of 3
per cent, carbolic solution (Heubner), injected in the
vicinity of the infiltrated tonsil, they were decidedly use-
less, and showed at post mortem hemorrhages at the seat
of the injection. Among internal remedies sherry, port
wine, champagne, and Greek Alicante wine were used.
Cognac, subcutaneous injections of camphor in oil, and
10 per cent, alcoholic solution were also employed. In
mild cases 1 to 2 per cent, kali chloric, was used, but
was always discontinued, fearing nephritic complications.
The same was true of ol. terebinth., which most children
vomited. Decoct china, 10 to 100, and added to this,
aq. chlori. ten parts ; tinct ferri chlorati seth. ; tinct.
ferri pomati; and papayotin wine were used internally.
Inhalations of oxygen did at times redden the lips and
mucous membrane of very sick children, but did not
have any curative action.
To counteract the deleterious effects of heart failure
subcutaneous injections of strychnine, camphor, and caf-
feine were used. I have recently discarded entirely the
use of strychnine. The complications — pneumonia, pleu-
ritis, nephritis— were treated in the regular way. Anti-
pyretics must be very cautiously used in all complications
following diphtheria; even cold packs must be cautiously
administered. Of 244 cases 125 were cured, 9 were
transferred, 9 refused to be treated, 5 were convalescing,
95 died. The mortality was 40.04 per cent. Thirty-
seven of these cases were of the severe gangrenous septic
diphtheria, and all died. Deducting the latter, and in-
cluding a great number in which tracheotomy was per-
formed, there remains a mortality of 23.01 per cent.
Since the time of the German and French authors,
more especially of the Koch school, things have changed
considerably. Behring is credited with giving us a new
remedy for diphtheria. In an elaborate book published
by Behring he details the subject, and treats of it ex-
haustively. Behring uses the blood serum of animals
immune against diphtheria as a specific remedy for the
treatment of diphtheria, or for the prophylaxis of cases
having been exposed to diphtheritic infection. Associ-
ated with Behring have been Ehrlich, Wassermann, and
Wernicke, besides a great many others. Hans Aronson
has followed the directions of Behring, and has made a
serum which appears to be equally as good, if not better,
than that made by the former gentleman.
In the Kaiser and Kaiserin Friedrich Hospital in Ber-
lin we have used an antitoxin which was generously given
to us by Aronson. The results obtained by the use of
antitoxin have been reported by one of my assistant
physicians, Dr. Katz. From March 14th until July
25th, 163 cases of diphtheria were treated, including
numerous malignant cases. Of this number only 23
died, so that the mortality was 14-37 per cent. This
excellent percentage has never yet been equalled with
our best form of treatment even in the mildest epidem-
ics. Among the fatal cases there were several tubercu-
lous children, and several whose genuine diphtheria was
complicated with scarlet fever, so that the mortality of
uncomplicated cases of diphtheria will be much less. It
is difficult to say if a nephritis would have appeared as
well without as with the injections. The course of ne-
phritis in the cases treated with antitoxin were exactly the
same as otherwise. Severe cases of nephritis following
injections were never noticed; whereas several cases
4i8
MEDICAL RECORD.
[October 6, 1894
with severe albuminuria had wonderful improvement fol-
lowing the use of antitoxin injections. The heart did not
show any difference in rhythm, or in the heart-sounds,
or in the character of the pulse. On the fourth day fol-
lowing an injection a small abscess appeared in one
case, which was treated by incision, and rapidly healed.
Child discharged cured.
Several cases showed exanthema following an injec-
tion, especially on the extremities and in the region of
the knee-joint. No elevation of temperature accompa-
nied the exanthema, nor was there pain. They appeared
like scarlet fever, but in small, confluent places, with no
temperature and rapid disappearance, proving them to
be simple exanthemata.
Other cases looked like measles. There was, how-
ever, no desquamation noticeable. There were four
typical cases of urticaria of the whole body. Katz no-
ticed in a four year old child a distinct capillary pulse
when the nettle-rash appeared. Constitutional symp-
toms were never noticed, and erysipelas never occurred.
The membranes in the pharynx behaved variously. In
some they appeared to spread, while in others they
seemed to disappear. Not one single case had laryngeal
diphtheria nor stenosis after the injection. Those cases
with laryngeal stenosis and croupy cough were admitted
with these symptoms, and all were treated either by
tracheotomy or intubation soon after their admission.
In one case, a child with excessive dyspnoea (laryngeal)
was tracheotomized, and recovered. The glands did not
seem to be influenced by this treatment. There was no
specific action noticeable which could be attributed to
this remedy. Some cases appeared very bright; this
might have been the case otherwise.
The temperature showed nothing of interest. In two
children there was a sudden rise followed by a sinking
to normal. In most cases the temperature sank after
the injection. If the pulse was bad, the heart-sounds
weak, and the rhythm irregular, the remedy did not
seem to influence the same. At times, absence of patel-
lar reflexes, processes of accommodation, rhythm of the
heart, paralysis of the musculi aducentes, paresis of the
respiratory miscles frequently appeared. Dsath took
place in the sams manner as in ordinary cases. Among
the cases mentioned several died of pneumonia, paraly-
sis of the heart, and septicaemia. Those that died of
croup were so far gone that we did not expect to save
them; still, tracheotomy was performed, and large mem-
branes pulled out of the bronchial tubes. Of the septic
cases three were admitted moribund, and a fourth case
was in a typical state of septic diphtheritis. Pneumonia
cases that died were of the severest kind. Improvement
appeared so freqiently during its course that at times
thsre was good hope. In those children (brothers and
sisters) where at times the disease was treated within the
first few days, the mortality was less than 10 per cent.
In former timjs the mortality among children where
tracheotomy was performed was much greater ; whereas
formerly from 22 per cent to 24 per cent, were cured,
since using the antitoxin on severest cases 34. 30 per
cent, were cu^ed. It was difficult to ascertain the cause
of the disease. Twenty-five cases which had been exposed
to diphtheria were carefully examined a number of days,
and all developed diphtheria. As they were examined
daily, they were attended when the first symptom ap-
peared. Not one of these developed nephritis nor car-
diac trouble. Their sisters and brothers, who had been
previously admitted to the hospital, some as severe cases,
died. All twenty-five cases were discharged cured.
Dr. Aronson gave us a mild solution of his remedy,
which was used in seventy two cases for immunity. Of
all these cases but eight took sick very mildly and re-
covered easily. We learned that much larger doses were
necessary to produce immunity in children. Not one
case relapsed nor showed a single symptom. It will
therefore appear that we have been using a remedy which
deserves further trial. If, therefore, the remedy will
give even more beneficial results than heretofore, then
we have in the blood serum therapeutics inaugurated by
Behring one of the greatest triumphs in the annals of
medicine.
DIPHTHERIA ANTITOXIN OR HEALING SE-
RUM IN THE TREATMENT OF DIPHTHERIA.
By LOUIS FISCHER, M.D.,
MSW YORK.
1NSTSUCTOX IN DI5BASB8 OF CHILDREN AT THS NEW YOKK POST-GKADUATS
MBDICAL SCHOOL AND HOSPITAL; PHYSICIAN TO THE CHILOBBN'S DEPART-
MENT OP GBRMAtt POUKLIMK, PHYSICI U* TO THE MESSIAH HOME FOE CHIL*
DXKH, ETC
While in Berlin a month ago, Professor Baginsky gave
me every possible opportunity for acquainting myself
with the new antitoxin treatment for diphtheria. The
clinical experience seen abroad is my reason for detailing
the method for use in both hospital and private practice
It will be proper to state that at present two kinds of
"serum" are being used. They vary only in strength
and are made by rival firms.
The one firm sells it under the name of " Behring-
Ehrlich Heilserum," the other is " Aronson Heilserum."
As I saw but a limited number of cases of diphtheria at
the Institut fiir Infektions Krankheiten (Koch), by
courtesy of Dr. Wassermann, I will confine jnyself more
particularly to the consideration of Aronson's serum,
with which my experience is more extended.
This serum is a clear, colorless liquid of thick consist-
ence, quite sticky, and has a slight carbolic odor. In
order to preserve it, it is mixed with 0.2 per cent
tricresol, as some of the organic material might otherwise
decompose.
Two objects are sought for in using antitoxin: 1.
Immunity during an epidemic, or where a person has
been exposed to diphtheria. 2. Healing after the
disease exists.
In giving antitoxin it has been customary not to
neglect the other usual forms of treatment, and it will be
interesting, I hope, to detail a typical case.
The place for injecting the antitoxin is behind and be-
tween the shoulder blades and also the connective- tissue of
the arm and the thigh. Gentle massage at a slight dis-
tance from the point of injection is done to diffuse the
injection ; but this is not absolutely necessary.
Of almost two hundred cases treated in the Kaiser and
Kaiserin Friedrich Hospital but one abscess appeared,
which was incised and healed promptly. No reaction
followed injections.
It will be remembered that when Koch's tuberculin
was injected, fever, chills, diaphoresis, etc., were noticed,
which made a typical and distinct reaction as the result
of the injection. These phenomena were evidently the
natural consequences of a septic material thrown into the
circulation, as was demonstrated by Dr. Shrady and
others who used the lymph in New York.
When antitoxin is injected, however, there is no re-
action. The quantity used varies according to the sever-
ity of the symptoms, the gravity of the epidemic, and the
age and vitality of the patient. In some cases one injec-
tion suffices, whereas in others a second injection on the
succeeding day may be required. The usual dose is 5
to 10 cc, hypodermically. At times 20 c.c. is ad-
ministered when a very rare epidemic exists.
The instrument used is an ordinary hypodermic
syringe with asbestos fitting, which can be sterilized in a
Bunsen burner, or the Koch's syringe is used in some
hospitals abroad.
Exanthemata, the rash of scarlatina or measles, re-
sembling typical urticaria, sometimes appeared following
injections, but without an evolution of temperature.
These eruptions last several days and then disappear
without special treatment.
Malignant cases of diphtheria are greatly improved
and frequently recovered; quite frequently even cases
with laryngeal stenosis recover rapidly, and in which
tracheotomy was even performed.
Professor Baginsky, who has prepared a special paper
October 6, 1894]
MEDICAL RECORD.
419
for the Medical Record, will give a detailed account of
the use of antitoxin, by Dr. Katz, under his directions.
All of his assistant physicians, notably Dr. Lewin, in the
diphtheria pavilion, gave me detailed accounts of their
cases, which are virtually the same as Professor Baginsky
has reported. Complications were rarely noticed, and
symptoms of cardiac weakness directly attributable to the
antitoxin were not observed.
The immunity conveyed by an injection of antitoxin
lasts about three or four months, after which it will be
wise to repeat the injection.
Dr. Hans Aronson told me that the serum made by
Schering's factory is much stronger than Behring's, and
expressed it by saying that his serum of 400 Einheiten
was equivalent to 800 of some specimens obtained by him.
It is the aim of Aronson to produce a serum much
more concentrated than the one in use at present, for he
informed me that 5 gm. of the present serum was as
strong as one litre or 500 gm. of what was previously
made in the beginning of the manufacture of this remedy.
The following case is the first one in which I have had
occasion to use antitoxin in private practice.
DoraT , aged eleven, a healthy, well-nourished
girl, had been ill about one day. On the same floor of
this tenement-house, in an adjoining room, a boy, aged
fifteen, was sick with diphtheria, being attended by Dr.
Schmid. My patient was exposed, and her cautious
mother examined her throat and discovered some
patches. When I first saw her I found the temperature
in the axilla io2-|° F. There was intense thirst, general
pains in the body, marked malaise, dysphagia, and a
headache. Pseudo-membranes covered both right and
left tonsils and the posterior pharyngeal wall. I ordered
a placebo, and returned with Dr. Gerlach, at present a
physician at the New York Post-Graduate Medical School.
I first made a culture from the throat, the report
proved Klebs Loeffler bacilli, verifying the clinical diag-
nosis. I then injected 5 c.c. of serum with a small
hypodermic syringe, at which injection quite some
serum was wasted. I then took a better syringe, and
having sterilized the point in an alcohol lamp, injected
5 c.c. of Aronson's serum in the back by pinching a
fold of skin between the shoulder-blades. No reaction
followed. The next day my little patient was greatly
improved in both subjective and objective symptoms.
Greenish-yellow pseudo membranes remained about two
days following the injection, and on the third day no
trace of membranes were visible, although the pharynx
and tonsils were still inflamed. On the fourth day no
sign of the disease remained, and the little girl was up and
seemed to be quite hungry. The general malaise seemed
to pass off about one day after the injection. This is
near the sixth day and the membranes have entirely dis-
appeared. The child eats and sleeps well and is appa-
rently in perfect health.
This little patient was attacked much more severely
than the first child that infected her. My patient eats
and sleeps well, and is apparently very bright. A careful
examination of the urine was made. Albumin sparingly
and an excess of phosphates were present. The trace of
albumin also disappeared. No reaction followed the in-
jection of antitoxin.
In the same family one other child has received 2
c.c. of serum as a prophylactic. m I am anxious to see
if she will be infected or remain immune.
In some severe cases much larger doses may and
should be used, for Aronson told me in Berlin that he
frequently injected 50 c.c. at one injection, and this
may even be repeated on the following day, although
the usual dose injected was 10 c.c.
This will convey a general idea of how this remedy
may be employed, and if we can rely on statistics, then
we have in antitoxin not only a positive remedy in
diphtheria, but the beginning of a new form of treatment
which will eventually save the lives of thousands of
patients.
187 Second Avbnub.
SURGICAL PROBLEMS IN INTRA-PELVIC AND
ABDOMINAL DISEASES.
By A. H. CORDIER, M.D.,
KANSAS CITY, MO.
Some time ago, while doing special work in a large
Eastern city, I had many opportunities to see the work
of the various operators, and it was a noticeable fact
that, while one operator would have a mixture of the
worst neglected and complicated cases imaginable, in-
cluding old adherent and caseous Fallopian tubes and
ovaries in emaciated and septic patients, another opera-
tor's cases would be confined to the removal of cystomas
and plastic vaginal and cervical cases. This led me to
inquire of one of the operators why he did not have so
many " pus cases " as some of his confieres. He replied
that he believed that " the woods are not full of them/'
as some would have us believe. A few days later I
visited this same gentleman's clinic, which is a large
one, and in two hours I found six pairs of old, seques-
trated Fallopian tubes full of pus, carried around by six
of the most careworn and miserable-looking women
imaginable. They had their vaults frescoed with
Churchill, and were directed to return for another dec-
oration the following week.
Conservatism is a grand principle, but unfortunately,
in the hands of skilful men the application of this rule
is only too frequently responsible for destructive or com-
plicative delays, if I may use such a term. Conservatism
is a prophylactic if early and intelligently carried out or
applied. It is equally injurious, if used with this same
idea in view, in cases where time and experience have
demonstrated its futility.
Occasionally an article appears in some of the many
valuable medical journals of our country entitled "A
Plea for Conservatism," or the like. That these articles
are well worded by conscientious practitioners in most
instances no one will doubt, and to one unaccustomed
to seeing the true pathology from a practical stand- point,
they carry with them weighty evidence that, with rare
exceptions, all surgical procedures for the relief or cure
of the same, are unnecessary and unwarrantable. But to
him who has handled these cases surgically, and under-
stands their progress, the position of the so-called con-
servative is not well taken. Many are attempting to do
this class of surgery (pelvic) who have not the anatomi-
cal or pathological knowledge or practical experience to
enable them to make a diagnosis between an operable or
non-operable case. To this class sermons on qualifica-
tions and attainments should take the precedence of
lectures on operative conservatism.
Good missionary work is being done in this field by
educating the general practitioner and the specialist that
they should go hand in hand in their work. By friendly
discussions and exchange of views on topics of vital im-
port to both, the patients reap the benefit of the com-
bined council.
We have men of renown in this country as operators
and authors, whose utterances along the line of so-called
conservatism are producing much mischief and causing
many deaths by the adoption of these false doctrines by
lesser lights. After seeing much of the work of some of
these men I am surprised to see some of their ideas in
print so foreign to the practice actually pursued by them
in their work. One is almost tempted to doubt the
sincerity of some of their utterances.
We should advise against the removal of sound organs,
but at the same time endeavor to impress upon our asso-
ciates the necessity for early surgical work where experi-
ence with like cases has demonstrated the futility of any
other course.
Operations for the removal of diseased appendages are
not followed by the same amount of reflex disturbance
as are those cases where sound organs are removed to
cure (?) a globus hystericus, or the like — an unwarrant-
able procedure. Most women with suppurating diseased
tubes and ovaries are unsexed by the pathology, and lm
420
MEDICAL RECORD,
[October 6, 1894
have had women with these diseases at an age too early
for a normal menopause to present all the climacteric
•phenomena. In many cases it is not a question of
"Will this woman have an exaggeration of the meno-
pause phenomena if we operate?1' so much as "Will
she be free from pain aftei the operation, and can she
recover without the aid of surgery? " These questions
have been answered many times, both by non interfer-
ence in the cases, with failures, and by demonstrations
at the operating-table — the successes. Women whose
appendages are diseased to such an extent as to require
removal are sick women, and are necessarily in that low
vital state that where there is an inherent tendency to
insanity or neurasthenia the surgical procedure for the
removal of the diseased structures may precipitate the
m?ntal phenomena to an exaggerated and disagreeable
degree. ,
If we are not to remove life-endangering and comfort-
breaking pathological processes when found, pray tell
us what are we to do? Fold our hands and let nature
(pathology) take its course? Or do worse, visit these
cases with poultices, Churchill, and hypodermics ? We
can illy afford, as true surgeons, to cater to the plea that
the poor sufferer will be robbed of her womanly traits ;
that she will be despondent, lose her sexual desires, suffer
from flushes and flatulence, and that her husband (too
often responsible for the wife's sufferings) will become
dissatisfied with the post operative condition of his wife.
I have never seen a woman suffering with diseased ap-
pendages where the disease was of sufficient severity to
require removal of the organs, who was not a sexually
useless and despondent wife, and a sick woman as well.
Sound organs should not be removed. Any condition
that may be induced by the surgical procedure may like-
wise be induced by the continuance of the disease re-
quiring the surgery.
I believe the sexual system is located elsewhere than
in the tubes and ovaries. The nymphomaniac manifests
not only an increased sexual desire, but a loss of self-
control, often with hallucinations and delusions, the
whole cycle having its origin in the cerebrum. ,
Radicalism is a dangerous expression to use ; equally
harmful is the term conservatism applied to a disease the
tendency of which is to destroy function, make life
miserable, or produce death if too long a delay of a
proper procedure for its cure is permitted.
Many cases early in the history of the malady are
permanently cured by intelligent and skilled surgery.
The same case, if allowed to run an uninterrupted course
for any length of time, may assume proportions or char-
acters of some magnitude or danger that to attempt to
relieve the same would not only be fraught with danger
from the operation, but the crippled surrounding organs
would preclude the possibility of a complete restoration
to health.
These are cases that bring disappointment to the pa-
tients and friends, as well as to the sanguine physician
and surgeon, run up the mortality, and give surgery a
bad name.
It is the early removal of diseased structures, the his-
tory of which is to continue a downward course, that
gives us a nil mortality, the patient renewed health, and
the family physician increased confidence in the justifi-
ability of the operative procedure.
Early operations are not only curative measures, but
prophylactic methods as well. It is not only the diseased
and worse than useless organs and structures the true
abdominal surgeon is removing, but he is liberating
sound imprisoned organs, the function of which is essen-
tial to life. This is not only life-saving work, but a
comfort-giving procedure. No true surgeon is clamor-
ing for a thousand or ten thousand laparotomies, but is
ever pleading for timely needed work — is ever pleading
for the recognition of the necessity for quick surgery in
cases where surgery, at some time in the history of the
malady, becomes necessary.
No one at this time would think of advising a woman
to wait until the growth was so large or her physical
condition such that she could not walk a mile, before
having the tumor removed, as was done a few years
ago, by a great writer. This would be dangerous con-
servatism.
It is as absurd to call the removal of a sequestrated
Fallopian tube and ovary a mutilation, as it is to call an
amputation of a hopelessly injured leg a mutilation.
These operations are performed to fulfil strictly surgical
indications — saving life and relieving suffering. It is a
daily occurrence to see reported that a case diagnosed as
appendicitis has recovered. That this is true no one will
doubt. Many cases reported as recovered have since
died from recurrence of the disease, and many an appen-
dix, supposed by the medical attendant to be dangling
healthfully in the peritoneum of his patient, is saturated
with Miiller's fluid or alcohol, in a specimen jar, while
the patient has long since died from a perforation, or has
been saved by good, timely surgery. No operation in
surgery has a higher mortality than that of the delayed
operations for the removal of a diseased vermiform ap-
pendix, but if done early the procedure has an almost nil
mortality. A late writer reports twelve cases treated on
the expectant plan with two deaths (sixteen per cent,
mortality), and two cases with recurrent attacks (six-
teen per cent, of recurrences). The writer says of the
two who died that they were almost in articulo mortis
when first seen by him. He does not tell us whether he
put on a fresh poultice and hid from view the big ab-
scess bulging in the right iliac fossa, or gave the patient
an extra dose of opium to relieve the pain of the sufferer
and obtund the senses of the doctor. These cases should
have been seen by a good surgeon who would have
stopped all opiates and let out the pus, applying the
same surgical principles to this locality as to other parts
of the body: "When you find pus, let it out." Ap-
pendicitis is a surgical disease, and the surgeon should
see the case with the physician as soon as the diagnosis
of appendicitis is made. Let the physician and the sur-
geon watch the case together.
The modern application of the principles of surgery as
applied to diseased Fallopian tubes is the same that has
been practised for ages as applied to the surface of the
body. A felon is lanced, the earlier the better. The
good surgeon does not advise delay, and while waiting
paint the finger with Churchill or apply hot irrigation.
As soon as evidences are present that pus is forming he
lets it out.
How thankful the abdominal surgeon would be could
he lift up a pus-filled Fallopian tube without entering the
peritoneum, " rip it up the back M (as suggested by a late
writer), scrape it out, destroy all the remaining epithe-
lium, and by redressing it restore its calibre so that the
spermatozoa may throng its canal and pregnancy take
place, just as though this culture tube had not been a
hot-bed for gonococci and other pathogenic bacteria for
months previous.
All cases of salpingitis are not operable cases, but the
majority of cases seen by the specialist are old purulent
cases with tubes filled with pus and caseous dibris strict-
ured in one or more places, uterine and abdominal ostia
closed. Here it is conservatism to remove these danger-
ous sequestra.
Hardly a week passes without seeing one or more cases
of far advanced cancer of the cervix uteri extending into
the broad ligaments, bladder, or rectum. These are in-
operable cases when so far advanced. Again I see cases
where a diagnosis of a cauliflower growth has been
made, which proves to be a badly lacerated cervix, with
the resulting local mischief attending an unhealed tear in
this locality. Surgical diseases should be attended by the
surgeon in conjunction with the regular medical attend-
ant. The time to operate, if necessary at all, could then
be arrived at mutually and timely.
When the masses are educated in every sense, when
gonorrhoea is stamped from the face of the globe,
when the perniciousness of criminally induced abortions
October 6, 1894]
MEDICAL RECORD.
421
and the dangers of the indiscriminate use of the sound
are understood, then there will be less necessity for the
practitioner to hurl at the specialist his " bucket or bar-
rel of ovaries;" then the specialist will cease his cry
against needless tinkering and dangerous procrastination ;
then our women will have their babies at full term, in
the good old way. Until this goal is reached, the use of
the knife will be found necessary in properly selected
cases to relieve the suffering and save the lives of these
unfortunate women with diseases, the result of the above-
mentioned causes.
A STUDY OF THE MEDICAL ASPECT OF FOUR
RECENT CASES OF ACUTE APPENDICITIS.1
By JOHN L. IIEFJPRON, M.D.,
PROFESSOR OF THERAPEUTICS AMD CLINICAL MEDICINE, COLLEGE OF MEDICINE,
SYRACUSE UNIVERSITY.
Mr. President, and Members of the Onondaga
County Medical Society : As a preliminary to the
study of the salient features in the four recent cases of
appendicitis which it is proposed to discuss to-day,
it will be necessary to give, briefly, the history of
each case, from its inception to the time when surgical
treatment was resorted to.
Case I. — Mr. G. K , aged thirty-nine, a Ger-
man, of sturdy build, weighing about two hundred
pounds. He worked all day July 25, 1893, at his trade,
stone-cutter, doing heavy work. He had a diarrhoea, at-
tributed to indiscreet eating, of which he made no com-
plaint until he returned from his work in the evening.
His diarrhoea continued during the night, with occasional
vomiting and colicky pains.
In the morning, not being relieved, he sent for me. I
found the patient in bed, and an examination showed, in
addition to the above symptoms, that the pain, which
had at first been indefinite in location, had become
limited to the right iliac region, though it radiated, in
paroxysms, from this point upward and inward toward
the umbilicus, but was never intense.
Palpation revealed slight tenderness, most marked over
McBurney's point, but also extending to a considerable
area in every direction.
Percussion indicated an area of diminished resonance
in the right iliac fossa.
His pulse was 70, of fair strength and volume, and
his temperature was normal. A tentative diagnosis of
appendicitis was made, and he was given an opiate and
saloL
At the evening visit it was found that he had had a
severe chill, lasting several minutes, which was followed
by an increase in the pulse-rate and fever, with sweat-
ing. At this visit his pulse was 90, and his temperature
was ioo° F. He had vomited twice during the day; his
bowels had moved several times, and the pain was more
intense, though not constant, land the tenderness was
increased. There was some tympanitis, so a saline was
added to the treatment. . The family were apprised of
the serious nature of the disease, and were told if no
decided improvement was manifested by morning, surgi-
cal measures must be resorted to.
July 27th. — Patient was seen about 10.30 a.m. He
had passed a fairly comfortable night ; his bowels had
moved early in the morning, the stool being a watery
discharge of very foul odor, but containing scarcely any
fecal matter. His pulse was 100, and of diminished
strength and volume ; his temperature was 1020 F.
There was a little increase in tympanites, the abdomen
being quite soft, but the pain was more marked, and
the tenderness was much greater, and most exquisite over
McBurney's point.
The opiate treatment was continued, and the family
notified that I would bring a surgeon at the earliest pos-
sible moment in the afternoon.
At 4.30 p.m. Dr. Jacobson saw the case with me. At
this time the temperature had fallen to 1010 F., but the
1 Read before the Onondaga County Medical Society, May 8, 1894.
pulse had increased to 116, and was irritable. The local
symptoms were aggravated, both pain and tenderness
having increased since morning, and the abdomen was
somewhat distended. It was agreed that the only hope
was in an immediate operation, which was at once ac-
ceded to, and prepared for, and accomplished by six
o'clock — forty- eight hours from the time he had com-
plained of any abdominal trouble, and thirty hours
after there had been any elevation of temperature or in-
crease of pulse rate.
A general septic peritonitis and a gangrenous appen-
dix were disclosed, the details of which will be given by
the operator. Death followed about twenty hours after
this operation.
Case II. — R. H. L , fifteen years of age, a student
in Colgate Academy, Hamilton, N. Y., having a good
family history and no previous abdominal trouble. He,
with his society fellows, participated in a " peanut bum,"
on Saturday night, March 17, 1894, consuming peanuts,
bananas, and soda-water, as only a fifteen-year old boy
can. All went merry until Tuesday night, March 20th,
when he was attacked with severe diarrhoea and vomiting,
keeping him busy all the early hours of March 21st. On
that day a physician was called, and placed him under
treatment, evidently wavering in his diagnosis between a
possible typhoid fever, which was endemic in the neigh-
borhood of his boarding-house, and appendicitis. His
temperature was 1010 F., and his pulse correspondingly
rapid ; he had considerable pain and tenderness in the
right iliac region, which was somewhat masked by a
strain of the abdominal muscles, received in practice on
the base- ball field. He was up and around during the day,
however, and partook of the usual supper served to
healthy boys.
March 2 2d. — The pain was considerably diminished, as
well as the tenderness, and the diarrhoea and vomiting
had ceased, but his temperature and pulse remained
slightly above the normal.
March 23d. — He was in about the same condition,
and was advised by his physicians to return home. In-
formation was sent me that he was probably coming
down with typhoid fever, a fear which was quite reason-
able. At n p.m. he came into my office, having walked
from the Central Depot with his father, who had met
him at the train. After securing the above history
an examination was made : The pulse was 100 ; temper-
ature, 101^° F. Complained very little of either pain
or tenderness ; abdomen flat and soft ; palpation dis-
closed a point of considerable tenderness at McBurney's
point, and a tumor was distinctly made out in this loca-
tion, about the size and shape of a butternut. There
was dulness over the descending colon, as' well as over
the tumor. Thinking there were more peanuts — though
being positive in a diagnosis of appendicitis — a mercu-
rial was prescribed. As the patient was suffering from
acute bronchial catarrh, a sedative was also given.
March 24th. — Patient had a good night. Pulse, 100 ;
temperature, ioo° F.; had three movements of the bow-
els ; is very hungry, but is allowed no solid food. Local
symptoms unchanged. A daily improvement in every
symptom was recorded until
March 28th. — At this visit his pulse was 92 ; tempera-
ture, 1020 F. No complaint of abdominal symptoms
from patient, but examination reveals an increased area
of dulness, not particularly tender, and tumefaction in
right iliac fossa evident to the eye ; abdomen elsewhere
flat and not tympanitic ; bowels have not moved in two
days. Closer questioning gives the added information
that the patient had a "weak spell " during the after-
noon, followed by free sweating. Arrangements were
immediately made for consultation with a surgeon.
March 29th. — Dr. Jacobson saw the patient with me
at 8.30 a.m. At that time his pulse was 90 ; tempera-
ture, 99jV° F. He had passed a pretty good night;
tumefaction more noticeable even than yesterday, and
the tumor distinct and larger. It was agreed that an
immediate operation was imperative. Arrangements
422
MEDICAL RECORD.
[October 6, 1894
were accordingly made and abdominal section was done
at 3 p.m, the tenth day after onset of symptoms. The
appendix was gangrenous throughout its entire length,
and was embedded in a large blood-clot, under which
were about two ounces of foul pus. The patient made
an uninterrupted recovery and is now about the house.
Case III.— P. W. G , aged thirty-one, Scotch-
man by birth; tall and slim. Of good family and
personal history. Went to Toronto, Canada. March
28, 1894, at 3 p.m. was attacked with cramps in the
bowels, and with vomiting, but no diarrhoea, which he
attributed to the drinking-water. He returned to Syra-
cuse by the earliest train, and called me the following
evening.
In addition to the above history, an examination re-
vealed considerable fulness of the abdomen ; no tumor
or tumefaction, but distinct tenderness at McBurney's
point. His pulse was 100, and his temperature ioi^°
F. His bowels had not moved in two days so he was
given sulphate of magnesia and carbonate of magnesia, in
moderate doses, in peppermint-water every hour until
his bowels moved freely, and Tully powder sufficient to
control excess of pain.
March 30th. — Pulse, 92 ; temperature, 99^° F. ;
bowels had moved three times ; abdomen flat, and no pain
except on motion. Tenderness is marked, and dulness
in the right iliac fossa was detected, but no distinct tu-
mor. At 10 p.m. Dr. Jacobson was called in consulta-
tion. Pulse, 84; temperature, 1010 F.; symptoms un-
changed, but, in addition to slight dulness, could detect
slight tumor in the region of the appendix.' It was
agreed to continue conservative treatment, but to be ready
for operation at any moment.
March 31st. — Pulse, 82 ; temperature, 990 F., in the
morning, and pulse, 80 ; temperature, 9&&0 F., in the
evening, with improvement of all the symptoms.
April 1st. — Pulse, 72; temperature, 98TV° F. No
pain, little tenderness, but tumor distinct.
April 2d. — Pulse, 70 ; temperature, 990 F. All symp-
toms favorable.
April 3d. — Pulse, 80; temperature, 1010 F. Bowels
moved twice, and had twinges of pain previous to each
movement. Tumor somewhat increased.
April 4th. — Pulse, 90; temperature, ioo^° F.; res-
piration, 22. Considerable pain during the night; tu-
mor increased in size, and tumefaction evident on exten-
sion of right leg. Dr. Jacobson was called and an
operation agreed upon, which was performed at 3 p.m.
A post-csecal gangrenous appendix, surrounded by about
an ounce of vile pus, was removed; and the patient is
now convalescent.
Case IV.— W. B , aged twenty-five, English by
birth ; an engraver. Was seized with pain in the stom-
ach and vomiting late in the evening of April 24th. The
pain persisting and the vomiting, bilious in character,
continuing, he sent for medical aid in the afternoon, and
was seen by Dr. Jacobson at 3 30 p.m. Examination
showed that his pulse was 105 ; temperature, ioi^6 F.;
abdomen dull on both sides over a great portion of the
area below the umbilicus; sensitive at various points,
and most tender to pressure about an inch below McBur-
ney's point; tongue, dry in centre and brown; pains
paroxysmal. Salol, phenacetin, and pepsin were pre-
scribed. At 11 p.m. patient was seen again; he had
had no severe pain since afternoon visit and had not
vomited; pulse, 90; temperature, ioo° F.; tongue more
moist ; abdomen softer ; dulness limited to caecum ;
marked tenderness on pressure in right iliac fossa. He
was prescribed, hourly, fifteen grains of sulphate of magne-
sia and five grains of carbonate of magnesia.
April 26th. — Patient had rested so well that he had
little medicine ; pulse, 72 ; temperature, 98^° F.; ab
domen a little more tympanitic ; tongue moist, slightly
furred; no changes in dulness; diminished tenderness.
Saline mixtures to be continued. At 6.30 p.m., pulse,
80 ; temperature, 99^° F. Patient had vomited once
during the day ; local symptoms and signs unchanged ;
bowels not having responded to salines, enema was ad-
vised.
April 27th. — Passed a comfortable night; vomited
once on getting up to help himself to milk ; bowels had
moved very freely; tongue a little dry ; puke, 80; tem-
perature, 99tV° f-> local symptoms unchanged. At
10.30 p.m. I saw the patient in consultation with Dr.
Jacobson. Pulse, 72; temperature, 99^° F.; abdomen
flat and soft ; dulness in limited area in right iliac fossa
below the line from the umbilicus to the anterior superior
spinous process, and tenderness confined to this area.
As his general symptoms had improved since an earlier
evening visit, and the local symptoms had not progressed,
it was agreed to send the patient to the hospital early in
the following morning and meet there in consultation,
prepared for operation, if indicated.
April 29th, 8.30 a.m. — Patient was seen in St Joseph's
Hospital. He had passed a restless night, but without
severe pain ; area of dulness was increased very slightly,
and degree of tenderness was heightened ; pulse, 6S ;
temperature, 100^° F. Because of the increase in local
manifestations it was agreed that the operation should
be done at once. An intensely congested, mahogany-
colored appendix and mesentery of unusual development,
with points of degeneration, evidently on the rapid road
to complete tissue-death, were removed; and this pa-
tient is now on a fair way to recovery.
Four cases are very few from which to make deduc-
tions of absolute value, but when they are fair representa-
tives of all forms of acute septic appendicitis which have
come under our observation in the past, the total number
of which is considerable, they are worthy of considera-
tion.
The physician is the person who, ordinarily, is first
called to see the patient suffering from appendicitis. The
existence of bellyache is not commonly associated with
the thought of the surgeon and his knife in the mind of
the average man. Accordingly, an ability to make an
early diagnosis and to appreciate the relative value of the
symptoms and physical signs is, for the physician, of the
utmost importance ; but of still greater importance is the
ability not only to determine the proper medical aid to
be extended, but to decide when surgical interference is
to be invoked.
Let us first consider the early symptoms presented in
these cases. They were abdominal pain and tenderness,
vomiting, diarrhoea or constipation, fever, and an accel-
erated pulse.
The abdominal pain was the initial symptom in each
case. It preceded the vomiting, the diarrhoea, and the
consciousness of tenderness, and the fever and the in-
crease of pulse-rate followed in its train. It was not
distinctly localized at first in any case, but in from twelve
to twenty-four hours it was distinctly felt by the patient
to be most intense in the right iliac region, and, when
paroxysmal, to radiate thence. The pain varies in char-
acter. It may be paroxysmal and intense, suggesting
colic ; or it may be dull and constant. In either case it
was always exaggerated by motion and by pressure, so that
the patient assumed a position protecting the affected parts
to the greatest possible extent. In walking, he bends
forward; in bed, he is easiest lying on the right side
with his knees drawn up.- Pain is a common symptom
of all abdominal disturbances ; but pain, at first vaguely
defined, but soon distinctly localized in the region of
the appendix and increased by motion, is of itself almost
pathognomonic, and could exist in acute diseases in only a
very few other pathological conditions, which fortunately
have distinctive symptoms of their own, like invagina-
tion, volvulus, and stercoral typhlitis.
Tenderness always accompanies pain. There may be
several sensitive places in the abdomen, as observed in
one of these cases, but careful palpation, with a single
finger-tip, will locate the point of greatest tenderness
exactly over the origin of the appendix. McBurney has
rendered us the greatest service in giving us an exact
point at which the appendix originates in all normal
October 6, 1894]
MEDICAL RECORD.
423
8, a point one and a half to two inches from the an-
terior superior spinous process of the ilium, on a line
drawn from it to the umbilicus. In the fourth case re-
ported, the point of most exquisite tenderness was
located nearly an inch below this line, but the short,
thick, inflamed appendix was disengaged from exactly
the region diagnosed. In my experience this is the
only instance of displacement of the appendix, even to
so slight an extent ; but there are many cases recorded
where the appendix has occupied an unusual position, as
under the right lobe of the liver and even in the left iliac
fossa.
Dr. Edebohls, at the last meeting of the New York
State Medical Society, read a paper demonstrating the
possibility of palpating the appendix, in every case where
the abdominal wall is not too thick, by deep pressure
from above with counter pressure from the posterior wall
of the abdomen, in a line from the umbilicus to the spine
of the ilium. I do not question but that a practised
observer could attain such precision, but in cases of
acute appendicitis the procedure is unwarrantable, except
in the very inception of the disease, as the force neces-
sary to compress the abdominal tissues against the pos-
terior abdominal wall would be sufficient to rupture a
degenerated appendix.
Vomiting was a symptom present in each of the cases.
Of itself it is a symptom of little value ; but, in connec-
tion with those already mentioned, aids in the formation
of a diagnosis. The vomiting in all the cases which I
have seen has been most severe in those following gross
indiscretion at the table. It has seemed to me possible,
that just as vomiting mechanically empties the stomach
and the liver, and even the trachea and large bronchi, so
it might mechanically force some of the contents of the
cecum into the appendix and thus originate conditions
of overdistention, giving rise to strangulation and in-
flammation of this organ, particularly where colonies of
bacilli coli communis, virulently active in fermenting in-
testinal contents, were forced through the so-called valve
of the appendix. But I do not know that any such
origin of appendicitis has been demonstrated or sug-
gested.
In two of our cases diarrhqpa was marked, and in these
two there was a distinct history of most indiscreet inges-
tion of a large amount of food difficult of digestion. My
other cases bear out this observation. In two, constipa-
tion was marked, so that neither diarrhoea nor constipa-
tion can be considered as diagnostic of this disease.
Either condition seems to depend on other factors than
the existence of an inflamed appendix.
Fever was not an initial symptom in any of these*
cases, though it developed in each case sooner or later,
and was, in none of them, a symptom upon which reli-
ance could be placed, either for early diagnosis or for
prognosis. In the first case, where septic peritonitis had
developed within twenty-four hours, the temperature was
lower on the day of the operation than on the day be-
fore.
In the fourth case, the temperature and the pulse were
both near the normal at the time of the operation and had
not been high at any period. In both of these cases
there was no attempt at walling off the seat of the inflam-
matory action from the rest of the abdomen. In the
second and third cases the temperature, at first elevated,
returned to the normal with the amelioration of the
primary symptoms, and became gradually elevated with
the development of the tumor. In both of these cases
an abscess cavity was established, more or less perfectly,
protecting the adjacent tissues from infection. With the
establishment of septic peritonitis, in the first case, the
pulse became more rapid and of wretched character, and
at the same time the temperature fell ; a similar phe-
nomenon has been observed in four other cases of ful-
minating appendicitis with very rapid general infection
that have come under my notice.
For a primary diagnosis I regard the pulse and the
temperature as of very little importance. On the other
hand, the increased puke rate and the elevation of tem-
perature attending the development of the tumor, seem
to indicate the formation of a perityphlitic abscess; and
a greatly increased pulse* rate, with lessened volume and1
strength, and with a falling temperature, is suggestive of
general septic infection.
To sum up : Right-sided abdominal pain, increased by
motion and by pressure, with tenderness on point press-
ure most exquisite over the origin of the appendix, with
vomiting, and some disturbance of the circulation and
temperature, coming on suddenly in a person previously
healthy, are sufficient to establish a diagnosis of acute
appendicitis.
The discussion of the prognosis and the indication for
surgical treatment I shall leave to my collaborator.
It remains for the physician to say when the surgeon
shall be called in consultation. To this, the only an-
swer must be, so soon as a diagnosis is made. I know
of no absolute signs that unequivocally indicate the
moment when medical aid is of no further utility, and
when, to save the life of the patient, surgery must te
resorted to. The surgeon should be associated with the
physician from the outset, and should share with him the
responsibility of the cage, and to his experience and
judgment must be referred the question of the ne-
cessity of any operation and the time when it should be
made.
Concerning the medical treatment, little need te
said. Locally, cold alone is appropriate in the begin-
ning, and is best applied by the coil. If tumor is form-
ing and is slow in development, heat may be of utility
in hastening the process. This was exhibited in the
second case, seen four days after its inception, and op-
erated on the tenth day.
Internally, opium is, in my opinion, by far the most
appropriate in all cases where it agrees ; and no fears of
" masking the symptoms," as some surgeons put it,
should be entertained. This drug gives physiological
rest; and, more than that, it controls the inflammatory
process, actually diminishing the calibre of the arterioles
of the mesentery and peritoneum better than any other
drug yet used.
If the colon be filled with fecal matter, a mild saline,
just sufficient to remove this cause of embarrassment, is
appropriate, and for the purpose I know of no prescrip-
tion superior to the one used in our cases, namely, fifteen
grains of sulphate of magnesia, with five grains of the car-
bonate of magnesia, in half an ounce of peppermint-
water every hour until the desired result is obtained.
This mixture is well borne by the stomach, and is effi-
cient after a few doses. The diminution of the abdom-
inal contents, from the emptying of the gut of fecal mat-
ter and of gas, was most marked in the cases where it had
been used, and, at the time of the operation, the free-
dom from interference of inflated intestines much facili-
tated the operation.
If general peritonitis develop, possibly the saline treat-
ment alone is more scientific ; but of this I confess I am
not yet thoroughly convinced. In such an event I have
yet to see a case which has recovered from either medi-
cal or surgical treatment, however skilfully it may have
been applied.
Salol is of great value, as in so many intestinal dis-
eases, by its efficiency in controlling fermentative pro-
cesses in the intestinal canal.
The diet should be entirely restricted to fluids ; and,
so long as vomiting continues, nothing but barley-water
or oatmeal-water or ice-water should be permitted.
With the amelioration of the primary s) mptoms diluted
milk, with a tablcspoonful of lime-water to each glass,
may be allowed.
If these cases, as well as all the others I have seen,
teach anything, it is that an early diagnosis, the timely
association of a surgeon in the management of the case,
and the harmonious working together of the physician
and surgeon will save many valuable lives that otherwise
might be lost to the world.
424
MEDICAL RECORD.
[October 6. 1894
FOUR RECENT CASES OF ACUTE APPENDICI-
TIS, CONSIDERED FROM THEIR SURGICAL
ASPECT.
By NATHAN JACOBSON, M.D.,
SYRACUSE, N. Y.
FROFESSOB OP CLINICAL SURGERY, COLLEGE OF MEDICINE, SYRACUSE UNIVER-
SITY; SURGEON TO ST. JOSEPH'S HOSFITAL.
Before entering upon a consideration of the surgical
questions in the cases under discussion, permit me to
complete their records as given by Dr. Heffron.
Case I. — G. K , seen at 4.30 p.m., July 27, 1893.
Although the temperature had fallen since the morning
from 102. 50 to ioi° F., the increase in the pulse-rate from
100 to 116, and the marked aggravation of local signs
indicated rapid progress of the inflammatory process. It
was therefore decided to operate at once. The prepara-
tion was hastily made. Despite anaesthesia the patient
strained constantly throughout the operation. His chest
was more or less filled with mucus, and respiration in
consequence impeded.
A straight incision along the dextral border of the rec-
tus muscle was made, about three inches in length. Im-
mediately upon incising the peritoneum there was a
profuse discharge of sero pus. Upon the deeply injected
intestines, at various points, inflammatory deposits were
present. As soon as the peritoneal discharge was re-
moved, the appendix was sought for and easily found.
Readily separated from its slender adhesions, it was seen
to be angry, swollen, and perforated, and so gangrenous
that in the attempt to seize and draw it up the forceps
broke off its end. Liquid faeces exuded from its perfora-
tions. It was cut off close to the caecum, the stump cau-
terized with pure carbolic acid, and the presenting sur-
faces irrigated with a saline solution. A glass drainage-
tube was carried down to the stump, and about it iodoform
gauze was introduced, and the ordinary surgical jdressing
applied.
At midnight the patient was seen again. His tempera-
ture had gone to 102. 8° F. ; the pulse was so feeble that
it could hardly be counted. A great amount of bron-
chial secretion was present. The lips were blue, the
extremities cold and discolored, respirations were frequent.
The surface dressings were badly stained and therefore
changed, and strychnia, digitalin,Jand nitro glycerine ad-
ministered hypodermically.
At nine o'clock in the morning the patient was found to
be bright, and reported himself as feeling materially bet-
ter. His pulse, however, was not improved ; tempera-
ture, io4°F.; lessened bronchial secretion permitted freer
breathing, the abdomen was distended, tongue dry, urine
had not been voided. From this hour the patient stead-
ily failed, the pulse soon became imperceptible, the patient
collapsed, and death resulted at 1.30 p.m.
Dr. May made a bacteriological examination of the
appendix and reported that it presented a pure culture of
the bacillus coli communis.
Case II. — R . H. L . Seen on the tenth day of his
attack at 9 a.m., March 29, 1894, temperature was 99. 50 F.,
pulse, 90. The local manifestations were entirely out of
proportion to the mildness of the constitutional one.
The right leg and thigh were flexed. Upon extending
the extremity the right side of the abdomen became im-
mediately prominent. An area of dulness present in the
right iliac fossa, reached within one* half of the median
line. A localized tumor was evident ; fluctuation could
be made out. Diagnosis of appendicicular abscess was
made, and operation advised.
At 3 p.m. an oblique incision was made over the outer
border of the tumor, that is, about an inch from the brim
of the pelvis, its centre opposite the anterior superior spi-
nous process. The peritoneum when reached was found to
be tense. Upon incising the tumor, pus and blood were
discharged. The abscess cavity was thoroughly walled off.
It was occupied by an infectious thrombus, in the centre
of which was the gangrenous appendix, collapsed and in
a state of sphacelus. The slightest effort to remove the
blood-clot awakened profuse bleeding. The cavity was
therefore irrigated with a hot normal saline solution and
packed with iodoform gauze. Throughout the operation
the patient, who was suffering from an acute bronchial
catarrh, took ether so wretchedly that the anaesthesia
gave us more trouble than did the operation.
Just before the operation the temperature was taken, and
was found to be 101.50 F. It steadily fell to normal, at
which point it was found at 10 p.m. On the following
day there was a slight rise to 100. 20 F., but after this it re-
mained substantially normal. On the second day after
operation, the dressing being removed from the abscess
cavity, it was irrigated with a sublimate solution of 1 to
8,000. The blood-clot was easily washed away and
no further bleeding occurred. The dead portion of the
appendix separated spontaneously. April 1st its stump
could be seen already covered by granulations. The en-
tire abscess cavity cleansed itself, and five days after the
operation presented nothing but a healthy granulating
surface. Iodoform gauze was carried gently to the bot-
tom, protecting the stump of the appendix, but firmly
packed at the surface in order to distend the opening.
Within' a short time the wound was thus rendered funnel-
shaped. The cavity granulated rapidly from the bottom.
May 1st, it being entirely healed, an abdominal supporter
was applied and the patient allowed to be up and about.
Case III.— P. W. G . At the visit, made late in the
evening of March 30, 1894, the third day of his sickness,
an examination revealed the presence of a large area of
dulness in the right iliac fossa, describing a quarter of a
circle, with a radius of at least three inches. Within this
tumefied area we were able to recognize as more distinct
a tumor located opposite the anterior superior spinous
process. There had been improvement in pulse, facial
expression, and general condition, although the tempera-
ture was not reduced. With this condition we felt justi-
fied in deferring the operation for the night. Dr. Hef-
fron reported the improvement in local and general
manifestations on the following day to be so decided that it
seemed possible that the patient might recover without
operation. I did not see him again until 10.30 a.m.,
April 4th, the eighth day of his sickness. The tumefac-
tion had in the meantime entirely disappeared, and a dis-
tinct tumor, two inches in length and one and one-half in
width, was present opposite the anterior superior spinous
process. It reached externally to the brim of the pelvis.
Temperature, 1010 F. ; pulse, 80. Operation was acceded
to, and as soon as preparations could be completed was
undertaken. An oblique incision four inches in length
.was made about three-quarters of an inch from the bnm
of the pelvis, well toward the outer border of the tumor.
Upon carrying the incision downward, despite its extreme
dextral location, I entered the free peritoneal cavity.
The following condition was found : A loop of small in-
testine adherent to the caecum was directly under the
incision, both large and small intestines were of normal
appearance, the tumor lay posterior to the caecum and
well against the outer border of the pelvis.
Protected by firm adhesions at this point from the gen-
eral peritoneal cavity, it was apparent that it would be
both difficult and hazardous to enter the abscess cavity
through the abdominal route. The incision into the
peritoneum was therefore closed and the transversalis fas-
cia sutured over it Through the same surface incision
I now dissected closely to the brim of the pelvis, until I
reached a point deep enough to feel the tumor behind the
caecum. In doing this, at the upper angle of the incision,
the omentum came into view. Surrounding the abscess
cavity with gauze pads I incised it. It contained offen-
sive pus, and a long, cord-like, gangrenous appendix. The
pus was carefully mopped out. At the lower angle the
abdominal cavity was likewise entered and protected by
gauze pads. Everything being thoroughly cleansed with a
1 to 1,000 sublimate solution, the appendix was tied off
as close to its base as possible. Here it was surrounded
by a firm exudate. Iodoform gauze, carefully folded to
prevent any ravelling, was first carried down to the bot-
October 6, 1894]
MEDICAL RECORD.
425
torn of the wound to protect the intestines below, and
then above against the omentum. Finally the cavity
proper was filled. The usual surgical dressing was ap-
plied.
Temperature before operation, 101.80 F., at 10 p.m.
98. 8° F. ; pulse 75. The following morning, temperature
990 F. ; pulse, 75 ; no vomiting had occurred. Catheteri-
zation was necessary the first night, but not again. The
dressings were not removed until the end of the third day,
at which time it was found that protective adhesions existed
on all sides. The odor, however, was very strong. The
skin, for an area of two inches, was found reddened and
infiltrated, and upon lifting up the inner flap the muscular
tissues as well as the aponeuroses, infected by the dis-
charge, had become gangrenous. For the following four
days care was required in dressing the wound. All gan-
grenous structures were thoroughly removed, sublimate
solution, 1 to 1,000, was carefully rubbed into every nook
and corner, and in {this manner by April 12th all dead
structures had been cleared away and the entire wound
surfaces presented healthy granulations. From this
period the patient progressed rapidly to a complete re-
covery.
Case IV. — W. B . During the first twenty hours of
his sickness he received no medical attention. At my
first visit, pain, vomiting, fever, but without characteris-
tic local manifestations, were present. In the course of
seven hours marked improvement in the general symp-
toms occurred. Tenderness at a fixed point in the right
iliac fossa appeared and continued. The fecal collection
in the caecum was cleared away by the exhibition of sa-
lines. The morning visit, on April 2 7 th, disclosed the fol-
lowing condition : Temperature, 99 20 F.; pulse, 80; he
had passed a comfortable night ; the tenderness remained
undecreased ; there was no dulness. By evening, how-
ever, the patient, having passed the entire day comforta-
bly, sleeping most of the time, exhibited a temperature
of 100. 6° F., and for the first time there was an area of dul-
ness lying a little higher than the point of tenderness, not
well defined but readily recognized. The disease was
evidently progressing. Dr. Heffron saw him soon after
with me and confirmed the diagnosis, but agreed that
operation could be deferred until morning. He was
taken to St. Joseph's Hospital at 8 a.m., April 28, 1894.
His pulse was 68, firm and regular ; temperature, 100. 20 F. ;
tongue was moist, area of dulness increased and now
about two inches in length and one in width. He was
prepared for operation.
An oblique incision was made four inches in length
and one inch from the anterior superior spinous process.
Upon opening the peritoneal cavity, there was no dis
charge of serum or pus ; the caecum was readily recognized,
drawn inward, and the presenting abdominal structures
were covered by gauze pads wrung out of a sublimate so-
lution. The finger recognized the appendix, which upon
being lifted out was found to be deep purple in color,
greatly infiltrated, with an equally thick mesentery ad-
herent to it, throughout its entire length. Its free ex-
tremity was on the point of gangrene ; upon the mesen-
tery, beginning ulceration was evident. The entire mass
was about two inches in length and one and one- half in
its transverse diameter. The appendix and its mesentery
were ligated separately with silk, and the few drops of pus
which were extruded were caught as it was severed.
Everything was carefully washed with a sublimate solu-
tion of 1 to 1 ,000. At no point was there evidence of ad-
hesions. Iodoform gauze was carefully packed about the
stump, walling off the omentum and intestines. The
peritoneum and abdominal walls were sutured to within
an inch of the lower end of the incision and the wound
dressed as usual.
At the conclusion of the operation, the patient's pulse
was 69, and, at 5 p.m., temperature, 98. 50 F. ; pulse, 68.
The outer dressings were changed on the following day,
but the packing in the wound was undisturbed until the
fifth day. He required catheterization on the night
following the operation. Temperature until the day
before the change of the deeper dressings were made,
reached no higher point than ioo° F. ; at this time,
however, it was 101.20 F. The wound was carefully
irrigated with a normal saline solution, cautiously dried
and carefully packed with iodoform gauze. The wound
cavity could be seen to be outlined by the intestines
covered with a grayish layer of inflammatory exudate.
It was thought advisable not to disturb the bowels until
the sixth day, when they were moved by an enema. On
the seventh day, three one drachm doses of Epsom salts,
at intervals of four hours, were administered, and a large
movement was secured, followed by two other watery
discharges. The abdomen was at no time distended.
General abdominal tenderness and a dry tongue were
present on the day following the operation, but after
this no symptoms suggesting peritoneal disturbances
appeared. The patient made an uninterrupted recovery.
Section of the appendix disclosed the presence of pus.
At its free extremity, corresponding to the site of gan-
grene, was an infectious thrombus. Upon bacteriologi-
cal examination, Drs. May and Levy report having
found a pure culture of the bacillus coli communis.
The four cases to which your attention has been
invited this afternoon, present varying types of acute
infectious inflammation of the appendix. The first, be-
cause of its malignant and rapidly progressive character,
is described as fulminating. In the second and third,
the inflammatory process reaching beyond the appendix,
and invading peri- appendicular structures occasioned
abscess formation. In the second the pus collection was
superficially placed, but in the third it was buried behind
the caecum. The fourth case, beginning probably as a
catarrhal appendicitis became changed in character by
the occurrence of an infectious inflammation of the
blood-vessels.
What to do for a given case of appendicitis, at once
becomes a most serious question. Which cases will
progress happily without surgical aid and which can be
saved by timely operation, are the questions, the answer
to which requires not only rare diagnostic acumen, but,
in their management, careful medical and energetic yet
painstaking surgical intervention.
I am less ready than I was eighteen months ago to
maintain that much the larger percentage recover by
medical treatment alone. Every case of appendicitis
should be seen during its first twenty- four hours so fre-
quently that the physician can satisfy himself of either
decided improvement in both local and general manifes-
tations or detect any disposition to progression. The
wise course is that, from the outset, the case should be
watched by both physician and surgeon. Of the two, I
believe more stress should be placed upon the local than
the constitutional manifestations. If there be equal dis-
appearance of both general and local symptoms during
this period, there is no need to feel that surgical aid is
to be invoked. Aside from the careful administration of
salines and intestinal antiseptics, the less medicine pre-
scribed for the patient, the better. Nothing should be
administered which in any way is to mask the symptoms ;
the exhibition of opiates, by relieving the pain, lulls the
patient into a feeling of security and prevents his proper
conception of the degree of his suffering.
The only safe rule to follow is, that evidence of con-
tinued progression at the end of twenty-four to thirty six
hours justifies and indeed calls for operation. Even the
cases remaining stationary during this period must be
viewed with suspicion. The cases presented in these
papers indicate very clearly that there may be mitigation
of all and complete disappearance of most of the symp-
toms and yet during the period of their subsidence the
diseased process has gone on steadily. The pulse may
become lowered, the temperature sink to normal, and all
this time gangrene may be advancing or ulceration im-
minent. With improvement in constitutional sy mptoms,
the local signs demand the closest attention. An in-
crease of tenderness, the appearance of tumefaction, the
development of a tumor, mean much more than any
426
MEDICAL RECORD.
[October 6, 1894
variation in pulse and temperature, or the feelings of the
patient. The first evidence of dulness in the fourth
case, despite apparent general improvement, was the sig-
nal for operative intervention.
When the patient is overwhelmed by an infectious in-
flammation as virulent as that presented in the first case,
or when septic peritonitis has manifested itself as a later
complication, the hope of aid by medical means is gener-
ally abandoned. But under these circumstances the
surgeon's art is equally powerless. It is in the other
group of acute cases, with less violent manifestations,
that it becomes a question of vital moment to decide
when the opportune •time for operation has arrived.
Operations are described as early and late. An early
operation implies its performance during the period in
which the inflammation is still limited to the appendix.
The element of time is not the only consideration in de-
termining whether or not the operation be early. If dur-
ing the first twenty four hours of an appendicular inflam-
mation the infection has spread through the lymph- vessels
of an unperforated organ, or has extended from one dis-
organized and involved the entire peritoneal cavity, it is
evident that the operation then performed is early in point
of time, but too late to avert wide spread and probably
fatal septic inflammation. On the other hand, an opera-
tion performed on the third day, as in our last case, while
not done upon as early a day, was still timely, for by it
we did no doubt avert septic peritonitis.
Late operations are those performed after abscess for-
mation has occurred, walled off by firm adhesions ; the
mere incision of these abscesses is a comparatively simple
operation. But during the period of their formation it
is often a matter of great difficulty to determine whether
the patient's chances may not be improved by delaying
operation until nature has rendered her fullest assist-
ance. There is a group of cases seen from the third to
the fifth day of sickness, when, as Richardson puts it, we
may hesitate whether we may not be too late for an
early operation and too early for a late one. Done at
this period, he believes no operation in surgery more
difficult than the removal of the appendix without infect-
ing the general peritoneal cavity. This situation pre-
sented itself in our third case. At the end of the third
day a tumor was beginning to form in the midst of the
tumefied area. An operation done at this time would
have been an entirely different procedure from the one
undertaken on the eighth day.
To perform a radical operation, the rule must be,
operate early. That this injunction adds greatly to the
security of the patient, is apparent in studying the re-
sults obtained by Fowler in 127 cases operated on by him.
Of 58 operated on during the first three days, eighty-three
per cent, recovered; of 9 on the fourth day, sixty- six
per cent. ; of 26 on the fifth and sixth days, fifty eight
per cent. ; of 18 on the seventh and eight days, fifty per
cent. ; while of 9 on the ninth and tenth days, thirty-
three per cent.
The great fatality attending his late operations is not
in accord with my experience. The operator probably
sought to do more than give vent to the contents of the
appendicular abscess, and by breaking down the protec-
tive barriers, infection gained admission into the perito-
neal cavity.
Increasing experience adds to the operator's ability to
deal with these cases. Preparations for the operation
must be hurriedly made. These cannot be as thorough
as in an ordinary laparotomy. The operator may be
handicapped by the facilities at his disposal. The sur-
faces purified as well as possible, the site of his incision
is selected according to the period at which the
operation is undertaken. The length of the incision
should be sufficient to afford the most free access to all
diseased surfaces. Dealing with an acute infectious
inflammation, nothing is calculated to produce more
serious consequences than an inadequate incision, which
must prevent both the protection necessary for the ab-
dominal viscera and the delicacy of manipulation abso-
lutely required. In our first case the incision was verti-
cal, along the outer border of the rectus muscle. This
was indicated because the acuteness of the attack foretold
that we would be obliged to enter the free peritoneal
cavity. Evidence of septic peritonitis at once encoun-
tered, presented the most dubious outlook for the patient.
The steps taken in the course of the operation have
been indicated in the history. A glass drainage-tube
was used in the first case. In the operations which I
have performed since that time, I have used only gauze
drainage, and have reason to believe that this procedure
is much the wiser one. The abdominal cavity was irri-
gated with a saline solution. Although this receives the
strong endorsement of most of the surgeons it was futile
with us. The Germans say that " Spuelerei ist Spiel-
erei " — that is to say, " irrigation is child's play."
Of thirty- two cases in which general peritonitis was
encountered by Fowler, not a single recovery occurred.
Others claim to have been more fortunate. This has,
however, been my experience in three cases in which
I encountered it in operating.
In Case IV., in which likewise an early operation was
undertaken, we were fortunate enough to secure the re-
moval of the appendix with its mesentery, the one about
to become gangrenous and the other on the verge of ul-
ceration, before further infection had been awakened.
No adhesions were present, but the greatest care was
taken to protect by gauze pads all visceral contact with
any infectious matter. The- appendix and its mesentery
after ligation presented a stump so broad and infiltrated
that it was impossible to undertake what in chronic
cases is an ideal step, namely, to dissect up a cuff of the
peritoneal investment, invert the remainder of the stump,
and secure the serous coat over it by a Lembert suture.
We were obliged to content ourselves with its purifica-
tion by means of the sublimate solution and the thermo-
cautery.
Iodoform gauze was carried into the wound. The
four strips carefully placed around the stump were in-
folded in such a manner as to prevent a free edge of the
gauze presenting itself at any point. This is essential,
that none of the threads may adhere to the abdominal
structures, and greatly facilitates the removal of the pack-
ing. Allowed to remain for four or five days, nature
throws about the gauze a protective wall. This usually
averts future general infection.
The second case was of all the most simple, but ex-
hibits a pathologic peculiarity, which as far as I can learn
is quite unique. The destructive process had evidently
reached the vascular supply of the appendix. The ver-
miform process, collapsed and gangrenous, was found in-
bedded in an infectious blood- clot. The surgical steps
taken with this patient have been amply justified in his
very rapid recovery. The wound quickly cleansed
itself, and in fact it has never been my experience to see
a cavity fill up so quickly as did this. Great aid to its
accomplishment was the manner in which the gauze was
inserted. At each dressing, by carefully carrying it to
the bottom of the wound, lightly placing it here, and
then distending the upper portion as much as possible
by firm packing, we secured within a few days a funnel-
shaped wound, sloping gently from the sides to the
centre, and gave it at the same time the largest possible
area for granulation.
Case III. presented a most serious surgical problem.
The incision was made well toward the pelvic brim,
inasmuch as it was recognized that the tumor could thus
be more easily reached. In taking this step, we disre-
garded the usual instructions given, which are to make
the incision over the most prominent portion of the
tumor. This was also done in Case II. It seems to
me wiser in performing a late operation to attempt, if
possible, to establish an extra peritoneal route. This is
accomplished better by making the incision as far out-
ward as possible, rather than over the most prominent
portion of the tumor.
After entering the peritoneal cavity, two courses were
October 6, 1894]
MEDICAL RECORD.
427
left open to us. Good surgeons state that with post-
cecal abscess, it is sometimes necessary to reach it by the
abdominal route and to drain through the ud implicated
intestinal structures. Aside from the impossibility of se-
curing drainage through an up hill channel, the virulent
infection which manifested itself within a few days after
the operation in this case and produced such destructive
gangrene of the abdominal walls, I believe shows the
wisdom of the course pursued. Such intense infection
could not have been withstood by the intestines, and
must have produced a rapidly fatal spreading peritonitis.
On the other hand, closure of the peritoneum and the trans
versalis fascia over it, permitted us, by means of another
incision through the muscular structures, to reach the
brim of the pelvis, and by careful dissection the abscess
was exposed and entered through its outer wall. Even
here we could not avoid exposing the omentum above
and the intestines below. After three days, however,
protective adhesions sealed up the extremities of the ab-
scess cavity and free drainage was permitted. More
than this, the removal of all gaDgrenous structures was
made possible. The appendix was readily exposed and
removed. Again the use of iodoform gauze, placed after
the manner described, secured not only limitation of the
abscess cavity, but also the desired funnel-shaped wound.
The recommendation to enter these abscesses by in-
cision through the rectum, it is evident could not have
yielded as satisfactory a result. The fear that extra-
peritoneal incision in the late cases may not be suffi-
ciently radical, because of the possible existence of mul-
tiple abscesses, is, I believe, no longer regarded as well
grounded. These rarely, if ever, occur late, although
frequently present early. In both of the cases reported
the sudden recurrence of fever indicated to the medical
attendant that the opportune moment for operation had
arrived.
The importance of the surgical attention required by
these cases after operation is not sufficiently appreciated.
I esteem it the duty of the surgeon to personally super-
intend the change of dressings until there is no further
possibility of infection. This can be done many times
only at a great sacrifice of time, but the best interests of
the patient demand it.
It must be evident that the three cases which have re-
covered by operation could none of them have been
saved by other than surgical intervention. In the ful-
minating cases complicated early by septic peritonitis,
the prognosis is almost hopeless. Where this complica-
tion appears at a later period, a gloomy termination is
likewise to be feared. I feel confident that twenty four
hours later this would have been the situation in Case
IV.
With a clearer conception of the nature of these infec-
tious inflammations and the improving technique, largely
the work of American surgeons, the percentage of recov-
eries will probably increase in the future, if operation be
done sufficiently early to anticipate the frightful results
of microbic invasion. I regret that in all of the four
cases bacteriological examinations were not made, but
in two the facilities for the same were not at hand.
The increasing importance given each year to the sur-
gical treatment of infectious appendicitis may be regarded
by some as uncalled for and unjustifiable. From my
standpoint, however, it is directly in the line of conser-
vative surgery. We remove a part not essential to the
animal economy, but thereby we have saved life.
Laws Relating to the Practice of Pharmacy. — The
Agricultural Department in Washington has published a
report upon the laws regarding pharmaceutical practice
in the different States and Territories of the Union. It
shows that there are no laws on the subject in Idaho,
Indiana, Montana, Nevada, Arizona, and the Indian
Territory. In Maryland, there is a law which applies,
however, only to the city of Baltimore. The compilation
is based on reports made by the various State pharma-
ceutical associations.
THE THYROID TREATMENT OF PSORIASIS,
AND OTHER SKIN DISEASES.
By GEORGE W. CRARY, M.D.,
NEW YOBK.
ASSISTANT ATTENDING SURGEON, ROOSEVILT HO&NTAI, OUT-PATIENT DEPART-
MENT.
Since Davies and Bramwell reported their remarkable re-
sults following the use of th)roid preparations in psoria-
sis and some other diseases of the skin, the method has
been perhaps somewhat widely employed, though but
comparatively few reports have been published. Below
I give briefly the histories of nine cases of psoriasis that
I have had under this treatment for varying periods 1 fol-
lowed by a short summary of previously reported cases.
Case I. — Male, aged twenty-six; disease of three
years' standing, with recurrent attacks ; longest period of
exemption was one month. Eruption in large and small
patches of general distribution. General condition fair.
Temperature before treatment was 98$° F. Doses of
glycerice extract (gr. xxiv. to 3 j)2 rose from 9 to 15
drops daily, in three divided doses. Highest tempera-
ture during treatment was ioo° F. After two or three
days' treatment, the irritation was allayed. Complained
of pain in joints. Treatment continued for two weeks.
No improvement.
Case II. — Male, aged thirty six ; seven months' stand-
ing; small spots general in distribution; very irritable.
Temperature before treatment was ioo^° F. Dose of
extract was 9 to 18 drops daily. During treatment tem-
perature varied from 9 7 j4° to 98$ ° F. Irritation much
lessened. General condition improved. Marked sheep
odor to perspiration. Treatment continued for five
weeks. No improvement.
Case III. — Female, aged thirty nine; eruption for
two and one half years, in spots over body with excep-
tion of face, neck, and chest. General condition gcod.
Temperature before treatment, 990 F. There was con-
siderable hypertrophy of thyroid gland. Dose of extract
was 15 to 40 drops a day. Temperature during treat-
ment, 98!° F. Irritation allayed. Duration of treat-
ment was six weeks. No improvement, and even grew
worse.
Case IV. — Male, aged twenty-five ; two years' stand-
ing, but disappears in summer; small spots upon aims
and chest. General condition poor. Temperature be-
fore treatment was 98$° F. Daily amount of extract, 15
to 45 drops. During treatment temperature between 970
and 97 j° F. Skin between spots much softened. Irri-
tation lessened. Pain in arm. General condition im-
proved. Duration of treatment *as eight weeks. No
improvement.
Case V. — Male, aged forty- six ; eruption for ten years,
severe and general. General condition poor. Temperature
before treatment, 99^ ° F. Daily amount of extract was
from r 5 to 36 drops. Temperature during treatment^e-
tween 970 and 990 F. Skin between patches became soft
and velvety. Irritation lessened. Sheep odor very pro-
nounced. General condition improved. Treatment con-
tinued for twelve weeks, with one interruption of two
weeks. Eruption much improved.
Case VI. — Male, aged fifty; eruption for twenty
years, and is general and severe. General condition
poor. Temperature before treatment, 9&j4° F. Daily
amount of extract varied from 15 to 75 drops a day.
Temperature during treatment ranged from 97$° to ioo°
F. Intercurrent attack of facial erysipelas and later of
cellulitis of leg, from external infection. Sheep odor
very marked. Skin not affected by disease became very
soft and smooth. Pains in joints. Treatment continued
for eleven weeks. Very marked improvement.
Case VII. — Female, aged thirty ; disease of ten
years' standing ; small spots upon upper and lower ex-
tremities and upon chest. General health is fair. Tem-
1 These cases were treated at the Out-Patient Department of the
Roosevelt Hospital with the kind permission of Dr. Frank Hartley,
the Attending Surgeon.
9 Medical Record, June 17, 1893.
428
MEDICAL RECORD.
[October 6, 1894
perature before treatment was 100 j£° F. Daily amount
was from 15 to 60 drops. Temperature during treatment
varied from 970 to 99$° F. Irritation very much al-
layed. Skin not affected became soft and smooth.
Treatment for fourteen weeks. No improvement.
Case VIII. — Female, aged thirty ; two years' stand-
ing, not severe but general. Temperature before treat-
ment, 98^° F. Daily amount was 10 to 30 drops.
Temperature during treatment, 98$° F. Treatment
continued for three and a half weeks. No improve-
ment.
Cask IX.— Female, aged twenty-three; disease of
two years* duration, and upon legs and thighs. General
condition fair. Disease persisted throughout a recent
pregnancy. Temperature before treatment, 99 ° F.
Daily amount taken was from 15 to 30 drops. Temper-
ature during treatment varied from 98^° to 98$° F.
Irritation not lessened. Pain in back. Duration of
treatment was five weeks. No improvement; grew
much worse.
We have here nine cases of psoriasis, in which im-
provement has been noted in only two, and in these
two the response to the treatment has been very slow and
not distinctly progressive. It may be objected that in
some of these cases the treatment has been of short
duration, but where cures have been reported the im-
provement became manifest very early. That the thy
roid has a beneficial effect upon the skin in myxoedema
is most certain, and indeed it is equally certain that in
other conditions such an effect is produced, for in all the
above cases the skin between the patches or spots of the
eruption became soft and smooth. The thyroid extract
has a very profound effect upon general nutrition, and
perhaps especially upon the skin, and to this js due the
changes noted. I have been struck in the above cases
with the absence of a rise in temperature following the
treatment, for in most of the cases the temperature has
fallen to the subnormal and remained there, the fall
roughly being in proportion to the dose. In some the
rheumatic pains, frequently noted during thyroid ad-
ministration, were present and complained of. In many
of the cases there was a marked and unpleasant odor of
mutton or lamb to the perspiration.
Below I give a short table of the cases of psoriasis
treated by thyroid, the reports of which have already
appeared:
Reporter and
Reference.
in
•S5 I W
1
2 z
.1'
r
Average Daily
Dose.
Da vies : Brit. Jour.
Derm., 1893. v. 257.
B. Bramwell : Brit i
Med. Jour., 1893, ii.
«l
L9R'illips: Brit Med. a
Jttur., 1893, ii. 1x52. 1
T. Jones : Brit. Med. x
Jour., 1893, ii. 1424.
B. Squire : Brit. Med. 2 I
Jour., X804, i. 13.
J. F. G. DM: Lancet,
London, 1894. i. 19.
P. Abraham : Lancet, 49
London, 1894, i. 94.
W. Anderson : Lancet
Ixmdon, 1894, i. 94.
John Gordon : Brit.,
Med. Jour., 1894, i.
186.
I
. . I Tabloids, gr. v.
a Extract, 1™, xv.
, . . I Tabloids, gr. xxx.
I Extract, Til x.-xv.
I x ; Tabloids, gr. xv.-
xx.
Extract, tq, xx.
I .
2 1 Tabloids, gr. xv.
x8! 16 ( 15 ( Tabloids, gr. xv.
I
x Extract, T?l xx.
Duration
of Treat-
ment.
6 wks. and
3 mos.
2 to 3 mos.
a and 3
mos.
23 days.
19 and 31
days,
x month.
3 weeks.
7 weeks.
1 Eleven of these improved cases received other treatment, and should therefore
be eliminated in drawing conclusions.
9 Syphilitic psoriasis, no other treatment.
We have left before us, then, including my own cases just
reported, 77 cases of psoriasis which have been treated
by thyroid preparations. Of these in six, or about eight
per cent., the treatment has been followed by a cure.
Twenty-two have been improved, but of these we must
deduct the n cases of Abraham's which received also
other treatment, and then we have 66 cases treated, with
17, or twenty- five per cent., improved. Of the 49 cases
which were not benefited by the treatment, ai grew dis-
tinctly worse.
Other diseases of the skin than psoriasis, and the re
ported results are no more encouraging :
Davis : Ichthyosis, one case, improved ; chronic ecze-
ma, one, improved.
Phillips: Eczema, one, no result; xeroderma, one,
marked improvement.
Dill : Acne rosacea, one, no result.
Abraham: Lichen planus, 5 cases — 3 improved with
other treatment combined. Eczema; 7 cases — 3 im-
proved, other treatment also. Chronic urticaria, 2 cases,
both grew worse. Prurigo senilis, 1 case — no result A
case of " peculiar papular eruption," 1 case — improved,
other treatment. Lupus, 5 cases, other treatment also,
improvement.
While then we know that in myxoedema, and in other
conditions also, the administration of thyroid prepara-
tions is followed by marked changes in the skin, render-
ing it soft and smooth and moist, we must look upon
these changes as merely nutritive, and while possibly in
some cases such changes, if more thoroughly understood,
could be used as an aid in therapeutics, I think we have
little reason to believe that thyroid extract is in any di-
rect way curative of any real disease of the skin or its
appendages.
15a West Fibty-seventh Steeet.
THE MANAGEMENT OF ABORTION.1
By EDWARD J. ILL, M.D.,
NEWARK, N. J
FELLOW Or THE AMERICAN ASSOCIATION OF OBSTETRICIANS AND GYNECOLO-
GISTS ; SURGEON TO WOMAN'S HOSPITAL ; GYNECOLOGIST TO ST. BARNABAS
HOSPITAL ', CONSULTING GYNECOLOGIST TO GERMAN HOSPITAL OP NEWARK,
N. J.; CONSULTING GYNECOLOGIST TO ALL SOULS HOSPITAL, OF MORRJSTOWW,
N. J., ETC.
The main object of a paper to be read before a society is
to furnish material for discussion. With this in view it
will be my object not to present an exhaustive discourse,
nor an opinion of writers. I wish to present for your
consideration and discussion such a method of treatment
as I have followed for a number of years, and with what
I consider very good results. How important this mat-
ter is to me will be shown when I tell you that I was
called upon lately to treat five septic abortions in a week.
I would divide the management of abortion into two
parts: 1st. The prevention of abortion, and 2d, the
management after we have once satisfied ourselves that
the product of conception must be expelled.
It will be proper to touch upon the causes of abortion,
since its prevention will in some measure depend on this
factor. I consider it as very rare to count external in-
jury, a jolt or jar, as a potent factor in the production
of abortion.
At the outset we will understand that disease of the
foetus or chorion may produce abortion as well as disease
of the mother. In this respect there is still a wide field
for observation and study.
Among the diseases of the mother may be mentioned :
Retroflexion of the uterus, chronic hyperplasia of the
uterus, chronic endometritis, laceration of the cervix
uteri, pelvic peritonitis, or rather its results, prolapse of
uterus, syphilis, and chronic nephritis.
When we find a retroflexed pregnant uterus it will be
necessary to replace it to its normal position with the
greatest possible care and gentleness. This having been
accomplished we may congratulate ourselves in having in
all probability prevented an abortion. The same can be
said of a complete prolapsus. When, however, the fifth
month of gestation is over the uterus can no longer be
replaced, and it either means death to the mother, or ar-
tificial interruption of gestation. In the other instances
of which I have spoken, our treatment must be directed
to the peculiar condition before conception takes place.
An exception to some extent is syphilis and chronic ne-
phritis. A lady of this town had aborted fourteen times
in succession, and became mother of a living child after
1 Read before a gathering of medical gentlemen at the house of Dr.
S. Pierson, Morristown, N. J.
October 6, 1894]
MEDICAL RECORD.
429
an operation for deep laceration of the cervix. Only the
other day I was told of a woman who gave birth to a
living and healthy child after having aborted six times
before the third month of gestation. The patient was
known to have syphilis, and was under antisyphilitic treat-
ment for five months.
I believe that after longer observation we shall be able
to discard the term habitual abortion, since we shall find a
cause for all these cases. In the treatment of threatening
abortion we are first confronted with the very important
question : Are there stitt well-founded prospects of pre-
venting an abortion or is it beyond our reach ? If we
have decided for the former the patient must be instructed
to keep quiet on the first appearance of a bloody dis-
charge or bearing-down pain, her lower bowel should
be kept emptied, her diet a bland one, sexual intercourse
stopped, and opium or cannabis indica administered.
When shall we know that our endeavors are in vain ?
The safest symptoms are when the cervical canal has di-
lated sufficiently to allow the finger to touch the ovum,
or when the os internum is dilated to such a degree that
the cervix and the corpus uteri shall form one cavity.
We would also know that our endeavors are in vain when
pieces of the decidua have been passed, or when there is
a fetid discharge from the uterus. The latter is a sure
symptom that some parts of the ovum have undergone
necrosis and death.
As a rule an abortion is sure to take place when the
patient has lost blood for a length of time in large quan-
tities, accompanied with labor-pains. I have seen preg-
nancies continue, however, when the patients had one or
two large hemorrhages, as well as I have known a child go to
full term when there was a bloody mucous discharge for
several weeks. " When we feel certain that the product of
conception will be cast off, then it becomes our duty to
relieve the patients as soon as possible so as to prevent
their undergoing the ordeal following retained secun-
dines.
If we have reason to believe that the ovum is intact
and the uterus is doing its work well, and gradually
emptying itself, then we had better not be meddlesome.
We can render the uterus valuable assistance in its en-
deavors by a large, hot vaginal douch or a tampon. A
large, hot rectal injection will often be of signal value.
Occasionally I was forced to assist the uterus by instru-
mental dilatation of the os externum, and then I used
GoodelTs dilator with much satisfaction.
So long as the ovum is intact, the uterus will probably
have no difficulty in forcing it out, and when it lies in
the cervical canal can be removed easily by the finger
with a sweeping motion. At times we will be confronted
by a severe hemorrhage, often of an alarming character.
Here an iodoform gauze, or a clean cotton tampon will do
its work well. It should be introduced through a large
cylindrical, or a Sims speculum, and care be taken to
plug the vagina around the cervix and os very thoroughly.
If the uterus itself is to be plugged it can only be done
through a Sims speculum, the patient lying on her back
with the hips over the lower end of a table. The vagina
and cervix should be thoroughly cleansed, the speculum
introduced, and the cervix drawn down with a tenacu-
lum forceps. A narrow pair of dressing forceps pushes
a long narrow strip of gauze into the uterus until this or-
gan is filled.
This is by all means the safest and surest remedy. I
would warn against the use of all styptics on account of
the great danger of sepsis. Occasionally we will succeed
in delivering the ovum in toto by a combined abdominal
and vaginal compression performed in the following way :
Two fingers of the right hand are placed anterior to the
cervix in an anteversion and posterior to the cervix in
a retroversion, while the left hand seeks the uterus from
the abdomen and on its posterior or anterior surface, as
the case may be, makes pressure in the direction of the
dingers in the vagina. When the ovum has been broken,
or a finger once introduced into the uterine cavity, then
an instrumental delivery with curretting of the endo-
metrium becomes a necessity. It becomes a life-saving
operation when the patient shows signs of sepsis. In
these cases it is my custom to operate in the following
way. The patient being under the influence of an anaes-
thetic, is placed in the lithotomy position on a table
with the hips well down over the lower end. A Kelly
perineum pad or ordinary oil cloth is placed under the
patient, so that all fluids are directed to a pail or bucket
below. The vulva and vagina are then thoroughly
washed with soap and hot water, and disinfected with a
hot solution of mercuric bichloride, 1 to 4,000. A Sims
speculum is now introduced and held by an assistant,
who also holds the right leg of the patient and the irri-
gating tube, while the left leg is held by a second assist-
ant, who also administers the anaesthetic.
The anterior lip of the cervix is caught up with a
tenaculum, or what is better, a tenaculum forceps, and
drawn down somewhat so as to straighten the canal.
The canal is now thoroughly dilated, if necessary, by an
Ehlinger or Goodell dilator, and the cavity of the uterus
thoroughly curretted with a sharp instrument, or else, if
large pieces of tissue were left they should first be re-
moved with a broad bladed dressing forceps. There is
very little danger of wounding the uterus unless sepsis is
far advanced. Under these circumstances we must
manipulate very carefully, for I have seen a curette
pushed right through the fundus of the uterus into the
peritoneal cavity. The horns and fundus must receive
our especial attention in curetting, as these are the most
difficult parts to clean.
During all this a constant stream of a solution of mer-
curic bichloride, 1 to 4,000, is poured upon the cervix.
When the uterus has been thoroughly curetted the cavity
is also irrigated with the same solution, preferably
through a return catheter. The whole procedure of
curetting and irrigating should be repeated to assure
ourselves of the successful accomplishment of our object.
Let me here say, that it must be done systematically;
thus the anterior wall, the posterior wall, the right horn,
the left horn, and the fundus are scraped in the order
mentioned.
As the uterus has now been thoroughly cleansed the
vagina is also irrigated. The fluid remaining in the
vagina is mopped up with a piece of iodoform gauze,
and a strip of the same material is laid into the cervical
canal and to the fundus of the uterus for drainage. The
tenaculum forceps can now be removed and the vagina
loosely filled with gauze. If there is reason to fear hem-
orrhage, and there is none if we have removed the cho-
rion and decidua thoroughly, it is well to fill the uterus
tightly with gauze, which must be done with one long
strip. In either case the gauze is removed in twenty-
four hours. If the patient has no fever a vaginal douch
of one per cent, solution of carbolic acid may be or-
dered. If she still has fever, the uterus should be irri-
gated again, and a strip of gauze again inserted into the
cavity. Great care should be taken that the strip of
gauze is not too wide, otherwise it will be the means of
blocking up the uterine discharge.
Instead of reapplying the gauze, we may choose to
irrigate the uterus every four hours with sterilized water,
or a solution of mercuric bichloride of 1 to 10,000, until
there is no more fever, or until we are satisfied that the
germs have gone beyond the cavity and mucous mem-
brane of the uterus.
From what has been said I would draw the following
conclusions :
Since an abortion is a pathological and not a physio-
logical condition, as is a birth at time, it must be treated
on other principles than the latter. In many cases our
interference becomes necessary because we deal with con-
ditions which favor a retention of the secundines, as,
for instance, a broken ovum, a displaced, a septic or
otherwise diseased uterus. When we can foresee the
probability of a retention we must use such efforts as
will further its expulsion, provided it can be done by
such means as will not produce injury to the mother.
430
MEDICAL RECORD.
[October 6, 1894
Id this condition, like in many others, to do a thing half
is worse than not to do it at all.
In a majority of cases a clean finger is the best instru-
ment. However, if the whole ovum and decidua have
not come away, then the forceps and the sharp curette
find their places, the latter for thorough removal of the
uterine decidua.
A temperature of ioo° R, or above, is always a dis-
tinct indication for an immediate cleansing out of the
uterus. The vulva, vagina, cervix, instruments, and
hands should be made thoroughly aseptic before an op-
eration is permitted.
In septic cases large, hot antiseptic intra-uterine in-
jections should follow the cleansing out of the uterus,
and the uterus should be drained by gauze. Let me
also say that I have never seen any good come from
ergot given previous to emptying the uterus.
THE USE OF THE RESORCIN TEST FOR THE
DETECTION AND QUANTITATIVE ESTIMA-
TION OF THE FREE HYDROCHLORIC ACID
OF THE GASTRIC JUICE.1
By JULIUS FRIEDENWALD, A.B., M.D.,
BALTIUJRS, MD.
CUMICAL PXOrCSSOX OP DISEASES OP TIM STOMACH, COLLEGE OF PHYSICIANS
AND SURGEONS ; VISITING PHYSICIAN BAY VIEW HOSPITAL, BALTIMORE.
Since the chemical examination of the gastric secretion
has assumed such importance in the diagnosis and treat-
ment of diseases of the stomach, it is important that the
simplest as well as the most reliable tests available should
become better known. It is for this reason that the re-
sorcin test of Boas is brought forward, and it will be the
object of this paper to show that with it quite as reliable
results can be obtained as with Giinzburg's reagent,
which, though more commonly employed, possesses cer-
tain disadvantages.
In 1888 Boas ■ first published the report of his reagent,
consisting of:
Resorcin resub .• 5
Sacch. alb 3
Spiritus dilut IOO
and claimed for it an accuracy equal to that of Giinzburg's
phloroglucin vanillin * test. Boas's reagent, like Giinz-
burg's, reacts only to free hydrochloric acid and never
to organic acids. The reaction is carried out as follows :
A few drops of the solution are heated gently in a porcelain
dish with an equal quantity of gastric filtrate to complete
evaporation ; a red mirror is produced when free hydro-
chloric acid is present. Puriz,4 A. Meyer,* and Leo * con-
firmed Boas's statements in regard to the accuracy of this
test. Yet the reagent has never gained the popularity
that it deserves. Stewart 7 almost habitually employs the
phloroglucin test, but in the few instances in which he has
resorted to the resorcin test the results have been equally
satisfactory. In such excellent works as the new editions
of Hoppe-Seyler's " Physiological Chemistry," and Von
Jaksch's " Clinical Diagnosis," this test is not even
mentioned, though far inferior tests are described.
My own observations with this reagent lead me to be-
lieve that it is not only quite as reliable for the detection
1 From the Clinical Laboratory, College of Physicians and Surgeons,
Baltimore.
a Boas : Ein neues Reagens fur den Nachweis Freie Salzsaure in Ma-
geninhalt. Centralbl. fur Klinisch. Med , 1888, No. 45, und Diagnos-
tic und Therapie der Magenkrankheiten, 1 Theil, S. 134.
* Gfinzburg: Neue Methode zur Nachweis freier Salzsaure im Ma-
geninhalt. Centralb. f Klinische Med., 1887, No. 40. GQnzburg's
reagent consists of :
Phloroglucin 2.0
Vanillin 1.0
Alcohol absol 30.0
4 Puriz : Ueber eine neue Quantitative Reaktion auf freie Salzsaure
ein MagensafL Centralb. fur klin. Med., 1890, S. 452
8 Mever : Ueber die neueren und neuesten Methoden des qualita-
tiven >?achweises freier Salzsaure im Mageninhalt. Dissert. Inaug.,
Berlin, 1890.
* Leo : Diagnostik d. Krankheiten d. Verdauungsorgane. Berlin,
1890, S. 98.
T Stewart : Hare's System of Therapeutics, vol. ii., pp. 897, 898.
of free hydrochloric acid as the phloroglucin test, but
that it can be as well used for quantitative examinations
as the latter, and perhaps with greater advantage. The
accuracy of both tests is about the same. It varies,
however, according to the various substances in solution
with the hydrochloric acid. According to Leo,1 .004
per cent, of hydrochloric acid in a purely watery solution
may be detected by GQnzburg's reagent, and .006 per
cent, by the resorcin test, while in the presence of other
compounds such as peptones, a much higher per cent of
hydrochloric acid may be remain undetected by either
test. The following is taken from his tables :
Substances in Combination with the Wa-
ter)- Solution of HC1.
Percentage of HC1 at which a Reaction
May Still be Obtained.
^dSP* Resorcin. Phloroglucin.
Water 0.00a
Acid potassium phosphate. Acidity =,
19V10 alkali 0.008
Albumen, 1 Albumen to 200 HaO 0.00a
Pepion, 2 per cent 0.002
Bread paste, 30 grammes to aoocc HsO 0.003
NaCK one per cent 0.003
Grape sugar, 1 per cent 0.002
Starch paste, 2 per cent. 0.003
0.006
0.09
0.08
0.16
0.03
0.05
0.16
0.03
0.0037
0.007
O-OIX
0.03
0.007
0.007
0.007
Inasmuch as certain substances, such as albuminous
compounds, combine with a part of the hydrochloric acid
and neutralize it, it was necessary for comparison in the
above cases to obtain the absolute quantity of free HC1
by a very accurate quantitative method, not relying on
the quantity of the HO which was added in the mixture.
According to recent observations of Kossler * the most
accurate method is the calcium carbonate test of Leo.
From my own experiments concerning the limit of ac-
curacy of phloroglucin and resorcin respectively, I have
found the following results :
Substances ia Combination with the Wa-
tery Solution of HC1.
Percentage of HQ at which a Reaction
May Still be Obtained.
IX5°TeSaCl1 Re*orcin. Phloroglu
Water 0.00a
Acid potassium phosphate. Acidity =
19V10 alkali 0.009
Albumin, t Albumin to 200 HaO 0.003
Pepton, a per cent 0.003
Hread paste, 30 grammes to 200 c.c HaO 0.003
NaCI, 1 per cent 0.003
Grape sugar, 1 per cent o.coa
Starch paste, 2 per cent 0.003
0.007
0.004
0.080
0.060
0.17
0.17
0.04
0.04
0.003
0.007
0.007
0.007
0.0 X
0.01
These experiments show that Boas's reagent is quite as
sensitive as that of Gilnzburg, and that it may readily be
employed for the detection of small quantities of HC1 in
place of the former reagent. In order to show that the
resorcin test may also be utilized for quantitative purposes
in the estimation of free hydrochloric acid, I have made
a number of quantitative estimations of the free hydro-
chloric acid in a number of specimens of gastric juices,
comparing the results obtained by Boas's and Giinzburg's
reagents with those of the more accurate method of Leo.
The method employed for the resorcin estimation is simi-
lar to the one of Mintz,* when the estimation is made
with phloroglucin.
The 'examination is made as follows : To ten c.c.
of gastric filtrate -fa normal, NaOH is added until a
reaction can no longer be obtained by testing with Boas's
reagent. If, for example, no reaction occurs after adding
1.3 c.c. decinormal NaOH, but a positive reaction
was still present with only 1.2 c.c. of NaOH, then the
amount of free HC1 equals 1.25 calculated for 100 cc
= 12.5, which multiplied by .00365 = .00456, the absolute
per cent, of free hydrochloric acid in 100 cc. of gastric
1 Leo : Diagnostik, S. 09.
1 Kossler : Zeitschrift flir Physiologische Chemie. Bd. xviL, Seite,
107.
* Mintz : Ein einfache Methode zur qualitativen Bestimmung der
freien Salzsaure ein Mageninhalt. Wiener Klin. Wochenschrift, 1889*
No. 20, und 1 891, No. 9.
October 6, 1894]
MEDICAL RECORD.
43i
secretion. This method, like the one of Mintz, gives
merely approximate but sufficiently reliable results.
Number.
Acidity de-
termined
by phen-
opthalein.
Per cent, free
HQ accord
ing to Leo.
Per cent, free
HC1 accord-
ing to Mintz.
Per cent, free
HC1 by means
of Boas'f re-
agent.
1
1 ' * '
0.08665
008391
0.081942
?
28
0.08541
0.08121
0.07921
3
33
0.090a 5
0.08154
0.08916
4
4»
0.13656
0.09982
0.09971
0.18492
5
68
0.19027
. 0.18341
6
6i
0.29035
0.24 72 x
0.84654
7
56
0.19877
0.17793
0.17343
8
1 72
0.314 16
0. 19926
0.19997
9
1 75
0.23591
0.22021
0 33154
10
67
0.21976
0.30987
0.30791
XI
80
0.31999
0.09984
0,21337
0.2.8*7
1a
! 3°
0x8963
0.08728
*3 *•
1 41
0.13x43
1 0. 13 102
0.11994
M
44
0.14227
O.XJ2I3
0.1 5982
15
12
0.11929
0.108ia
0. 10927
16
0.28984
0.369X5
0.26303
\l
*
0.18824
O.I430a
0.14059
0.30981
O.27536
0.37316
>9
^
o-34453
O.31247
0. 33243
so
46
0.154 10
0.14739
0 14327
The above table shows that while neither Giinzburg
nor Boas's reagents give perfectly reliable figures, results
sufficiently accurate for practical purposes may be ob-
tained with either. It yet remains to show the advan-
tages of the resorcin test over phloroglucin.
1. Phloroglucin is quite unstable and frequently de-
composes when kept for some time. Boas has recog-
nized this fact and has modified the formula thus :
9 . Phloroglucin 2.0
Vanillin 1.0
Alcohol (eighty per cent. ) 100.0
making it more stable.
The resorcin test may be kept for years in a dark col-
ored bottle without undergoing decomposition or in any
way losing its sensitiveness.
2. Resorcin can be had at any pharmacist's, at a trifling
expense, while phloroglucin-vanillin is a comparatively
expensive substance which can only be purchased from
the agents of the European manufacturers. I have re-
peatedly used with advantage filter-paper dipped in Boas's
reagent and allowed to dry to make the tests, in a man-
ner similar to the phloroglucin test-paper of Rosenheim1
and Boas. *
RECENT INVESTIGATIONS OF THE THERA-
PEUTIC VALUE OF ORGANIC FLUIDS, ESPE-
CIALLY SPERMINE, IN STERILIZED SOLU-
TIONS.*
By G. E. KRIEGER, M.D.,
CHICAGO, ILL.
Some five years ago the eminent physiologist and neurolo-
gist, Brown Slquard, established the fact that the tes-
ticles of young animals contain chemical substances of
high dynamo-genetic properties, and since then a great
many scientific investigations have been made in order
to reveal the character of those agents. The novelty of
this discovery has led, at first, to very different criticisms,
and the prevailing incredulity that anything could exist
which would be of such a remarkable power as claimed
by the author, rendered the majority of the profession
unquestionable opponents of the new doctrine. The
announcements of Brown-S6quard regarding injections
of testicular juice on patients suffering from nervous and
functionary debility, were ridiculed and, frequently with-
out examination, Brown-S6quard's statements were flatly
denied.
The efforts on the part of the inventor of this method
could not prevent advantage being taken of some
failures and septic accidents, probably due to a lack of
asepsis in the preparation of the remedy, or during its
application, and for quite a while bis method seemed to
be condemned as well by the public as by the profession.
1 Rosenheim : Deutsch. Med. Wochenschrift, 1891, No. 49.
3 Boas : Diagnostic u. Therapie der Magenkrankheiten, Leipzig,
1891, Seite, 134, and Deutsche Med. Wochenschrift, 1891 S. 1080.
* Read before the Chicago Medical Society, March 5th.
However, reports of other experimenters became more
and more encouraging, and what first had been looked
upon as a worthless idea of an enthusiastic head, is
to-day considered a discovery of the greatest therapeutic
value. In fact the remarkable results obtained in some
nervous affections, which previously were irremediable,
have made the subject_worthy of the most careful inves-
tigation.
In 1878 the German chemist, Phil. Schreiner, as de-
scribed in the Annals of Chemistry and Pharmacology,
found and analyzed in testicular juice a substance,
called spermine, which, at first, by other chemists was
declared identical with sethylenimin. Later, however, by
the ingenious researches of Professor Alexander Poehl, in
St. Petersburg, it was proven that spermine is an organic
base with characteristic properties, and that it can be
prepared from almost any organ, especially the various
reproductive glands of animals.
Professor Poehl's first publication of these investiga-
tions in the St. Petersburg Medical Society, in 1890,
was received with great interest by the Russian and Ger-
man profession, and was soon followed by clinical exper-
iments of noted medical men, who all agreed that sper-
mine is the active principle of Brown- S6quard's fluid
and, as a first-class stimulant, a therapeutic of unlimited
value.
Such prominent physicians as Dr. Rotchinin and
Professor Tarchanow in St. Petersburg, have reported a
great number of cases treated successfully with spermine
injections, some of which I would like to mention.
Case I. — Gentleman, fifty- three years of age, suffering
from asthma, angina of the chest, and very low action of
the heart, was treated with ten injections, after which all
symptoms greatly improved. He could climb stairs
without trouble.
Case II. — Another gentleman, sixty years of age, with
short breath, pain in the chest, low pulse, recovered
also very rapidly.
Case III. — A physician, seventy years of age, with
paralysis of the right leg and arm, paralysis of right
facial nerve, and aphasia, showed marked improvement
after the second injection.
Case IV. — A man, sixty-five years of age, with dia-
betes (4. 7 per cent, sugar), dizziness, general debility,
so that he could not walk, was jgreatly benefited by the
injections. The sugar was reduced to about two per cent.
From these and many other experiments, Dr. Rotch-
inin came to the following conclusions : The effect of
spermine injections is that of a strong stimulant, and
corresponds with those obtained by injections of Brown-
S6quard's fluid. It has, however, several advantages
over the latter. 1. No danger of local inflammation, as
frequently observed after the use of Brown-Slquard's
fluid. 2. No fever or other symptoms caused by septic
elements. 3. Equality of concentration of the fluid ad-
ministered.
According to Professor Tarchanow's investigations, a
direct effect of spermine injections upon the blood's cir-
culation has been observed. The action of the heart is
greatly retarded, and the height of the pulse and its
strength, as shown by the sphygmograph, five times, and
even more, increased. These phenomena are explained
by a stimulation of the nervous centres, especially the
heart ganglia and the vasomotor nerves. Doctors Sich*
arew and Hubbenet, in the St. Petersburg Kalinkin
Hospital, reported the following interesting case :
A woman, twenty-nine years of age, who had suffered for
thirteen years from syphilis, was treated with blue oint-
ment for the last six years. She became very anaemic;
had at the time three ulcers on her forehead, two of
which affected the bone ; on the right radius periostitis
gummosa, which made the movement of the hand
very painful; inflammation of the right knee-joint,
which was greatly swollen ; periostitis on the right tibia ;
oedema on lower limb and foot ; movability of the right
knee-joint but fifteen degrees; gait very uncertain,
digestion poor, frequent diarrhoea, pulse weak. In this
43*
MEDICAL RECORD.
[October 6, 1894
condition the patient was put under the treatment of
spermine injections. The pulse strength in the right
hand and general feeling improved after the second in-
jection. Pain of the right wrist decreased, oedema of
the leg disappeared, and even the movability of the knee
was restored almost to the normal condition after five
injections. The pulse, being 106 before, fell to 86.
The digestion became normal, and the muscular strength
increased about fifty per cent, within ten days.
Another startling effect was obtained by Dr. Procho-
row on a man who suffered from chronic ulcers of the
lower leg, and who for several months had been treated
in a hospital without success. After the second injection
the ulcers commenced to heal, and within three weeks
the patient was cured. From such and a great many
other results, published by competent authors, one is
justified in concluding that spermine has doubtless some
dynamo-genetic power, and it remains to be explained
what function it has as a normal factor of the organism.
We know that by the chemical change of material
some products originate which are poisonous to the sys-
tem, and are, therefore, by the aid of some glandular or-
gan, discharged from the circulation. Without doubt
such poisonous products must have antagonists which
render them comparatively harmless during their pres-
ence in the body, and in this way prevent auto-intoxica-
tion. Therefore such agents are of substantial impor-
tance to the system. In an average healthy organism a
physiological balance is observed between these two
chemical opponents. If the noxious products increase,
or the stimulating agents decrease, it means a lack of
resistance and strength — a disposition to disease. If,
on the other hand, the stimulating agents are predomi-
nating, it means vigor and health. If such is the case,
why should it not be possible, by the introduction of
such stimulating agents into the system with which the
organism defends itself, to overcome the lack of resist-
ance brought on by any cause which is detrimental to
health?
The difficulty, of course, will be to prove that the
substance artificially obtained is identical, or at least
similar, to those prepared in the organism. It is not
very long ago that Charcot and Leyden made the dis-
covery that in certain diseases on the surface of the
lungs, spleen, and other organs, small crystals appeared,
the significance of which was not understood until later
examinations revealed their chemical composition. The
crystals found, especially in asthmatic persons, and
known as Charcot Leyden crystals, are nothing else
but phosphate of spermine. These crystals have also
been found in the discharges of persons with typhoid,
consumption, cholera ; in leucaemia and other diseases.
By their discharge from the circulation the organism of
such patients evidently lost a quantity of spermine, and
therefore such stimulation to the nervous centres as would
be necessary to check the power of weakening elements.
The evidence of the chemical relation between these
crystals and spermine led to the treatment of asthmatic
persons with injections of spermine, and, as anticipated,
generally with good, sometimes with excellent, success.
Lately I treated a case which greatly improved after ten
injections. There can, therefore, be no doubt that
spermine has a stimulating effect upon those centres to
which the cause for asthmatic attacks is attributed.
Not less remarkable results were obtained in cases of
neurasthenia and anaemia. Professor Sicharew1 reported
several cases of severe neurasthenia with agrophobia
and claustrophobia — those strange phenomena in persons
who become dizzy and nervous while being on a wide
field, and who feel frightened when inclosed in a room
— in which cases these symptoms disappeared after in-
jections of spermine. In another case of severe anaemia
the person referred to had nine or ten hysteric spells
daily, suffered from insomnia and great weakness ; perfect
cure was obtained. An old gentleman, sixty-three years
of age, with general debility, apathetic to his surround-
» B;rl. Klin. Woch., No. 40, 1891.
ings, unable to follow a conversation or to move about,
improved so much that he could walk alone and grew
stronger physically and mentally.
A special effect seemed to be obtained by spermine
upon the spinal plexus ; quite a number of cases of loco-
motor ataxia have been reported in which either a per-
fect and lasting cure, or at least a great improvement,
was the result of spermine injections.
A patient of Dr. Sicharew,1 fifty-three years old, with
myelitis of the lumbar part of the spinal cord, causing
paresis of the lower extremities, incontinence of urine,
constipation, and loss of his sexual energy, recovered
after nine injections.
To quote from the statistics of 182 cases recently pub
lished in % the Berlin Klin. Woch., an exceedingly good
effect was* secured in 52 cases of neurasthenia. Only 2
did not show an improvement. From 14 cases of loco-
motor ataxia, 12; from 23 with other nervous troubles,
21 improved. Also 57 with general debility, 9 with
scorbutus, 14 with consumption, have shown a favorable
effect.
Very much interested by all these reports, I have made
this subject a special study for over a year, and have in-
vestigated the therapeutic value of spermine on my pa-
tients. To have sufficient material without depending
on the Russian drug, which is very expensive — about two
dollars a dose — I have experimented for fourteen months
in my laboratory, fitted up for the purpose of securing an
equally effective substance, and finally succeeded in get-
ting the specimen I wished to obtain. I also, by the
courtesy of Professor Poehl, in St. Petersburg, with
whom I communicated, got into possession of a quan-
tity of his preparation, which I used to compare the
effects obtained from his spermine and the one prepared
by myself. The result was equally favorable in cases
selected for this treatment. I have since been supported
in the investigation of the therapeutic value of my prod-
uct by other gentlemen, who are present to night, and
wish to demonstrate the result of some cases which have
been treated during the last three months.
Case I. — Mrs. H , thirty-nine years of age, five
feet three inches high, very stout, weighs one hundred and
ninety pounds. Has always menstruated regularly, but
generally with great pain. Was married sixteen years
ago, has two children. Since the last two years she has
suffered from abdominal and lumbar neuralgia, for which
she was repeatedly treated, without success. The ab-
dominal organs are in a normal condition. Patient had
also frequent palpitations and neuralgic pain of the heait,
was very irritable, nervous, and easily frightened ; could
not sleep well, and complained of frequent headaches.
In this condition she came to me three weeks ago. Tak-
ing the symptoms described as caused by general neuras-
thenia, I advised her to be treated by spermine injec-
tions. After one injection of a ten grain spermine
solution she felt easier and quieted. She received one
dose daily for nine days, during which she evidently im-
proved. On the fifth day she stated that all her ailments
had left her, and her husband claimed that she had
changed remarkably. It is now twenty days since the
first injection was given, and for the last two weeks the
patient has felt perfectly well.
Case II. — Another treatment I began on this gentle-
man, who is seventy years of age, and, as you see, in
apparently very good condition. He was never sick up
to his sixty-fifth year ; in 1889 he had an attack of inflam-
matory rheumatism of the joints; in 1890 was treated
for gravel in the bladder, which disappeared after the
use of lithia water, and since the last four years com*
plains of neuralgic pain in the head and lumbar regions,
heaviness in the legs, general weakness, and insomnia. I
attributed these symptoms, naturally, to his advanced
age, and thought spermine would refresh him. The in-
jections, given as usual in the back, affected him in a
peculiar way. He claimed to feel them all through his
chest as a warm, stimulating agent, and soon assured me
1 Petersburg Med. Ges., February 26, 1891.
October 6, 1894]
MEDICAL RECORD.
433
of their good effect upon his general health. The neu-
ralgic pain in the back, and weakness in the limbs disap-
peared, his sleep and strength improved, the headache
became less, and taking all together, he says he feels
twenty five years younger.
Case III. — Of special interest, I think, is another case
which I would like to present, and about which I would
be glad to hear the opinion of some gentlemen who
make diseases of the nervous system a specialty. From
the most apparent symptoms I may call it a case of
spinal sclerosis, but it seems to me that there are also
other atrophic processes, possibly of a cerebral nature.
As far as I could learn, the history is as follows : The
patient, a man, fifty seven years of age, five feet ten
inches tall, weighed two hundred and thirty pounds, was
always in good health up till March, 1893. He did not
indulge in alcoholic drinks, never suffered from syphilis,
but was a heavy smoker. In March, 1893, ne com-
plained of slowly growing weakness -in the right, later in
the left, leg. His limbs were as if burdened by weights.
Then a constant dizziness in the head set in. He was
treated for apoplexy, with no effect. The weakness of
his legs progressed until they would not carry him any
more. His dizziness also grew worse ; he became irrita-
ble, nervous ; could not sleep, but had fair appetite and
digestion. He was under the treatment of several physi-
cians, the last of whom supposing the disease was of
syphilitic origin, put him under inunctions and iodide of
potash. The patient lost about thirty pounds. His con-
dition, however, did not improve, and when I saw him
first, on February 6th, I found the following state :
A man, strongly built, sat in an arm-chair, his features
showing signs of despair, his eyes were clear but un-
steady ; he was unable to rise, or even to raise his legs,
but could move his arms pretty freely. His grasp was
weak, and the movement of the hand and arm somewhat
inco-oxdinated ; for instance, when he wanted to reach
for something he foiled to strike it. The fingers spread
apart, trembled; on the fingertips and under the sole
he had a numb and prickling sensation. He was free of
pain, but complained of a heavy and dizzy feeling in his
head. Reflex of the pupils was good. When lifted from
the chair he could stand, his legs spread apart about
eighteen inches. With closed legs he tumbled. He
also became very uncertain with his eyes closed. Sup-
ported on either side he tried to walk; the legs were
moved with difficulty and inco-ordinately ; the feet were
swung forward and set down with force, as though the
patient was uncertain in reaching the floor ; brought back
to his chair he felt very tired. The sensibility of the
skin and reflex of the patella were but little disturbed.
The' functions of the bladder and rectum have lately be-
come weak, the patient has frequent pressure to pass
urine, the examination of which showed nothing ab-
normal. Examination of the eyes showed atrophy of the
left optic nerve, otherwise no characteristic signs. For
the last two months he has been unable to lie down, was
obliged to sit up all night, and compelled to sleep in his
chair. He also complained of an almost constant ring-
ing noise in his ears.
In this condition I subjected him to a treatment of
spermine injections, with the following effect : After five
injections he could easily rise and stand with his heels and
toes closed, without tumbling. He got fifteen injections
altogether and is now able to walk fairly well, and even
to climb stairs with some effort. He feels a great deal
stronger, can lie down and sleep sometimes all night.
During this treatment I avoided any other therapeutic
aid. The only symptom that still annoys him is the
dizziness in the head, to which he pays so much more at-
tention after being relieved from the confinement to his
chair.
On these, and quite a number of other cases, I have
studied the effect of spermine injections, and have had in
some of them surprisingly good results, while the rest
were more or less favorably affected. One feature I
would like to emphasize ; spermine seems to be a direct
antidote against the bad effects of anaesthetics, probably
due to the stimulation of the heart action. In 1891 the
Russian surgeon, Weljaminoff, and recently I, myself, have
observed that patients who received one spermine injection
shortly before an operation was to be performed, had a
splendid narcosis, and no nausea or any other bad effect
after they awoke. In order to ascertain if their condition
was really obtained by the action of spermine, I have ex-
perimented in the Chicago Hospital on a patient who
had to take ether several times. He was a man of thirty-
nine years of age, upon whom I was going to perform
Lange's or Whitehead's operation for haemorrhoids. He
received a fifteen-grain spermine solution shortly before
the anaesthetic was given. He was one hour and a half
under the influence of ether ; had a splendid narcosis,
and when he awoke felt perfectly well. Eight days later
I gave him again some ether to remove the stitches with-
out using spermine. He then was only fifteen minutes
under the influence of the narcotic, but it took him all
day to overcome the nausea and bad feeling with which
he awoke. It is, of course, a question in how many
cases such a favorable effect will be obtained, and I do
not doubt that frequently the injections may fail to act as
desired, but still I think it may be worth trying.
Before I conclude I wish to say a few words about the
chemical and physiological properties of spermine.
Spermine, according to the analysis of Phil. Schreiner,1
is a substance with the chemical formula Cs H6 N. Like
other bases it forms salts when in contact with acids or
metals. Some of these salts are long prismatic crystals
which, though prepared by chemicals, retain the physio-
logical properties that spermine possesses. Such crystals
I have photographed from microscopical specimens ; the
specimens were obtained from preparations from different
organs: No. 1, from testicles of a young bull; No. 2,
from ovaries of a young cow. Nos. 3 and 4, prepared in
a different way, are not as pure as the first ones ; No. 3 is
made from a small quantity of genuine Brown- Seqaard's
fluid ; No. 4, from an extract of pancreas. Regarding
the chemical composition, spermine belongs to the group
of the imins, and has at first by some chemists been
taken for sethylenimin, which has the formula C,H4NH ;
that is, the same elements, but in another group. By
the investigations of Professor Poehl this opinion has
been proved to be a mistake. He found that spermine
is a base/ir se, with certain characteristic properties dif-
ferent from those substances with equal elements. Some
of its reactions are : 1. With chloride of gold it forms a
yellow precipitate, which later changes into fiat crystals.
2. With chloride of platina it forms a crystalline precipi-
tate. 3. With sodium of tungstate it gives a cloudy pre-
cipitate soluble in alkalies, insoluble in acids. The
most characteristic property is a smell like human sperma,
if spermine is brought in contact with chloride of gold
and metallic magnesia. I have here a sample of such
combination, and you may convince yourselves that my
preparation really contains spermine. It was for these
reactions that I worked over a year and made many
thousands of experiments ; after which I learned to under-
stand why such a noted firm as Merck & Co. pronounced,
in the Pharmaceutical Zeitschrift for Russia in 1890,
that they did not succeed in preparing this valuable sub-
stance. The same statement has been made by other
chemical firms ; and I think this is the reason why, up to
date, spermine has not appeared in the list of our modern
therapeutics. Professor Poehl himself said, in the Berlin
Klin, Woeh., 1891, " The conditions by which spermine
crystals may be obtained from solutions which contain
spermine are sometimes very difficult to determine ; "
and I also have found that, when I repeated the same
process on the same preparation, I would at times not ob-
tain the same crystallization as previously found.
Regarding the physiological action of spermine, chemi-
cal and physiological experiments have revealed the fact
that the stimulation~and otherwise beneficial effects from
spermine injections are very natural. Since it is known
1 Ann. Chem. Pharm., 1878, 194.
434
MEDICAL RECORD.
[October 6, 1894
that spermine is not only an important factor of the re-
productive glands in the male as in the female organism,
but also exists in the thyroid gland, the thymus, pancreas,
spleen, and other organs, it has become evident that sper-
mine is a normal substance circulating in the blood,
which has to and does accomplish a certain task in the
economy of life. Medical science was greatly mistaken
when it was believed that some organs, as the spleen,
subrenal glands, and others, were of no use in a biological
respect, and could just as well be parted with. By the
bad effect obtained from the extirpation of the thyroid
gland we have been convinced that in this, as in other
glands, a substance is produced which is absolutely neces-
sary for our system, and which is probably similar to
spermine ; and so I believe that an important function
of those organs is the production of spermine. The fact
that male animals deprived of their sexual glands in their
early days cannot compete in strength with their brothers,
who are still in possession of these vital organs, has led
to the interesting experiment on dogs to inject spermine
as a substitute. Of four young dogs, all brothers, two
treated this way, after being castrated, grew twice as large
and strong as the other two. The incorporation of such
substances as are produced in our glands into the blood
is therefore a very natural support of a physiological
process.
The manner in which spermine acts upon the organ-
ism has been carefully studied by Tarchanoff, Poehl, and
others, who are of the opinion that the stimulative effect
of spermine is due to its great oxidizing power. This
theory is supported by the following facts :
1. Metallic magnesia in solution of the chloride of a
metal changes into oxide of magnesia by the influence
of spermine in very small quantity.
2. The blood, if influenced by chemical agents which
diminish its oxidizing power, as chloroform, oxydul of
nitrogen, strychnia, urea, can be brought to its normal
condition by the support of spermine. This explains the
favorable effects of spermine injections during and after
the narcosis.
3. A direct test for the oxidizing power of spermine
was obtained by quantitative examinations of the urine
before and after spermine injections, which showed a
stronger oxidation of the albuminoids after the injec-
tions.
From these facts it does not seem strange that in dis-
eases which diminish the oxidizing energy of the blood
and nervous system, as in neurasthenic, anaemic, cachec-
tic persons, spermine injections have a very favorable
effect. The same observation has been made in auto-
intoxications, that is, in diseases where the products of
the regressive albumin metamorphosis accumulate in the
organs.
A very important factor for the effect of spermine is
the alkalinity of the blood. As a rule, in all the named
diseases, as well as in acute fevers, as typhoid, scarlet,
pneumonia, erysipelas, the blood possesses a higher de-
gree of acidity, in which spermine becomes insoluble,
and therefore inactive. If the acidity is neutralized, as,
for instance, in diabetes, by the use of Carlsbad salts,
the spermine gets its activity again, and the improved
oxidation causes the disappearance of sugar in the urine.
The same result has been obtained without alkalizing
the blood by artificial introduction of spermine. As the
latter is a normal substance of the organism its applica-
tion is an imitation and support of nature, and therefore
entirely harmless if used under certain precautions.
It is different from Brown-Slquard's fluid, inasmuch as
the latter contains a number of substances, as kreatin,
kreatinin, hypoxanthin, lecithin, guanin, nuclein, and
so on, which do not benefit and may hurt. Further-
more, as it is known that the organs from which the
emulsion known as Brown-S6quard's fluid is obtained
often contain the germs of disease and other products,
the toxines cannot be eliminated by the way the fluid is
prepared, and is, in a strict sense of asepsis, not a safe
method. The injections are sometimes followed by an
abscess, an accident that has recently occurred in this
city in the hands of a physician of very high standing, a
complication I have never seen reported nor observed
after spermine injections.
The isolation of the active principle is therefore of
vital importance, and besides has the advantage that the
dose can be regulated, which is impossible in Brown-
S6quard's fluid, because no one can tell how much sper-
mine it contains. The solution I use is equal to two per
cent., and always bacteriologically tested before being put
in flasks, so I am sure it will be aseptic; and although I
do not claim that it will have the desired effect in every
case, on the contrary am fully prepared to see occasion-
ally a failure, I think the subject is worth trying.
As far as the technique is concerned, I have found it
advisable to use a series of from ten to fifteen injections,
one a day, commencing with small doses, about five to
ten minims, and gradually increasing the dose to twenty
minims. The number of doses required is, however, a
matter of personal judgment, and sometimes two or
three injections are sufficient to secure a remarkable
effect.
In order to keep this solution perfectly aseptic I have
put up single doses in separate flasks, as the one demon-
strated. They are opened by hitting against the neck,
which will break at the mark. The fluid is then taken
out with a hypodermic needle, which should always be
thoroughly cleansed before and after using. The most
aseptic instrument for the purpose is a syringe with a
piston of asbestos. It seems practical to inject very
slowly after the skin has been thoroughly sterilized.
With these precautions, I have never had any trouble,
except slight local irritation.
In conclusion, I wish to resumS the different effects
obtained by spermine injections in various diseases
treated by other physicians and myself:
1. The action of the heart is stimulated. (Drs. Hub-
benet, Sicharew, Rotschinin, Nicholsky, Philipps, Tarch-
anow, Krieger.)
2. The respiration becomes easier, more regular, and
less frequent. (Drs. Nastjukoff, Rotschinin, Injaseff-
sky.)
3. The general feeling improves. (Drs. Stange, Kis-
sel, Rotschinin, Hubbenet, Ritter, Krieger.)
4. The muscular strength increases. (Drs. Tarcha-
now, Sicharew, Rotschinin.)
5. Sleep and appetite improve. (Drs. Nicholsky,
Wikterow, Philipps, Krieger.)
6. CEdema, due to lack of power in the arterial sys-
tem, disappears. (Drs. Hubbenet, Sicharew, Rotsch-
inin.)
7. Sugar in the urine decreases. (Drs. Tarchanow,
Poehl.)
8. Ataxy of muscles, especially caused by spinal
troubles, decreases. (Drs. Sawitsch, Wiktorow, Hubbe-
net, Krieger.)
9. Neuralgia, especially of lumbar origin, disappears.
(Drs. Rotschinin, Ritter, Krieger.)
10. The sexual functions are stimulated. (Drs. Sicha-
rew, Hubbenet, Tarchanow, Krieger.) This may be
taken as a result of general improvement, but in my esti-
mation should not be considered a specific effect.
11. The functions of the bladder and kidneys, also of
the intestinal tract, improve.
12. Local reactions are either of a slight and harmless
nature or do not happen at all.
Although such favorable results have been recorded in
hundreds of cases, I do. not wish to say that they will
always be obtained, and we have to be prepared in some
cases to miss the desired effect. The exceptions, how-
ever, do not speak against the method as a whole, but
rather, as the Latin phrase says : " Exceptio firmai reg-
u/um."
1003 Columbus Msmokial Building.
Professor Onssenbaner, of Prague, has been elected
President of the German Surgical Congress for 1895.
October 6, 1894]
MEDICAL RECORD.
435
gvoffczsa ot Udjeflical Sttiznce.
The Treatment of Pelvic Abscess. — According to the
Berlin correspondent of the Medical Press, Dr. L. Lan-
dau recently gave an address on this subject. He said that
with the perfection of gynecological technique gynecolo-
gical diagnosis, as regarded the individual operations, had
not advanced with great pace. For, first of all, diseases
had to be discovered for given operations ; and in the sec-
ond place a large series of diseases of unequal importance
had been grouped together under collective names, and
had been frequently submitted without discrimination to
a single operative treatment. This was especially the
case as regarded pelvic suppurations, where the usual
diagnoses— pelvic abscess, pelvic suppuration, adnexitis
— were used without distinction for simple non-suppura-
tive inflammation in the tubes or ovaries, or peritoneum,
as well as for multiple extra- and intra-peritoneal ab-
scesses. He had above all endeavored to fix an exact
pathologico anatomical basis and a rational division of
pelvic suppurations. He distinguished in the large group
of extra- or intra-peritoneal abscesses, the abscesses in
pre formed spaces (pyometra, pyosalpinx) and those not
in pre formed spaces (abscesses in paravaginal, parami-
tral tissues, in subperitoneal pelvic tissues, and in the con-
nective tissue of the abdominal walls), with intermedial
position of ovarian abscess. The abscesses might be sin-
gle or multiple, or in the most varied combinations.
The cause was always an infection. Among these was
the gonorrhoea^ the puerperal, and, "last not least/'
the infection of medical assistance (from the sound, cu-
rette, intra-uterine injections, caustics, operations on the
cervix, and vagina). These abscesses terminated very
differently. Inspissation, absorption, and spontaneous
cure might take place, or perforation into the neigh-
boring organs, and spontaneous cure or perforation into
the peritoneum with circumscribed or general fatal
peritonitis and pyaemia. Occasionally death took place
from amyloid disease. The old motto, Ubi pus ubi
evacua, was to be firmly held to, and this was to be car-
ried out wherever the pus was accessible by simple, spar-
ing, conservative methods. Incision came first under
consideration. This was before all indicated with soli-
tary uncomplicated pus cavities, whether lying within or
without the peritoneum, or whether done from the vagina
or abdominal wall. It should not be done through the
rectum, as he had observed that healing was difficult.
He made abdominal incision either above or below Pou-
part's ligament, at one sitting where dulness was com-
plete, at two sittings if intestine apparently intervened.
The first incision as for ligature of the iliac artery, push-
ing up the peritoneum, packing with iodoform gauze, etc.
A means of distinguishing abscesses from induration, ex-
udation, and fibroids, indispensable in many cases, was
exploratory puncture. It at the same time formed an
important preliminary to the incision. When operating
from the vagina it was always done at one sitting. Soli-
tary abscesses in the pelvis of whatever kinds were to be
treated in this way, even pyosalpinx when the pus was in
one cavity.
Considering the good results obtained by simple in-
cision, the attempt was justifiable to try it in multiple ab-
scesses (double one cavities, pyosalpinx, etc.). The
causes of recurrence might be in fineness of the walls of
the abscess, in adhesive fixations preventing the walls of
the abscess foiling in or otherwise. For cases in which
simple incision would evidently be insufficient, as in
multilocular pyosalpinx with or without perforation
into the pelvis or abdomen, bladder or multiple perime-
tric and perisalpingial abscesses, a variety of other pro-
cedures had been practised, of which he would only men-
tion historically the little-promising sacral and para-sacral
incision. Here laparotomy was the operation usually
practised, with removal of the abscess walls and its con-
tents. He had treated one hundred and forty -one
cases of inflammatory and suppurative tubal disease by
laparotomy, with a mortality of 2.8 per cent. This
undeniable good result coincided with those of other
operators (Chrobak, Schanta, Zweifel, and others).
But, unfortunately, as observation had shown, the per-
manent results were not equally favorable. Complete
cures took place in only from sixty to eighty per cent.
(Chrobak, Schanta, Landau). The reasons for this were
threefold: 1. In the disadvantages of laparotomy itself
(abdominal hernia, adhesion of intestine and omentum
to wound and to one another, etc.). a. In recurrences
of inflammation and suppuration through impossibility
of removing all excitors of inflammation. 3. In the pur-
ulent nature of the disease.
Then arose the question, how could these disadvan-
tages be guarded against? The first step thereto at-
tended by success was made in France ; in the first place
by P6an, «nd after him by Segond, Doyen, Richelot.
The uterus was removed, and excellent results had been
reported from this method of treatment. But want of
exact pathological data made it difficult to determine the
value of such a mutilating operation. Spurred on by
the statements of P&n and Segond, and instructed by a
number of vaginal extirpations of uterus performed since
1881, he had treated, since May, 1893, twenty-six cases
by the French vaginal procedure. He had, however,
deviated from this method in two essential points, and
had extended the limits of the operation as laid down by
these authors. He had never contented himself with re-
moving the uterus and leaving behind the adnexa, but
had always removed the diseased parts. He had adhered
to this principle so firmly that when it was impossible to
root out all the disease per vaginam, he had also opened
the abdomen from above. He had, moreover, operated
in this way on women when there was not only a simple
double inflammatory disease, but in cases of complicated
pelvic abscess. His definition of complicated pelvic ab-
scess was one when, independent of double pyosalpinx
or ovarian abscesses, there were present perisalpingial,
periphoritic, or multiple isolated intra- or extra perito-
neal abscesses; thus perisalpingitis purulenta, perime-
tritis purulenta, pyocele uterina, retro- peritoneal sup-
purations. Such were cases that could neither be
treated by simple incision from the vagina nor through
the abdominal walls by laparotomy, as it would either be
impossible or would be too dangerous to carry out the
operation. In all these cases there were multiple collec-
tions of thick, yellow, or green stinking, decomposing,
or creamy pus. In some cases there was fistulous com-
munication into the bladder or rectum, most of the cases
were disabled from long-standing disease, and six had
been repeatedly treated in other hospitals. In a large
number operation had been already performed with tem-
porary success (puncture, ( incision, resection, laparo-
tomy). In some cases the attachments to the rectum,
and especially the sigmoid flexure and to the bladder,
were so firm that in carrying out the principle of remov-
ing all diseased parts the walls of these organs were torn.
In two cases of vesical fistula originating in this way he
had operated there and then, once from the vagina and
once from the abdomen. In two ruptures of the sigmoid
flexure he had performed circular resection. The whole
of the twenty-eight cases were cured by the operation.
The Treatment of Typhoid Fever in Children.— -At
the onset of the attack, when the diagnosis is still uncer-
tain and resembles in some respects the fever due to gas-
tric disorder, it is well to administer small doses of calo-
mel with a little milk-sugar, and to give a rectal injec-
tion of an infusion of chamomile in boiled water, with
four per cent, of boric acid, morning and night {Thera-
peutic Gazette), Internally, to give from a coffee- to a
dessert-spoonful every two hours of the following prescrip-
tion:
3 . Benzonaphthol gr. xiij-xxx.
Syrup of peppermint | j.
Syrup J iv.
In the way of nourishment the patient may be given
436
MEDICAL RECORD.
[October 6, 1894
every two hours a very small cup of milk, to which may
be added as a stimulant a little coffee, tea, cognac, or a
very slight flavoring with vanilla or chocolate. In cases
where the diagnosis is thoroughly assured after the calo-
mel has acted, it is well to prescribe citrate of magnesium
to move the bowels and large rectal injections morning
and night of a borated solution already named ; or,
$. Naphthol gr. iij.
Boiled water Oij.
To be used in four equal quantities.
Internally, an antiseptic dose, composed as follows, is
useful :
3 . Benzonaphthol gr. xv.-xxx.
Salicylate of magnesium 3 ss.- 3 j.
Syrup of peppermint 3 vj.
Simple syrup J iv.
If there is a bitter taste, it is well to replact the sali-
cylate of magnesium by the salicylate of bismuth. Of
this mixture give a teaspoonful every two hours, and
morning and night administer a capsule or cachet con-
taining two to four grains of the hydrochlorate of qui-
nine, or else give the same dose by injection or supposi-
tories. If the headache is severe, replace the quinine by
antipyrin ; spongings with tepid water may be resorted
to, and care should be taken, by the use of a boric-acid
mouthwash, to keep the mouth clean. If the fever is
of great intensity, the same treatment, with the addition
of constant spongings with cooler water, is to be followed,
and should the nervous disturbance be very great, small
doses of coffee or of chloral may be used, but antypyrin
is not to be employed. In grave cases the baths are
given even more frequently, as often as is necessary to
keep the temperature down. For the nervous agitation
the following mixture may be prescribed :
9 . Hydrate of chloral gr, yj.-xv.
Tincture of musk gtt. xx.-xl.
Syrup of orange 3 j.
Water J ij.
Cold compresses are to be applied to the head, if there
is delirium. In cases showing marked adynamia the
cold should be applied to the head and the following
mixture given :
B . Hoffmann's anodyne gtt. x.-xv.
Malaga wine J j.
Syrup of mint |j.
Water |iij.
A teaspoonful to a tablespoon ful every hour.
In cases of typhoid fever in which there seems to be
great cardiac depression, the pulse being feeble and show-
ing evidences of collapse, it is well to use the following
injection hypodermically morning and night :
Q .' Caffeine gr. xxx.
Tjenzoate of sodium gr. xlv.
Distilled water, enough to make f j.
Ten to twenty minims of this may be used.
Where complications such as bronchitis, broncho-pneu-
monia, etc., arise, the same treatment is to be continued
.as that just given, but the cold spongings are to be
stopped and a cotton jacket is to be applied to the chest.
Morning and night a mustard sinapism should be applied
to the chest and the stimulating treatment already indi-
cated employed.
During the period of convalescence the baths are di-
minished as the temperature approaches the normal.
Soups, broths, and thoroughly softly cooked meats and
pulpy vegetables are allowed, and the following tonic
mixture given in the dose of a dessert-spoonful three times
a day:
Q . Tincture of gentian,
Tincture of cinchona, of each J v.
Fluid extract of kola TTLlxxv.
Champagne also is sometimes useful if it agrees with
the patient. Should hemorrhage from the intestine com-
plicate the case, absolute rest, with local application of
cold, is to be resorted to. Small doses of opium may be
administered by the mouth, and every two or three hours
two or three drops of perchloride of iron are to be em-
ployed. Ice-compresses should be applied over the belly.
Where there is danger of sloughs and abscesses it is well
to wash the part with a four-percent, solution of boric
acid, and afterward apply iodoform or salol. Abscesses,
of course, should be opened, drained, and irrigated with
mild antiseptic solutions. For the prophylaxis of typhoid
fever the discharges of the patient should he received in
a five-per-cent. solution of sulphate of copper or in a 1 to
1 ,000 solution of bichloride of mercury. The milk which
is taken by the patient should be carefully sterilized, and
after the case recovers careful disinfection of all the ves-
sels used by the patient should be carried out.
The Value of Boiled Milk as an Article of Diet. —
Every practitioner of medicine knows that in the treat-
ment of certain cases of diarrhoea, where an absolute milk
diet is required, better results follow the use of boiled milk
than of raw milk, and for this reason it has become a popu-
lar idea among the laity and members of the profession that
cooked milk is the more digestible. However this may be
in clinical experience, it is certain that experimental re-
search does not justify this conclusion. Ten years ago the
late Dr. Randolph, of Philadelphia, made an interesting
series of experiments to determine this point. A number
of men in perfect health were given raw milk to drink ;
an equal number, equally healthy, were given a similar
quantity of boiled milk. An equal time after the inges-
tion of the liquid a hypodermic injection of apomor-
phine was administered to each, and a careful examina-
tion made of the vomited matters to determine how far
the process of digestion had proceeded. In every in-
stance it was found that the raw milk was more digested
than the cooked, and as Randolph graphically expressed
it, " We obtained proof that in making milk, nature
made that compound most easy of digestion."
The experiments of Crolas, on the other hand, seem
to point to a different result, for he believes as a result
of his studies that boiling has no action whatever on the
casein or lactose, and removes from the liquid a small
quantity of butter, which is entangled with the film of
albumin which forms on the surface of the milk. He
also thinks that boiling increases the quantity of the free
soluble phosphates, and concludes, in opposition to the
studies of Randolph, that boiled milk is equivalent, if
not superior, to raw milk.
The correct solution of the problem probably lies in
the class of cases to which the milk is administered.
There is no doubt whatever that raw milk is more diges-
tible than boiled to the healthy individual, and it is an
undeniable fact that boiled milk is far more constipating,
and that an attempt to place a patient upon a diet of
boiled milk would more certainly tend to disorder diges-
tion and assimilation than a similar attempt with the raw
article. In Bright' s disease, diabetes, and similar con-
ditions in which a milk diet is desirable, we may
therefore conclude that raw milk is the liquid to be em-
ployed, whereas, in cases of diarrhoea, the boiled milk is
by far the best preparation. We have already pointed
out in earlier leading articles that both raw and boiled
milk have their digestibility very much increased by be-
ing somewhat diluted with any sparkling water, or by the
addition of a sufficient quantity of salt to give a distinct
flavor. — Therapeutic Gazette.
Treatment of Vaginismus. — In a paper read before
the British Medical Association, Dr. T. More Madden
held that vaginismus is ordinarily of constitutional or
neurasthenic origin, and is frequently associated with a
morbid condition of the pudic nerves. Hence he relies
chiefly on constitutional treatment in combination with
local nerve-stretching. To effect this he recommends
forcible dilation, under ether, of the vagina, so as to
thoroughly stretch, or even partially rupture, the fibres
of the affected pudic nerve and its terminal branches.
If this treatment be adopted, Dr. Madden believes that
it will seldom be found necessary to resort to operative
treatment for thecureof dyspareunia caused by vaginismus.
October 6, 1894]
MEDICAL RECORD.
437
Medical Record:
A Weekly Journal of Medicine and Surgery.
GEORGE F. SHRADY, A.M., M.D., Editor.
Publishers
WM. WOOD & CO., 43, 45, & 47 East Tenth Street
New York, October 6, 1894.
BRIGHTS DISEASE AND ITS INSANITIES.
Bright's disease in its various forms is so common and
dreaded a malady that all the phenomena connected
with it are justly objects of importance to every practi-
tioner. One particular phase of the Brightique state is
mental disturbance. Concerning this, much has been
written of late, so much, indeed, that tie matter has be-
come rather beclouded than otherwise by the learned,
scholastic, and not very accordant contributions of alien-
ists. One writer has placed uremic poisoning among
the frequent causes of insanity and the starting-point of
nearly all cases of melancholia. Dr. Savage, on the
other hand, as the result of several hundred examinations
of the urine of the insane, declares that he has rarely
found albuminuria.
There can be no doubt of the importance of the arte-
rio-renal sclerosis associated with Bright's disease in
causing many of the insanities of middle and late life.
The psychical symptoms which develop in connection
with kidney disease are usually grouped in three classes.
There is first the acute delirium which sometimes is asso-
ciated with acute nephritis due to some infection. The
uremic poisoning here, if it exists, is only one factor,
and the delirium itself is classed as a " nonvesanic"
insanity, i.e., it is not insanity at all in the technical
sense.
Uremic or Brightic insanity proper occurs only under
two forms. In the one the patient has no insane hered-
ity or tendency, but is perhaps of neurotic temperament.
The poisons of the uremic state in such an individual
affect the nutrition of the brain, there is some arterial
spasm or thickening of the walls, and the total amount
of blood sent to the brain is inadequate. The patient
suffers from a mild and quiet mania which is allied to
dementia. He improves or gets worse with the course
of the albuminuria, and if that disappears he may get
entirely well. In the other cases the patient is a person
predisposed to insanity, and the renal trouble acts simply
as an exciting cause. The form of mental trouble in
these cases is not much affected by the albuminuria. It
may be a monomania, a melancholia, or some more ex-
citable state.
When the practitioner notes the appearance of mental
symptoms in a case of chronic Bright's disease, it is of
the first importance that he make himself familiar with
the history and diathesis of his patient. If the insanity
is of the first type and due mainly to the renal trouble,
treatment directed to this will often relieve and even
cure the patient. He can be treated at his home. In
the second class of cases the outlook is more uncertain ;
serious outbursts may occur, and restraint in some insti-
tution is indicated.
THE COMPOSITE PHYSICIAN.
Professor H. P. Bowditch has published in McClure's
Magazine two series of pictures of twelve Boston physi-
cians with their composite photographs. The second
series and its composite represents the same gentlemen
five years later. Dr. Bowditch' s article is a contribution
to science rather than to the beautiful. We say this
after a really unbiassed and sympathetic search for a
handsome man among the twelve esteemed and eminent
confreres. We do not find, to be sure, any striking
type of the opposite kind ; there are no features that are
absolutely Socratic in their curves or their as) mmetry.
But it is evident that Boston's twelve have not won suc-
cess through the meretricious aid of personal loveliness.
There is no Antinous there ; no Apollo, or any of the
quality that used so seductively to " hang upon the
cheek of night" in the Cleopatra days. However,
classic authority says it is a nuisance to be too beautiful —
"miseria nimis pulchrum esse hominem." And we
note that the individual Boston physician is interesting,
and his composite a most agreeable-looking gentleman.
The age of the composite is about forty. The hair is
thin, and the parting is nearer the right ear than urban
fashion dictates. He wears a heavy mustache with the
ghostly suggestion of an imperial. The nose turns up a
trifle and reveals well-defined nostrils, suggesting an
absence of Semitic and a touch of Celtic blood. There
is a deep naso oval fold indicating a consciousness of
life's burden and responsibilities. The forehead is high
and broad as in all types of successful men except the
artist. The eyes are those of a composite, bright and
kindly. The collars and ties date back into the last
decade.
Altogether the Boston composite is a good type of a
man, not resembling in the least any of the individuals of
which it is made.
TUBERCULOSIS AND BUTTER.
It is hard to get away from the malign influence of the
cow. Such at least is the case if we may trust the inves-
tigations of bacteriologists and sanitarians. The statis-
tics of slaughtered animals in Prussia, Hanover, Switzer-
land, and other European countries show that from two
to twelve per cent, of the cattle are tuberculous, and
though their flesh is not often dangerous, yet the milk
must in most cases have been so. We can guard against
tuberculous milk by sterilization, but now danger is
threatened us from the butter. Several years ago Heim
showed that butter from tuberculous milk contained ba-
cilli and could produce infection. Bang (Dcut. Zcitsch.
/. T/iiermed, vii., p. 5) reached similar conclusions.
Professor Roth, of Zurich, has, however, recently
made experiments of more striking significance {Cor-
respond, bl. /. Schweit. Aertz.). He went into the
markets and purchased butter from twenty different
sources representing different cantons of Switzerland.
He then inoculated guinea pigs with this butter. In
43«
MEDICAL RECORD.
{October 6, 1894
eighteen series of experiments the results were negative,
but in two the inoculations were followed by tubercu-
losis. In other words, ten per cent, of the butter of
the Swiss markets contained tubercle bacilli.
Quite independently of Roth, Dr. Brusaferro, of
Turin, made experiments with the butter of the Italian
markets. In nine tubs he produced infection once,
which gives about the same proportion as Roth's.
It is not to be supposed that ten per cent, of market
butter is necessarily dangerous, for in many instances
the number of bacilli is small and quite unable to cope
with the juices of the stomach. Still, infected butter is
not safe to the predisposed, and the fact of its existence
in Europe at least should be borne in mind. What
makes the matter additionally serious is the fact that
there is not, so far as we know, any practical way of
sterilizing butter. ■
AN ANTI-OPIATE SOCIETY.
An Anti- opiate Society has been organized in this city,
and announces that its objects are to use such means as
may be considered best to prevent the unnatural use and
the abuse of opium and its preparations, and of cocaine,
chloral, etc.
We are told that there are now in the United States
one and a half million men and women who habitually
use opium in some of its forms. Twenty years ago there
were less than three hundred thousand opium users in
the same territory. The extent to which this vice is in*
creasing may be inferred from these figures : in the city
of Chicago, 25,000 persons are addicted to the habit ;
in New York City, over 50,000 ; and in St. Louis about
20,000 are slaves of this merciless tyrant.
It is added that " There are other thousands of habitual
users of morphine who would never have touched it had
they not been ignorant of its powers, influence, and ef-
fects. It is such ignorant ones that the Anti- opiate So-
ciety is trying to reach with informa' ion regarding the
nature of the insidious drug, and with warnings to the
young and unwary against a vice so delusive and so dan-
gerous, trying to reach them before they have become
hopelessly degraded by its influence."
The increase and the prosperity of the various " anti "
societies is one of the evidences of the development of
altruism as well as of intelligence in modern times. Some
of these societies, unfortunately, show more altruism than
intelligence. We trust that the present organization will
not be of such kind. There is indeed little room for ex-
aggeration in describing the evils of the opium habit ;
and there is, we fear, among some physicians, though
they are vastly in the minority, a disposition to be care-
less in prescribing the narcotics. Perhaps the one thing
which general practitioners least realize is the quickness
with which a tenacious habit is formed. The constant
use of opium for a few weeks, for example, will as a rule
establish a habit hard to break.
On the other hand, we regret to see the new society
starting out with exaggerated and unsupported statements
of the prevalence of the opium habit. Fifty thousand
opium users in New York City means that one out of
every twenty adult persons is a habitu6. This is too
absurdly untrue to need contradiction. Our advice to
the new society is to re write its circular, and afterward
to be earnest but also honest.
%zxo% of ttte W&etk.
Death of Dr. Francis 0. Kosher, of Coeymans, H . Y.
— Dr. Francis G. Mosher died September 2 2d, at his
residence, Coeymans, N» Y., of cancer, aged seventy-
one. He was a great sufferer for many months previous
to his death, but continued his work up to within a short
time of his death, completing forty- six years of practice.
He was fitly mourned by the entire village, and all
business was suspended during the funeral ceremonies.
Dr. Charles A. Powers has resigned his position as At-
tending Surgeon to St. Luke's Hospital, and to the New
York Cancer Hospital, and has removed to Denver, Col.
Medical Society of Virginia. — The Twenty-fifth Ar-
nual Session of this Society will be held in Richmond,
Va., beginning October 23, 1894. An interesting pro-
gramme is offered. The president of the society is Dr.
William P. McGuire, of Winchester, and the secretary,
Dr. Landon B. Edwards, of Richmond. The address
to the public and profession will be delivered by Dr. R.
S. Martin, of Stuart, Va.
Physicians on a Strike. — The daily papers state that
the physicians of Mount Vernon, N. Y., are on a strike.
They have announced that they will not examine luna-
tics, because the Board of Supervisors of Westchester has
cut down the charge from $ 10 to $$ for each case. There
are two insane prisoners in the Mount Vernon jail wait-
ing the result of a doctor's verdict.
Chicago has 22 general and 16 special hospitals, with
3,409 beds.
The Chicago Health Board has adopted the New York
plan of supplying culture- tubes and making microscopic
examinations in cases of suspected diphtheria.
Women in Medicine. — Without egotism, we think that
the women in medicine as a class are superior to men as
a class ; because it is the picked woman, the ambitious
woman, whose desires are above the common level, who
enters the profession. It takes grit and gumption to be
a woman physician even to day, for the woman in the
profession must have a double motive for success : she
must succeed for her own sake as well as for the reputa-
tion of capability all women desire. This may not seem
fair, but it is nevertheless true. — Woman's Medical
Journal.
Medical Journals in the United States. — There are
two hundred and twenty- one medical journals published
in the United States, but then there are one hundred
thousand ph> sicians.
Take a Vacation. — Dr. Alexander Stone says : " Doc-
tor, whatever you do, do not forget to take your vaca-
tion. I can assure you that you will be able to do more
work, better work, make more money, enjoy life fuller
and live longer, if you work eleven months in the year,
than you would if you labored for twelve." But per-
haps some of the doctors' hearers feel as the tramp did
when advised to take three regular meals a day.
A Medical Populist. — The Medical Sentinel says that
the democrats and populists of North Dakota have nom-
inated Dr. M. F. Merchant, of Ellendale, for State Com-
missioner of Labor. The Sentinel adds: " Of all the
nominations made so far this fall in any of the States,
October 6, 1894] MEDICAL
this is one of the most appropriate. What man of all
men understands so well what ' labor9 means?" Dr.
Merchant is perhaps the first medical populist who has
run for office.
Sugar as an Oxytocic. — A French obstetrician, Morso,
asserts that sugar is an excellent and useful stimulator of
uterine contractions during labor. He gives an ounce
dissolved in eight ounces of water, and reports ten suc-
cessful cases. Sugar is a direct stimulant to smoothe
muscular fibres.
A Hew Method of Giving Thyroid Extract. — Dr.
Edward Blake writes to the Provincial Medical Journal
that in a case of myxoedema in which thyroid extract was
not tolerated by the mouth, twice a day, after hot
sponging and vigorous towelling, the body was well
rubbed all over with the following mixture :
IJ . Thyroidine io parts.
Ether 60 parts.
Lanoline 480 parts.
A rise in the temperature of one degree followed the
inunction, showing that the extract was really absorbed.
This proceeding was well borne, and was followed by
satisfactory results.
The Library of the French Academy of Medicine —
Dr. Dureau, the librarian of the Academy of Medicine
at Paris, gives some interesting details concerning his
charge in a recent report. The library contains 147,405
volumes, including pamphlets, of which 8,164 were con-
tributed during 1893. Tne greater part of these works
was due to generous benefactors. Among other curiosi-
ties the library contains a collection of six thousand en-
gravings and portraits of medical men, the greater number
having been presented by a country doctor named
Munaret, who for upward of forty years has been an
ardent collector.
Further Reports Upon the Value of the Antitoxin
Treatment of Diphtheria — M. Roux has communicated
the following statistics with regard to the trial of the
remedy at the Hdpital des Enfants Malades in Paris.
Between February 1st and July 24th, 448 children were
admitted into the diphtheria pavilion. Of this number
109 died; a mortality of 24.33 Per cent- This was to
be contrasted with the mortality in the four previous
years, when 3,971 cases were admitted, and 51.71 per
cent. died. The improvement in the death-rate attribu-
table to the treatment was therefore 27.38 per cent. If
compared with the mortality among the cases of diph-
theria admitted during the same period into the Hdpital
Trousseau the results appeared still more satisfactory.
Of 500 children admitted into that hospital 316 died; a
mortality of 63 20 per cent. A critical examination of
the statistics for this year involved the drawing of a dis-
tinction between cases of true and false diphtheria. Of
the 448 children admitted into the diphtheria pavilion,
bacteriological examination showed that 128 were not
infected with true diphtheria; further, 20 of the cases
were already moribund when admitted. There re-
mained, therefore, 300 cases which afforded a fair test of
the efficacy of the treatment ; they yielded 78 deaths, a
mortality of twenty six per cent., which was to be con-
trasted with an earlier series of cases subject to the same
eliminations bat treated by other methods, which gave a
mortality of fifty per cent. The rule had been to give
RECORD.
439
an injection of the serum, which was obtained from the
horse, immediately after the admission of the child.
The injection was not repeated if bacteriological exami-
nation showed that the case was not one of true diph-
theria. In none of these cases was the injection fol-
lowed by any unfavorable symptoms ; it was not painful,
and if made with aseptic precautions was not followed
by any local disturbance. In cases of true diphtheria a
second injection was given twenty-four hours after the
first, and as a rule this was sufficient. If the tempera-
ture remained elevated a third injection was given. As
a rule a child received an amount of serum equivalent to
one-thousandth of its weight, but in a few cases the quan-
tity reached one-hundredth of the child's body weight.
Under the antitoxin treatment complications were ob-
served in only a few cases, but in some paralysis super-
vened. Occasionally during convalescence an* urticarial
eruption was observed, apparently due to the injections.
The treatment appeared to diminish the liability to albu-
minuria. Dr. Aronson, of Berlin, states that he em-
ploys serum of the immunized horse, which is three times
stronger than that of Professor Behring. In the five
months ending with July he had treated with his serum
192 patients suffering from diphtheria, as ascertained by
bacteriological examination. The mortality was four-
teen per cent. In twenty-three cases the children were
moribund when admitted; eliminating these there re-
mained 169 cases with 19 deaths — a mortality of 11. 2
per cent. This contrasted with a mortality in the same
hospital varying in the three years before the adoption
of the antitoxin treatment from 32.5 per cent, to 41.7
per cent. Eighty- two cases had been treated by the
serum in other hospitals in Berlin, and the general mor-
tality of the. whole series of 274 cases was 15.3 per cent.
He had also employed the antitoxin serum with the ob-
ject of producing immunity in the children belonging to
families in which one case of diphtheria had occurred.
Among the 130 children thus inoculated 2 only con-
tracted diphtheria, and that of a very mild type.
The Health of the Czar.— There seems to be no
doubt that the Czar of Russia is seriously ill, though the
reports as to the nature of his malady are very contra-
dictory. He has been said to have diabetes, influenza,
simple coryza, rheumatism, mental disease, Bright 's dis-
ease, epilepsy, and apoplexy. It appears probable, how-
ever, that the trouble from which he is suffering is ne-
phritis, following upon the attack of influenza and pneu
monia with which he was visited last winter. Professor
Leyden, of Berlin, was called to see the Czar in con-
sultation with his regular physician, Dr. Zakharin, and
has advised him to pass the coming autumn and winter
in some mild climatic resort in southern Europe. He
has gone temporarily to Livadia in Greece.
Medical Legislators in Prance. — The medical mem-
bers of the French Parliament held a meeting on June
2 1 st in the Palais Bourbon, and decided on forming an
extra-parliamentary group which should occupy itself
with the examination of the numerous questions concern-
ing the medical profession, the organization of charitable
institutions, and the public health. There are in the two
Chambers no fewer than forty seats occupied by members
of our profession ; and there are also two medical men
in the Cabinet, Drs. Lourties and Viger.
440
MEDICAL RECORD,
[October 6, 1894
The Southern Surgical and Gynecological Association
will hold its seventh annual session at Charleston, No-
vember 13th, 14th, and 15th. The meeting promises to
be the most successful in the history of the organization.
Papers will be presented by the leading surgeons and
gynecologists of the South. The medical profession is
cordially invited to attend. Dr. Cornelius Kollock, of
Cheraw, S. C, is president, and Dr. W. £. B. Davis, of
Birmingham, Ala., secretary.
A Hew Carriage for Medical Ken. — Medical men,
says The Lancet, will be interested in a new " inter-
changeable " or " convertible " carriage, which has re-
cently been introduced. It has been shown at the
Coaching Exhibition recently held at the Royal Aqua-
rium. It is a radical change in the method of building
convertible carriages. The inventor builds a foundation
consisting of wheels, undercarriage, and driving seat,
and upon this he places the movable bodies, forming an
open or a close carriage of perfect shape in either case,
and free from such defects as draught, rattle, and com-
plication of parts. This carriage will enable its owner
in crowded towns, where coach-house room is scarce and
dear, to keep an open and a close vehicle — for there are
practically two carriages in the space usually occupied by
one. The change from brougham to victoria, or vice
versa, is readily and easily made in the coachhouse, and
the carriage in either form cannot be distinguished from
the ordinary private brougham or victoria.
Treatment of DiarrhoBa, Whooping-cough, and Noc-
turnal Enuresis at the Evelina Hospital for Sick Chil-
dren.— At this season of the year, writes the London
correspondent of The Therapeutic Gazette, the most
common ailment in the medical department is diarrhoea.
Dr. Fenwick tells me that his experience leads him to
rely chiefly upon antiseptics in such conditions. His
favorite remedy is benzo-naphthol, which is given in
grain doses thrice daily, even to very young children.
It will be remembered that benzo-naphthol is a benzoate
of /3-naphthol, and that it is said to break up in the
intestine into its constituents, both of which have an
antiseptic action. Another remedy much used in this
condition is carbolic acid, which is given in minim doses,
either as a mixture or in the form of perle. Some of the
physicians prefer creolin, giving it in drop doses on
sugar, and in many cases this treatment is highly success-
ful. Its nauseous odor and taste, however, prevent its
finding favor with children. Lastly, creosote is used by
some, but this is open to the same objections, and to a
greater degree, as those already referred to in regard to
creolin. Whooping-cough comes so often under treat-
ment that it has been deemed desirable to devote a whole
ward to the treatment of this affection. The most suc-
cessful of all drugs at present in vogue is bromoform. It
is given in doses of from 1 to 5 minims, either suspended
in syrup or in a mixture, the taste being concealed by
means of paregoric or some other flavoring ingredient.
The drug does not appear to alter the duration of the
affection, but is most useful in checking the paroxysms
of cough and vomiting. I do not know whether it is a
matter of common observation in other institutions, but
I am given to understand that quite a large proportion
of the serious cases of whooping-cough admitted at the
Evelina develop miliary tuberculosis after admission.
Another ailment frequently met with in all children's
hospitals — nocturnal incontinence — is generally treated
by the application of the faradic current, used as strong
as the patient can bear it. One pole is applied to some
neutral ppint, such as the nape of the neck, and the
other is applied to the perineum, the latter electrode
being more or less cone-shaped, and provided with a
movable covering of either chamois leather or, better, of
amadou. With this arrangement a fresh covering can be
used for each patient. Improvement is generally very
rapid, and the trouble often ceases after a few appli-
cations of the current. Should it relapse, a renewal of
the treatment is attended with equal success. Treat-
ment by such means is found to be far more successful
than by any of the drugs, such as belladonna, which were
formerly employed, but which, if used at all, are given
solely as adjuncts to the electrical treatment.
Society Reports.
AMERICAN ASSOCIATION OF OBSTETRICIANS
AND GYNECOLOGISTS.
Seventh Annual Meeting, held in Toronto, Ontario,
September 19, 20, and 21, 1894.
First Day, Wednesday, September 19TH.
The Association met in the Council Chamber of the
College of Physicians and Surgeons at 10.15 a.m., and
was called to order by the Second Vice-President, .Dr.
George F. Hulbert, of St. Louis, Mo.
An Address of Welcome on behalf of the local medi-
cal profession was delivered by Dr. James Thorburn,
which was responded to by Dr. Hulbert.
The Incision in Abdominal Surgery — Methods and
Results. — Dr. J. Henry Carstens, of Detroit, read a
paper with this title, of which the following is a sum-
mary :
1. With a small, narrow- bladed, sharp knife, make a
clean incision through the skin of the necessary length,
and with another sweep or two cut through the lineaalba,
muscle, etc Lift the peritoneum with your fingers, open
it, and enlarge the incision. The use of the forceps to
lift the tissues, or the grooved director is unnecessary.
2. In closing the abdominal incision use animal liga-
ture, kangaroo tendon, and catgut. First carefully brirg
together the peritoneum in a running stitch, then the
transversalis fascia, and the rectus if the incision is
through this muscle. Then carefully bring together
edge to edge the tendinous insertion of the oblique
muscles. The fat and loose cellular tissue above can be
brought together in one or two tiers, according to thick-
ness. Bring the skin together carefully with Marcy's
cobbler stitch, thus burying all your sutures.
3. Then seal with collodion, and if everything con-
nected with the operation has been carefully aseptic, ab-
solute primary union will take place, and the different
layers of the abdominal wall will have been brought to-
gether as near as possible as they were in the fir>t place,
and no hernia will result.
4. In cases of extensive umbilical, ventral, or other
hernias, it is best to bring the peritoneum together with
an over-and-over stitch of kangaroo tendon or catgut ;
to make a flap splitting operation of the ring, which is
brought together with silkworm gut or silver wire, which
are buried, and then the fat and skin are united with the
buried animal suture.
Plastic Surgery in Gynecology. — Dr. Joseph Price,
of Philadelphia, read a paper on this subject, in which he
said that the practice of surgery in all its branches re-
quired a mechanical trend and an ability to devise means
to accomplish a given end. In order to mend a perineum
intelligently, the mechanism of labor must be understood
October 6, 1894]
MEDICAL RECORD.
441
and the lines of fracture appreciated. In cases of seri-
ous pelvic invasion with accompanying lacerated cervix,
it is often better, or imperative; first to do the pelvic
operation, and to follow this at another time with the
cervical repair. The author condemns the plan advised
by some to perform internal and external operations at
one sitting. Perineal tears always occur at certain parts
of the perineal structure. These tears are either lateral,
under the ramus of the pubes, or central, extending from
the vagina toward the rectum. The tears toward the rec-
tum tend to run around it rather than through it, owing to
the differentiation of structure in these two tubes. The
tears of the vagina are always from within outward, from
above downward, and that therefore the external or skin
operations for perineal lacerations are essentially unscien-
tific procedures. All operations for the restoring of the
integrity of these parts should be done in the lines of
their destruction, and therefore from within outward and
from above downward. When the skin of the perineum
is involved, mending of this is merely a cosmetic proced-
ure. The cosmetic element too often predominates in
many of the so-called perineal devices. The silk-worm
gut with shot is by far the most preferable material to be
used for sutures. As little tissue as possible is to be in-
cluded within the ligature, and strangulation is to be
avoided.
The Care of Pregnant Women.— Dr. W. B. Dewees,
of Salina, Kan., read a paper in which he held that the
paramount duties of the obstetrician in the study and
care of pregnant women may be classified as follows : 1.
To discover if the patient be actually pregnant. 2. To
determine positively if the impregnation be uterine or
normal as contradistinguished from tubal, abdominal,
or abnormal pregnancy. 3. To carefully note the preg-
nant woman's history, including her age, primiparity, or
multiparity, environments, station in life, general condi-
tion of health, period of gestation, as well as her dress,
food, drink, and habits of life. To make repeated ex-
aminations of the urine and ascertain the tempera-
ture from the time pregnancy is established to the
termination of gestation. 4. To make a physical exam-
ination for the purpose of accurately determining the
diameter of the pelvic straits ; the symmetry and size of
the bony outlet ; the integrity, condition, and position
of the vagina, uterus, and other intra-pelvic viscera, and
adjacent structures ; the state of the abdominal muscles ;
the presence or absence of hernia, varicose veins, tu-
mors, etc., the shape, size, and condition of the breasts and
nipples ; the condition of the heart, lungs, mind, stom-
ach, bowels, etc. 5. To observe the state of the foetus,
its strength and viability, as well ps the implantation of
the placenta. The thoughtful obstetrician will advise
his patient as to the requisite regime. The conscious-
ness of his full duty will impulse him to insist upon : 1.
Absolute regular hours and wholesome environments.
2. Plain but nutritious and wholesome food and drink,
being principally composed of fresh lean meats, fresh
fruits, pure milk, and distilled water. 3. A proper
amount of exercise, by walking or light labor on foot,
and maintaining the correct erect posture. 4. An open
condition of the bowels and skin, which is to be chiefly
maintained by proper diet, exercise, and bathing, the
wearing of flannels, warm low-heeled shoes, and loose
garments, and in rare cases the proper use of laxatives
and hot-water enemas.
Appendicitis, With Report of Oases. — Dr. George
S. Peck, of Youngstown, O., read this paper.
Case I. — Operation during interval of attacks ; ob-
struction; July 6th did second operation; recovery.
Operation July 27, 1894. Appendix buried in mass of
strong adhesions between ileum and caecum containing
large fecal concretion. Appendix removed in segments.
Ileum returned to abdominal cavity. During first six
days highest temperature ioo° F. ; pulse, 100. On the
fifth day four attacks of vomiting, fourth containing
fecal matter. August 4th reopened incision ; found
about three feet from ileo-csecal valve complete obstruc-
tion by band of dense adhesions. Obstruction liberated,
ileum brought out in the incision, and abdominal cavity
packed with gauze. During entire day of August 1st
pulse ranged from 140 to 160; vomiting fecal matter
continued at frequent intervals ; tympanites increasing.
Seven o'clock symptoms of obstruction continued, be-
coming worse every hour. As a temporary expedient a
small opening was made in ileum, fetal matter and flatus
came away in large amount ; vomiting ceased and tym-
panites disappeared. From the thirteenth day to the
present time patient has had from one to three daily
passages per rectum ; sat up for the first time the thirty-
third day. Discharged from hospital on the fifty-fifth
day after first operation.
Case II. — Operation during the fourth day, first at-
tack. Large appendix removed, containing two drachms
of pus and fecal concretion. Adhesions broken up, in-
cision packed with iodoform gauze. Uninterrupted re-
covery. Discharged from hospital twenty- eighth day
after operation.
Case III. — Operation third day of third attack. Peri-
toneal cavity opened, adhesions broken up ; large ap-
pendix removed ; uninterrupted recovery.
Case IV. — Operation during tenth day. Death from
septic peritonitis in sixty- five hours. Large abscess cav-
ity evacuated; appendix gangrenous and detached;
washed out by irrigation. Autopsy revealed general sep-
tic peritonitis.
Case V. — Perforating appendicitis. Operation dur-
ing third day of attack. Death from septic peritonitis
twenty-seven hours or more after operation.
Case VI. — Similar to previous one, died from general
septic peritonitis.
Appendicitis; Observations Based on a Clinioal
Study of Eighty-four Oases Dr. W. G. McDonald,
of Albany, presented a communication with this title.
Out of the great amount of literature, controversial and
otherwise, three important landmarks are established :
1. That for all practical purposes all inflammatory proc-
esses in the right iliac fossa arise from the appendix.
2. That practically the appendix is always intra-perito-
neal, and that any operation undertaken for appendicitis
that does not involve the entering of the peritoneum is
false in its surgical conception. 3. That idiopathic peri-
tonitis does not occur. That many cases diagnosticated
as such, are really cases of perforating appendicitis. The
author classified the varieties as 1, acute perforating, ful-
minating appendicitis with general peritonitis ; 2, acute
suppurating appendicitis with local plastic peritonitis and
abscess ; 3, subacute appendicitis, variously termed ca-
tarrhal, chronic, relapsing, or obliterating appendicitis, or
appendicular colic. The perforation occurs very much
earlier than is commonly believed. That acute suppurative
appendicitis with local peritonitis presents the most fav-
orable field for operation during fhe attack. The removal
of the appendix is to be undertaken with great circumspec-
tion when it lies in the wall of an abscess cavity. The
third group of cases do not require operations during the
first attack, but if repeated attacks occur, operation dur-
ing quiescence is demanded. Operative results in these
cases are most favorable.
Second Day, Thursday, September 20TH.
Ligation of the Uterine Arteries for the Cure of Fi-
broid Tumors and Oheoking Hemorrhage. — Dr. W. B.
Dorsett, of St. Louis, read a paper with this title. The
object of which, he said, was to establish his priority in
resorting to ligation of the uterine arteries for the cure
of fibroids. He made observations during December,
1889, anc* January and February, 1890, and reported a
case of atrophy of the genitalia and described the tech-
nique of the operation of ligation of the uterine arteries
for the cure of fibromatous growths in a paper read
before the St. Louis Medical Society, May 17, 1890, and
which was published in the St. Louis Courier of Medi-
cine.
442
MEDICAL RECORD.
[October 6, 1894
Remarks on the Surgical Treatment of Intussuioep-
tion in the Infant Baled on Two Successful Cases.— Dr.
Henry Howitt, of Guelph, Ont, read the paper. In
it he recommends early abdominal section as being the
best method of treatment to reduce the high mortality
rate of intussusception in early infancy. Of the two
cates cited, one child was at the time of operation under
three, and the other under six months of age. In regard
to the steps of the operation, among other things he ad-
vises a small median incision ; evisceration ; reduction
by pressure on apex of intussusceptum, while the intus-
susception is drawn in the opposite direction ; and forc-
ing the contents of ileum into colon before returning the
intestines to abdomen.
Dr. Robert T. Morris, of New York, demonstrated
a method of intussusception in rabbits.
Treatment of Distention of the Fallopian Tubes With-
out Laparotomy and Removal.— Dr. Frank A. Glas-
gow, of St. Louis, read a paper which was intended to
bring before the profession a method of curing tubal
distention by means of intra-uterine treatment, in contra-
distinction to laparotomy and removal. By this means
the uterine ends of the tubes are made more patulous and
a discharge takes place from the tube through the uterus.
He called attention to the fact that the tubes, as far as
his observation goes, are always pervious at the outer
extremity of the cornu, hence when removing them we
must always clamp them before cutting. The obstruc-
tion must be within the uterine wall, probably in the
endometrium, and also to the fact that gonorrhoea! in-
flammation is not an adhesive inflammation, and hence
it does not follow that the tubes have a true atresia fol-
lowing this inflammation. His opinion is that the clos-
ure is due to a swelling of the endometrium, and hence a
closure at the uterine end takes place. When this in-
flammation and swelling are overcome by pressure and
antisepsis, the tubes become patulous again. The intra-
abdominal pressure will cause fluid in any pendant por-
tion of the tube to ascend into the uterus. The above
procedure can be carried out in three different ways :
1, By gradually packing with gauze without anaesthesia;
2, by rapid dilatation of the cervix and packing with
gauze after curetting — this is done under anaesthesia —
3, his own method of dilating by means of antiseptic or
sterilized elm-bark tents. These tents are small strips of
elm bark made just long enough to enter the cervix com-
pletely and not press on the fundus. They should be
kept in an alcoholic solution or bichloride of mercury,
1 to 4,000, and have a short string attached, by means of
which they may be withdrawn. They are partially
broken in a number of places for the purpose of making
them more pliable. They may be dipped into glycerine
or water just before introduction. These tents may be
used when it would be impossible to pack with gauze.
He had treated twenty or more cases during the past
year, and does not recall one in which he did not get
some discharge from the tent. All of the cases were
either cured or very much benefited.
Inflammatory Disease of the Uterus and Appendages
and of the Pelvic Peritoneum.— Dr. William W. Pot-
ter, of Buffalo, presented a communication with this
title. He began by recalling the well-known fact that
the pathology of pelvic disease has been entirely recon-
structed since i860, and that now we had come to re-
gard inflammation of the pelvic peritoneum as generally
symptomatic of disease of the ovaries or Fallopian tubes,
or both. Mr. Tait, within the last ten or twelve years,
together with men who have worked abreast of him —
some of whom are members of this Association — have
driven out the theory of pelvic cellulitis that for so long
held sway, and now peri- and parametritis have been
dropped from the gynecological vocabulary. The strug-
gle has been a long one, but abdominal surgeons have
demonstrated the truth of this proposition, viz., that pus
originating outside of the tubes or ovaries in the non-
puerperal state is a very rare condition, and that speak-
ing generally pelvic are pus tubes. The largest number
of women in the consulting rooms of gynecologists are
those suffering from pelvic inflammation or its residues,
hence the importance of the subject under discussion
cannot be overestimated. But, he asserted, it is only
within the past seven or eight years that anything like
uniformity of opinion as to the causes and proper treat-
ment of pelvic inflammation have been adopted. Now,
just as we are beginning to agree as to the essentials
governing these cases, we are told by a number of agree-
able gentlemen who call themselves conservatives that
these diseases do not demand operation, but that they
can be cured in most instances by tentative measures,
such as diet, rest, electricity, and the like. By denounc-
ing the work of abdominal surgeons as unnecessary mu-
tilation, and stigmatizing it as castration or unsexing
women, they have created a panic among the medical
journals that is reaching far into the ranks of the pro-
fession. Hie effect of this is to turn back the wheels of
time and stay the advance of progress, with harmful re-
sults to suffering women. It must be admitted that these
so-called conservative men are clever, which makes their
subtle and dangerous doctrine all the more damaging in
its results.
Dr. C. A. L. Reed, of Cincinnati, discussed the clin-
ical history of inflammatory disease of the uterus and
appendages and of the pelvic peritoneum; Dr. L. S.
McMurtry, of Louisville, the causation and pathology ;
Dr. James F. W. Ross, of Toronto, diagnosis and prog-
nosis; Dr. M. Rosenwasser, of Cleveland, the treat-
ment, along with Drs. A. Vander Veer, J. Henry Car-
stens, and Dr. Joseph Price.
Pus in the Pelvis and Abdomen— its Diagnosis and
Treatment. — Dr. Joseph Hoffman, of Philadelphia,
said that pus in the abdominal and pelvic cavities had
been treated and considered with far more leniency than
pus anywhere else in the human economy. It was the
tramp manifestation of all disease. He considered
briefly the various organs in which pus makes its ap-
pearance, and in the order of frequency he mentioned
the kidneys, appendix vermiformis, tubes and ovaries,
liver, pancreas, and spleen. Eaxh case should be treated
according to the demands it makes and according to its
complications. There was no use in doing an ideal
operation and have the patient die when it is over.
Ideal work was that which gives the best result in the
line for which it was done. Surgery of the abdomen
was a work of self denial, of trial, of unexpected com-
plication, and lurking disaster. He best can rise to it
who has for his motto, " My Patient. Nothing bat
for the good of her who trusts me.1' Self seeking care-
lessness of lives has its place in the carnage of inter-
necine strife, not in the shadowy sorrows of suffering
humanity, of dying women.
A New Operation for the Radical Cure of Inguinal
and Femoral Hernia. — Dr. C. A. L. Reed, of Cincin-
nati, described the operation as follows : The incision in
inguinal hernia is made from a point two inches above
Poupart's ligament, midway between the anterior supe-
rior spinous process of the ilium and the spine of the
pubis, obliquely downward and inward as nearly as pos-
sible consistent with the access of the inguinal canal to
a point at the base of the scrotum. The dissection is
then carried into both scrotal and pelvic cavities. The
protruding viscera is then reduced and carefully in-
spected after being brought out above. The sac is then
carefully dissected from its scrotal connections and re-
versed by invagination. It is then opened by two in-
cisions, one toward the pubes, the other toward the
ilium, being thus converted into an anterior and a pos-
terior flap. The cord is now dissected loose and placed
in the canal, now denuded of its peritoneum at its outer
angle. The internal ring is closed by several interrupted
sutures, animal or buried silk, these sutures being applied
beneath the peritoneal flaps formed by splitting the sac,
care being taken that in the closure of the ring undue
pressure shall not be brought to bear upon the cord.
The posterior peritoneal flap is now excised, the stump
October 6, 1894]
MEDICAL RECORD.
443
being ligatcd should there be any necessity for doing so.
The anterior flap is carried across the now obliterated
internal ring, and stitched by interrupted sutures to the
posterior parietal peritoneum. The external ring is now
closed by passing a number of sutures through its pillars
externally to the cord, which is now fixed in the internal
(pubic) angle of the outlet of the canal. The incision
into the abdomen is closed by interrupted figure of eight
sutures, the internal loop embracing the peritoneum, the
aponeurosis] of the transversalis and of both oblique
muscles, and the external loop embracing the superficial
fasciae, fat, and skin. These sutures should not be more
than three-fourths of an inch apart. The incision into
the scrotum may be closed in the ordinary way. Drain-
age should not be employed except in the presence of
marked oozing or obvious infection.
Ovariotomy. — Dr. A. Vander Veer, of Albany, pre
sented a report of one hundred and forty five operations
done for removal of ovarian tumors and pathological
conditions associated with the ovaries and uterine append-
ages only. He gav$ a careful review of the subject of
the preparation of patient, embodying all the strong
points pertaining to the technique of such work, placing
great stress upon the importance of the room in which
the operation was to be done being put in a thoroughly
aseptic condition, and thorough cleanliness of the pa-
tient herself. The operations comprise all the varieties
of pathological conditions met with in connection with
the ovaries and tubes. The histories of the cases were
somewhat interesting. Thirty-nine gave a history of
phthisis, fifteen of cancer, fifty-seven of irregularity of
menstruation. The mortality amounts to eleven per
cent. While not 'criticising adversely the methods of
other operators in closing the wound by means of differ-
ent rows of sutures, kangaroo tendon, and other forms,
yet he has no reason to give up his usual method
of closing the wound by deep sutures of silk worm-
gut, placing them three or four to the inch, taking in
carefully only a margin of the skin, a portion of the
fascia and muscles, and not to exceed one- quarter of an
inch in width of the peritoneum itself, placing much
stress upon the importance of careful, thorough, com-
plete apposition. The causes of death in the seventeen
cases were as follows : Obstruction of the bowels due to
a coil of small intestines becoming attached to the stump
of the pedicle, causing death on the fourth and fifth day,
two cases. Septic peritonitis, two cases. Immediate
hemorrhage from the pedicle, slipping of the knot,
within six hours after the operation, though the wound
was reopened, the vessels secured, abdomen flushed, and
hemorrhage controlled, one case. Undoubted hemor-
rhage from the pedicle, causing general peritonitis, al-
though no distention of the bowels was present, death
on fourteenth day, one case. Shock within twelve
hours after operation, one case. Shock within twenty-
four hours after operation, one case. Autopsy in both
cases revealed everything in good condition. Pulmo-
nary infarction on sixth day, one case. Aggravated dia-
betes, one case. Exhaustion on the sixth day, no other
apparent cause found, one case. Another case of ex-
haustion on the third day, symptoms in the last two
cases, including an autopsy not revealing any other
cause. Multilocular ovarian cyst, tapped twice, opera-
tion complicated with four months' pregnancy, one case.
Puerperal septicaemia, one case. Intestinal obstruction
on twenty-first day, one case. Advanced age compli-
cated with the recent effect of an attack of la grippe, one
case. Delayed operation in a case of extra-uterine preg-
nancy possibly four months, one case.
Hydrosalpinx.— Dr. A. H. Cordier, of Kansas City,
read a paper with this title. He said articles had ap-
peared in medical journals by the so-called conservative
writers in the last few months, in which aspiration or
catheterization of the Fallopian tubes filled with liquid
of any character had been advocated as a procedure of
relief and cure. Such articles had engendered a retro-
grade tendency on the part of many, and it is sure to be
at the expense of an increased mortality from subsequent
operative procedures to cure these cases after abandon-
ing the unsurgical and uncertain tinkering. Hydrosal-
pinx had been looked upon as the least hazardous of all
inflammatory results to the Fallopian tubes. The writer
claimed that hydrosalpinx was a sequel of some old in-
flammatory diseases of the tubes, an offspring of a viru-
lent process that had wrought permanent and irrepara-
ble injury to the delicate structures of the tubes. The
writer did not consider hydrosalpinx as a retention cyst.
Cases were rarely diagnosed prior to operation. A digi-
tal examination of one of these cases causes less pain
than is produced in examining a pyosalpinx. In one
case, occurring in the essayist's practice, the uterine ex-
tremity of the tube was largely dilated and filled with a
clear fluid, while in the ampulla there existed a collec-
tion of pus, separated from the clear fluid by a closed
stricture.
Inflammatory Disease of the Uterus and Appendages
under Various Modes of Treatment. — Dr. Joseph
Price, of Philadelphia, said that the methods of treat-
ment of pelvic disease may be broadly classed as those
that are proved, and those that are experimental. Many
of the operations now successful were formerly failures
because of the insufficient knowledge of how to deal
with a wounded gut, how to make an anastomosis, or to
do a bowel resection. Hence it is to be put down as a
postulate in pelvic surgery that no man has a right to at-
tempt it who does not know how to deal with all the
complexities of intestinal surgery. To know when to
stitch and when not to stitch the intestine is as necessary
as to know when and when not to operate. The leav-
ing of pus- tubes to recover of themselves is just one step
removal from stuffing them with gauze and trusting to
Providence. To puncture and evacuate and stitch a
suppurating cyst — say a real ovarian cyst — would be de-
rided out of sight, and yet, said the essayist, we have
operators who do not hesitate to do this with the smaller
pus- tube.
Dr. George H. Rohe, of Catonsville, Md., said that
conservative surgeons were very much shocked at first
by the proposition to remove the uterus together with
the adnexa in cases of inflammatory disease in the pelvis.
However, the operation has won its way against opposi-
tion, and must now be considered as an elective proced-
ure in cases of extensive suppuration with adhesion, and
especially in those cases, so numerous, in which the en-
dometrium is likewise the seat of purulent inflammation.
Gonorrheal, puerperal, or tubercular inflammations and
dense adhesions, with displacement of the uterus, demand
removal of this organ as well as of the appendages if
permanent good results are expected. Total extirpation
of the uterus and appendages by the vaginal method for
pelvic suppuration was first done by Pean in 1886.
Pean, Segond, Doyen, Jacobs, and Landau have per-
formed the operation upward of five hundred times with
an average mortality of less than five per cent. The
operation by the vagina is easier than abdominal extir-
pation, and in the hands of most surgeons who have
performed it, is attended by less shock. It leaves the
parts in condition for perfect drainage. The after-
treatment is simple. Patients may sit up in a week or
ten days. Forceps are preferred to the ligature for
hemostasis.
How Shall we Seal with Pelvic Inflammatory
Troubles ?— Dr. W. B. Dorsett, of St. Louis, Mo., pre-
sented a paper with the following conclusions : 1. Pus in
quantities is hard to deal with down in the pelvis in lap-
arotomy cases, and, if possible, should be evacuated prior
to taking out the tubes and ovaries, either through the
cul de-sac of Douglas, or if between the layers of the
broad ligament, at the side of the uterus, laparotomy
should be done at some future time. 2. Pus sacs in the
tube near the uterine end of the tube can be evacuated
through the uterus by packing the horn. 3. Parametritis
or cellulitis of the ancients is, except under rare instances,
a secondary trouble due to a foul uterine cavity. Clean
444
MEDICAL RECORD.
[October 6, 1894
out the cavity and stop the source of poison, and you do
the best thing possible to be done.
The Relations of Renal Insufficiency to Surgical
Operations. — Dr. C. C. Frederick, of Buffalo, reported
observations based on nearly three hundred operations at
the Buffalo Woman's Hospital, supplemented by the
experience of several prominent operators. By renal
insufficiency is meant any condition of the urine
which shows deficient elimination of waste products,
whether from functional inactivity or from disease of the
kidneys. Whether renal insufficiency is a contra-indica-
tion to operation depends on the consideration of three
factors : 1. The amount and nature of the insufficiency.
2. The character of the lesions for which operation is pro-
posed. 3. The causal relation which the patient's disease
holds to the renal insufficiency. Every patient's urine
before operation should be collected for twenty-four
hours, except when operation is urgent, as in ruptured
ectopic pregnancy, for example. In examination of
urine the important fact to ascertain is, whether the kid-
neys are crippled, or in full or nearly normal functional
activity. Women with chronic endometritis are espe-
cially liable to functional insufficiency. Most gynecolog-
ical patients who are run down physically present the
same condition. A knowledge of the state of the patient's
kidneys is of value to the operator and anaesthetizer.
Renal insufficiency renders the patient more liable to
shock from operation, and a slower convalescence.
The Cause of Thirst following Abdominal Section.—
Dr. Eugene Boise, of Grand Rapids, Mich., after stat-
ing the generally accepted proposition that thirst is a
sensation indicating that the tissues of the body are in
want of more water, argues that the sensation as felt in
the mouth and throat is reflex, and that the real point
from which the sensation arises is in the abdominal vis-
cera ; that from these the sensation is conveyed to the
consciousness by fibres of the sympathetic system of
nerves ; that while ordinary thirst is caused by the with-
drawal of water from the tissues to refill the veins depleted
by excessive perspiration or otherwise, the thirst following
abdominal section is caused by the withdrawal of water
from the abdominal viscera to fill veins partially collapsed
by reason of diminished blood-supply because of contrac-
tion of the arteries of the viscera. He briefly stated
those physiological facts which are universally accepted
or have been experimentally proven on which the theory
is based : 1. Thirst is a sensation indicating that the
tissues need more water. 2. The sensation felt in the
throat is reflex. 3. The origin of the sensation is
believed by leading physiologists to lie in the sympathetic
system of nerves, because (a) no cerebrospinal nerves
can be found which convey the sensation to the con-
sciousness, and (£) nutrition is presided over by the
sympathetic system, and thirst is a disturbance of nutri-
tion. 4. The origin of the sensation is probably from
the abdominal organs, because (a) these are so rich in
sympathetic fibres, and (3) introduction of water into
the stomach so instantaneously allays thirst. 5. The
sensation invariably follows the withdrawal of any con-
siderable amount of fluid from the body ; the withdrawal
of such fluid causes proportionate collapse of veins and
capillaries. 6. Capillaries tend to remain at normal
tension, and when suddenly collapsed in any degree at-
tempt to regain that tension by taking water from the
surrounding tissues. 7. Irritation of sympathetic nerves
causes contraction of the arterioles supplied by such
nerves. 8. Sudden contraction of the arterioles supply-
ing any organ is followed by lessened tension in the cap-
illaries and small veins of that organ. 9. Abdominal
section invariably causes direct and reflex irritation of
the abdominal sympathetic nerves. 10. Such irritation
causes contraction in some degree of the arterioles of the
abdominal viscera, with subsequent lessened tension in
their capillaries, and compensatory withdrawal of water
from their tissues. And is it not probable that such cir-
culatory disturbances give rise to the sensation of thirst ?
President's Address. — Dr. Rohe then delivered his
address. He selected for his subject " Intestinal Ob-
struction following Operations in which the Peritoneal
Cavity is Opened. He said obstruction of the bowels
causes between one and two per cent, of the deaths fol-
lowing ovariotomy and other operations involving open-
ing of the peritoneal cavity. Sir Spencer Wells lost n
out of his first series of 1,000 cases of ovariotomy from
this cause. Fritsch places his mortality from ileus post
laparatomian at 1.6 per cent. Klotz has reported 31
cases of intestinal obstruction, with five deaths due to
this complication, in a series of 421 abdominal sections,
and 148 vaginal extirpations of the uterus. The speaker
had seen a case where the small intestine was doubled
upon itself, and so firmly adherent that the gut was en-
tirely impervious. Similar cases have been reported by
Skutsch and Turtle. Joseph Price quotes an interesting
case from Louis, where an adherent ovarian cyst, emp-
tied by the trocar, so dragged upon the bowel as to
cause obstruction. Volvulus sometimes occurs after ab-
dominal section, but probably only after some previous
adhesion or constriction of the bowel. Two cases re-
ported by Nieberding illustrate this. The symptoms of
intestinal obstruction post laparatomian are essentially
the same as those of primary obstruction. ^ Klotz has
had much success in treating acute obstruction follow-
ing abdominal section by the following method: As
soon as symptoms indicating obstruction appear, he
washes out the stomach with from four to six quarts of
warm salt solution. Should this fail to relieve the symp-
toms he repeats it, and then passes into the stomach
through a tube a large dose (one and a half to two
ounces) of castor-oil. In all cases so treated the active
peristaltic movements set up caused passage of flatus and
faeces within ten hours. Evidently it is only in cases of
fresh and friable adhesions that this method can be suc-
cessful. Rectal injections of water or air may at times
be curative when the obstruction is due to intussuscep-
tion, volvulus, or soft adhesions of the lower portion of
the intestine, but where the obstruction is due to cords
or bands they can manifestly be of no avail.
Third Day, September 21ST.
Vephreetomy. — Dr. L. H. Dunning, of Indianapolis,
Ind, reported four cases of this operation, of which the
following is a synopsis :
Cass I. — Nephrectomy for painful movable kidney.
An unsuccessful nephrorrhaphy had been done two and a
half years previously. The patient had been bedridden
four years. A lumbar nephrectomy was done, the pa-
tient recovering and obtaining entire relief from pain.
The author deplores the necessity of removing a healthy
kidney only because movable and painful. He thinks
that the success of recent methods for anchoring the
kidney will obviate the necessity of such a procedure.
Case II. — Nephrectomy for persistent hydronephrosis
due to stricture of the ureter at its pelvic extremity.
The tumor was mistaken for an ovarian one. It was re-
moved by a median abdominal incision.
Case III. —Sarcoma of the kidney in a child two years
old. Nephrectomy and recovery. The tumor had been
discovered only four weeks previously. A median in-
cision (abdominal) was employed.
The writer has collected the histories of twenty cases
of sarcoma of the kidney operated upon since 1885 in
children under five and a half years of age. Of these
five perished, and fifteen survived the operation, thus
showing a mortality of twenty-five per cent. This is a
surprising decrease in mortality, and is probably due to
improved details in technique rather than to radical
changes in the method of operation.
Case IV. — Nephrectomy for uretero-vaginal fistula
following vaginal extirpation of a cancerous uterus. The
operation was done four weeks after the hysterectomy.
The ureter was torn across in enucleating a nodule of
cancerous tissue from the folds of the broad ligament on
removal of the uterus. Nephrectomy was done four weeks
October 6, 1894]
MEDICAL RECORD.
445
subsequently because of intermittent closure of the fis-
tula and the morbid mental condition of the patient.
The cancer had recurred in seven weeks, and patient
died three months later of exhaustion and septicaemia.
Progressive Cutaneous Atrophy of the Vulva (Krau-
rosis vulva). — Dr. C. A. L. Reed, of Cincinnati, read
a paper with this caption. He reported six cases in
which the pathological and clinical features were char-
acteristic. The first changes obvious to the naked eye
consist of small vascular areas around the introitus va-
ginas. These areas are not elevated, as if seats of merely
inflammatory engorgement, but are slightly depressed
relatively to the adjacent epithelial surfaces. They are
exquisitely painful to the touch, and efforts at sexual in-
tercourse are generally agonizing and futile. About this
same time inspection will reveal a narrowing of the vag-
inal orifice associated with diminished elasticity of the
structures. The cutaneous or muco-cutaneous surfaces
will now be observed to have lost a certain proportion
of their pigment, giving them a more or less translucent
appearance, which increases until it becomes so trans-
parent that the larger capillaries and minute ecchymoses
may be readily discerned beneath it. The skin thus af-
fected becomes tense, effacing in a more or less degree
all of the normal folds of the vulva and narrowing the
vaginal orifice until, in the case of a multipara, " incredul-
ity may be excused when the patient states that she has
borne children."
Knowledge relative to progressive cutaneous atrophy
of the vulva is too nebulous to justify final conclusions.
That which seems to be conclusively demonstrated may
be summarized as follows: 1. Progressive cutaneous
atrophy of the vulva is a distinct disease. 2. It is of very
rare occurrence. 3. It is essentially inflammatory in char-
acter, differing from other inflammations of the skin in
the marked progressive atrophy which succeeds the stage
of hyperemia and infiltration. 4. It is limited in its
manifestations to the vulva. 5. It is manifestly not of
syphilitic origin. 6. Its etiology is so obscure as to sug-
gest a primary causal lesion in the trophic nerve-supply
of the vulva. 7. The affected areas may be successfully
excised.
Dr. George F. Hulbert, of St. Louis, read an inter-
esting paper on " The Element of Habit in Gynecic
Disease," an abstract of which would not do justice to
its author.
One of the interesting features of the meeting were re-
marks on intestinal anastomosis and a beautiful demon-
stration of the uses of the Murphy button by Dr. J. B.
Murphy, of Chicago.
Restoration of Intestinal Continuity Without Me-
chanical Devices.— J3r. W. £. B. Davis, of Birming-
ham, Ala., said that the purpose of this paper was not to
claim originality for any special technique, but rather to
consider the various operations and to show that me-
chanical devices can in a great proportion of cases be
better dispensed with by the surgeon who has had much
experience in intestinal work, either on the lower ani-
mals or on the human intestine. Still there is a place in
anastomotic work for bone plates, catgut plates, and other
devices of this sort, and the Murphy button, but the
experienced surgeon will find the field of their applica-
tion very limited. These devices are of great assistance
to the surgeon of limited experience in this class of work,
and should be recommended in the event of an operation
having to be done by one who has not had the oppor-
tunity of becoming familiar and skilled in suturing of
the intestines. The Murphy button is a valuable device
for cholecystenterostomy, and is superior to anything yet
suggested for that purpose. The button is so small that
it can pass through the intestine without causing any
trouble, and it can be depended upon with almost abso-
lute certainty to produce satisfactory adhesion and a
competent opening between the gall-bladder and intes-
tine. The end-to-end operation or circular enterorrhaphy
is a dangerous procedure, from the fact that injury to the
mesenteric border is liable to produce sloughing, and it
is never possible to say that a surgeon will not have this
complication follow the operation. Besides any stitch
method in the end to end operation requires so much
time that it should be objected to usually on that ac-
count. The Murphy button can be used very satisfac-
torily for this purpose, and where end-to-end operation
is to be resorted to, Dr. Davis is of the opinion that this
device could be used unless the surgeon is an expert in
intestinal suturing. The operation of Abbe is a plausible
one, but it is not so reliable as the one which has proven
satisfactory in the experimental work of the author.
The incision is not made so long as in the case of Abbe,
and is about three inches in length. In the case of
gastro enterostomy the intestine and stomach are both
brought into the wound, and the incision three inches in
length made in both. Interrupted sutures are taken
through coats of the bowel and stomach around the en-
tire length of the incisions and are tied on the inside,
the last stitch being tied on the outside and turned in. A
continuous outside safety stitch is then taken through the
peritoneal and muscular walls. In bringing the small
intestine together the same procedure is followed, the
interrupted through - and - through stitch of large silk
being taken instead of an over-hand stitch, as recom-
mended by Abbe, and only one row of outside sutures,
which may be interrupted or continuous, preferably the
latter. This operation can be done very quickly, and is
more reliable than the various ones with mechanical aids
to anastomosis. Particularly is this method of operating
valuable in cases of simple stricture of the bowel, and
there will be a great many of these cases now inasmuch
as there are more operations done on the intestines.
Dr. F. Blume, of Allegheny, Pa., reported a very
interesting case of cholelithiasis in a woman, thirty-seven
years of age, in which the number of calculi removed, be-
sides minute concretions, was one hundred and twenty-
three, weighing fourteen drachms. The stone removed
from the gall- bladder weighed four and three quarter
drachms.
The Season why Patients Beoovar from Tuberculosis
of the Peritoneum after Operation. — Dr. Robert T.
Morris, of New York, stated that he had been experi-
menting with a view to determining the reason for the
cure of tuberculosis of the peritoneum after operation, it
being a well-known fact that more than eighty per cent,
of these cases recover as a result of simply exposing the
peritoneal cavity to the air. Dr. Morris collected fluid
from the abdominal cavity of patients with tuberculosis
of the peritoneum, placed it in an incubator for forty-
eight hours, and developed the bacteria of putrefaction
which would ordinarily enter in such fluid exposed to
the air. From this fluid Dr. Eiloart then isolated a
toxalbumin, the product of the growth of putrefactive
bacteria in this peritoneal fluid. The toxalbumin em-
ployed to destroy tubercle bacilli in culture-tubes de-
stroyed them very promptly. A control experiment,
which was not yet completed, was in progress for deter-
mining if these bacteria were absolutely dead. How-
ever, enough had been proven to show that tuberculosis
of the peritoneum recovers after operation because putre-
factive bacteria produce a toxalbumin in the fluid which
is fatal to tubercle bacilli in the peritoneum. The rea-
son why it is more effective in curing cases of tuberculo-
sis of the peritoneum than tuberculosis of the knee-joint
is because the lymphatic anatomy of the peritoneum is
such that any toxic agent absorbed by the lymphatics of
the peritoneum is brought into close contact with the
entire structure ; whereas in the knee-joint the lymphat-
ics are fewer and with more definite channels.
Election of Officers.— President, Dr. J. Henry Carstens,
of Detroit, Mich. ; First Vice-President, Dr. W. E. B.
Davis, of Birmingham, Ala. ; Second Vice-President, Dr.
Henry Howitt, of Guelph, Ont. ; Secretary, Dr. William
Warren Potter, of Buffalo, N. Y. ; Treasurer, Dr. X. O.
Werder, of Pittsburgh, Pa.
The place of meeting for 1895 was referred to the Ex-
ecutive Council for decision.
446
MEDICAL RECORD.
[October 6, 1894
(&0tvesvon&mtt.
OUR VIENNA LETTER.
(From our Special Correspondent)
THE EIGHTH INrERNATIONAL CONGRESS OF HYGIENE AND
DEMOGRAPHY AT BUDAPEST — FOREIGN DELEGATER PRES-
ENT— OPENING OF THE INTERNATIONAL HYGIENE EXHI
BITION — RECEPTION OF THE DELEGATES BY THE ARCH-
DUKE CHARLES LEWIS — THE SEMMELWEISS MEMORIAL —
WORK OF THE SECTIONS — THE CAUSE OF CHOLERA —
CREMATION — IMMUNITY, NATURAL AND ACQUIRED — TY-
PHOID FEVER AND THE WATER SUPPLY.
Vienna, September 13, 1894.
The Eighth International Congress oi Hygiene and
Demography, which has just been closed, was brilliantly
successful. About three thousand members, among
whom representatives from various countries of the world
participated in it. The number of ladies present was
about three hundred. The Co ogress was opened on Sun-
day, September 2d, at eleven o'clock, by the Archduke
Charles Lewis of Austria, in the place of the Emperor,
who is the protector oi die Congress, but who was pre
vented from being present at the opening ceremonies.
The Archduke emphasized the great importance of the
Congress, which served the purposes of humanity and civ-
ilization. The endeavors of the members of former in-
ternational hygienic congresses to practically realize the
resolutions of the Congress were partly crowned with
success, and on this occasion the Archduke alluded to
the fact that in various states new, regular, and obliga-
tory courses on the principles of hygiene had been
introduced into the public school instruction.
The Archduke, who hitherto had spoken in French,
then began to speak in Hungarian, and saluted the beau-
tiful capital of Hungary, congratulating her on the dis-
tinction which the Congress had bestowed on her by
chosing their city as the place of present meeting. He
did not doubt that the Hungarians would sustain on this
occasion their world-wide reputation for hospitality.
The Archduke Charles Lewis then declared, in the
name of the ' King-Emperor, the Congress opened.
Among the foreign representatives who afterward ad-
dressed the Congress I will only mention Professor
Leyden, of Berlin, who spoke in German ; Professor v.
Inama-Sternegg, of Poland (German) ; Dr. Bergerau, of
France (French) ; Dr. Billings, of the United States
(French); Dr. Crocq, of Belgium (French) ; Dr. Corfield,
of England (English) ; Professor Don Amalis Girneno, of
Spain (French") ; Professor Bambos, of Greece (French) ;
Dr. Luigi Bodis, of Italy, (Italian) ; Professor Erismann,
of Russia (Russian and French) ; Dr. Joao Lopez de
Silva Martins, of Portugal (French) ; Dr. Hansen, of
Norway (French), and others.
At 1 p.m. the International Hygienic and Demographic
Exhibition was opened in the " Polytechnicum." This
was divided into six sections, namely, sewage of towns,
general exhibition of Germany, Austria-Hungary, and
various other countries, cremation, and balneology.
On Sunday evening the Congress was received at court
by his Imperial and Royal Highness the Archduke
Charles Lewis, where a splendid banquet had been pre-
pared for the guests. This meeting presented a particu-
larly picturesque appearance owing to the different
dresses of the representatives of the various states. The
President of the Congress,*State Minister of the Interior
Hieronymi, presented the delegates of the foreign states
and the other prominent members of the Congress to the
Archduke, who addressed them in French and German,
directing to them questions referring to their specialties
and their countries. I wish to mention on this occa-
sion as an interesting incident of the Congress the so-
called'" Semmelweiss-Sitzung," held on Sunday afternoon
in the buildings of the Academy of Medicine. Semmel-
weiss was the first to introduce antisepsis into obstetri
cal practice, but during his life his doctrines attracted
little favorable notice, and he was even persecuted by his
colleagues. Medical science had long ago acknowledged
the immortal services which Semmelweiss had rendered
to the science of obstetrics and to humanity, and Hun-
gary, which is always ready to reward the merits of her
great men, decided on doing the last, and pay due homage
to her great citizen, who was born at Budapest. A com
mittee had been established for the erection of a monu
ment in honor of Semmelweiss, and in the meeting now
referred to, Professor K6zmarszky, of Budapest, presi-
dent of the committee, made a report. A sum of 12,586
florins had thus far been collected; but subscriptions
toward the erection of the monument were still being
taken. Professor Ferdinand Hueppe, of Prague, de-
livered an address on Semmelweiss, which was re-
ceived with great enthusiasm by all present. The
members then betook themselves to the cemetery in
which Semmelweiss is buried, to assist at the ceremony of
the unveiling of his monument. On this occasion Pro-
fessor Hueppe spoke again, and Professor Chautemesse,
of Paris, delegate from France, answered in feeling
words, saying, among other things, that if all the chil-
dren whose lives Semmelweiss had saved were still living,
the city of Budapest would be unable td hold them all.
On Monday the sections of the Congress proceeded to
their work. There were nineteen sections, and the num-
ber of the papers announced amounted to nearly eight hun-
dred, all of which, of course, could not be read. The sec-
tions on hygiene were most frequented, and among these,
particularly the first, second, and third sections, in which
questions „of bacteriology and blood serum therapy were
most eagerly discussed. Among the lectures which were
delivered on the first day, that of Princess Christian of
Schlesweig-Holstein, on the advances in nursing science,
as well as on the spread of sanitary and hygienic knowl-
edge in England during the past few years, attracted
great attention.
In the other sections the discussions on diphtheria
and cholera were among the most interesting. The
discussions upon cholera were opened by Dr. Baker, of
Paris, and Professor Gruber, of Vienna. The latter
pointed out that besides the bacillus of Koch, there
must still be some others. The famous Paris scientist,
Professor Elie MetschnikofF, spoke to the same effect,
and said that the vibrio of cholera could not be the sole
cause of cholera. There were people who had ingested
pure cultures of cholera bacilli without becoming in-
fected with the disease. He had found in the stomach
and the intestines other bacteria, which either favored
or checked the development of the specific microbe.
Those in whose stomach or intestines there were bacteria
which favored the development of the cholera bacillus
became affected with cholera, while those in whose sys-
tem the antidotal bacteria were to be found remained
immune. Professor MetschnikofF added that he had
thus succeeded in provoking cholera in animals which
had hitherto been thought to be immune.
The Section on State Hygiene, which was presided
over by Professor Kratter, of Graz, formulated the fol-
lowing unanimous resolutions with reference to crema-
tion :
1. The least dangerous and most rapid, and at' the
same time cheapest, method of disposal of dead bodies
is cremation.
2. Cremation is the best substitute for suitable ceme-
teries where these are wanting.
"3. Cremation is of the greatest importance for the
welfare of peoples in times of epidemics.
4. The governments of the various countries must be
invited to permit of a facultative legal cremation, and
thus provide for an excellent means of prophylaxis
against epidemics.
In the first section of hygiene Professor Hans Buch-
ner, of Munich, delivered a lecture on the subject of
immunity and immunization, in which he arrived at the
following conclusions :
October 6, 1894]
MEDICAL RECORD.
447
1. The natural power of resisting infections, the so-
called " natural immunity/1 is due to quite different
conditions and causes than the artificial or acquired im-
munity. Both are conditions which in principio differ
from each other, and which must scientifically be sepa-
rately considered and inquired into, though, practically,
they may occur simultaneously in the same individual.
2. The natural power of resistance is due, on the one
hand, to the bactericidal influence of certain dissolved
constituents of the organism, the so-called "alexines,"
and, on the other hand, to a congenital power of re-
sistance of the tissues and the cells of the body against
bacterial poisons. This natural power of resistance can-
not, as a rule, be conferred through the blood on other
organisms.
3. The leucocytes play an important part among the
natural means of protection of the organism, but they do
not do so through their virtue as 'phagocytes, but only
by means of dissolved substances which they secrete.
Phagocytosis is only a secondary appearance.
4. The immunity which is artifically produced, or
which is acquired later in life, is due to the presence of
modified specific bacterial products, which have become
deprived of their poisonous influence — the so-called
" antitozines ; " these are to be found either in the
blood or in the tissues of the body, or in both. The
antitoxines, and also the immunity produced by their
action, can be transmitted by means of the blood or the
milk.
5. The effect of the antitoxines is not due to direct
destruction of the specific bacterial poisons by mutual
contact. The effect is only produced within the body,
and by means of the same, as the faculty of the living
parts of the body to resist the specific poisons becomes
thus increased.
Dr. I. Polak, of Warsaw, read a paper on " The Re-
lation between Typhoid Fever and Drinking-water."
He presented tables of the mortality in Warsaw since
1877, which showed that among the infectious diseases,
such as small pox, measles, scarlet fever, typhoid, ty-
phus, diphtheria, and croup, the mortality from typhoid
fever had considerably diminished since 1887, when the
new water- works were established in that city, and new
measures for sewage were adopted. Daring the period
from 1879 *° x886 the mortality from typhoid fever in
Warsaw amounted to from 60 to 105 deaths in 100,000
inhabitants, whereas in the period from 1887 to 1893,
it only amounted to from 18 to 30 deaths. Another
table which Dr. Polak showed related to gastro enteritis,
pneumonia, phthisis, and bronchitis. In this case the
regular decrease in the mortality from pulmonary phthi-
sis and bronchitis was also alleged as being the result
of the better conditions of the drinking-water in that
city.
The festivities before and during the Congress were
numerous and brilliant, and gave convincing proof of
the Hungarian hospitality.
IS MALAJUA A WATER BORNE DISEASE?
To the Editor or the Mbdical Record.
Sir : I wish to add my experience and observation to the
line -of inquiry pursued by Dr. W. H. Daly, of Pittsburg,
Pa., in his most excellent paper in the Medical Record
of September 15, 1894 regarding malarial infection. In
the summer of 188 1, while employed under the directions
of Major G. J. Lydecker, U. S. A., in the construction
of the KampsviUe Lock (Illinois River Improvement),
Ramps ville, Calhoun Co., 111., I had occasion to ob
serve the effects of drinking-water on persons tempo-
rarily residing in this malarial district, as well as upon
the native inhabitants. The land immediately adjacent
to the lock site, was known as bottom-land — it was over-
flowed at each high- water season — and was poorly
drained, being very flat. Water stood in the bogs or
swamps until the dry weather of summer had completely
evaporated it. Drinking-water was obtained for the men
employed in the construction of the lock foundation from
drive-wells, put down to the depth of about twelve or fif-
teen feet. The men employed on the dredge and tow-
boats, and the officers, used filtered river-water.
Among the many laborers who sought employment
were forty Swedes, who had arrived in this country, from
their native land, about ten days before coming to the
lock ; they were a vigorous, well nourished body of men,
eager for work. They took board in quarters near the
lock, and drank water from the drive- well. Within ten
days one of them was taken down with malaria, and be-
fore two weeks had elapsed ten or more had succumbed;
one died and two were seriously ilL At the end of a
month but three were able to continue work; one of
these had no malarial symptoms at all ; he worked on
one of the boats, where he also lived ; he drank filtered
river water. Now all of these men seemed peculiarly
susceptible to malarial infection, and as quickly as they
could returned to Chicago to escape its ravages. The
men who worked on the boats escaped the disease. The
natives who drank of the well-water were not so much
affected, yet quite a number of them had to quit work.
The wells used by the natives, however, were located on
the edge of the bluffs, about one-half mile from the river.
Here we have, I think, marked evidence of the infection
coming from drinking-water ; for all the employees, offi
cers and all, were situated under like atmospheric con-
ditions, and exposed to the same heat, etc., during the
day, yet those who used river-water escaped while those
using drive or open well-water were afflicted. Some
three and one half years spent in engineering work on
the Illinois River confirmed my belief in the possi-
bilities of infection from water-supply rather than from
atmospheric conditions.
I endorse Dr. Daly's views,
Frank P. Norbury, M.D.
Jacksonville, III.
IS IT TIME TO CALL A HALT?
To thk Editor of the Mbdical Record.
Sir : It is a continual surprise to me the indifference of
many oculists about the accurate adjustment of glasses.
Many jewelry stores have professional refractionists, and
a widely circulated jewelry monthly devotes several col-
umns each issue to the instruction and answering absurd
queries from men in stores who fit glasses. I know
reputable physicians who send patients to these stores be-
cause they get better work done than some oculists do.
Isn't it about time more attention was paid to accurate
refractive work, or are we to lose sight of this in the
chase after some ignis fatuus like trifling muscular de-
fects.
The phoria craze has reached the stage where conser-
vative men are met with pitying smiles if they venture
to suggest that some cases of asthenopia can be relieved
by proper glasses. The last two days of the Pan-Ameri-
can Congress the ophthalmological section was in the
hands of the phoria men, who pounded the table in their
enthusiasm concerning wholesale muscle-cutting. They
stated that many operations were often necessary, and
admitted that the result was not invariably satisfactory.
Their ideas about glasses were inferred when a well-
known disciple said that a weak myopic lens should be
given the patient if it seemed comfortable, no matter
whether the victim was myopic or hyperopic.
No one denies that muscular insufficiency occasionally
calls for operation, but it is a pity to lose sight of the
good that lean be accomplished by proper glasses. If
one eye sees as well as the other, if both are equally re-
lieved of strain, then the glasses are right, and the mus-
cles will adjust themselves in the majority of cases.
Such being a fact, which would seem more sensible, fit
the eyes properly, or hack the muscles forty times with
no assurance but that another forty may be necessary.
Richard H. Satterlee, M.D.
189 Delaware Avenue, Buffalo, N. Y.
448
MEDICAL RECORD.
[October 6, 1894
THE ANTIDOTAL ACTION OF POTASSIUM
PERMANGANATE IN OPIUM POISONING.
To tub Editor op tub Medical Record,
Sir : In your issue of September 15th I notice an article
by Dr. C. Monroe McGuire, under the heading " Un-
successful Employment of Potassium Permanganate in a
Case of Morphine Poisoning/' and in justice to Dr.
Moor (the original claimant to the discovery of this an-
tidote), who no doubt has become very tired of answer-
ing uncalled-for questions and criticisms upon a subject
which has been very carefully explained, and by himself
and others successfully operated, I would suggest that Dr.
McGuire read Dr. Moor's original article in order to un-
derstand that his (Dr. Moor's) representations can in no
way be called a failure as an antidote in the case he
mentions.
It struck me at the time that Dr. Moor had very
plainly and concisely pointed out to his medical brethren
that after the ingestion of morphia in lethal doses,
the administration of potassium permanganate would
chemically oxidize and render inert the amount of the
poison still in the stomach at the time of the administra-
tion; in other words, the part of the morphine with
which it comes in direct contact. He does not claim
that it has any other effect, and his best proof of the effi
cacy of the drug as a local antidote was his experimenta-
tions upon himself, which prove his absolute faith, which
I think no one will question, and again, other prominent
medical men have had very successful results from its use.
How are physiological or pathological effects of a drug
to be determined except by such methods ?
Many of our most important discoveries have been un-
derstood only by such means and accident, and I do not
think Dr. Moor's results should be denied and decried
until good grounds are had for so doing ; and particu-
larly upon the grounds given in Dr. McGuire's article,
where the stomach had been relieved of every particle of
the poison, both by emesis and into the circulation, pre-
vious to the administration of the permanganate. So
what I cannot understand is, why permanganate should
have been given at all in the case mentioned, for it is
not claimed to be a physiological antidote, and at that
time there was no use for a chemical action.
Under the circumstances I do not see why Dr.
McGuire should have been surprised at a depressing
effect upon a stomach and system so weakened by emetics
and physiological antidotes, and in which there was no
morphine.
Clarence Warfield, M.D.
Galveston, Tsx.
THE MARRIAGE OF SYPHILITICA
To thk Editor or the Medical Record.
Sir : For the purpose of securing reliable statistics on
the subject of the marriage of syphilitica, I desire to en-
list the assistance of those of your readers who have had
experience which will be of value in determining the pe-
riod when this disease ceases to be communicable and
inheritable. I shall, therefore, esteem it a great favor
on the part of any physician who will send me answers
to the following questions, and due credit will be given
in a future publication to those who desire to aid me in
this work.
1. What is the latest period, from the date of the ini-
tial lesion, that you have known the disease to be com-
municated by a patient who has been from the first under
your observation ?
2. What is the latest period, from the date of the ini-
tial lesion, that you have known (a) a syphilitic man,
or (£) a syphilitic woman to become the parent of a
syphilitic child ?
3. Have you ever known syphilis to be either commu-
nicated or handed down, at a later period than four years
from the date of the initial lesion, by an individual who
has been constantly under your observation during that
time?
In answering these questions I should like a brief but
complete history of each case and an account of the
treatment that has been pursued.
I hope by this means to obtain the experience of a
large number of observers, and to reach a fairly reliable
conclusion as to the time when we may safely permit our
syphilitic patients to marry.
Yours very truly,
Burnside Foster, M.D.
fjtoedtatl Stems.
Contagious Diseases — Weekly Statement.— Report of
cases and deaths from contagious diseases reported to the
Sanitary Bureau, Health Department, for the week end-
ing September 29, 18^4.
Tuberculosis
Typhoid fever
Scarlet fever
Cerebro-spinal meningitis
Measles
Diphtheria
Small-pox
135
83
33
10
ai
2
2
2
8
2
87
3i
6 ,
3
Mr. W. Salmon is the oldest member in years, as well
as by appointment, of the Royal College of Surgeons of
England. He was born in 1790, and was admitted to
the College in 1809.
Myxcedema. — Dr. G. P. Marner, of Marion, Kan., in
a paper read before the Kansas State Medical Society,
on May 4, 1894, reports a case of myxcedema successfully
treated with thyroid extracts. The patient was a mar-
ried woman, aged thirty-eight, in whom the first symp-
toms appeared about ten years ago. The disease had
progressed slowly but steadily. Treatment was bqgun on
New Year's Day with the exhibition of a five-grain pow-
der every day. From the beginning of the treatment
she improved rapidly, and on April 28th was apparently
cured. Her weight had decreased in four months from
one hundred and seventy to one hundred and fifty pounds,
and the transformation in her general appearance was so
great that her most intimate friends scarcely recognized
her.
Longevity in Bussia. — In the province of KiefF, dur-
ing 1893, there were fourteen deaths of persons over
one hundred years of age. In the city of Kieff one man
died aged one hundred and ten years, while within the
suburban circle two women died aged respectively one
hundred and two and one hundred and four years. In
Berditcheff two men reached the ages of onejiundred
and one and one hundred and fourteen years respectively.
In Vassilkoff another died in his one hundred and fif-
teenth year. In the same district there died a woman
aged one hundred and five ; in Svenigorodka, a man of
one hundred and ten years ; in Tarastscha, another one
hundred and fifteen ; in Uman, two men, aged respec-
tively one hundred and six and one hundred and two
years ; in Radomytzel, two aged respectively one hun-
dred and three and one hundred and seven ; and lastly
a man of one hundred and five years died at Tcher-
kassy. The united ages of these fourteen persons
amounted to 1,489 years. A man is still living in Sara-
toff who has already celebrated 126 birthdays.
A Missionary to Lepers in Trouble.— Miss Kate
Marsden, who achieved some notoriety some years ago
as a missionary to the Siberian lepers, was recently ac-
cused oi acts unbecoming a missionary. The charges
were investigated by a committee in St. Petersburg, with
the result that Miss Marsden has been called upon to
give up, in accordance with a promise made at die be-
ginning of the investigation, all decorations, letters, etc.,
bestowed upon her by royal and imperial well-wishers.
Medical Record
A Weekly Journal of Medicine and Surgery
Vol. 46, No. 15.
Whole No. 1249.
New York, October 13, 1894.
$5.00 Per Annum.
Single Copies, zoc.
Qfcrtgitral Articles.
THE NECESSITY OF INTERNATIONAL SANI-
TARY REGULATIONS GOVERNING THE MI-
GRATION OF LARGE BODIES OF PEOPLE
IN THE PREVENTION OF THE SPREAD OF
CONTAGIOUS AND EPIDEMIC DISEASES.
Illustrated by the International Sanitary Confer-
ence of Paris, 1894 l
By STEPHEN SMITH, M.D.,
NSW YORK.
Those diseases which are classified as contagious and in-
fectious are the common enemies of mankind. Every
hum in being inherits a predisposition to these affections.
No one, therefore, is exempt from an attack, on pioper
exposure, by reason of nationality, civilization, rank, or
condition. In their spread these pestilences have no re-
gard for the lines which bound nations, but wherever
man finds his home there they find a congenial soil for
propagation.
The influence of these diseases upon the history of our
race has always been disastrous. They have proved
more fatal to human life than all other causes combined ;
they have destroyed the armies of conquerors whom no
earthly power could resist ; they have, indeed, obliter-
ated from the earth, as by an omnipotent force, whole
races of mankind. They have often given the death-
blow to an advanced civilization, or have left a strange
enduring impress on the intellectual life of great nations.
The historian states that among the causes which brought
about the fall of the might and civilization of Greece
and Rome must be mentioned destructive pestilences
which swept over the Eastern and Western Roman Em-
pire during the period between antiquity and the Mid-
dle Ages (Ziemssen).
The problem of preventing and suppressing these
scourges of the race has been studied exhaustively in an-
cient and modern times, but with very different degrees
of success. To the ancient student their origin remained
a mystery which no means at his command could pene-
trate. With all his research he could discover neither
their causes nor the laws governing their propagation.
One solitary fact of vast importance was impressed upon
his mind by the abundant opportunities for observation,
viz., that complete non-intercourse of the sick, and his
personal effects, with the well was a reliable means of
protection and prevention. Hence came the famous
institution of quarantine, or forty days' isolation of ves-
sels from infected ports, a period believed to be suffi-
ciently long for the destruction of the contagium. Its
true significance was non- intercourse of the sick with
the well. This was, indeed, the only means by which a
city could at that time protect itself from an invasion of
the pestilence. And even now cities and states, when
left to their own individual resources against epidemic
diseases, find quarantine the most effective measure
which they can adopt. It is true that the quarantine of
to day differs greatly from the quarantine of the past.
Formerly, time was the chief feature relied on to destroy
the contagious principle, and hence the period of deten-
tion was of long duration. Now, detention is enforced
1 Read at the Annual Meeting of the New York Medical Associa-
tion, October 10, 1894.
only during the period necessary for the destruction of
the contagium by germicides, or of the incubation of the
germs of disease. Still, quarantine means the detention
of the traveller and his effects, and of articles of com-
merce liable to convey infection.
Though the rigors of the ancient quarantine have
been relaxed, it was not until within the last decade that
there began to be a clear conception of a method of sub-
stituting for them measures far more effective, and com-
paratively free from inconvenience, either to traveller or
to commerce. This was the co operation of the states
exposed to the epidemic in well - concerted measures
against a common enemy.
The first step toward international action in regard to
public sanitation and maritime quarantine was taken, in
1847, by the French Government, which has always been
foremost among the nations of Europe in advancing
sanitary science. Preliminary to the calling of an Inter-
national Sanitary Conference, she appointed medical
sanitary agents in the East. The posts of observation
thus created were at Constantinople, Smyrna, Beirut,
Alexandria, Cairo, and Damascus. The information in
regard to sanitary conditions in those cities derived from
these sources formed the basis for the Conference of
Paris, which was convened on invitation from the French
Government in 1851. Twelve powers were represented
by delegates at this conference. The results obtained
were, a relaxation of the rigor of quarantine in Mediter-
ranean ports, and a scheme of rational maritime prophy-
laxis.
Thus was inaugurated international hygiene, a system
of sanitatary administration which seems destined to
control, suppress, and finally exterminate contagious and
infectious diseases.
Nine International Sanitary Conferences have since
been called, and six have been held. The earlier Con-
ferences were not fruitful of immediate results. The
field of labor was new and unexplored, and diplomatic
questions arose which greatly interfered with that har-
mony of action of states essential to success. The dis-
cussions of representatives of different states, did, how-
ever, improve the sanitary administration of each. But
their greatest value appeared in the better understanding
which the states of Europe came to have of the aims and
purposes of each other when discussing measures of pre-
vention against a common enemy. Mutual confidence
was in a measure established, which led to far more ef-
fective work in future Conferences. This was apparent
in the Conference of Venice, the seventh in the series,
held in 1892, which was called to consider the means of
preventing direct communication between Europe and
the infected regions of India, by way of Egypt and the
Mediterranean ports. The Conference succeeded, first,
in regulating the duration and method of quarantine in
the Suez Canal; second, in preventing the passage
through the Canal of infected vessels ; third, in requiring
disinfection of suspected vessels ; fourth, in creating the
Council of Alexandria, with a preponderance of Euro-
pean influence.
The resolutions adopted by the Conference were em-
bodied in an agreement which was signed by the plen-
ipotentiaries and afterward ratified by the powers rep-
resented — the first formulated conclusions of any
Conference made authoritative by the signatures of the
plenipotentiaries.
Still greater progress was made toward the creation of
45°
MEDICAL RECORD.
[October 13, 1894
international laws by the Eighth Sanitary Conference,
which met at Dresden, March, 1893. The programme
proposed for consideration the following subjects :
1. The duty of a Government when cholera is reported
within its territory.
2. The measures to be taken when cholera exists in a
neighboring country.
The Conference decided that the declaration of the
presence of contagious diseases is obligatory, and that
every means should be taken to prevent its spread. It
formulated a system of sanitary measures which afforded
a maximum of protection for public health with a mini-
mum of restriction to travel and traffic ; it fixed the
period of detention and isolation ; it defined the dis-
tinction between medical surveillance and observation ;
and finally it permitted a person arriving from an infect-
ed port to proceed to his destination, but it maintained
a rigid observation of him during the period of incuba-
tion of the cholera germ. The resolutions of this Con-
ference were followed by a convention which was signed,
with but one or two exceptions, by all of the powers
represented.
These last two Conferences proved conclusively that
international agreements could be made designed to pre-
vent an invasion of Europe by cholera, which, though
placing severe restrictions upon commerce and travel,
were not incompatible with the laws and customs of the
contracting powers. But valuable as these agreements
might prove to be, they were simply barriers erected
around the immediate frontier of the state against a foe
whose habitat was in the far distant delta of the Ganges.
Modern science has proved conclusively that the germs
of this plague have never left their native soil except when
they were conveyed by human agency. Repeated epi-
demics had also demonstrated the fact that cholera never
invaded the districts of Northern and Western Asia ex-
cept when large bodies of people made pilgrimages to
the holy places of the Orient. The chief and most
important of these pilgrimages was that to Mecca by the
pilgrims of India. It was equally demonstrated by re-
peated observations that cholera reached Europe only
through its pilgrims who visited the holy places of
Asia, and especially Mecca. It became, therefore, a well-
established fact that the transmission of the cholera in-
fection from India to Europe was, in its first stage,
through the pilgrimages of the Mussulmans from India to
Mecca, and other places of resort. At these places it
was transferred to the European pilgrim, who conveyed
it to Europe. It was evident that the international rules
and laws enacted did not meet existing conditions. As
a matter of fact, cholera appeared at Mecca eight times
between 1871 and 1893. The European states, there-
fore, could not be certainly protected when the cholera
infection was brought without hindrance to Mecca, and
the European pilgrim was allowed to visit Mecca and
return without any proper sanitary surveillance.
Such considerations as these induced the French Gov-
ernment, always alert in its efforts to provide adequate
measures for the prevention of cholera epidemics, to is-
sue a call for another Conference, the ninth in the series,
and the fourth called by the Government of France.
The object of this Conference was to provide measures
for preventing, by international agreements, the trans-
mission of cholera from its native habitat by pilgrims.
The task was the greatest and most important ever
undertaken by any state or combination of states.
This Ninth Conference met in Paris, on February 7,
1894, and was attended by representatives from sixteen
states, viz., all the powers of Europe except Switzerland ;
and Persia, and the United States, Egypt, the British
possessions in India, and the Straits Settlements of the
Netherlands.
In his opening address the President of the Confer-
ence, M. Casimir Perier, now President of the French
republic, eloquently portrayed the duties of the assem-
bled delegations. "The modern scientific spirit," he
remarked, " has proved both its firmness and its flexibil-
ity in the course of extended efforts to combat the Asi-
atic pestilence by means of international agreement.
By more exact information of the disease and the phe-
nomena attending its transmission, it has gained a
knowledge of prophylactic measures both more certain
and more prompt. It has demonstrated that the more
simple methods are at the same time the more efficacious.
It has conserved public interest at the same time that it
has protected human lives. The connections which
diplomacy has had the honor of concluding have been
matured in the laboratories where men of science pursue
their disinterested researches. It is the common labor
and the common honor of science and diplomacy to
acquire and exercise the knowledge necessary to recon-
cile the customs which govern international commerce
and the laws on which depend the protection of human
life. . . . You have to continue now the labors
which were commenced at Venice. It is your duty to
pursue cholera toward its source ; toward that part of
Central Asia where it is said to have its origin so far as
it affects us. This part of your task is particularly deli-
cate, and the method and the principles which have
heretofore guided you should again govern your actions.
They are now recognized as correct, and they have hence
acquired a high authority. But in applying them you
should not forget that sympathy for those who suffer, in-
dividual kindness, and international fellowship, generos-
ity and equity, ought also to have their proper place in
your deliberations. It is in these previous deliberations
that you will have found the discretion necessary to
unite to all of the guarantees that health and the public
interests may require, respect for local customs, usages,
and traditions, and especially that persuasive influence
which shall secure to your decisions the concurrence of
all upon whom they ought to be binding.'9
M. Barrere, the acting President, after explaining at
some length the events which led to the present Confer-
ence, introduced Professor Proust, who read an elaborate
paper, in which, after reviewing the work of preceding
Conferences, showing how effectually they had protected
the immediate approaches to Europe from an invasion
of cholera, he proceeded to detail the questions which
the present Conference was called to consider. They
involved problems more difficult of solution than any
ever presented to a deliberative body. The danger to
Europe from an epidemic of cholera, primarily, depends
upon the periodical migration of large bodies of the
Mussulmans from India, the natural habitat of the cholera
germ, to the holy places of Northwestern Asia, and espe-
cially to Mecca. Cholera has never visited Europe ex-
cept when transported from the delta of the Ganges by
pilgrims. These pilgrimages are made by vast hordes
of people, the greater number of whom are poor and
feeble, or actually sick, and all are accustomed to filthy
habits. It appears that sixty per cent, of those who
leave India on these pilgrimages never return to their
homes. The problem of preventing epidemics of cholera
in Europe could only be solved by subjecting these pil-
grims to rigid sanitary regulations, and to effectually
accomplish this object there must be international agree-
ments.
The difficulties to be encountered in adopting and en-
forcing sanitary rules for pilgrims were numerous. 1.
The pilgrims themselves would be intolerant of any
restrictions upon their performance of a religious obliga-
tion. 2. Sanitary regulations adequate to prevent the
transportation of cholera infection must in some degree
interfere with the ordinary freedom of commerce. 3.
These sanitary rules and regulations, in order to be ef-
fective, must be enforced under the supervision of a
central authority and not by local authority.
It was very evident, therefore, that this Conference
was confronted with difficulties which no other had to
encounter. While it might prove an easy task for the
technical delegates to formulate an ideal code of sanitary
rules which, if rigidly enforced, would effectually pre-
vent the transportation of cholera by the pilgrims, it
October 13, 1894]
MEDICAL RECORD.
45i
was apparent that the diplomatic delegates would have
do slight difficulty in reconciling the various commercial
and public interests involved.
It will forever redound to the credit of this Conference
that it resolutely set to work on the programme laid before
it, and not only created a body of admirable sanitary
rules governing pilgrimages, but provided adequate
means of enforcing them.
The programme presented by the French delegation
was as follows : 1
I. Prophylaxis of the Pilgrimage of Mecca.
II. Protection of the Persian Gulf ports.
The programme of discussion was formulated as follows :
I. — Prophylaxis of the Pilgrimage to Mecca.
(A) Sanitary police in Indian ports.
1. Medical inspection of pilgrims.
2. Disinfection.
3. Refusal of embarkation of infected or suspected persons.
4. Refusal of embarkation to all pilgrims who snail fail to
show that they possess means to defray the expense of the
pilgrimage ; five days' observation of other pilgrims.
5. Sanitary passport.
6. Disinfecting apparatus on each vessel.
7. Adequate supply of potable water protected from infec-
tion.
(ff) Sanitary surveillance of pilgrims at the entrance of the Red
Sea.
1. Choice of site for quarantine station.
2. if Camaran be chosen, improvements to be instituted.
3. Disinfecting apparatus.
4. Formation of board of management to be under the con-
trol of the Sanitary Council of Constantinople.
(O Improvements to be instituted at Abou-Saad and Vasta.
(Z?) Supervision of land caravans of pilgrims to Mecca.
{£) Reorganization of the sanitary station of £1 Tor.
II. — Protection of the Persian Gulf ports.
(A) Establishment of sanitary posts at Fao, Bender-Abbas, Koveit,
Bender- Bouchir, Bassorah, Mohammerah.
(B) Sanitary surveillance at Menama, in the Bahrein group of isl-
ands.
( C) Sanitary supervision at Mascate and Guadar, in Beloochistan.
(D) Constitution of a sanitary authority to have charge of carrying
out quarantine measures.
A wide divergence of views, in regard to the best
method of treating an epidemic of cholera very early
appeared among the technical delegates, and became
very pronounced in the discussion of many questions
throughout the entire session. These different opinions
were as follows :
i. The French delegates held that cholera infection
should not be allowed to be conveyed from place to
place, either by travellers and their effects or by articles
of commerce, hence they approved of enforcing such
sanitary rules as would free the traveller and his baggage,
as well as articles of commerce, of the contagion of
cholera at any place in their transit where they were dis-
covered or suspected to exist. This policy was sustained
by every delegation except that representing Great
Britain and its dependencies.
ad. The British delegation held that the proper
method of dealing with cholera is to perfect the sani-
tary conditions of cities, villages, and the homes' of the
people, and allow the contagium of the pestilence free
course along the routes of travel, whether by sea or land.
All harriers to the entrance of cholera into any state
were condemned, especially any form of quarantine
which delayed the progress of vessels into ports and the
immediate discharge of cargo. This public policy was
supported only by the delegation from Great Britain.
3d. The delegate who represented the British posses-
sions in India held that cholera is due to epidemic in-
fluences quite beyond human control ; hence he advo-
cated non inteference. This policy was supported only
by the delegate who represented India.
The scope and character of the regulations adopted
can be illustrated by a few selections. In general it may
be stated that the pilgrim is placed under sanitary sur-
veillance of a very rigorous character from the moment
he announces his intention to go on a pilgrimage, till
his return home. 1st, He must obtain a sanitary pass-
1 See Abstract of Sanitary Reports issued by the U. S. Marine
Hospital Service for Summary of Conference proceedings.
port from the local authority. This rule is taken from
the Netherlands' Straits Possessions. Before the pass-
port is issued, the intending pilgrim must prove that he
has complied with all of the conditions necessary for his
departure ; and that he has money sufficient for the voy-
age, and to sustain his family in his absence. This pass-
port the pilgrim must retain and show to the sanitary
authorities, en route, and he can enter the Hedjaz, the prov-
ince in which Mecca is located, only on presentation of
it, and on passing an examination. He is under sani-
tary observation while at Mecca, and on his return a new
passport is given him, which he must show to the author-
ities en route.
At the port of departure the pilgrim comes under the
sanitary police, and the following regulations are to be
enforced :
^Medical inspection of all persons taking passage on board a pil-
grim vessel made individually, by daylight, on land, and by a physi-
cian appointed by the local sanitary authority.
Thorough disinfection made on land under the direction of the
physician appointed by the sanitary authority of all infected or sus-
pected articles.
Refusal of embarkation to any person attacked with cholera or
choleriform disorders.
When a case of cholera exists at the port, embarkation on board
of pilgrim vessels shall not take place until the persons to be em-
barked have been segregated and subjected to observation for five
days.
Each pilgrim vessel must have the following pro-
visions :
Every vessel embarking one hundred or more pilgrims shall carry
a physician commissioned by the government to which the vessel
belongs. If the number of passengers exceeds one thousand a sec-
ond physician shall be engaged.
The physician should see that the rules of hygiene are observed
on board, and that food and water are distributed according to
agreement.
Pilgrims shall be lodged between decks.
The deck should remain clear. It should be placed at the dis-
posal of the passengers.
Passengers shall be allowed to retain only such baggage as is
strictly necessary.
The vessel shall be provided with latrines in the proportion of
one to each one hundred passengers. These shall not be located in
the hold or between decks. They shall be cleaned three times daily
and flushed with sea water.
Each person shall be gratuitously furnished with five litres of
drinking-water a day.
If there shall arise any doubt as to the condition of the drinking-
water it should be boiled and sterilized, and the captain is directed
to empty it overboard and replenish at the first stopping- place.
Two kitchens shall be provided for the use of the pilgrims. They
shall not be allowed to cook elsewhere.
Medical care and attendance shall be furnished gratuitously to the
pilgrims.
A regularly organized infirmary shall be provided for the sick.
It shall be large enough to accommodate five per cent, of the pas-
sengers, with a space of three square metres per capita.
The vessel shall be provided with the means of isolation in case
of choleraic attack.
Each pilgrim vessel is subjected to the following reg-
ulations at the port of departure :
The captain of a pilgrim vessel is required to declare to the poit
authority, at least three days in advance, his intention of embark-
ing pilgrims. He must also declare the date of intended departure
and the port of destination.
The sanitary authority of the port shall then inspect and measure
the vessel. The consul representing the flag carried by the ship
may assist, if he so desires, at this inspection.
The port authority shall not permit the departure of a vessel until
he is assured :
(a) That the vessel is clean, and, if possible, disinfected.
Id) That it is in condition to undertake the voyage, and that the
sanitary conditions are good.
(c) That the food and fuel provided for crew and passengers are
sufficient in quantity and good in quality.
(a) That the water is good and obtained from a pure source ;
that it is sufficient in quantity, protected from contamination on
board, and dispensed by faucets.
(*, /, g, k) That the vessel carries distilling apparatus capable of
producing five litres of water a day per capita for all persons on
board, passengers and crew; that it carries a disinfecting stove and
has on board a physician and a ship's medicine- chest, and that the
deck is clear.
The captain shall post notices drawn up in the principal language;
spoken by the pilgrims stating :
45*
MEDICAL RECORD.
[October 13, 1894
1. Destination of the ship.
2. Daily ration of food and water.
3. The price of provisions not included in the daily distribution.
The captain shall not be free to leave port until he holds :
1. A list of the pilgrims whom he is authorized to embark, vised
by the port sanitary authority.
2. A bill of health stating the name, nationality, and tonnage of
the vessel, name of the captain and physician, the number of persons
embarked, crew, passengers, and pilgrims, nature of the cargo,
place of departure and destination, and condition of public health
m the port of departure.
Daring the voyage the following requirements are en-
forced:
All articles that have come in contact with the sick shall be
promptly disinfected. Articles of no value should be thown over*
board if the vessel is at sea, or else burned if the vessel is at port.
In case of a death occurring on board during the voyage the cap-
tain shall note the fact with all particulars.
The bill received at the port of departure shall not be altered in
any way during the voyage. It shall be vised in every port at which
the vessel stops by the sanitary authority who shall note thereon :
The number of passengers landed or embarked.
Any facts touching the condition of the passengers and any in-
cidents of the voyage.
The sanitary condition of the port at which the vessel is stopping.
The captain shall see that all prophylactic measures taken on
board during the voyage are inscribed in the log.
The captain shall pay all sanitary taxes.
Arriving at the Red Sea, and before proceeding to
Hedjaz, the pilgrim ship must touch at the sanitary
station at Camaran and there be subject to the following
treatment :
Vessels declared upon medical inspection to be clean shall be al-
lowed free pratique after compliance with the following regulations :
The pilgrims shall be disembarked ; they shall take a spray bath or
a bath in the sea ; their soiled linen and such of their baggage and
effects as may be suspected of infection shall be disinfected. The
duration of this process, including landing and re-embarkation, shall
not exceed forty-eight hours. If during this period no case of
cholera, diarrhoea, or choleriform disorder shall develop, the pil-
grims shall be at once re embarked and the vessel shall proceed to
the Hedjaz.
Suspected vessels — that is to say, vessels on board of which
cholera declared itself at the moment of departure, but on which no
new case has occurred within seven days — shall be treated as fol-
lows : The pilgrims shall be disembarked ; they shall take a spray
bith, or else a bath in the sea; their soiled linen and such* of their
baggage and effects as may be suspected of infection shall be disin-
fected, at the discretion of the medical officer. The duration of this
process, including landing and re-embarkation, shall not exceed
(forty-eight hours. If no case of cholera or choleriform disorder
shall develop during this period, the pilgrims shall be at once re em-
barked, and the vessel shall proceed to Djeddah where a second medi-
cal inspection shall be made on board. If the result is favorable,
on the written and certified declaration under oath that no case of
cholera has occurred during the voyage from Camaran, the pilgrims
shall be disembarked. If, on the contrary, cholera or choleriform
disorder shall have declared itself during the voyage, or at the mo-
ment of arrival, the vessel shall be remanded to Camaran, and there
undergo a second time the treatment for infected vessels.
Infected vessels — that is to say, vessels on board of
which cholera and choleriform disorder shall have de-
clared itself within seven days — shall be treated as fol-
ows : The persons attacked with cholera or choler-
iform affections shall be disembarked and isolated in
hospital. Thorough disinfection shall be performed.
The other passengers shall be disembarked and isolated
in groups, consisting each of as few persons as possible,
in order that only a small front shall be exposed to chol-
eraic attack, should the disease develop. The soiled
linen, utensils, and clothing of crew and passengers shall
be disinfected ; also the vessel itself.
The sanitary authorities shall decide whether the un-
loading of the larger baggage and the cargo is necessary,
and whether the entire vessel or only a portion of it shall
be disinfected.
The passengers shall remain five days at Camaran. If
the cases of cholera date back for several days, the period
of isolation may be curtailed. It shall vary according to
the date of the last outbreak and in the discretion of the
sanitary authority.
From Camaran the vessel shall proceed to Djeddah,
where thorough medical inspection shall be made on
board. If the result is favorable the pilgrims shall be
disembarked. If, on the contrary, cholera or choleri-
form disorder shall have developed on board, either at
the moment of arrival or during the voyage from Cama-
ran, the vessel shall be remanded to Camaran, and shall
there undergo for a second time the treatment for in-
fected vessels.
Such is but a summary of the rules made by the Con-
ference governing the pilgrimages from India by way of
the Red Sea. Similar rules were made to apply to pil-
grims going by way of the Persian Gulf, or approaching
Hedjaz from the north. These rules were to be equally
enforced on the return of the pilgrims to their homes by
any route. While at Mecca the pilgrims were under rig-
orous sanitary surveillance.
An examination of these rules will make it apparent
that if they are rigidly enforced cholera cannot reach
Europe again through the medium of Mussulman pil-
grimages. And herein we have the possible failure of
the work of the Conference. Sanitary rules are worth-
less if not faithfully executed, and yet no class of laws is
so difficult of enforcement as those designed to protect
the public health.
In their practical application, to be effective in the
prevention or control of contagious and infectious dis-
eases, individual rights, religious observances, commer-
cial interests, and even national customs, must be subor-
dinated to the exigencies which these pestilences create.
It has been held that health laws are anomalies in
civilized government. They arbitrarily set aside ordi-
nary laws because they are adapted to an anomalous con-
dition of the people. When it is considered that the
health laws created by the Conference were to be applied
to people intolerant of any restriction upon individual
liberty, and especially upon the customary performance
of ancient religious obligations, it will be apparent that
when the technical delegates had perfected their work of
completing the rules and regulations, a serious responsi-
bility was imposed upon the diplomatic delegates in pro-
viding the ways and means for their execution.
There was a strong disposition manifested by those
states within whose jurisdiction these rules were to be
chiefly executed, to be alone responsible for their en-
forcement. But the other states very properly opposed
such action, alleging that local interests might interfere
with that rigid execution of every necessary detail so
essential to success. A failure of one state through which
the pilgrims might pass, to rigorously apply the rules,
would imperil the entire scheme. It was determined,
therefore, after much discussion, that all of the contract-
ing powers should have a part in the enforcement of these
international agreements. The following method of
accomplishing this object was finally agreed upon:
1. The application of the measures adopted by the Conference in
regard to the pilgrimages shall be intrusted to a committee chosen
from among the members of the Council of Health of Constantinople.
This committee shall be composed of three representatives of Tor-
key and of the several powers who accepted the sanitary agreement
signed by the Conferences of Venice and Dresden. The president
ofthe committee shall be an Ottoman.
2. To secure effective service at the several sanitary stations, com-
petent corps of physicians, disinfectors, mechanics, and sanitary
guards, recruited from among ex-officers, commissioned and non-
commissioned, shall be created.
3. The expense of carrying out the system proposed by the Con-
ference shall be divided between the Ottoman Government and the
Council of Constantinople, according to the scale already fixed by
the several powers interested.
4. The sanitary authority at the Ottoman port of arrival or de-
parture shall draw up a statement of any infraction of this agreement,
to which the captain of the, offending vessel shall attach any expla-
nation he may have to make. A certified copy of this statement shall
be transmitted to the consul representing the country to which the
vessel belongs. The consul shall require the fine to be placed in
his hands. In the absence of the consul the fine shall be deposited
with the sanitary authority. The fine shall ultimately go to the
Council of Constantinople, when the consular commission shall have
declared it valid. A second certified copy of the statement shall be
forwarded to the Council of Constantinople* who shall refer it to the
consular commission.
5. A consular commission shall be formed at Constantinople to
have cognizance of disputed cases, and to act as judge between the
October 13, 1894]
MEDICAL RECORD.
45.3
sanitary agent and the ships' captains. It shall be elected every
year.
6. The taxes and sanitary fines shall not be diverted to any objects
but those relating to the sanitary councils.
In addition to these regulations the Conference pro-
vided for the equipment of suitable stations on the route
of the pilgrims, with all the apparatus necessary to make
each a sanitarium, where the traveller will receive the
most perfect sanitary care and treatment. The Otto-
man Government had already created several stations,
and the Conference took measures to perfect them and
add others. Thus the island of Camaran, near the en-
trance to the Red Sea, it recommended should be en-
tirely devoted to a sanitarium for the pilgrims coming
from the south. For this purpose all the present inhabi-
tants are to be removed, the harbor is to be rendered
secure to shipping, and every facility supplied for the
comfort of passengers, and the thorough cleansing and
disinfection of themselves, their effects, and the pilgrim
ships. In the same manner, Djebel-Tor, at the northern
extremity of the Red Sea, is to be provided as a sanita-
rium for the pilgrims from the north. Hie ports of the
Hedjaz, where the pilgrims debark for Mecca, are to be
equally well equipped as sanitary stations. A large
number of similar sanitary stations will be created along
the Persian Gulf route, and also along the overland
caravan routes. Finally, Mecca is to have its sanitary
conditions perfected, and a complete surveillance of the
pilgrims organized.
For nearly two months the Conference devoted itself
assiduously to its duties. It was aided and encouraged
in its work by the highest officials of the French Govern-
ment. President Carnot frequently met the delegates ;
M. Casimir Perier, the Premier, accepted its presi-
dency. M. Barrdre, now Ambassador to Switzerland;
M. Hanotaux, now Minister of Foreign Affairs ; Profes-
sor Brouardel, Dean of the Faculty of Medicine of
Paris; Professor Proust, Inspector- General of the Sani-
tary Service ; and M. Monod, Councillor of State, com-
prised the French delegation. To the courtesy, con-
stant efforts, and judicious management of this delegation
is due in large measure the harmony which characterized
the deliberations of the Conference and the happy con-
summation of its labors.
The code of sanitary rules governing the migration of
large bodies of people from or through districts infected
with cholera which the Conference finally completed and
adopted, is based on the most advanced principles of
sanitary science. When this code is finally accepted by
the powers of Europe and Asia, and by the United
States, and then becomes in effect international law, it
will mark the commencement of an era which will be
characterized by the extermination of those roving pes-
tilences which have heretofore been the scourge of the
human race.
One feature of the Conference remains to be noticed,
which is of special interest to the people of the United
States. As this Conference was called to devise inter-
national measures to prevent the transportation of chol-
era by the migration of large bodies of people, it seemed
to the delegates from the United States, or at least to a
majority of them, that it would be a fitting occasion to
consider also the closely allied subject of the conveyance
of cholera from Europe to the United States by emi-
grants. It was apparent that the sanitary rules and
regulations relating to travel and traffic which would
prevent the transmission of the cholera infection from
India to Europe by the pilgrim, would, if properly ap-
plied, prevent the transmission of cholera from Europe
to America by the emigrant. The instructions which
the delegates received from their Government led them
to believe that the President also entertained the opin-
ion that the question of the transportation of cholera by
emigrants would be a legitimate subject of discussion in
the Conference.
Actuated by these considerations the delegation
brought the matter before the Conference at its third
session in a formal paper. It was shown in this state-
ment that cholera has as yet never reached the United
States from Europe except through the emigrant classes.
The imminent danger of an invasion of the United
States by cholera, when it is prevalent in Europe, will
appear when we consider :
1st. The vast numbers of immigrants who land on our
shores annually. In 1893, 357,857 emigrants from Eu-
rope arrived at the single port of New York. In seme
years the number has been quite half a million.
2d. These immigrants are, for the most part, the poor-
est, filthiest, and most insanitary class of the population
of the states of Europe. They are not only extremely
filthy in their persons and habits, but they bring large
quantities of filthy baggage and household goods, which
are admirably adapted to preserve the germs of contagi-
ous and infectious diseases in all their potency.
3d. The rapidity with which the transit of the ocean
is now made by the great passenger vessels — and it is on
this class of steamers that the bulk of the immigrants
reach the port of New York — renders it possible now for
an emigrant to receive the cholera into his system in
Europe and be safely domiciled in New York City be-
fore the period of incubation has fairly expired.
To meet these exigencies the United States has but
one remedy, and that is a rigorous quarantine. Such
sanitation of cities, villages, and the homes of the people
as might make it safe to allow the cholera contagium free
access to our ports is impossible. The opinion was ex-
pressed that if, by an international agreement, such sani-
tary regulations could be enforced as would secure to
the emigrant from Europe to America cleanliness of
person and baggage, adequate means for his care during
the voyage, and a reasonable guarantee that he is not
the carrier of the cholera germ, would be followed by
greatly diminished restrictions, which our Government
must otherwise impose upon travel and commerce in our
ports.
The communication of the delegates concluded by
requesting that the programme of the Conference be so
enlarged as to include the preparation of international
sanitary rules governing the migration of the laboring
classes of Europe to America.
At a subsequent session the United States delegates
submitted more in detail, at the request of the Confer-
ence, the questions for consideration. The several prop-
ositions were nearly those already under discussion in
regard to the pilgrims, viz.
1. Measures to be adopted to enable the emigrants to
come to the port of departure free from contagious dis-
eases. Each emigrant should obtain from the local au-
thority a passport or certificate showing the sanitary
condition of the place from which he came, the route
that he has followed to the port of departure, and, as far
as possible, the state of his health during his journey.
The passport for the pilgrim made nearly the same pro-
vision.
2. Measures to be taken at the port of departure to
prevent the germs of cholera being taken on board of
vessels, either by the emigrants personally, or by their
clothing or other effects. These measures would corre-
spond with those adopted by the Conference with refer-
ence to pilgrims at the port of departure, viz., detention
for several days in reception quarters where bathing and
disinfection could be thoroughly performed and any in-
fection present destroyed.
3. Measures to be taken to secure the best sanitary
condition of vessels carrying emigrants, before their em-
barkation, in order that the health of the emigrants may
be preserved during the voyage. The excellent sanitary
regulations which the Conference adopted for pilgrim
ships would apply with some modifications to emigrant
ships.
4. Measures to be taken during the voyage both to
preserve the best sanitary condition of the ship, and of
the emigrants and equipage, and to promptly suppress
any focus of infection which might develop on board.
454
MEDICAL RECORD.
[October 13, 1894
These provisions were amply made by the Conference
with regard to pilgrim ships during the voyage.
5. Measures to be taken at the port of arrival, which
would comprise such changes in the regulations of our
quarantines as would adapt them to the new conditions
which these international regulations would secure as to
the liability of emigrants to be the carriers of cholera in-
fection.
The communication of the American delegates was
received with marked attention by the members of the
Conference. It was conceded that there was such a
close analogy between the methods of conveyance of
cholera infection from India to Europe by the pilgrims,
and from Europe to America by the emigrants, that the
international sanitary regulations governing the migra-
tion of one class would be nearly applicable to the other.
Tae delegates of several states cordially adopted the
views of the American delegates, and were disposed at
once to consult their respective governments to obtain
the power to enlarge the programme in accordance with
our request. Others, while acknowledging the great
importance of the subject, were of the opinion that, as
the present Conference was called for a specific purpose,
it should not add to its duties another obligation, how-
ever closely it might be allied to the one in hand. They
proposed that the emigrant question be deferred to an-
other Conference called for that special purpose. The
British delegation opposed enlarging the subjects for dis-
cussion at the present Conference, and also to the calling
of another Conference to consider the emigrant question,
basing their objections upon their often-reiterated opin-
ions that the prevention of the spread of cholera should
not be attempted by restrictions upon travel and com-
merce, but that every state should secure to its people
homes so healthy that they would defy the potency of
the cholera germ. It should be stated that at one of
the sessions of the present Conference, on the occasion
of the statement of the above opinion by the distinguished
medical officer of the Local Government Board of Eng-
land, the technical or medical delegate of Greece, re-
plied that his Government had no such power as would
secure that degree of sanitation of the homes of the. peo-
ple of which the English boast, and it must, therefore,
rely upon a rigorous quarantine against cholera. As to
the value of home sanitation compared with a rigorous
quarantine in the protection of the people against chol-
era, he reminded the British delegation that during the
last year there were several outbreaks of cholera in Eng-
land, with a number oi deaths, while for forty years
there had not been an outbreak of cholera in Greece,
though the pestilence had many times prevailed in sur-
rounding countries.
After considerable discussion the Conference decided
not to change its programme, but with much unanimity
concurred in the opinion that another Conference should
be called, if requested by the Government of the United
States, to formulate international sanitary regulations
governing the migration of European populations to
America.
Meantime the delegates from several of the powers
received instructions to unite in the call of such Confer-
ence, and two delegations presented the formal requests
of their governments to be permitted to entertain the
Conference at their respective capitals. The United
States delegation reported the action of the Conference
to their GDvernment, and asked for instructions. The
President replied that it was too late in the season to
call another Conference. Thereupon further efforts to
arrange for a Conference were discontinued, but the find
sentiments expressed to us by many members were to the
effect that, whenever the United States Government sig-
nified to the European powers its desire to enter a Con-
ference with them for the purpose of establishing an in-
ternational agreement relating to the sanitary supervision
of emigrants from Europe to America, all of the states
invited would respond.
To one who has practically studied the problem of the
prevention and suppression of such world-wide epidemics
as Asiatic cholera, the importance to the people of the
United States of the co operation of the governments of
Europe with our Government, in freeing the emigrant
from the germs of contagious and infectious diseases be-
fore he embarks for our ports, cannot be overestimated.
The proposed scheme of sanitary surveillance of the emi-
grant would begin at his domicile abroad, and follow him
every step of the way to his home in this country. His
passport issued by the local European health officer, and
vis6d at every point in his progress, would not only con-
tain a record of his condition as regards his freedom from
infection and his health, but it would be his only guaran-
tee that he could travel at all on railways to the port of de-
parture or that he could embark on any steamship bound
to a port in the United States. It is at once apparent
that such an international agreement would bring to our
shores only healthy emigrants and in healthy ships.
Two consequences would inevitably follow, viz., first
cholera would never be brought to this country by the
European emigrant; and second, our quarantine would
consist only in a detention for the examination of the
passports of emigrants and the inquiries and inspections
necessary to determine that shipmasters had faithfully
complied with the international sanitary regulations.
Thus closed the Ninth International Sanitary Confer-
ence, in many respects the most important of the series.
It was in fact a congress of nations summoned to create
a code of international laws entirely in the interests of
human health, and consequently of human happiness.
Its sessions were characterized throughout by that ear-
nestness in the discussion of theoretical questions and that
conciliation in harmonizing practical methods which
distinguishes the modern scientific spirit. We cannot
doubt that when the laws which it enacted are faithfully
executed, not only will Europe and Northern Asia be
relieved from periodical visitations of the most destruc-
tive plague of modern times, but that the vast hordes of
roving pilgrims which traverse Asia, scattering a pesti-
lence which decimates the people among whom they
pass, while it strews their own pathway with their dead,
will be transformed to an orderly body of travellers,
characterized by that physical and mental health and
cleanliness of person and baggage so essential to the ra-
tional discharge of religious obligations.
But have not the nations winch in this Conference
accomplished so great a work in the relief of the Mussul-
man pilgrim, and the protection of Europe from cholera,
a similar duty to perform toward the Western emigrant,
who, taking up the germs of the plague brought to
Europe, conveys them in his filthy person and effects to
America ? M. Casimir Perier complimented the dele-
gates to the Ninth International Sanitary Conference on
the success which science has had in breaking down
those ancient barriers which the varied interests of man-
kind have created, and urged them to persevere in the
good work until all such restrictions are removed. Must
there not be a Tenth Conference, which shall unite the
efforts of the European powers and the United States in
removing the barriers with which commerce and cus-
tom protect the emigrant from the application of those
sanitary measures which would strip him of every form of
contagion, and bring him to our shores in good physical
and mental health ?
The Prussian Government expends over £50,000 a
year in support of the laboratories connected with the
medical department of the University of Berlin. This
is exclusive of the salaries paid to professors.
Asphyxia and Tongue Traction. — Dr. Bories reports,
in the Tribune Medical; , the case of a child who appar-
ently died during the performance of a tracheotomy for
croup. Artificial respiration was of no avail, but life
was restored in five minutes by rhythmical tractions of
the tongue.
October 13, 1894]
MEDICAL RECORD.
455
THE PLACE OF PHYSICAL TRAINING IN THE
MILITARY SERVICE.
By JAMES E. PILCHER, M.D., Ph.D.,
CAPTAIN IN TUB M1DICU. DEPARTMENT OF THE UNITED STATES AKMV.
It is an admitted fact that the mortality from disease at-
tains a considerably higher percentage in war than that
from wounds. It would seem, then, that the prevention
of disease is the most important function of the medical
officer in active campaign. In peace, where the mor-
tality of the battle-field is entirely eliminated from con
sideration, prophylaxis plays a still more important tole.
Recognition of the value of careful attention to the sug-
gestions of the medical officer as an important factor in
securing the greatest efficiency of a command has been a
matter of slow growth, but it has been progressive. The
influence upon a command of the sanitary condition of
camps, cuisine, and clothing, has come to be fully recog-
nized through the active labors of army medical officers,
until the surgeon is no longer considered a useless en-
cumbrance except when sickness is present, but takes his
place as the most important member of the staff.
It is singular that, while the medical department has
devoted ample attention to the prevention of disease by
the removal of threatening conditions, it has almost en-
tirely neglected prophylaxis by increasing the resisting
power of the soldier himself. It is true that the line has
been equally unmindful of so potential an agent in secur-
ing efficiency in the soldier, devoting centuries to the de
velopment of the weapons of war, entirely regardless of
the development of the men who were to handle them.
Latterly, however, a new interest has arisen in the sub-
ject, and at some military posts useful work has been
done with insufficient appliances. The sentiment of
those officers who have given physical training a fair
trial is unanimous in favor of its vast utility. Medical
officers, however, have given it but little attention, al-
though they alone are qualified to fully understand its
value or to supervise its conduct.
The culture of the body, to be correctly accomplished,
demands not only sufficient anatomical and physiologi-
cal knowledge to locate defective parts, but sufficient
pathological perceptivity to appreciate the advantages or
dangers to be incurred by training these parts. That it
is impossible for any but a medical man to comprehend
the needs of the body in the matter of training, has been
recognized by the better class of instructors in physical
culture, from Ling, the founder of the Swedish system,
down to the great teachers of the present day, who have
almost invariably qualified as physicians, as an essential
preliminary to the proper comprehension and application
of physical culture.
While physical training may with propriety be called
muscle-building, it should be understood that the cult-
ure of every other constituent of the organism progresses
tori passu with that of the muscles, to which the chief at-
tention is given. It requires the most accurate notions
of the muscular structure to select the individual muscle
to which a part owes its weakness or lack of symmetry.
The anatomical and physiological knowledge necessary to
individualize and educate distinct muscles in such a man-
ner as to produce symmetry and correctness of contour,
and the maximum of strength combined with the great-
est facility in its employment, demands special medical
training. Anyone can run a tape measure about an
arm, but it requires not only the information acquired in
the dissecting-room and the physiological laboratory, but
the power of discrimination developed by careful and
intelligent clinical observation, in order to discover what
particular member of a group of muscles is responsible
for the lack of power which it is desired to correct. Not
only does it require the most correct appreciation of mus-
cular function to understand the particular movement
or combination of movements adapted to the develop-
ment of a defective muscle, but, in order to secure the
best results, there must be a familiarity with the secondary
and remote effects upon the other portions of the system.
The perfect man is a figment of the imagination. No
person is known to have existed who was an embodiment
of perfect health. A physical examination of the most
vigorous would reveal in each some lesion of actual dis-
ease, some predisposing weakness, or both. The object
of physical training is to take cognizance of physical de-
ficiencies and correct them by movements adapted to
secure growth. Hard labor is far from being an equiva-
lent of physical training. It is true that laboring men
acquire great strength in certain groups of muscles, but
this gain is overbalanced by losses in others. The plough-
man has strength in his arms, back, and legs, but he
loses in his respiratory muscles and the anterior thoracic
muscles. The deformities of occupation, due to the ex-
cessive use of one portion of the body, to the neglect of
others, have a recognized place in orthopedics.
The material obtained by taking the average man is
excellently shown in Prince Hohenlohe's description of
the men obtained in the recruitment of his own regi-
ment. "The barracks were soon full of figures that
would put to shame the most exaggerated cartoons of the
comic papers. The awkward fellows, whose neglected
carriage made them look like a set of botched-up images,
tried hard, but in vain, to stand erect. Ill made and
undeveloped, their uniforms would not fit them, and, if
altered to fit their present figure, would need to be re-
made when they should have been remodelled by physical
training. So, before teaching them a single movement
of the military drill, or providing them with uniforms
other than their canvas fatigue suits, they were drilled
in gymnastic exercises leading progressively and gently
from the easy to the more advanced, until finally they had
a reasonable command of themselves.'1
This picture reminds one somewhat of the appearance
of the " candidates " at West Point. These young men
have quite generally been subjected, before coming to the
Academy, to a physical examination by a competent med-
ical man and by him pronounced physically sound. But
they are almost to a man awkward, unsymmetrical, and
unevenly developed, making an appearance, as they are
marched to the mess hall, fully as absurd as the con-
scripts of Prince Hohenlohe. And they form a particu-
larly instructive contrast with the "yearlings" who have
enjoyed the advantages of a year's drill in physical train-
ing.
Methods of recruiting employed by the regular army
in times of peace to a large extent prevent the admission
into the military service of men with muscles clearly un-
developed or atrophied by distinctly marked disease.
Still it is not infrequent in my observation that men are
enlisted, particularly by the regimental recruiting service,
with defects or deficiencies sufficiently pronounced to
contribute to their life for the next two or three years an
important bearing upon their future health. While act-
ual deformity or disease is a bar to the admission of the
recruit, the variation in structure is so great that but a
small proportion of recruits is either symmetrical or de-
veloped.
In the National Guard, where, for evident reasons, the
physical requirements need not be as severe as in the reg-
ular service, the field for physical training is still broader
and the results obtainable still more striking. Volun-
tary service lends to the work of the guardsman an en-
thusiasm which is an important factor in the attainment
of the best results.
Physical training may by divided into two categories :
1. Preparatory training, by which deficiencies are cor-
rected and a proper equilibrium of the system secured.
2. Conservative training, by which a well balanced
state of the system is maintained after having once been
obtained.
The preparatory training, particularly, demands med-
ical supervision. Here the methods of physical diagno-
sis come into play. Mensuration, inspection, and palpa-
tion are of particular importance. In many gymnasiums
mensuration is the only diagnostic method employed,
but it is evident that it is necessarily insufficient, since
456
MEDICAL RECORD.
[October 13, 1894
one group of muscles may be so over-developed as to
neutralize, in the measurement of a limb, the effect of
the atrophy of another — the girth of a part may be up to
the average, and yet a very definite defect may be readily
detected by experienced inspection, and its character ap-
preciated by careful palpation.
As a general rule, weight, height, and breadth may be
said to be in direct proportion to the strength. But the
exceptions to this rule are numerous and pronounced.
Weight may be due to an excess of adipose tissue, tend-
ing to produce debility rather than strength. Height
may be due to excessive length of legs or neck, both ele-
ments of weakness. Breadth may exist with flaccid
muscles and fatty deposits, which are incompatible with
great physical power. As already suggested, there is
usually a lack of harmony in development between the
various parts of the body, and in this disproportion
may lie the source of marked physical deficiency. The
well developed chest and arms are more than likely to
be accompanied by spindling legs. The limbs of the
left side are, in a large proportion of cases, smaller than
those of the right — an asymmetry which extends to
numerous other details.
The preliminary facts upon which to base the prepar-
atory training are of ten varieties : 1, The weight ; 2,
the height from the floor of the knees, the pubic arch,
the sternum, and the vertex of the head, the latter with
the body standing and sitting ; 3, the girth of the head,
neck, chest, waist, hips, thighs, knees, calves, insteps,
arms, forearms, and wrists ; 4, the depth of the chest and
abdomen ; 5, the breadth of the head, neck, shoulders,
waist, and hips ; 6, the length of each side from shoulder
to elbow, elbow to tip of middle finger, of the feet and
of the body laid horizontally ; 7, the stretch of the arms ;
8, the capacity of the lungs; 9, the strength of the
lungs, back, chest, arms, and forearms ; and 10, the de-
velopment of the body. The appliances necessary for
obtaining these data are a steel tape-measure, a large
pair of callipers, several spring dynamometers, a spiro-
meter, a manometer, a pair of suspended rings, and a set
of parallel bars.
We are fortunate in having at our disposal at the
present day the data based upon a large number of
pbservations already made, by the consolidation of which
types of manhood have been obtained. Sargent's obser-
vations are perhaps the best known and the most exten-
sive, but in the records of the scientific gymnasiums of
the country a vast amount of information can be obtained,
particularly pertaining to the dimensions of youth and
early adult age.
These data are exactly what is required by the surgeon
in the examination preliminary to the preparatory train-
ing, for recruits are — invariably in time of peace — young
men. Accurate examination of the recruit, using the
eye, the hand, and the accessory instruments already
enumerated, will show his deviation from the normal
type, from which the exercises necessary to assimilate
him to the normal will be a natural deduction. Muscu-
lar development depends on frequency of muscular ac-
tion. The man with undeveloped calves would be given
foot and ankle exercises, and he with a slender forearm
would engage in the wrist and finger movements. The
flattened che3t would be brought out not only by use of
the accessory respiratory muscles, but all exercises would,
by causing deep and frequent breathing, cultivate the
respiratory apparatus. The muscles of the neck and face
can each be brought up by individual and combined
movements. In connection with the special exercises
prescribed for the compensation of deficiencies, the
recruit will naturally engage with his comrades in other
movements which will at the same time keep up the
general physical tone, until he shall have attained a
sufficiently uniform development to permit his passing
into the class of the soldier and engaging only in conser-
vative training.
The time during which the recruit remains in the pre-
paratory class is very variable, being dependent upon two
factors: 1, The amount of deviation from the nonml
type, and 2, the readiness with which he responds to
treatment. During this period he should be continually
under medical supervision, but when he passes into the
second class, the personal medical inspection need be
far less minute, although it should never be entirely with-
drawn as long as the training is continued.
The soldier now enters upon the conservative train-
ing, extending to the general field of gymnastics where
the exercises are numerous and varied. Every move-
ment of the manual of arms and every evolution in
marching have an effect upon the muscular system. But
it is an error to presume that these are sufficient for
thoroughly maintaining bodily efficiency. Not only are
they by themselves insufficient for the maintenance of
symmetrical development, but they even tend to the ac-
centuation of asymmetry. The very existence of the
" setting up " drill is an evidence oi this fact. But whi?e
the expanded "setting up " drill, as now practised, serves
excellently to correct the vicious attitudes imposed by
certain phases of military duty, it is not competent, un-
aided, to maintain a high physical ton$. Even were the
prescribed military drills efficient in maintaining a sym-
metrical physique, they would soon, by constant repeti-
tion, become merely mechanical in their execution, a
fact which would detract vastly from their usefulness.
Physical training, in order to retain the interests of its
participants, should be the subject of unlimited variation.
There are no movements like those of the manual of
arms requiring incessant repetition to secure precision in
execution. Infinite diversity, then, may be obtained by
the employment of the almost boundless category of
muscular action — running, leaping, climbing, swinging,
turning, lifting, striking, and the like, in various attitudes
and with various surroundings, without apparatus and
with the great variety of apparatus contributed by mod-
ern inventive genius. Athletic sports are also a powerful
factor in stimulating interest in physical training, and
for that reason should be heartily encouraged. The
spirit of competition thus introduced into the work is of
very considerable advantage, although a tendency, ap-
parent at the present time, to subordinate physical train-
ing entirely to a preparation for participation in sporting
contests, is to be deprecated.
An objection urged against physical training in the
army is that the men do not take interest in it. This
would hardly be supposed to be a valid objection to any
plan looking to the improvement of the service. And
moreover, it is not a valid objection. If there is absence
of interest anywhere it is due to some defect in the man-
agement of the training. To put up a horizontal bar
and a dozen dumb bells, and magnificently remark to a
garrison: "There is your gymnasium, use it," is dis-
couraging enough to ruin any project. The untrained
man does not know how to use gymnastic apparatus.
He may have seen the " Queen of the Air " swinging in
a trapeze, but he quickly finds that circus acts are not
physical training, and he naturally loses interest in the
subject. He would lose interest in just the same way in
the choicest book of Arabic that might be put before
him. He must be taught how to utilize his opportu-
nities. It is like any game, it must be understood to be
enjoyed. And here is where the work of the medical
officer comes into play and the instructors in physical
training find their functions.
But he will require no instruction to appreciate the
benefit of the training. The muscular growth begins at
once ; the size of the body increases ; the circumference
of the limbs is greater ; the chest is enlarged, and the
weight is augmented. The influence upon the system of
the enlargement of the chest alone cannot be computed ;
the greater expansion permitted to the lungs, the greater
play allowed to the heart, the greater amount of oxygen
introduced into the system, the greater excretion of ef-
fete matter from the blood, with their secondary effect
upon every cell and organism in the body cannot be
expressed. The increased girth of the extremities is not
October 13, 1894]
MEDICAL RECORD.
457
the only indication of their added strength, for it does
not take into account the firmness and contractile power
gained even before the growth began. The quickened
sympathy between the brain and the muscles cannot be
shown by any test. The suppleness, the agility, the self-
confidence that have developed, cannot be represented
by figures. The added keenness of perception, the
comfort and satisfaction contributed to existence itself
cannot be estimated, much less represented.
Physical training, then, should occupy a twofold place
in the military service :
1. In its preparatory phase, it should be at the basis
of all service (a) to build up to symmetry men whose
physique is below the standard ; (b) to improve the mus-
cular harmony of all recruits, none of whom are symmet-
rical at enlistment ; (c) to give to the men that ready
command over the muscular system that only comes from
thorough training ; and (d) to contribute that quickness
of mental comprehension only to be derived from exer-
cising in response to frequently varied commands.
2. In its conservative phase, it should still remain at
the foundation of all service. It is not enough to bring
a soldier up to the maximum of physical serviceability,
but he must be kept there. To overcome the retrograde
tendency characteristic of all forms of life when stimu-
lated to a higher grade, and no less present in physical
development, a certain degree of training must be main-
tained constantly.
3. In both phases it should receive (a) the active per-
sonal support of the medical officer, for by strengthen-
ing the weaker portions of the system it will increase the
resistance to disease and vastly diminish the sick-rate of
his command ; and (b) his most careful supervision as
well, in order to insure the proper direction of the train-
ing and prevent excess in its application, an error in
either case being sufficient to preclude a healthful growth.
The results of the scientific application of physical
training to the military service will be wide-reaching in
their beneficial effect.
1. The serviceability of the recruit will be more
quickly obtained, not only by insuring the symmetrical
growth of his frame, but by the awakening of his mus-
cular activity and the consequent quickening of his .men-
tal faculties.
2. The efficiency of the entire army will be increased
by the development of the physique of the units compos-
ing it.
3. The morality of the army will be elevated by sub-
stituting the healthful sports connected with physical
culture for the less reputable amusements in which sol-
diers are sometimes tempted to indulge.
4. The economical administration of the government
will be materially assisted, for training the soldier to
physical vigor will result in keeping from the pension
rolls the names of many who would otherwise promptly
degenerate into helpless dependents upon the bounty of
the State.
5. Not only will it vastly increase the efficiency of the
military service, but it will have an extensive influence
upon the entire community. As the years roll by, it
will present to the commonwealth, upon their discharge
from the army, a class of men, by their physical develop-
ment and mental capacity, qualified to be more than
ordinarily useful citizens. By its extension to the mili-
tary schools, springing up all over the country, it will
encourage healthful tendencies and manly inclinations in
our youth. Through its adoption by the National Guard
— always quick to adopt the best features of the regular
service — it will disseminate physical development and
intellectual activity throughout the young men of the
nation. In every class of society, in every grade of life,
wherever health is understood and length of life desired,
its influence may be felt and its effects may be appreci-
ated.
Edinburgh is Advancing, for there are now eight
Women practising medicine in that city and Leith.
ETHMOIDAL DISEASE.
By F. H. BOS WORTH, M.D.,
NEW \ORK CITY.
Ethmoidal disease, both from the anatomical character
of the region involved, and with reference to the symp-
toms to which it gives rise, differs essentially from dis-
eased conditions found in any of the other accessory
cavities of the nose. For whereas the maxillary, frontal,
and sphenoidal sinuses present to us a single cavity con-
fined by bony walls, the ethmoidal cells consist of a large
quadrangular mass of small cells, or trabecule, varying
in size, and each cell more or less completely separated
from its neighbor by a thin, bony partition. This is
fairly well shown in Fig. 1, the turbinated bone having
Fig. i.— The Trabecular Character of the Ethmoid Cells, shown after the Re-
moval of the Middle Turbinated Bone. From a Specimen in the writer's collec-
tion.
been removed. Hence while the problem which presents
itself to us in dealing with morbid conditions in the other
cavities consists simply in making an opening for proper
drainage and irrigation, in dealing with diseased processes
in the ethmoidal cells the radical arrest or cure of the
disease, especially where suppuration has taken place, de-
mands the opening of each of the large number of small
cells which compose this mass. This is impossible.
Hence we are compelled to resort to the breaking down
of these small partitions within the ethmoid body in such
a way as to convert it into one single cavity. And here,
perhaps," it may be proper to say, that in a diseased con-
dition of any of the accessory cavities I think we will all
recognize the fact that the tendency in every case of a
simple inflammatory process which does not undergo res-
olution, and which develops into a chronic inflammation,
is to result in suppurative action, and thus the establish-
ment of a more or less permanent pus discharge through
the normal opening, namely, into the nasal cavity. The
other respect in which disease of the ethmoidal cells differs
from that of the larger sinuses is in that whereas in the
latter we have simply a purulent discharge, in the former
diseased action sets up a train of symptoms more or less
neurotic in character, such as watery discharge from the
nose, violent sneezing attacks, asthma, headache, neural-
gias, which according to Berger and Tyeman x are usu-
ally intermittent in character ; certain disturbances in the
muscular control of the eyeball, asthenopia, and espe-
cially what has been called aprosexia. This latter really
constitutes one of the most distressing symptoms of the
disease, and has been described to me by patients as a
sort of blanket over their brain which interfered with
mental activity and the free use of their faculties. It is
what the Germans call Retentions- Erschbpfung, and is
defined in Billings's Dictionary as " inability to fix the
mind upon a subject or to retain a lesson, accompanied
by headache, and due to over study or prolonged irrita-
tion in throat or nasal passages."
The topic which I am asked to discuss to day, as I
understand it, is the surgical treatment of ethmoidal dis-
ease. Practically I suppose when we speak of ethmoidal
disease we refer to suppuration in these cavities. The
subject of ethmoid disease is to me exceedingly interest-
ing, and is, I think, perhaps, the most interesting which is
» Dis. Ethmoidal and Sphenoidal Sinuses. Wiesbaden, 1886. (Com-
pare also Schech.)
458
MEDICAL RECORD.
[October 13, 1894
engaging the attention of laryngologists. I hope, there-
fore, that I may be allowed to refer somewhat briefly to
the whole question of diseased processes here, prefacing
this by the statement that I regard ethmoidal disease as
not only by far the most frequent of all diseases of the
accessory cavities, but as of very much more frequent
occurrence than we ordinarily have been taught to be-
lieve, as will be inferred by the statement that in the
past five years ninety-eight such cases have come under
observation in my private practice. In the chapter on
acute rhinitis, in all of our text- books on throat diseases,
Bosworth among others, there is described a disease
characterized often by nasal stenosis, frontal headache,
intra-orbital pressure, asthenopia, watery discharge, and
violent sneezing, which I very frankly confess I have
rarely seen where I was enabled to detect a rational ex-
planation of the symptoms in the morbid condition of
the nasal mucous membrane alone, as seen by ocular in-
spection. I contented myself with the old teaching that
these symptoms were to an extent reflex in character.
I do not hesitate to say that I believe a very large pro-
portion of the cases of so called acute rhinitis are really
instances of acute ethmoiditis, and that such inflamma-
tion as may exist in the nasal mucous membrane is really
secondary to the graver and more distressing conditions
of the lining membrane of the ethmoidal cells. I thus en-
dorse the statement made by that excellent observer,
Moritz Schmidt, of Frankfort,1 who, however, assigns
these symptoms of a head cold to an involvement of some
of the accessory sinuses, not confining it to the ethmoid
cells.
Among the cases which I shall briefly analyze later,
are a number of instances, both of acute ethmoiditis
and suppurative disease, which have had their onset in
unmistakable attacks of la grippe, which leads me to
hazard the suggestion as to whether the influenzal type
of la grippe is not really an invasion of the ethmoid
cells by the specific bacillus which is supposed to be
the exciting cause of that disease.
In a paper on ethmoid disease,* published two and a
half years ago, I described five varieties of diseased con-
ditions of these cells which practically reduced themselves
to three, viz. : 1. Extra-cellular myxomatous degenera-
tion; a, intra-cellular myxomatous degeneration; and
3d, purulent ethmoiditis. I really think that, practi-
cally, we have but one primary morbid condition in the
ethmoid cells, which progressively and with more or
less rapidity develops into these three. In other words,
that these three conditions are successive stages of one
and the same disease. An acute inflammatory process
of the mucous membrane lining these cells very soon
either results in resolution or a chronic morbid process.
Owing to the peculiar anatomical character of tins mem-
brane, a chronic inflammation tends to develop a soft,
jelly-like thickening of the tissue, which takes on what
we may describe as a myxomatous character. Now, this
may persist for a somewhat prolonged period of time,
giving rise to distention of the cells, with its train of
symptoms already alluded to, which are, watery or
muco purulent discharges, violent attacks of sneezing,
headache, intra-orbital pressure, aprosexia, etc., and if
the constitutional habit be neurotic, hay fever, and
asthma, these symptoms being simply exaggerated on
the occurrence of more or less frequently repeated at-
tacks of acute inflammation, to which the patient is
liable.
The further course of this disease I take it to be, in a
certain small percentage of cases, is the crowding out from
the ethmoid cells, through the normal opening, of this
myxomatous tissue, which presents in the nasal cavity in
the form of small polypi. Not that I believe the large
proportion of cases of nasal polypi have their origin in
the ethmoidal cells, for Zuckerkandl ' has demonstrated
conclusively that this is not the case. As the result of
1 Krankheiten der Oberen Luftwege. Berlin, 1894.
• New York Medical Journal, November 7, 1891.
' Norm, und Path. Anat. der Nasenhtile, Band x, Auflage a, s. 360.
this inflammatory process within the cells, the thin walls
become distended and we have a somewhat curious de-
velopment, by which the outer wall of the cells yields
before the pressure, and we have the middle turbinated
bone crowded outward, and gradually an extension of
these cells into this body. See Figs. 2 and 3. And
here for the first time there presents a condition by which
we may recognize a morbid process in the ethmoid cells
• Fig. a.— Distention of the Ethmoid Cells, with Extension into the Middle
Turbinated Body. (Zuckerkandl.)
by ocular inspection through the nose ; in other words,
as far as rhinoscopic examination goes, in the inflamma-
tory stage of the disease, this distention of the cells and
extension into the middle turbinated body gives rise to a
protuberance into the middle meatus, which is easily
recognized, the middle turbinated body presenting as a
rounded ovoid mass, usually in contact with the septum
and encroaching notably upon the middle meatus of the
nose. At the same time this curious myxomatous degen-
eration of the mucous membrane and lining cells con-
veys itself to the mucous membrane covering the outer
wall, which is now the middle turbinated body in the
nose, and lends additional aid in the recognition of the
condition.
These two conditions constitute what Zuckerkandl has
termed "ethmoiditis superficialis" and "ethmoiditis
profunda ;M the former term applying to the disease
Fig. 3.— Distention and Extension of the Ethmoid Cells, with Displacement of
the Middle Turbinated Body . (Zuckerkandl. )
when it is confined within the cells, and the latter desig-
nating the disease when the myxomatous degeneration
has extended to the nasal cavity, making its appearance
on the surface of the middle turbinated body.
The next stage in the development of the disease con-
sists in suppuration. The time of its development may
be very early or very late in the history of the disease,
this being governed somewhat by adventitious circum-
stances. The method of its development seems very
clear. The inflammatory process, involving the mem-
brane within the cells necessarily gives rise to hyperse-
cretion, which materially contributes to the intra-cellular
October 13, 1894]
MEDICAL RECORD.
459
distention, and also results in a closure of the normal
orifice. The necessary consequence is practically the
formation of an acute abscess, which, failing resolution,
soon develops into a chronic abscess, or chronic suppura-
tion of the cells, for I believe it to bean almost universal
rule that where we have a chronic inflammation of a
mucous membrane, with hypersecretion in a closed cav-
ity, the tendency of the process is very rapidly to develop
into a purulent action. We thus have established a
chronic suppurative disease. The pus finds its exit
through either the anterior or posterior ethmoidal cells ;
and I may state here, from a practical point of view, that
the anatomical division of these- cells into the anterior
and posterior group is of no special interest to us in
dealing with the diseased conditions, in that I believe
they are really converted into a single group of cells by
either a normal or a rapidly established abnormal open-
ing between the two. The pus makes its way into the
nasal chambers through one of the normal openings,
either in front into the hiatus semilunaris, or through the
posterior opening into the superior meatus. Thus on
ocular inspection we may find the pus making its appear-
ance either from beneath the middle turbinated body or
from between the middle turbinated body and the septum
above. As a rule, the pus from the anterior and lower
opening makes its way into the lower meatus and is ex-
pelled through the anterior nares ; while the discharge
from the posterior opening makes its way into the
pharynx, giving rise to the symptom so often complained
of, viz.: that of dropping in the throat, in which way
the disease may be confused with an ordinary nasopharyn-
geal catarrh ; although J should say here that the secre-
tion of this latter disease is usually thick and adherent,
and expelled by somewhat violent nasal screatus, whereas
a dropping in the throat should always suggest the great
probability of an empyema of either the ethmoidal cells
or the sphenoidal sinus.
While the most natural exit for the pus is into the
nasal cavity, this is by no means its invariable course, as
is shown by the large number of cases in which the pus
escapes through the os planum into the orbital cavity,
giving rise to exophthalmus and orbital disease. Further-
more, we occasionally meet with exophthalmus from, dis-
tention of the cells in the cavity, without escape of pus,
as is* still further and notably illustrated by the case re-
ported by Bull,1 of ethmoidal suppuration in which an
artificial puncture through the orbit was followed later by
a spontaneous rupture into the nasal cavities, the ulti-
mate cure resulting probably from the latter.
As the result of the persistent suppuration the lining
membrane of these cells necessarily becomes soft and
very much thinned. The much-discussed question of
necrosis of bone never has interested me greatly, because
I regard its importance as much over-estimated. Zuck-
erkandl* states that he has never seen caries of the
ethmoid cells, thus contravening Woakes/ who describes
what he calls a necrosing ethmoiditis as practically the
sole cause of nasal polypi. The membrane covering the
bone is so far thinned and softened that to the impact
of the probe it gives the sensation of being exposed.
That it is genuinely necrosed I do not believe. The
odor, moreover, which is almost constantly present in
these cases in the later stage, is the odor of sulphuretted
hydrogen developed from retained pus, and not the odor
of bone necrosis. Hence in making our diagnosis I
should not be disposed to attach so much importance to
the use of the probe as many writers do, depending
mainly for the diagnosis on the appearances about the
middle turbinated body of distention, and on the myxo-
matous degeneration of the mucous membrane covering
it This deceptive sense of necrosed bone can be ob-
tained by passing the probe either beneath the middle
turbinated body toward the hiatus semilunaris, or above
it toward the opening of the posterior ethmoidal cells in
1 New York Medical Journal, 1893, vol. lvii., p. 75.
» Loc. dt., p. 361.
* Nasal Polypus, Am. ed., p. 8 et seq. Philadelphia, 1887.
the superior meatus. I have frequently detected it in a
normal and healthy nose.
Our most important consideration, of course, has to
do with the question of treatment, and that this should
be instituted early in the history of the disease and be-
fore the suppurative process has ensued need not be
urged, in view of the very serious discomfort, and even
danger, which attends the stage of empyema, and the
great difficulty with which it is brought under control
after pus formation has become chronic. In acute eth-
moiditis the ordinary measures which our text books
recommend in the treatment of acute rhinitis are indi-
cated of course, and need not be dwelt upon, further
than to say that of all measures I regard the use of the
douche as most potent, directing that from one to two
gallons of water rendered thoroughly saline be passed
through the nasal cavities by means of the Thudichum
douche at least twice daily. The water should be as hot
as can be borne. This instrument I regard as devoid of
the danger to the ears, of which Roosa has warned us,
provided that the patency of each nostril be tested before
its use and that the stream be made to pass into the nar-
rowest nares, thus emerging without obstruction from the
most patent side.
When the disease has reached the chronic stage with-
out suppuration, I believe that, other measures failing,
surgical interference should be resorted to in all cases,
as we here have to deal with an affection which does not
tend to undergo resolution, but one in which there is
imminent danger of suppuration setting in at any time.
The test that this chronic stage has been reached is to
be found in the swollen and distended condition of the
ethmoid cells, as shown by the projecting and swollen
turbinated body, whether the mucous membrane covering
it be in a state of myxomatous degeneration or simply
turgescent. The object to be accomplished is to relieve
intra- cellular pressure, and this is accomplished by uncap-
ping, as it were, the ethmoid cells. The steel-wire loop
of the Jarvis or Bosworth snare is easily slipped over the
projecting turbinated body and the whole mass removed,
presenting usually in the form of an elongated ovoid
shell. This also reveals to us the condition of the mu-
cous membrane within the ethmoid cells, which may be
either in a simple state of turgescence, or, as has not
infrequently happened in my own experience, a soft,
gelatinous mass of myxomatous tissue is found filling the
cavity thus opened. If this does not drop out of place,
it is very easily removed by the mouse-tooth forceps or
the snare.
After pus-formation has occurred the problem before
us, as before stated, consists in converting the large
number of small cells which compose these bodies into a
single cavity and establishing thorough drainage. In
these cases the primary procedure is, as before, to uncap
the cells by use of the snare, and after that I believe our
best instrument consists in the use of the dental burr.
Schaeffer, Moure, Cozzolino, Gleitsmann, and others
prefer the use of the curette. I have never been able to
freely manipulate this instrument in the ethmoidal cells
or to break down the trabecular walls by its use. Its
manipulation is hampered, and its action, to my mind,
seems inefficient and not radical enough in extent.
Griinwald's sharp spoon is a more efficient instrument,
but still hampered in its action. The same criticism
applies to the forceps and sharp spoon, as advocated by
Zarinko.
That this disease can be radically cured, or even mod-
ified or controlled to any great extent, by the use of disin-
fecting lotions, as recommended by Lichwitz,1 Hartman*
Michel," Schalle,4 Myles * and Moure,6 1 do not believe.
The small oval or round burr, attached to the dental
1 Diseases of Accessory Cavities of Nose, Bui. M6d., Paris, 1893,
lxxxvi., p. 963.
9 Quoted by Berger and Tyrman, Dis. of Ethmoidal and Sphe-
noidal Sinuses, p. xa. Wiesbaden, 1886.
• Idem,
f Idem.
• Mbdical Record, 1802, vol. xlii., p. 607.
• Manuel pratique des Fosses nasales, ad ed., p. 535. Paris, 1893,
460
MEDICAL RECORD.
[October 13, 1894
engine, or, better still, the De Vilbiss engine, in my
hands has answered a better purpose than any other de-
vice. Manipulated with the De Vilbiss engine it is made
to enter the ethmoidal cells either before or after they
have been uncapped, when the trabecular walls are easily
broken down or burred away. Its motion can be instantly
arrested at will, when it can be made to act as a probe,
exploring the cavity for exposed bone or such parts as it
is desired to remove. In this manner our operation be-
comes not only intelligent, but, I think, absolutely safe,
a consideration which of course is to be very carefully
borne in mind, when we remember that we are separated
in our operation not only from the orbit of the eye by an
exceedingly thin plane of bone, but if we progress very
far we are getting in close proximity to the base of the
brain. I do not mean to intimate that at a single session
the whole of the trabecular which constitute the ethmoid-
al cells can be opened out and thoroughly drained. In
many of my cases the operations have been repeated a
number of times at intervals varying from one week to a
month, or even longer. During the intervals of course
the patient is directed to use disinfecting lotions with as
much intelligence and thoroughness as can be accom-
plished by the ordinary devices which we place in the
hands of our patients for use. I have no special sugges-
tion to make as to the character of these lotions, as thor-
oughness of application is of more value than the special
character of the antiseptic used. Moreover, it should be
stated that the operation is not attended with anything
like the pain that we should suppose when we consider
the exceedingly sensitive character of the parts operated
upon. Of course the procedure is not an agreeable one,
but it is not an especially painful one, provided that we
can sufficiently reach the parts to thoroughly saturate
them with a cocaine solution.
I may seem to the general practitioner to be discussing
and describing not only radical but perhaps rough and
even dangerous methods; but when we consider the
great discomfort and distress to which a patient suf-
fering from ethmoidal disease is subjected, and the still
greater danger which threatens him, as has occurred, of
involvement of other sinuses or neighboring cavities, such
as the orbit, or even the development of the disease in
the brain tissue itself, I think there can be no question
that these radical procedures are not only fully warrant-
able but absolutely indicated.
The charge has not been infrequently made in the past
few years that intra-nasal surgery has been very greatly
overdone. Some of our English friends have delicately
suggested that we attack the nasal tissues " with the
energy of the backwoodsman," " with more energy than
discretion,11 with recklessness and without justification.
These charges are not deserved, and are unjust. We do
not confine our work to the saw and burr and drill. The
very large majority of our cases are dealt with without re-
sort to surgical measures. But we meet with a large num-
ber of cases in which other measures are inadequate, and
these we attack, not with the energy of the backwoods-
man, but with the trained and delicate hand of the sur-
geon, who recognizes unmistakable indications and car-
ries them out; the gratifying result fully justifying the
means.
As before stated, during the past five years I have re-
corded in my private practice 97 of these cases, a brief
summary of which I append. Of the 97 cases 3 were
carcinoma and 4 sarcoma of the ethmoidal cells, which
may be left out of consideration. As regards age, 3 oc-
curred in the second decade of life, 14 in the third, 23
in the fourth, 28 in the fifth, 18 in the sixth, and 7 in the
seventh decade. Sixty-one were males and thirty two
were females. Fifteen cases were inflammatory in char-
acter, without suppuration or polypoid degeneration. Of
these, 9 were cured, 3 were improved, and 3 disappeared.
Twenty-nine cases showed myxomatous degeneration
without suppuration. Of these 12 were cured, 10 im-
proved, and 7 were seen but once or twice, and their prog-
ress not known. Twenty-two cases showed myxoma-
tous degeneration, or fully developed polypi, together with
pus discharge. Of these, 9 were cured, 10 improved, and
3 disappeared. Of the purely suppurative cases there
were 27 ; of which 8 were cured, 12 improved, both as
regards subjective symptoms and the amount of discharge,
while 7 were seen but once or twice and not further
noted. In nearly all these cases radical operative meas-
ures were instituted, as carrying out the suggestions al-
ready made. In many of them the simple irrigating
measures failed to give relief, either to subjective or ob-
jective symptoms, and the cells were opened either by
the snare or drill, or, and in many cases, both were used.
•6 West Fobtt-sixth Smsi?
ON
DYSPEPSIA NERVOSA AND GASTROIN-
TESTINAL NEURASTHENIA.
By LEONARD WEBER, M.D.,
It is just ten years since Leube published his paper on
" Dyspepsia Nervosa," and defined it as a disorder all
the symptoms of which are caused by a functional dis-
turbance of the nervous system, and especially of the
nerves of the stomach, while gastric digestion remained
normal both as to time and chemical process. Leube
found this class of patients to be generally delicate, thin
at the outset or in the progress of the complaint, rarely
stout or of healthy appearance. In some cases there
was a previous history of anaemia. Intermittens, renal or
uterine trouble, sexual excess, or some real disease of the
stomach that was cured, but left a state of nervous dys-
pepsia behind it ; all cases were characterized by more or
less suffering accompanying the act of digestion, which
seemed to originate in the nervous system.
Prominent among the symptoms, as I have observed
them, are a feeling of fulness and congestion in the
head, headache, vertigo, cardiac palpitation, slight pseu-
do angina, dyspnoic oppression, abdominal pulsation.
And on the part of the stomach a sense of pressure and
fulness in the epigastrium, while palpation of the stom-
ach generally reveals neither tenderness nor pain. Glo-
bussensation and pyrosis are rather frequent, and volu-
minous eructations of gas without odor or taste are very
generally complained of. Nausea with occasional vom-
iting is not rare, and the vomiting may sometimes be
rather severe and obstinate.
The appetite may be good, or bad, or changeable,
and sometimes ceases after the patient has swallowed a
few morsels. The bowels are generally constipated, sel-
dom loose, almost always flatulent. In some cases nearly
all these symptoms are present, in others again a few ot
them only. Great as Leube's merits have been in bring-
ing the important subject of gastric neuroses prominently
before us, it is nevertheless shown, not only by the labors
of Ewald, Boas, Rosenthal, Bouveret,* and others in this
special field, but by the clinical observations of most of
us, I believe, that Leube's standpoint is not sufficiently
comprehensive, and we have to widen his definition of
nervous dyspepsia, because we know that we meet numerous
cases with all the symptoms of nervous dyspepsia, but
also with disturbances of the secretory and motory func-
tions of the stomach. Cases enough have been described
where the secretion of hydrochloric acid is considerably
diminished, insufficient for healthy digestion or even tem-
porarily absent, not only for days but weeks ; then normal
again or increased, hyperhydrochlorie. There is gene*
rally a combination with motory weakness where hydro-
chloric production is diminished or absent, but with ab-
normal motory activity where there is supernormal secre-
tion of hydrochloric acid. Gastralgia severe enough to
simulate gastric ulcer with Burkhard's points douloureux
in the region of the eleventh and twelfth vertebrae and
in the epigastrium, I have noted sometimes, but they are
variable and fugitive, not permanent as in gastric ulcer,
aside of the other pathognomonic symptoms of the latter.
From my own observations, therefore, I believe that for a
October 13, 1894]
MEDICAL RECORD.
461
number of cases, at least, the designation " nervous dys-
pepsia" is too narrow, that they cannot be considered
and treated apart from the other neurasthenic symptoms
which are correlated to and associated with it, and that
it is gastro intestinal neurasthenia as a part. Neuras-
thenia rather than nervous dyspepsia we have to deal with
in a large number of cases. From my case-book I could
add quite a little number of neurasthenias such as described
by Ewald, and Burkhard, and Bouveret, who presented
well-marked dyspeptic symptoms with the chemism of
the gastric organ altered in various ways as marked
above. It will be appropriate therefore, I think, to
divide the cases into two classes : 1, dyspepsia nervosa
with functional disorder of stomach; 2, neurasthenia
gastro-intestinalis in general neurasthenia.
The causes of nervous dyspepsia are many. Aside of
those caused by direct or indirect disturbance of the
pneumogastric centre through cerebrospinal disease or
disease of peripheral nerves, there are gastralgias by re-
flex through affections of the genital organs, gall-stones,
renal calculus, a floating kidney, and the presence of in-
testinal parasites, particularly tape-worm. >But we are
now concerned with those forms which are part of gen-
eral naurasthenia brought about by physical or mental
overexertion, or both, excessive care and excitement, sex-
ual excess, debauch, masturbation, or by intoxication such
as malaria, morphine, nicotine ; also those by hysteria and
such constitutional anomalies as chlorosis and anaemia.
With regard to age, sex, and the influence of life's
vocation, my experience coincides with that of all other
observers, I believe: i.e., gastrointestinal neurasthenia
is prevalent among men between twenty and thirty, and
is more often seen among brain-workers than among
mechanics, though I have quite a little experience with
the latter class also in that direction. Women are per-
haps less often affected than men, and, for reasons easily
understood, at an earlier period of life. With regard to
children I have no personal experience of value, but some
observers maintain that the disorder is not as rare among
them as is generally supposed.
Now, with regard to the treatment of dyspepsia nervosa,
I have always been delighted when I got hold of a case
where I could remove or control the cause, and feel sure
then to cure, or almost cure, my patient. For instance, a
tape- worm by giving 10.0 of extr. fil. mar., a displaced
uterus by a pessary, a floating kidney by a suitable truss,
an irritable urethra by the use of the steel-sound and
tepid sitzbath. Or when anaemia or chlorosis was at
fault, by iron, quinine, and arsenic, salt-water baths, and
change of climate, and by the elimination of malaria and
nicotin poison where the attacks were produced by them.
Of nerve drugs, I am not in the habit of prescribing opium
or cocaine, except where there is severe gastralgia pres-
ent ; here I often use a cold wet bandage over the abdo-
men with a coil on top of it through which hot water is
allowed to flow for some time — a plan of application sug-
gested and recommended by Winternitz, that will often
bring relief without morphine. Extractum cannabis,
however, introduced by Germain-S6e in the treatment of
nervous dyspepsia where there is much sense of pressure
and discomfort felt after eating, I have often prescribed in
doses of one sixth of a grain t.i.d, and been well satisfied
with the results obtained. Some praise here the use of
aqua chloroformi or atropia. Electricity also does well
here, with a very large electrode over the epigastrium, as
first proposed by von Ziemssen, especially also where there
is a good deal of motory weakness of stomach. In cases
accompanied by obstinate vomiting, I have found noth-
ing answer so well as to make the patient fast for two or
three days, giving meanwhile nutritive enemata. - Last,
but not least, a Weir Mitchell rest and feeding cure will
be of service in certain female cases too well known to
need description, and in those of men who are much re-
duced and present hysterical symptoms.
I wish that I could say half as much of positive
results obtained by me in the management of cases of
gastro-mtestinal neurasthenia in neurasthenics, leaving
out of consideration altogether those caused by organic
disease of the central nervous system. So long as I did
not understand the causal connection, or rather insepar-
able relation and interdependence of the general and
local condition, I tried for cure and failed in the one as
well as in the other state. Now that I know we cannot
yet cure a case of grave neurasthenia, although they have
quite occasionally a queer way of getting better by them-
selves, I do not try any more to cure them by active
treatment, but I do them more good than before. By
dealing more with the individual, regulating his life,
correcting his had habits, admonishing him to spare
himself and pay close attention to his dietary, physic his
bowels from time to time to remove putrid material, and
go on short vacations two or three times a year, I be-
lieve to succeed pretty well in keeping them in fair or-
der not only, but putting them actually in the way to
get as nearly well as they can. Of symptomatic rem-
edies I know none better than those mentioned in the
first class of cases, which we may more truly call nervous
dyspepsia than the latter.
To be sure, we all know of neurasthenic dyspeptics
who went to the high Alps of Switzerland, or to
fine places at the sea, or to specially fitted sanatoria
here and abroad, and were sent home cured. No won-
der that they came home better after doing the very
best things for themselves under the best possible condi-
tions of climate, food, care, and rest, and recreation of
mind and body ; but it is at best a great improvement
only, and it is generally not very long before we see them
return to us with their old complaints.
•5 West Forty-sixth Street.
g*00t*ss of IPjeflijcat jfciettce.
The Absorption of Iron. — Dr. Macallum finds that
inorganic iron is absorbed (in guinea-pigs) by the in-
testinal mucous membrane. Whatever iron salt was ad- .
ministered, whether the phosphate, chloride, sulphate, or
" peptonic," when the dose was not very large, the
evidence of its absorption was very plain in the villi of
the upper end of the small intestine, but in them only
{The British Medical Journal). When the dose was
large, the presence of iron in the villi was observed far
down the intestine, but the reaction for iron was less dis-
tinct the more remote the villus from the pylorus.
With very large doses of the phosphate or " peptonate "
the villi near the caecum gave an intense reaction. It
is suggested that the reason for this difference is that
when the dose of iron is small, and when, consequently,
the quantity of iron in the chyme is small, it is wholly
precipitated by the alkaline, biliary, and pancreatic se-
cretions ; as these three fluids do not at once and com-
pletely mingle, the iron is not at once precipitated, and
consequently absorption goes on in the first few inches
of the intestine. The acidity of a larger dose of iron
salt may be sufficiently great to destroy the alkalinity of
the chyme after admixture with the bile and pancreatic
juice, and, when this is the case, the unprecipitated ex-
cess of iron-salt will go on down the intestine, and
be absorbed lower down. When the oxide or the re-
duced metal is given, a certain quantity of the acid of
the chyme is taken up in effecting their solution, and
therefore in the intestine the alkalinity of the bile and
pancreatic juice must go farther in the precipitation of
the iron. Speaking generally, the larger the amount of
free acid in the chyme the greater must be the quantity
of iron absorbed. Sulphides in the contents of the
bowel will also precipitate the iron still in solution. On
an ordinary diet, therefore, the extent of intestinal mu-
cous membrane which absorbs iron must be, in propor-
tion to that which does not, remarkably small. Macal-
lum, however, thinks it possible that in anaemia there
may be a diminution in the amount of the biliary and
pancreatic secretions, a condition which, for the reason
above stated, would prevent precipitation, and thus favor
462
MEDICAL RECORD.
[October 13, 1894
absorption. His grounds for stating that iron salts are
absorbed, a fact which has been denied, are drawn from
microscopical examination of the mucous membrane un-
der various conditions. In well-fed guinea pigs taking
iron, the intestinal mucous membrane, after treatment
with alcohol, assumes, when treated with ammonium
sulphide, a more or less dark color, due to the formation
of sulphide of iron, which, under the microscope, is seen
to be limited to the subepithelial portions of the tips of
the villi. Here it is deposited in leucocytes which sur-
round the end of the lacteal vessel. When the dose of
iron is larger, or, apparently, when the administration is
continued for a long time, the iron is present also in the
epithelial cells themselves, and passes from them by a
process of internal secretion into the plasma of the ven-
ules. These venules are the portal radicles, and leuco-
cytes containing iron are found in capillaries of the liver,
and the peripheral cells of the lobules contain iron.
Similar leucocytes are found in the spleen. Beyond this
point the iron was not traced, and the question whether
it is ultimately assimilated and fixed as inorganic iron
remains unsettled ; but the research serves to prove that
iron salts have not, as has been asserted, merely a stimu-
lant action on the epithelial cells of the mucous mem-
brane. Any stimulant action they may exert is a con-
comitant of their absorption. Though some of the
subepithelial leucocytes of the villi appear thus to carry
part of the absorbed iron into the general circulation,
the more important agent in the transference of the in-
organic iron from the villi to other parts of the body is
the blood plasma.
Thiofonn —Dr. Julius Schmidt states that thioform is
a grayish yellow powder, which is a chemical combina-
tion of bismuth, sulphur, and salicylic acid. It is tasteless
and odorless, insoluble, and was first prepared as a sub-
stitute for iodoform. This expectation has been veri-
fied in so far that surgically its value is equally great,
but the specific action of iodine as required in tubercu-
lous affections is not obtained. When applied to fresh
wounds thioform produces rapid drying of the surface,
leading to a more rapid cicatrization than has been ob-
served after the use of any other application ; this was
noticed even in extensive surface lesions, such as burns,
weeping eczema, and gangrenous patches, the latter
having^ healed in four days. The author tested the
powder in five cases of ulcer of the leg which had re-
sisted other treatment. The ulcer having been cleaned
and disinfected, the thioform was thickly dusted over it,
and covered with cotton-wool and a bandage. Every
fourth day the whole dressing was changed, and though
the patient continued to walk during the treatment, the
cure required two or three weeks only. Some pain was
occasionally produced, but no sign of irritation could be
seen. Similar results in the practice of other surgeons
are given. Finally, the author used thioform internally
after having satisfied himself as to its non- poisonous
character, and with daily long-continued doses of fifteen
grains, better, though similar, results were obtained
than with salicylate of bismuth.
Tuberculous Typhlitis and Appendicitis. — Dr. Re-
ctus observes that the clinical reports of tuberculosis of
the caecum have accumulated rapidly during recent years.
The cases of Bouilly, Terrier, Hartmann, Reynier, Broca,
Roux, Salzer, Billroth, and Hochenegg, the anatomical
researches of Duguet, Spillmann, H6rard, Cornil, and
Hanot, and the recent descriptions of Pilliet and of Le
Bayon, have thrown some light upon this hitherto but
little recognized affection. The cases have been numer-
ous enough for one to attempt to tabulate a statement of
the clinical manifestations of tuberculous typhlitis and
appendicitis. Reclus himself has observed two cases
where a long-continued clinical history has been sustained
by post- mortem examinations. This affection may mani-
fest itself as a localized tuberculosis without infiltration,
without concomitant degeneration of the lungs and other
important viscera, developing itself around the ileo csecal
valve and its vicinity without invading the other tissues.
This suffices to class this tuberculosis among the surgical
tuberculoses ; from the moment it is confined to a limited
focus and this focus is accessible, in such favorable cir-
cumstances intervention is legitimate. Therefore, in cer-
tain cases — and the observations are becoming daily
more numerous — perityphlic tuberculosis is an ordinary
surgical affection. As to the etiology of this condition
the literature is scant ; the degeneration here, as in most
of the other tuberculoses, seems most frequent in adult
age, but the young do not escape ; a little boy aged ten
has been cited as dying from this affection ; the greatest
number of the cases published, however, have been in in-
dividuals who neighbored upon or who had passed thirty
years of age. It seems that two distinct anatomo-patho-
logic forms may be described, associated with different
symptoms: the one a fibrous or hypertrophic and the
other an ulcerous variety ; moreover these may be com-
bined, or there may be noticed all the intermediate
stages between them. The majority of the cases thus far
reported have been characterized by an abundant new-
formation which gave to the degeneration the appear-
ance of cancer. In this form, the tumor after incision
of the abdominal parietes appears fused with the double
parietal peritoneum, with new membranous formations
which cover the intestines and mark their limit; the
original form of the caecum and its appendix, the ascend-
ing colon, the ileo-caecal valve, and the termination of
the ileum cannot be recognized. There is a muscular
and a mucous hypertrophy at this point which causes
the intestinal wall to measure at times up to three or four
centimetres. The lesions ordinarily are most marked
around the ileo-caecal valve ; the valve is profoundly al-
tered from the beginning ; in its place is found an ir-
regular cavity, covered by a partly ulcerated mucosa;
the loss of substance is irregular, its edges sinuous, the
base sanguineous with small rigid villosities. The ap-
pendix is bent upon itself and adherent at times in front
of the caecum, at times behind it ; it is lost in the thick-
ness of the false membrane.
The second or ulcerated form may present thickening
of the serous and false membranes around the intestinal
loops, but these have not the remarkable hypertrophy of
the other form ; on the contrary, the ulcerative process
predominates, the mucosa has often completely disap-
appeared, especially at the site of the ileo-caecal valve,
where ordinarily a veritable cloaca is found due to the
destruction and anastomosis of the various intestinal seg-
ments. The softening of the cheesy masses in the tunics
and the neighboring ganglia has given rise to puriform
collections, which run in various directions, but generally
make their way toward the abdominal wall ; through the
resulting fistulse fecal matter and pus escape. These pyo-
stercorous canals are often multiple. There exists a third
form which Professor Cornil has especially studied.
Often, in place of the fecal concretion which forms in
the appendix, some foreign bcdy, bone, a fruit
seed lodges there, and by its presence irritates or perfo-
rates the vermiform process and tuberculosis forms, the
bacillary colony destroying the walls. The symptom of
the first form in the beginning is the existence of deep
pains in the region, lasting for some hours during the
day, then disappearing and appearing anew. This at-
tack subsides only to reappear in a few weeks in a more
aggravated form. Constipation accompanies it and may
be extreme. On examination the presence of a tumor is
demonstrated in the right iliac fossa, hard, resisting, bos-
selated, irregular. In these cases where softening has
taken place fluctuation may be pronounced, or the skin
becomes red and the abscess opens with the formation of
a fistula. The diagnosis becomes plainer still when in
place of the extreme constipation a rebellious diarrhoea
appears resulting from the abundant and persistent ul-
cerations of the mucosa. The general health does not
suffer in either form at first. As to the treatment of these
cases, surgical intervention is the only proper and justifi-
able course. — The Medical and Surgical Reporter.
October 13, 1894]
MEDICAL RECORD.
463
(SliiuicaX g«pa»tmetit
A SOURCE OF INFECTION IN CORNEAL AB-
SCESS.
By J. H. THOMPSON, M.D.,
clinical PRoressox of ophthalmology, Kansas city medical college, Kan-
sas CITY, MO.
lifts not the purpose of this paper to consider the nature
and variety of micro-organisms which cause abscess of
the cornea. The probabilities are that the septic cases
are responsible for most purulent inflammations of that
tissue. But it is important to learn where these septic
germs arise and how they reach the eye. We know that
the tears and conjunctival secretions contain them, and
late investigations have proved that the cutaneous edges
of the lids, especially about the roots of the lashes, are
surgically unclean. The greatest source of infection is
the lachrymal sac, and woe be to an eye if its cornea is
injured during the course of a purulent dacryocystitis.
I am inclined to the opinion that the pyogenic cocci are
not always so virulent as we have been taught to believe ;
for very few eyes could survive the simplest operation
which necessitated an incision or puncture of the cornea.
Therefore, it is not unreasonable to think that in a large
majority of instances the conjunctiva of an unwashed eye
is, for all surgical purposes, aseptic.
In an experience of fifteen years, during which time I
have made many extractions and corneal incisions, I have
never had an instance of suppuration, and I do not take
any antiseptic precautions other than wiping the lids
with a bichloride solution, 1 to 2,000, taking care that
the instruments are clean. Of course, it is to be under-
stood that all such cataract operations were made on un-
inflamed eyes.
Many cases of abscess of the cornea are the result of
infection from the lachrymal sac, the mucosa of the sac
being in a condition of purulent inflammation. Many
other cases of corneal abscess are not complicated by
that disease. In such instances I have usually found the
source of the infection to be the mouth. It is not an ex-
aggeration to say that the mouth of an unclean adult is
often extremely dirty. Should the reader desire proof
of this statement, let him examine the teeth of the ordi-
nary dispensary patient, or, what is more agreeable, take
the opinion of a dentist. Unless extra care is taken by
most persons the tartar will collect around the roots of
the teeth, which will ultimately excite an alveolar pyor-
rhoea and, finally, recession of the gums. During the
course of that disease the mouth may be horrible and the
smell disgusting. No wonder the bite of such persons
cah be fatal. If we take a minute particle of the mass of
decomposing food and pus from between the rotting
teeth and examine it through an eighth objective, after
staining the cover-glass preparation by Gram's process,
we will be astonished at the multitude and variety of mi-
cro-organisms. I cannot conceive how the pharynx and
nasal passages can be healthy if the mouth is so diseased.
The mass of organisms cannot remain localized about
the teeth, but must infect the entire mucous tract, and
by continuity reach the conjunctiva. They do not nec-
essarily inflame that membrane, nor do they excite such
disturbances in the lachrymal passages as would be de-
tected by the patient or careless observer, but the mucous
membrane of the eye is infected when an intentional or
accidental wound of the cornea may suppurate.
For some time I had been suspicious that there was
some relation between a dirty mouth and a suppurating
cornea, when the following case rather convinced me.
M. B , aged forty-three, a farmer. While cutting
weeds something hit him in the eye. He did not pay
any particular attention to it, and would have forgotten
the accident had not his eye inflamed three days after-
ward. He was cared for by his family physician, who
referred him to me ten days after the accident. When
I saw him, his cornea was. destroyed by an abscess. He
had no disease of the lachrymal passages, but his mouth
was fouler than the uninitiated can conceive. His
breath overcame me. Is it surprising that he lost his
eye?
Some weeks ago I saw another similar case.
F. N , aged about thirty, laborer, was wounded in
the left eye by a piece of stone. He complained of the
injury from the first, and, when I saw him several days
afterward, he had a suppurating ulcer of the cornea with
hypopion. The ulcer was round, 3 mm. in diameter,
with a dirty white floor and ragged edges. There was
no evidence of dacryocystitis, but there were evidences
of a foul mouth. The ulcer was completely destroyed
by the actual cautery; the eye bathed every two hours
with a bichloride solution, 1 to 4,000. The patient was
introduced to, and taught the mysteries of a tooth-brush,
as much care being taken to clean his mouth as his eye.
The eye did not improve, and when the hypopion filled
the anterior chamber, I made the Saemisch cut, and re-
moved the pus en masse with forceps. From then on
the patient improved, and was discharged six weeks
afterward with useful vision.
At present I have on hand a case of hypopion keratitis
evidently caused by infection from the mouth. The
patient is an Italian miner, who has suffered for years
from alveola pyorrhoea. His mouth is in a dreadful con-
dition ; the roots of all his front teeth are exposed, and
the spaces between them and the receding gums filled
with tartar, pus, and decomposing food.
If the source of infection in the cases above reported
was the mouth, it behooves us to pay some attention to
oral cleanliness in the treatment of suppurative keratitis ;
and since this may account for some distressing and un-
expected results following cataract extraction, we should
be especially careful in that regard before undertaking
that operation, since we know that old people are apt to
be careless, and usually suffer from bad gums and de-
cayed teeth.
AN UNUSUAL CASE OF PERFORATING AP-
PENDICITIS—DEATH FROM HEMORRHAGE
DUE TO RUPTURE OF THE COMMON
ILIAC VEIN.
By J. C. LEWIS, M.D.,
PANAMA, N. Y.
B. E , fourteen years of age, was taken sick on
Friday, March 23d, with vomiting, chills, and pain in
the bowels. The pain increased in severity until Sun-
day, March 25th, when I was called to see her. I found
the patient inclined to lie mostly on the right side, with
limbs flexed. Temperature, 1030 F. ; pulse, 135. Her
bowels were slightly swollen and tympanitic, with tender-
ness especially marked in the right iliac region. The pa-
tient had taken for her relief nine of" Carter's " pills and
one tablespoonful of castor-oil, without, however, obtain-
ing any movement of the bowels more than a few small
scybalae, and at one time, on Saturday, March 24th, about
a tablespoonful of fresh blood was passed. The patient
ascribed her sickness to some peanuts which she had
eaten at a party on Friday evening, March 16th.
The treatment pursued was the use of large enemas
with opiates to relieve the pain. On Monday and Tuesday
the symptoms were unchanged, except that the tempera-
ture rose to 1040 F., the pulse varied from 120 to 140,
the countenance became cadaveric and expressive of
severe pain. The swelling and tenderness in the right
iliac region became more manifest, with point of severest
pain an inch below McBurney's point. On Tuesday,
while up in a chair, the patient fainted away, and it was
quite difficult to restore her, and for an hour or more
her breathing was labored. The enemas had been con-
tinued without any success. I became convinced that
the patient had appendicitis and recommended an
operation. On Wednesday, Dr. Murphy, of Sherman,
N. Y., saw the case with me and confirmed the diag-
nosis, but advised waiting two days and keeping up the
464
MEDICAL RECORD.
[October 13, 1894
use of the enemas, as her symptoms seemed somewhat
improved, the pulse having come down to 100, and the
temperature to ioo)40 F., and the countenance was im-
proved, though pain, swelling, and tenderness of bowels
remained the same.
On Friday, March 30th, with a view to an operation,
Dr. Seabury, of Sugar Grove, Pa., was called, and met
Drs. Murphy and Glidden. The patient's condition was
unchanged, except that the pulse was down to 90, and
the temperature for the last two days had ranged from
normal to ioo° F. The result of the consultation was a
delay in the operation. On Saturday, a.m., the tempera-
ture was only 96^° F., and the condition otherwise un-
changed, except that the swelling in the right iliac region
seemed less prominent. The bowels were but little
swollen and tympanitic, but pain was not lessened. The
bowels had not moved from enemas, which had been con-
tinued.
Dr. John Parmenter, of Buffalo, was called, and
operated in the presence of Drs. Seabury, Glidden, Mur-
phy, and the writer.
At the time of operation the physical examination
showed a good countenance, a clean and moist tongue ;
respiration, 20; pulse, 100 (full and regular); tempera-
ture normal ; abdomen slightly tympanitic and not re-
markably tender. In place of a perceptible tumor, only
dulness was manifest in the right iliac region. This ex-
tended toward the median line. Coeliotomy was made
in the median line, and after cutting through the ab-
dominal wall pus welled up in the incision. Omentum
formed the background and seemed intimately adherent
to the intestines beneath. The pus seemed to come
mostly from the right side, and upon examination a
large abscess cavity was discovered in the right iliac
region. Incision was made over this; that is, at the
right border of the right rectus muscle, through which
a pint and a half of malodorous pus was removed.
The intestines were found matted together, and for fear
of disturbing the adhesions no force was used in the ab-
scess cavity. This was drained with iodoform gauze, a
counter-opening in the loin having first been made in or-
der to more freely drain the parts, and the patient was
put to bed in practically the same condition as before the
operation. She became restless in coming out from the
anaesthesia and tossed about in the bed, requiring the ef-
forts of the bystanders to restrain her. An hour after
the operation she became resdess a second time and
showed signs of collapse. Examination revealed the
bed and the dressings posteriorly to be saturated with
blood, and, notwithstanding the generous use of stimu-
lants, she shortly died.
Autopsy, immediately after death, revealed the follow-
ing conditions: There was pus throughout the whole
abdominal cavity, covering all the viscera, even occupy-
ing the space between the liver and diaphragm. In the
right iliac region, the ileum for some twelve inches was
intensely congested, and at the junction of the ileum and
caecum the parts were gangrenous. The caecum con-
tained three gangrenous openings, averaging one- fourth
of an inch in diameter. The distal three-fourths of the
appendix was gangrenous and separated from the proxi-
mal end, and lying in the debris was a peanut. The
healthy condition of the proximal end precluded the
idea of the peanut having passed through from the
caecum by this route, so that the inference is that it must
have come through one of the openings in the caecum
and was deposited in the neighborhood of the appendix.
The portion of the ileum near the junction at the caecum,
as before stated, was in a gangrenous condition and bent
sharply downward to become attached to the common
iliac vein: In this latter structure a small opening, out
of which exuded blood, was discoverable, and from this
area, through the posterior opening in the flank, blood
had continually poured until death ensued. The amount
of blood exuded in a given time must have been com-
paratively small, and' in all probability the rupture of the
vein occurred during some of the violent movements of
the patient on coming out from her anaesthesia, for at
the time of the operation no hemorrhage of any kind
was perceptible.
The following features seem worthy of notice :
1. The absence of marked symptoms of diffuse suppu-
rative peritonitis.
2. The cause of death — from hemorrhage.
3. The absence of fecal impaction, which was supposed
to exist in connection with appendicitis, from the fact
that no satisfactory movement of the bowels had been
obtained after the taking of so much physic
4. The necessity of an early operation in cases pre-
senting marked symptoms of appendicitis.
THE INFECITVTTY OF PHTHISIS PULMONALIS
—AN INSTANCE.
By CHARLES O. MAISCH, M.D.,
-NBW YOftK.
Some weeks ago I was consulted by a man whom I have
known for a number of years, whose mode of living,
surroundings, and family were perfectly well known to me.
The patient is a German, sixty-two years of age, well
preserved, and weighs about two hundred pounds ; ante-
cedents and family history good, except that he had
pneumonia a year ago.
He states that he has lost forty pounds in the last four
months ; his complaints are those of a patient in ad-
vanced consumption — cough, profuse expectoration, oc-
casional hemorrhages, anorexia, sweating, wasting, etc
Physical examination disclosed both apices to be in-
volved, and the sputum I examined contained the tuber-
cle bacillus in large numbers.
The further history is important. Two years ago
this man lc«t a son, aged twenty* three, who, after a
sickness lasting six or seven months, died of pulmonary
tuberculosis. About three months later, the young man's
mother, who had been nursing him, began to sicken. She
was a German, fifty-nine years of age, strong, robust, and
well preserved, weighing upward of two hundred and
twenty- two pounds, and had a good family history.
She gradually failed, and died after an illness lasting
some twenty months, during the last of which she had
frequent hemorrhages from the lungs and intestines, and
almost constant diarrhoea.
This was five months ago. Upon visiting mv patient
at his home, I found that he always expectorated on the
walls, floors, and in the corners of his apartment, the
place of special selection being under his bed. This had
also been the practice of the deceased members of his
family.
The daughter who takes care of the sick man says
that their attention had never been drawn to any danger
from this habit, but that the physician who had attended
ordered a saucerful of black (crude") carbolic acid to be
kept in the room, evidently with tne intention of com-
bating or lessening the evil.
It is, of course, impossible that the emanations from a
saucerful of crude carbolic add would have sufficient
germicidal potency to make any impression upon an at-
mosphere loaded with the germs of latent tuberculods.
There have been two deaths, a third member of the
family is hopelessly sick, and a fourth, a daughter, aged
twenty-two, is worn out and delicate from long and
constant attention to the sick (brother, mother, and
father). She sleeps in the same room with the sick man,
and slept at the side of the mother during her illness,
constantly inhaling the dried products of the expectora-
tion, which were everywhere, and she now is in a fair way
to become phthisical, if she is not so already.
Without entering upon the details of what prophylac-
tic measures should have been employed in these in-
stances, it will be readily seen that, with proper hygienic
precautions and intelligent co-operation of the family in
the first case, the last two, and possibly the third, would
probably not have occurred.
90 Madison Stmet, September 9, 1894.
October 13, 1894]
MEDICAL RECORD.
465
Medical Record:
A Weekly Journal of Medicine and Surgery.
GEORGE F. SHRADY, A.M., M.D., Editor.
Publishers
WM. WOOD & CO., 43, 45, & 47 East Tenth Street.
New York, October 13, 1894.
OLIVER WENDELL HOLMES.
How familiar has been the sound of this name ! How
deep is the regret with which we add in reverential tone
that Doctor Holmes is dead. But is he dead ? Do such
men really die?
He has won the love, the admiration, the respect of
two hemispheres; his influence has extended as far as the
English language is understood ; his teachings have been
a benefit to the whole human race. His loss is not one
to be felt by one community. Boston cannot claim
him, nor Massachusetts, nor North America. He be-
longs to the world. Proud as we are to think of him as
a member of our profession, and proud as we are of his
achievements in it, we realize that his great work in life
had more to do with making people better spiritually
than making them well physically. Physician by edu-
cation, he devoted himself to practice and the acquisi-
tion and imparting of scientific knowledge. Poet by
nature, he spent his leisure time and declining years in
those writings which have so endeared him wherever
they have been read. Philosopher by thoughtful study
and love of his fellow-man, he made for many life's path
less rugged by kind and philanthropic words, and when
his own long path brought him toward life's foot-hills
he was content and said, " he should sorrow deeply if he
had the idea he was to become helpless in body and
mind" This was spared him. He reached the end,
"eighty-five years young," as he has expressed it, and
happily met death as a little child meets sleep, uncon-
scious of fatigue, and only mindful of a day more full of
pleasures than of pain.
To his students of twenty or thirty years ago, as they
recall the words of the genial Professor in describing,' the
arch of the female pelvis, " Gentlemen ! this is the tri-
umphal arch under which every candidate for immortal-
ity has to pass," the thought must occur how nearly has
been attained that immortality of which he spoke, and
how like a triumphal march the whole modest life !
Almost the last leaf upon the tree (for nearly all his
contemporaries had fallen from the bough which bore
the date of his birth and college graduation), he still
dung to it with a vitality which indeed elicited a smile,
bat one wholly of admiration, and carrying with it a
"God bless you I"
The ever-speaking presence in his charming books,
the genial infusion therein of his cheerful spirit, the
lofty tone of his pathos, the sound philosophy of his
humanity, the soul-touching sweetness of his poetry, the
subtle humor of his generous and loving nature, will keep
him always with us through the never-ending flight -of
future days.
THE PERCENTAGE OF IRREGULAR PRAC-
TITIONERS IN THE UNITED STATES.
According to Polk's Register, Toledo, with a population
of 100,000 in 1890, had 209 physicians in 1892, of
whom 70.3 per cent, were regulars. In Cincinnati, a
city with a population of 296,908, there are 596 physi-
cians, of whom 70.6 per cent, are regulars. In Cleve-
land, with 270,000 inhabitants, there are 545 physicians,
of whom sixty-three per cent, are regulars.
Out of the first hundred names {Medico-Surgical Bul-
letin) taken from a list of physicians in small towns, ar-
ranged alphabetically by post-offices, including Aber-
deen, Ada, Adams Mills, etc., we find sixty-six per cent,
classed as regulars.
The explanation of this lies in the number of cheap
medical colleges. Ohio and Missouri are States which
are offensively prominent in this respect. Thus Ohio
has a population of 3,672,316 and seventeen medical
colleges, while New York, with a population of 51997,853,
has only twelve.
The evil is being slowly corrected, however, and we
have no doubt that in ten years the percentage of edu-
cated physicians will be greatly increased, while at the
same time that of cheap medical colleges will corre-
spondingly decline.
It would be quite unjust also to suppose that two-
thirds of American physicians are irregular practition-
ers and uneducated men. In New York, for example,
the law requires evidences of graduation from a college
of respectable standing, and the percentage of ignorance
is small. The same is true of many other States.
FOOT-BALL AS A MEANS OF PHYSICAL DE-
VELOPMENT.
The advent of the foot-ball season has already given
rise to discussions about the value and dangers of the
game. As to the dangers there is no longer much dis-
pute, and it is stated that the new rules will not make
any appreciable difference. We can only trust that the
record of last fall's mortality will not be repeated.
As to the practical advantages of the game as a means
of physical culture and mental stimulus, there is still
much controversy. What is wanted is, however, not so
many opinions and more facts. Dr. Beyer, in the Ameri-
can Journal of the Medical Sciences, has contributed
somewhat to our actual knowledge of the matter. He
finds that in the Annapolis Academy the foot-ball players
are four per cent, superior in height, twenty- eight per
cent, in weight, twenty- one per cent, in lung capacity,
and forty-nine per cent, in total strength. These were
only average players, many of whom never played in a
big game, and nearly all the measurements represented
the player as he was at the beginning of the training
period. Between the average Yale student and the
average American foot-ball player, the players were
one year and one month older, but they were 2.8
per cent, taller, twenty per cent, heavier, had ten per
cent, more lung capacity, and were forty per cent.
466
MEDICAL RECORD.
[October 13, 1894
stronger than the fifty mercantile grade of Yale students.
Between average American players and Amherst students
the comparison is on rather a different footing, because
here the students are nearly two years older than the
players; but the latter have a superiority of three per
cent, in height, twenty-three per cent, in weight, twenty
per cent, in lung capacity, and thirty- seven per cent, in
total strength.
This all shows simply that the bigger, stronger, and
more active men are selected for foot-ball. As it is just
the opposite class who most need physical education,
it seems as if these figures furnish a very telling argu-
ment against foot ball as a means of securing a good
general athletic training. The strong boys train and
play; the weaker sit around, drink beer, smoke ciga-
rettes, and shout.
Dr. Beyer gives some further statistics which have
a rather academic interest. They show that after two
months work at foot-ball, the player gains four or five
per cent, in weight, about four per cent, in lung capacity,
and fourteen to sixteen per cent, in general strength.
This gain in strength continued for a long time after
training. The lung capacity was not much increased.
As compared with rowing and gymnasium work, Dr.
Beyer shows that foot-ball is inferior as a means of
physical development, as by the first two methods the
physical strength was increased about twenty-eight per
cent
The case for foot-ball is not helped by Dr. Beyer's
investigation.
AN ANTI-CORSET LEAGUE.
Every month brings us news of a new " anti-" society.
We gave notice recently of the formation of an anti-
opiate league ; now the London papers inform us of an
Anti-Corset League, which has been organized at Liver-
pool.
The objects of this association consist in inculcating
true principles of clothing, which neither offend the eye
nor the requirements of health. The use of the corset
will be specially discouraged, but its place will be taken
by an easy and natural form of support, consistent with
the wholesome development of the body and the due
exercise of its functions.
This easy and natural support is not to be the male
arm, as might be supposed by frivolous minds, but is a
pliable, plaited affair, conforming to hygienic principles
and the natural curves of the trunk. There is no article
of apparel which has been so vigorously, and we have no
doubt justly, criticised as the corset ; but it stays just
the same, and we fear it will continue to do so. How-
ever, the Anti-Corset League has our sympathy and
support. The corset is always a source of some danger,
and in a good many cases does positive harm.
Placarding of Apartments Where Contagious Disease
Exists.— At the last meeting of the Board of Health a
recommendation made by Dr. H. M. Biggs was adopted,
providing for the better protection of the public by the
placarding of all apartments where there are contagious
diseases. The warning placards are to be in different
colors : white for diphtheria, red for scarlet fever, and
blue for measles.
fjews ot tfoe fflteetu
Death of Dr. Oertel. — Telegraphic news reports the
death of Dr. Oertel, of the Hygienic Institute of Ham-
burg, from Asiatic cholera contracted while making
investigations of infected water from the Vistula.
Dr. Pliny Earle's Bequest to Leicester, Mass.— The
town of Leicester, Mass., has received six thousand dol-
lars under the will of the late Dr. Pliny Earle, for the
erection of a building for the public library of the town.
Dr. B. Matas has been appointed Professor of Surgery
in Tulane University, New Orleans.
A Forty-five day Fast. — For forty-five days Professor
George Sloane, of Chicago, has lived on morphine and
mineral water. No food has passed his lips. He began
his fast to relieve pain in his stomach.
Li Hung Chang, says his biographer, took a deep inter-
est in medical missionaries, and among his contemplated
reforms was the introduction of Western medicine. " If
these people,1' he said to me one day, " ever come into
the Chinese heart, the physician will open the door."
The Serum of Asses. — Under the title of a " New
Cure for Consumption," a lay contemporary, says the
Medical Press, announces that Dr. Viquerat, of Geneva,
after a long study of tuberculosis, has reached some
extraordinary results by a treatment which consists in the
subcutaneous injection of the serum of asses. Twenty-
seven tuberculous patients of the second and third de-
gree have undergone this treatment ; twenty five of these
cases, it is said, had been given up by their physicians as
lost, but were, it is alleged, entirely cured, the names
and addresses of these lucky twenty- five being authenti-
cated by an authoritative report. On the strength of
this, it is further stated that a philanthropic Genevan has
founded the Viquerat Institute for the treatment of per-
sons whose case is looked upon as hopeless. We fear
that our contemporary is the victim of a joke.
Mushroom Colleges. — It is scarcely known on this side
of the Atlantic (says the Medical Press) how easy a mat-
ter it is to found a mushroom college in the United States.
In speaking upon this question our contemporary the
Lancet Clinic recently observed that, " In Ohio any fm
men can organize and obtain a legal college charter, and
with it in six weeks, or six days, can grant a legal diploma.
Hence, the only protection for the people, and for the
medical profession, is to be found within the medical
profession itself." Our contemporary adds: "What a
farce ! It is difficult to understand how such a deplor-
able state of things is allowed to persist. Why are not
new laws passed, and the medical education of the
country placed upon a proper footing? The public
would be the first to benefit by the change, and the
status of the profession would at once be raised." It is
but fair to add that the conditions in Ohio are except
tional, and that in the great majority of the States gradu-
ates from such institutions are not allowed to practise.
The Medical Society of Virginia will hold its next
annual meeting in Richmond, Tuesday, Wednesday, and
Thursday, October 23, 24, and 25, 1894. The subject
for general discussion, open to any physician registered
in attendance, is appendicitis.
October 13, 1894]
MEDICAL RECORD.
467
The Hew York State Association of Railway Sur-
geons will hold its annual meeting Thursday, November
*5> i&H* &t the New York Academy of Medicine. All
railway surgeons of the United States are invited to
attend.
A State Medical and Surgical Association has been
organized in Jackson, Miss. A membership of one
hundred and twenty names was enrolled. The officers
are : Temporary President, Dr. J. H. Lucas, of Green-*
ville, and Dr. H. H. Hughes, Secretary.
The Tri-State Medical Society of Alabama, Georgia,
and Tennessee. — The sixth annual meeting of the above
Society was held in Atlanta, Ga., on October 9th, 10th,
and nth.
An Excited Practitioner. — A Kentucky doctor writes
to the Louisville Medical Monthly like this : " The hun-
gry and unprincipled learned physician does more harm
than an honest one of less capacity. He tramples upon
your feelings ; he lies to your people ; he makes capital
out of your labor ; he boldly takes possession of a case
when he is accidentally called upon; he introduces a
speculum, and tells your patient she has lacerated cer-
vix, from carelessness of her attendant ; he calls, or
sends wife (who belongs to the same euchre club, or
church), to see how she is getting along. You call him
in consultation, and he drops in socially afterward, just
because he was passing. You can't lance a boil ; you
must send for the surgeon (who treats measles, whooping-
cough, and obstetrical cases). This surgeon is your
friend socially, but takes your cases, and when called in
your place, tells the family how he would have treated
the case if he had seen it in time. A plain case of belly-
ache is now a case of appendicitis, and the regular fam-
ily doctor is * not in it.' All kinds of ovarian troubles
meet with prompt removal at the hands of some so-called
specialist. A family doctor can't set a common fract-
ure, and if he does, on his return call he finds this so-
called surgeon has taken off his dressing, and has dressed
it himself, with the excuse to his friend, the family
M.D., that he had to, as the family asked him. You are
called to a man hurt in a railroad accident, or at a fire,
and spend all night ministering to his sufferings ; next
morning you are called to the telephone, and notified
that the railroad or fire department doctor will take care
of your patient, as he is paid by the company, and you
can take a walk. I have met with all the above abuses
time and again, and I have always kept my temper, re-
membering a physician should be a gentleman. But I
have changed my mind, and this is about what I intend
to do : take the next unprincipled doctor by the neck,
and make him think that old Drs. Kellar, Gilpin, and
Ross are still alive. Yours, etc., F. E. Corrigan, M.D."
Pneumatic Tires for Hospital Ambulances.— The
makers of hospital ambulances have learned something
from the bicycle makers. They are now using the pneu-
matic tires, which save the jarring and jolting.
Gift to Hospitals. — It is announced from Vienna that
Baron Albeit de Rothschild has given half a million
florins ($250,000), to be called the "Bettina Fund," to
the Vienna hospitals. Out of this sum a pavilion is now
being built for women suffering from cancer, on the
grounds of the Empress Elizabeth Hospital, in the west-
ern suburb of Rudolfaheim.
The Mississippi Valley Medical Association meets at
Hot Springs, Ark., on November 18th.
The Southern Surgical and Gynecological Associa-
tion meets in Charleston, S. C, November 13th.
Chicago Medical Colleges Unite An alliance offen-
sive and defensive will probably soon be entered into by
the Northwestern University Medical School, Rush
Medical College, and the College of Physicians and Sur-
geons, whereby there shall be between these institutions
absolute uniformity in respect to entrance regulations,
and also in respect to the methods of recording condi-
tions of admission of each member of the class. The
primary object of such an arrangement is that each
party to the agreement shall promptly inform the other
parties of any candidate for admission to the class, so
that the other parties shall be protected against accept-
ing rejected candidates. A similar agreement is in a
fair way to be consummated between the homoeopathic
medical colleges of the city. — Chicago Medical Recorder.
Hospital for Life-savers. — The Marine Hospital
Bureau has issued a circular carrying into effect the law
extending the benefits of the marine hospitals to the
keepers and crews of life-saving stations. A list of nine-
teen hospitals where they can be treated is given.
The Doctor's Doorman, — The French papers, says the
British Medical Journal, are commenting with a kind of
awe on the fact that a site in the Rue de Vaugirard in
Paris, which was surveyed the other day and valued at
600,000 francs (f 120,000), turned out to be property of
a former hall porter of Ricord's. That sum certainly
represents very pretty pickings, but we have little doubt
that the case could easily be paralleled in this country.
The august functionary who guarded the portals of a
certain court physician used, it is said, to think, like the
Emperor Titus, that he had lost a day when he did
not pocket six or seven sovereigns in "tips ; " another
estimated his revenue from what he playfully called the
"guinea bell " at ^600 a year; a third ran his master
(a celebrated specialist now deceased) as if he were a
show, and had a regular scale of prices for admission,
with reserved seats — on the stairs or in the hall opposite
the great man's door — and other special privileges for
such as cared to pay for them. This sort of thing is still,
we believe, a custom of the effete East.
The Fauna of Dead Bodies. — M. M6gnin, in a work
presented to the Paris Academy of Medicine on the
fauna of dead bodies, indicates the importance of these
entomological studies wjth regard to medical jurispru-
dence. The insects appear in relays according to the
period of putrefaction. The first which appears is the
musca curtonea and callophora. It is present on dead
bodies buried in the most careful manner. The eighth
group, coleoptera, are found in dead bodies which have
been buried four years. The dust that remains after the
decomposition of the body is really the excreta of these
animals.
A French Physician, Dr. Grellety, advises doctors to
marry a pretty woman without vanity, an intelligent
woman who does not make too great a display of what
she knows, and above all an amiable one. If this seems
too much, profound love will make up for many defi-
ciencies.
468
MEDICAL RECORD.
[October 13, 1894
A Busy Doctor. — A Swiss doctor is said to have
counted his steps by a pedometer last year. The total
was 9,760,900, or an average of 26,740 daily. This
makes about fifteen miles a day.
Female Eduoation at Johns Hopkins. — The remarks
of Dr. Osier at the recent dinner of the Harvard Medical
Alumni Association that 33.3 per cent, of the women
medical students at the Johns Hopkins Medical School
has been married at the end of the first session, has been
gravely quoted by the medical press as a failure in co-
education. Dr. Osier very properly asks what will hap-
pen at the end of the fourth year ? The remaining two
women in the class stand a poor show of graduating. —
Maryland Medical Journal.
Gift to a Hospital.— The sons of the late Fredeiick
Billings, of Woodstock, have made the generous gift of
l5,ooo for the endowment of a free bed in the Mary
Hitchcock Memorial Hospital at Hanover. This is in
memory of their honored father.
Wanted Doctors in Stato Hospitals.— The State Civil
Service Commission finds great difficulty in securing
competitors for places on the medical staff in the various
State hospitals. The statutes provide for the appoint-
ment at each hospital of a woman physician at a salary of
$1,200 per annum, with maintenance. There are also
various places on the medical staff of the several hospitals
with salaries ranging from $800 to J 2,000 per annum,
with board. Each hospital also employs an apothecary.
Vacancies occur in these places from time to time, and
but few candidates appear for the examinations. There
is not an eligible list at present from which apotheca-
ries can be appointed, and the commission ordered an
open competitive examination of all applicants to be
held at its offices in the Capitol, Wednesday, Octo-
ber 3d, at 10 a.m. The salary paid in this place is
from thirty dollars to fifty dollars a month, together
with board.
The Placarding of "Animal Extracts " on the public
bulletin boards of the city will awaken the keenest skep-
ticism as to their real utility.
The Chief Subjects for Discussion at the French
Medical Congress to be opened at Lyons on October
25th will be the Etiology of Diabetes, the Clinical Value
of the Chemical Examination of the Gastric Contents,
and Aphasia. The President of the Congress will be M.
Gailleton, Professor in the Medical Faculty of Lyons
and Mayor of the city.
Professor Billroth'* Widow.— The Emperor of Austria
has granted to the widow of the late Professor Billroth a
yearly pension of 2,000 florins. This is to be interpreted
as a mark of special favor, because according to the law
of Austria the pension allowed to widows of professors is
only 600 florins. The distinguished surgeon is under-
stood to have left little or no private fortune.
The Quarters for the Board of Health.— On Septem-
ber 29th the City Health Department moved from its
old quarters in the building on Mott Street, which it
shared with the Police Department for many years, to
the new Criminal Court Building on Centre Street,
adjoining the Tombs prison. In its new location the
Board of Health will have much more ample accommo-
dations than in its former quarters, and the facilities for
the proper discharge of its functions will be greatly
increased. Fourteen rooms have been assigned for its
use on the ground floor of the building, nine on the
second floor, and two on one of the other floors.
Unveiling of the Statue of Dr. J. Marion Sims. — It is
proposed to unveil the bronze statue to Dr. J. Marion
Sims on Saturday, October 20th, at 3 p.m., in Bryant
Park, N. Y. Full details of the ceremonies will be
given in our next issue.
Dr. Augustin H. Ooelet, of this city, has been elected
Associate Fellow of the Philadelphia Obstetrical Soci-
ety.
The Health of the (bar. — Now it is known that the
Czar is suffering from contracted kidney. His disease
is consequently incurable.
Unveiling of the Sims Statue. — On November 20th,
at 3 p.m., it is proposed to unveil the statue of the late
Dr. J. Marion Sims, and formally present it to the city.
It will be placed on the north side of Bryant Square,
where the dark granite pedestal has already been com-
pleted. Addresses will be delivered by his Honor the
Mayor of New York, Dr. Paul F. Mund6, Dr. George F.
Shrady, and others. The profession is cordially invited
to attend.
WILLIAM A. M. WAINWRIGHT, M.D.,
HAKTPOBD, OONN.
William Augustus Muhlenberg Wainwright, ot
Hartford, Conn., the well known and highly esteemed
physician and surgeon, accidentally shot himself while ex-
amining a revolver Sunday, September 23, 1894. The
ball passed through the body, seriously wounding the
liver, mesentery, and small intestine. Conscious to the
last and fully appreciating the nature of his injury, he
placed himself in the hands of his associate surgeons of
the hospital for an operation, which from the first was
hopeless excepting to prolong his life. He died about
4 p.m. the following day, twenty-seven hours after the
accident.
Dr. Wainwright was born in New York City, August
i3> 1844, the youngest child of Bishop Jonathan Mayhew
Wainwright. Graduated from Trinity College, Hart-
ford, in 1864, he received his medical degree from the
College of Physicians and Surgeons, New York, in 1867,
and after two years service in the New York Hospital,
settled in Hartford, where he has continued in prac-
tice.
A member of his city, county, and State medical so-
cieties and the American Medical Association, he was
always ready to assist in advancing the interests of his
profession. He was President of the Hartford County
Medical Association in its centennial year, and delivered,
an address upon its celebration of that event. At the
time of his death he was Visiting Surgeon of the Hart-
ford Hospital, and Medical Visitor of the Retreat for the
Insane.
A handsome man of commanding presence, of scrupu-
lous honesty and strict integrity, he was successful in
social circles, while his keen perceptions, good judg-
ment, and skilful treatment made him a leader in his
profession.
His widow, two daughters, and two sons survive him.
The eldest son, now a senior in Trinity College, purposes
to follow his father in the profession of medicine.
October 13, 1894]
MEDICAL RECORD.
469
THE AMERICAN ELECTRO THERAPEUTIC AS-
SOCIATION.
Fourth Annual Meeting, held in New York, September
2s, 26, and 27, 1894.
First Day, Tuesday, September 25TH.
The meeting was called to order by the President, Dr.
W. J. Herdman, of Ann Arbor, Mich., who stated in
his address that the function of the Association was to
improve and standardize electrical apparatus, to improve
electrical nomenclature, and to assist in fixing a uniform
standard of electrical measurements. By appointing
each year committees, whose duty it was to report on
special scientific questions, it had been possible to ac-
complish a vast deal of systematic work, which must in-
evitably prove in time of great aid and benefit to the
general profession.
Dr. William James Morton, of New York, Chairman
of the Committee on Standard Coils, stated as his opin-
ion that an induction apparatus suitable for the needs of
any physician would comprise, 1, a standard cell; 2, a
primary coil of half an ohm resistance, made of No. 22
wire ; 3, a vibrator of the reed type ; and 4, a second-
ary coil of No. 32 wire, about five hundred metres in
length. Such a coil would give the two effects required
— muscular contraction and sedation.
Dr. A. H. Goelet, of New York, said that an appa-
ratus which would answer the purposes of the neurologist
would not be suitable for the gynecologist on account
of the much lower resistances encountered in the latter
class of work. He therefore believed that to be gener-
ally useful a medical induction apparatus should have a
combination of coils of wire of different lengths and
sizes.
In the discussion which followed, the opinion seemed
to prevail that the most suitable apparatus of this kind
for the physician would be one having two different
coils.
The Committee on Standard Meters presented its re-
port through Dr. Margaret A. Cleaves, of New York.
After describing minutely a careful series of tests which
had been made with a dozen or more milliamp&emeters
made by well known manufacturers, the committee rec-
ommended that for ordinary use the meter should regis-
ter up to one hundred milliamp£res, and should be of
the horizontal type. A double scale was desirable on
the more costly instruments, and all meters should be
re-calibrated once a year. To obtain greater clearness
of the scale it was recommended that the meter should
read only in one direction. The question of the value
to the physician of knowing the energy used, in addition
to the rate of flow, had been considered by the com-
mittee, and the opinion was expressed that, whereas the
wattmeter was a very delicate and expensive instrument,
and the voltmeter and ammeter had their individual
values, it was better to use them in connection, and es-
tablish by an easy mathematical calculation the number
of watts used, or fraction of an electrical horse- power in
a given treatment. This point had been established by
a series of observations made by the chairman of the
committee.
Physios and Current Distribution of the Constant
Current.— Mr. W. J. Jenks, M.A.I.E E., of New York
City, in this paper gave a historical sketch of the meth-
ods of distributing the current employed in the various
systems of electric lighting, and also the probable dis-
tribution of the current when criminals were executed
by electricity. Electricity, he said, was not a source of
energy, but only an intermediary agent, and the chief
point to be considered in its distribution was the one
element of pressure. In conclusion, he offered the sug-
gestion that the varying resistances of the human body
might eventually be nude a means of diagnosis.
Dr. J. H. Kellogg, of Battle Creek, Mich., said that
this thought about turning the varying resistances of the
body to account in diagnosis had also occurred to him a
few years ago, but on attempting to put it in practice he
had found such great variations in the thickness of the
skin in different individuals, and that such a large pro-
portion of the entire body resistance was due to the skin
itself, that he had abandoned the method as impracti-
cable.
The Physiological Effects of the Constant Current. —
Professor A. E. Dolbear, of Tuft's College, Boston,
then read a paper with this title. He said that in a mag-
netic field all the molecules were acted upon by a press-
ure tending to twist them into new positions. Dr.
Frederick Peterson, of New York City, and Professor A.
E. Kennelly, of Philadelphia, had failed in their interest-
ing experiments with magnets to observe any appreciable
effect on the human body, even though the brain were
placed in the field of a very powerful magnet. But these
experiments did not necessarily prove that such magnets
exerted no influence on the human body ; in fact, as the
brain itself was not a sensitive organ, why should we ex-
pect that it would be affected by a powerful magnetic
field ? The reason these experimenters failed to detect
any magnetic effect on the body might have been that
the stress was exerted upon the molecules only. A con-
stant pressure producing no muscular movement could
hardly be expected to produce a sensation. The author's
opinion was that the effect of magnetism was to produce
a diminution of sensitivity, and that theoretically the hu-
man body might be considered to be a mass of atomic
magnets. He would entirely disassociate magnetism and
chemical affinity.
The Therapeutic Uses of the Constant Current in
Gynecology. — Dr. G. Betton Massey, of Philadelphia,
then read a paper on this subject. He believed that the
chief and initial lesion in the majority of uterine and
peri-uterine diseases was a catarrhal condition, and he
found the constant current the best of all remedial
agents for the treatment of catarrhal hyperplasias.
Ultimate Results of Conservative Electrical Treat-
ment in Gynecology — Consecutive Pregnancies. — Dr.
George Apostoli, of Paris, sent a communication with
the above title. The writer stated that the constant cur-
rent was often an effective substitute for the curette, not
only on account of the ease with which the degree and
extent of the action could be controlled, but because of
its microbicidal power. The electrical treatment of
uterine fibroids was purely symptomatic, yet with it
hemorrhage could be controlled in ninety per cent., the
pain relieved in eighty per cent., and the fibroids reduced
in size in seventy per cent, of the cases. Although his
patients came to him at an average age of from thirty-
five to forty-five years, and often with fibroids, a very
considerable proportion had become pregnant subsequent
to the electrical treatment. A detailed account of thirty-
two such cases was appended to the paper.
The Electrotherapeutics of Diseases of the Eye. — Dr.
L. A. W. Alleman, of Brooklyn, N. Y., read a paper
in which he detailed the especially favorable results he
had obtained from the use of the constant current, 1, in
the removal of eyelashes which irritated the eyeball ; 2, in
granular conjunctivitis ; 3, in stricture of the lachrymal
duct ; 4, in keratitis and opacities of the cornea ; and 5,
in retinitis diabetica and retinitis pigmentosa.
Dr. M. A. Cleaves added to this list the report of a
case of optic atrophy treated by the constant current,
with improvement in vision but no changes in the fun-
dus.
Second Day, Wednesday, September 26th.
The Action of Electricity on the Sympathetic. — Dr.
A. D. Rockwell, of New York, continued the consid-
eration of the effects obtained from the constant current
by presenting a paper on "The Action of Electricity on
the Sympathetic." The paper dwelt more particularly
47P
MEDICAL RECORD.
[October 13, 1894
on the results of his experience with electricity in the
treatment of exophthalmic goitre and hyperidrosis.
In the course of the discussion Dr. A. Lapthorn
Smith, of Montreal, and Dr. F. B. Bishop, of Washing-
ton, D. C, cited instances in which the patients show
a very strong tendency to syncope during the treatment.
Most of the speakers were agreed as to the decided effi-
cacy of the constant current in the treatment of goitre,
but Dr. J. J. Putnam, of Boston, did not think it so
generally useful in these cases, and expressed the belief
that statistics seemed to show that better results were
obtained, at least so far as giving prolonged relief from
the symptoms, by surgical operation.
Notes on Goitre, and Improvements in the Appara-
tus for its Treatment was read by Dr. Charles H.
Dickson, of Toronto. This communication was supple-
mentary to two or three others on the same subject which
had been presented by the writer at previous meetings.
In the early stages of simple hypertrophy a current of
100 to 150 milliamp£res should be given for ten minutes
at a time, a clay electrode being applied over the goitre,
and a large wire gauze electrode between the shoulders.
When puncture is resorted to, one should not be content
with a current of less than 50 milliamp£res applied for
eight or ten minutes, and care should be taken to ob-
serve antiseptic precautions, and to see that the portion of
the needle outside of the capsule is thoroughly insulated.
In his experience, the pure cystic goitres had proved to
be the most amenable to treatment. His method was to
aspirate the contents of the cyst, inject a hot solution of
chloride of sodium (one drachm to the ounce), apply
through the trocar a current of from 50 to 100 milliam-
p£res for ten minutes, and then withdraw the salt solu-
tion. It should be remembered that puncture alone
involves some risk, and that change of residence and
attention to hygiene are important adjuncts to all forms
of treatment.
Dr. Robert Newman, of New York, referred to a
method of treatment which was employed by Dr. Wat-
kins, of New York City, with good results. A needle
was connected with each pole of the battery, and cur-
rents of only from one-fourth to one-half a milliampdre
were found to answer.
Dr. Rockwell objected to the strong currents advised
by Dr. Dickson.
Dr. Morton said the object of using these strong cur-
rents was to secure adhesion of the cyst walls, but the
same object could be attained with a current of only 5
or 10 milliamplres by calling to our aid metallic elec-
trolysis.
metallic Electrolysis. — This was the subject of a brief
communication from M. Gautier, of Paris, and also of a
paper by Dr. William James Morton, of New York.
The latter detailed some experiments regarding the dif-
fusion into the tissues of the metal dissolved from the
electrode. He had found that the apple-green color of
the tissues after cupric electrolysis was due to an inter-
stitial deposit of an amorphous insoluble salt of copper,
and that there was also a soluble salt of copper deposited
in the tissues. His experiments had also shown that sol-
uble electrodes might be used with the negative pole, one
of the best metals for such a purpose being aluminum.
Among the clinical adaptations of metallic electrolysis
might be mentioned its prompt and curative action in
trachoma.
Dr. Goelet also made some remarks on the clinical
uses of metallic electrolysis, particularly as to the great
value of zinc electrolysis in uterine disease. The good
effect of the treatment as regards arrest of hemorrhage
may not be apparent for some time.
Dr. Holford Walker, of Toronto, emphasized its
delayed action in arresting hemorrhage by citing a well-
chosen illustrative case.
Dr. O. S. Phelps, of New York, reported a case of
long-standing and obstinate mucous cyst of the tongue
which he had quickly and permanently cured by cupric
electrolysis. He also exhibited some elliptoid electrodes
which he had had made of hard rubber covered with cop-
per, thus diminishing their weight, and rendering them
more susceptible of delicate manipulation.
The President said that his experience with metallic
electrolysis had been in the treatment of inflammations
of the mucous membranes, and he thought that its power
of reaching into the innermost recesses of the tissues
made it particularly valuable in the treatment of gonor-
rhoea.
Dr. William James Morton, Chairman of the Com-
mittee on Standard Electro-static or Influence Machines,
reported that the committee recommended that the
smallest machines of this class intended for medical work
should have at least six revolving disks twenty eight
inches in diameter, instead of four disks, as recommended
last year. It was considered necessary that the machine
should have an enclosing case, and highly desirable that
there should be a small separate exciting machine within
the case, and also an arrangement for producing the
static induced current.
Dr. Lucy Hall-Brown, of Brooklyn, N. Y., then ex-
hibited a stand and universal electrode which she had
devised, and which greatly facilitated the giving of static
electricity.
Dr. M. A. Cleaves exhibited a form of water rheostat
which she had had constructed for the purpose of con-
trolling the static induced current at a distance from the
machine.
A Report to Dato of the Treatment of Urethral
Stricture by the Constant Current was read by Dr.
Robert Newman. The report stated that his further ex-
perience had only served to confirm his former state-
ments and observations. In some instances the patients
had been kept under observation for eleven years. In
proof of his claim he submitted statistics and documen-
tary evidence from practitioners in various parts of the
country.
The paper was discussed by Dr. Beaver, of Reading ;
Dr. Frank Ross, of Elmira ; Dr. F. B. Bishop, of
Washington, D. G; and Dr. Wallace, of Boston, all
of whom spoke highly of this treatment from their per-
sonal experience. Several of the speakers contended
that equally good, if not better, results were obtained
from the use of the ordinary urethral sound as from the
bulbous-tipped instrument recommended and used by
Dr. Newman. The latter, however, stoutly contested
this point, asserting that his instrument allowed of greater
delicacy of manipulation, and a more perfect localiza-
tion of the current at the seat of stricture.
The Behavior of Oaneer under Mild Galvanic Cur-
rents.— Dr. R. J. Nunn, of Savannah, reported the case
of a lady, aged sixty, in whom he had succeeded in
greatly reducing the size of the carcinoma of one breast
by mild percutaneous applications of the current. She
then drifted away into the hands of some faith curers.
At the time she left him the tumor measured two by two
and a half inches, but on her return to him five months
later it measured fully thirteen inches in circumference,
and there were secondary deposits in the other breast,
and in the pelvic and abdominal viscera. The treat-
ment was resumed, and with benefit, but she eventually
died of the disease. His special object in reporting the
case was to show the effect of such mild currents in
a case in which the diagnosis of cancer was beyond a
doubt.
The President also related his experience in the treat-
ment of tumors by electricity. It tended to show that
some tumors of the breast, either benign or of doubtful
malignancy, might be rapidly dissipated, but that when
the diagnosis of malignancy was beyond dispute there
was nothing in such treatment which could be considered
at all curative.
Hydro electric Methods, Physics and Appliances —
Mr. H. Newman Lawrence, M.I.E.E., of London,
read the paper. After speaking of the importance of
using well made and carefully installed apparatus, he
stated that nothing surpassed the electric douche for
October 13, 1894]
MEDICAL RECORD.
47i
giving the maximum of concentration and localization
of the current with the minimum of pain, and expressed
the belief that it was particularly suitable for the electri-
zation of the internal cavities of the body. The resist-
ances to the current increased greatly as the temperature
of the water decreased. In the dipolar bath only a
small proportion of the current passes through the pa-
tient.
The Hydroelectric Therapeutics of the Constant
Current. — A communication was then read from Dr.
W. S. Hedley, of Brighton, England, on this subject.
He said that the temperature of the bath should be be-
tween 900 and 1040 F., and a faradic current should be
allowed to flow for a few minutes before the patient
leaves the bath. He had obtained his best results with
this treatment in rheumatoid arthritis.
Special Hydro - Electric Appliances. — Dr. M. A.
Cleaves followed with some remarks on this subject.
She described Boudet's excellent method of treating oc-
clusion of the bowel, and exhibited electrodes for mak-
ing such applications to the bladder, rectum, pelvic tis-
sues, ear, and nose. This was the most important
method of employing cataphoresis, and perhaps in no
disease was its good effects so apparent as in the treat-
ment of gonorrhoea by hydro - electric applications.
With her new water electrode, a description of which
appeared very recently in the Medical Record, a
douche could be given, and pelvic exudates thus brought
more effectually under the influence of the current than
by the more usual intra-uterine galvanic treatment. In
conclusion, the author detailed some observations she
had made, which gave not only the number of watts or
electrical horse-power used, but also the number of joules.
Third Day, Thursday, September 27TH.
The Effects of High Frequenoy Discharges.— Pro-
fessor Elihu Thomson, M.A.I.E.E., of Lynn, Mass.,
sent a communication on this subject, in which he stated
that if a person were subjected to a current of over ten
thousand alternations per second, and a voltage of one
hundred or two hundred thousand, comparatively little
sensation would be experienced, although the heating
effect might be sufficient to bring a no-volt incandes-
cent lamp to full brilliancy. Its comparative harmless-
ness he had demonstrated to b$ due not to its physical
properties but to physiological peculiarities of the nerves
of the human body.
Some Experiments on Death by the Alternating
Current — Professor Edwin Houston read a paper,
prepared by Professor A. E. Kennelly and himself,
on this subject. The object of the experiments was to
refute the startling assertion made by M. D'Arsonval
that the criminals condemned to death in the electric
chair were not really killed by the electricity, but sub
sequently by the post-mortem examination. Their ex-
periments seemed to show that at least in the case of
dogs, where electrocution was properly carried out, there
was not even a remote possibility of subsequent resusci-
tation, and that death was instantaneous and painless.
The Treatment of Neuritis by the Galvanic Current.
— Dr. Landon Carter Gray, of New York, read a
paper with this title. He advised waiting three or four
weeks if a motor nerve were involved, or if a sensory or
a mixed nerve were affected, until the pain had entirely
subsided, and then experimentally and very carefully
apply a galvanic current of from one quarter to one
milliampere. It was important to use a broad electrode
above and beneath the affected nerve, and to use a reli-
able rheostat and milliamperemeter. The discussion
seemed to show a general unanimity of opinion regard-
ing the recommendations made in the paper.
Sinusoidal Current. — Dr. J. H. Kellogg, in treating
of the " Physiological and Therapeutic Effects of the
Sinusoidal Current," stated that with fourteen thousand
to sixteen thousand alternations per minute he had ob-
served a decided diminution in the sensibility of the
parts to which the current was applied, so much so that
in ten minutes the strength of the current could be
doubled without producing increased sensation. He
considered the faradic current in every way inferior to
the sinusoidal current.
Dr. Morton remarked that in actual practice he had
found this current particularly useful for treating chil-
dren, as it did not hurt or frighten them, which could
not be said of any faradic current, however skilfully ap-
plied.
Dr. Walker was also loud in praise of the sinusoidal
current.
Dr. Goelet thought it was not as distinctly tonic as
the faradic, or so generally useful.
Dr. Hall Brown described a method which she had
devised for controlling and regulating the sinusoidal
current as obtained from certain electric lighting cir-
cuits. Almost any induction coil would make a suitable
transformer for this purpose, but such an apparatus was
preferably constructed of one layer of No. 20 wire for
the inside coil and ten layers of the same wire for the
outside coil.
The following papers were also read, but they were of
such a nature as not to admit of being presented in ab-
stract: "Some Landmarks in Electro- therapeutics,"
by Dr. O. S. Phelps, of New York ; " Some Therapeu-
tics of the Incandescent Electric Light," by Dr. J. H.
Kellogg, of Battle Creek; "On Constant Current Gen-
erators and Controllers/ ' by Dr. W. J. Herdman, of Ann
Arbor; "General Faradization,* ' by Dr. A. D. Rock-
well, of New York ; "Electric Light as a Therapeutic
and Diagnostic Agent," by Dr. Margaret A. Cleaves, of
New York; "Physics of the Sinusoidal Current," by
Professor A. E. Kennelly, of Philadelphia; " Physics of
the Static and Static Induced Current," by Professor
Edwin Houston, of Philadelphia; "The Transforma-
tion, Measurement, and Therapeutic Applications of
Alternating Currents," by MM. Gautier and Larat, of
Paris ; "The Physiological Effects and Therapeutic Uses
of the Static Induced Current," by Dr. W. J. Morton,
of New York ; " The Electric Reaction of Muscles and
Nerves after Great Exercise in Sport," by Professor J.
Benzonie, of Bordeaux; and "Secondary Peripheral
Neuritis in a Stilt- walker," by Professor J. Benzonie
and his assistant, H. Bordier, of Bordeaux both of the
Faculty oi Medicine of Bordeaux.
Dr. A. Lapthorn Smith, of Montreal, was elected
President, and Dr. Emil Heuel, of New York City, Sec-
retary for the ensuing year.
Ingenious Plea of a Quack.— A man was recently
tried in France for the illegal practice of medicine, the
charge being that he sold Matlei's magnetized water.
He entered the plea that he employed a remedy which
physicians had declared to be nothing but water and en-
tirely innocent of therapeutic effect, and that he could
not therefore be accused of practising medicine in the
ordinary acceptance of the term. The learned Tribunal
admitted the force of the prisoner's plea, and set him at
liberty.
The Dumber of Marriages in England is on the in-
crease, the first quarter of 1894 showing the highest rate
of any like period, with but one exception, since 1883.
In the first three months of this year there were 93,366
weddings, corresponding to an annual rate of 12.9 per
1,000 of the estimated population. This is not less than
18.3 per cent above that in the first quarter of 1893,
which was 10.9, and the lowest on record. It exceeds
the mean rate in the corresponding quarters of the ten
years 1884-93 by 9.3 per cent, and is the highest in the
first quarter of any year since 1883, except that of 1891,
when it was 13.7. The Registrar- General points out
that this is the more remarkable, inasmuch as in the last
quarter of 1893 the marriage rate had been 6.9 per cent,
below the average rate in the December quarter of the
previous ten years.
472
MEDICAL RECORD.
[October 13, 1894
AMERICAN PUBLIC HEALTH ASSOCIATION.
Proceedings of the Twenty second Annual Meetings he la
in Montreal, September 25, 26, 27, and 28, 1894.
First Day, Tuesday, September 25TH — Morning Ses-
sion.
The President, Dr. E. P. Lachapelle, of Mon-
treal, in the Chair.
The Association met in the Hall of the Y. M. C. A.,
and was called to order at 10 a.m. by the President.
Dr. Robert Craik, of Montreal, reported on behalf
of the Local Committee of Arrangements a very attrac-
tive programme. He also announced the social features
of the meeting. The Committee had arranged for trips
over the Lachine Rapids and down the St. Lawrence to
Grosse Isle.
The reading of papers was next proceeded with.
Hygienic Notes made on a Journey through Italy in
1894. — Dr. H. F. Nuttall, of Baltimore, contributed a
paper on this subject, which was read by Dr. A. L.
Gihon, in the absence of the author. This paper de-
scribed the sanitary conditions, particularly in reference
to water-supply and sewage, of Rome, Naples, Venice,
and other Italian cities. In Naples poverty and igno-
rance provided an easy prey to every epidemic until
1884. But after the cholera epidemic of 1884 the
Government resolved to spend one million francs for
sanitation. New sources of water-supply were secured,
new sewers built, and whole blocks of tenements were
torn down and replaced by modern houses. The result
has been to impart habits of cleanliness to the people
and to greatly reduce the death rate.
The Cart before the Horse, by Dr. Benjamin Lee,
of Philadelphia. The object of the paper may be briefly
embodied in the two following propositions : 1. Copious
water supplies, with the aid of what is known as modern
plumbing, constitute a means of distributing fecal pollu-
tion over immense areas through the soil, through sub-
terranean water courses, and in surface streams, and
cannot therefore be regarded with unmixed approbation
by the sanitarian. 2. The question of drainage and
sewerage, whether for individual residences or for com-
munities, should always precede that of water supply ;
and no water-closet should ever be allowed to be con-
structed until provision has been made for the disposition
of its effluent in such a manner that it shall not constitute
a nuisance prejudicial to the public health.
Observations upon Sedimentation in Water. — Dr.
Wyatt Johnston, of Montreal, read a paper with this
title. The amount of settling which takes place in what
is called the settling basin of the Montreal Water- works
is too small to be seriously considered. The capacity
of the basin being only twenty- three million gallons and
the daily consumption about eighteen millions, the water
really only passes in and out of the basin. In the reser-
voir the change in the water is also very rapid, although
not to the same degree, for similar causes. However,
analysis proves that bacteria are far less numerous in the
reservoir water than in the settling basin. The melting
of snow in the spring has a tendency to increase the
number of bacteria in the reservoir water. As to the
value of sedimentation from a hygienic point of view, it
is much below that of a sand-filter.
The Long Island Water-basin, Brooklyn's Reservoir,
by Dr. A. N. Bell, of Brooklyn. After a lucid de-
scription of the basin, the author said that while the
waste of streams is enormous, it is nevertheless easy to
appreciate, from a knowledge of the conditions of the
soil and the wells sunk in it, the inexhaustible adequacy
of the Long Island water-basin to supply water sufficient
to meet the demands of Brooklyn for all time.
The Water of our Farm Homesteads.— Dr. Frank
T. Shutt, of Ottawa, Canada, contributed a paper on
this subject. During the past six years the chemical de-
partment of the Dominion experimental farms has exam-
ined some hundreds of samples of water from wells on
Canadian forms, and the fact has been impressed upon
the writer that the evil of polluted water is a lamentably
common one throughout the country districts, both in
the villages and on the farms. The only method the
speaker knew for lessening this evil was by instruction
and advice, by first emphasizing the great danger that
lies in using water polluted with excreta or drainage from
filthy sources, and, second, to teach the people that pure
water is as much a necessity for the farm animals as for
man. Third, farmers must be cautioned against sinking
wells in barnyards, stables, or near the pig-pen or privy.
Sand Filtration of Water, with Especial Reference
to Recent Results Obtained at Lawrence. — Mr. George
W. Fuller, of Lawrence, Mass., followed with a paper
with this title. While the removal of pathogenic bacteria
by chemicals, including coagulants and by heat, will
forever be directly dependent upon human attention, he
ventured to predict that the day will come when a knowl-
edge of filtration among sanitary scientists will be such
that filters may be constructed and operated by which
water free from objectionable bacteria will be supplied to
hundreds and thousands of citizens and require the at-
tention of only a mere handful of men. During the fat
years preceding the use of the filter at Lawrence, the
average annual death rate from typhoid fever in Lawrence
was 1.27 per 1,000 inhabitants. The population of Law-
rence is 50,000, and this average is equivalent to 63
actual deaths per year. During the past year there have
been 26 deaths from typhoid fever, a reduction of sixty
per cent. Furthermore, it has been learned that of the
26 who died 12 were operatives in the mills, each of
whom was known to have drunk unfiltered and polluted
canal water, which is used in the factories at the sinks
for washing. In conclusion, it has been found practi-
cable to protect the consumers of infected water-supply by
means of sand filtration.
Borne Deductions from Bacteriological Work on
the Water of Lake Ontario. — This paper was by
Mr. E. B. Shuttleworth, of Toronto. It dealt with
the normal bacteriological character of Lake water and
the depth of water as affecting the number of bacteria,
and the author is inclined to think that the number of
bacteria is directly influenced by season. He is con-
vinced that in their nature certain micro-organisms mul-
tiply most rapidly at certain seasons of the year. He
threw out the suggestion that this may have an important
bearing in explaining the prevalence of typhoid fever at
certain times during the year. This seasonal peculiarity
is very well marked in Toronto, when every September
shows a sudden increase in the typhoid rate, with a cor-
responding decline after October. Since May last he
had been paying attention to the temperature of tap-
water, which seems to be related to the development of
this disease. He hoped in the future to throw some
light on this subject, as the experiments of numerous in-
vestigators had shown that it is possible for micro organ-
isms to exist and multiply enormously in distilled water,
or, at all events, containing only the minutest traces of
organic matter.
Afternoon Session.
The Pollution of Water-supplies. — Dr. Charles
Smart, of Washington, D.C., Chairman, read the report
of the Committee on the Pollution of Water-supplies.
The report reviews at length the influence which a pol-
luted water-supply may have had in the recent cholera
epidemic in Europe, and upon the spread of typhoid
fever on both continents. The efforts to purify water
by sand filtration were also reviewed, wherever made,
and the report concludes : " From this brief review of
facts and opinions concerning filtration, it will be seen
that your committee hesitates to reaffirm its former
positive language with regard to the sufficiency of filtra-
tion as protection against typhoid fever. Nor, on the
other hand, do we regard the testimony as authorizing
a formal declaration of opinion in favor of the efficiency
October 13, 1894]
MEDICAL RECORD.
473
of filtration. Oar experience in this country is extreme-
ly limited, but it is hoped that the success achieved at
Lawrence will lead to the filtration of other surface
waters, each of which will probably teach an important
lesson in connection with bacteriological experiments
and with the mortality from typhoid fever before and
after the construction of the filter beds. In view of an
unbroken record of typhoid fever in communities that
use raw river- water, and an equally unbroken record of
lessened typhoid rates following the filtration of such
river supplies, your committee considers that in Washing-
ton, D.C., special attention should have been given to
the improvement of the general supply. This country
needs some practical lessons in methods of water purifi-
cation."
At the conclusion of the report Dr. Gardner, of
London, Ontario, offered the following resolution :
Resolved, That in view of the danger to the public
health by the sewage contamination of our fresh- water
lakes, rivers, and streams, this Association memorialize
the different Federal Governments, as well as the State
and Provincial Governments, to pass laws prohibiting
the contamination of these water-supplies by sewage
from cities, towns, and villages, and compel them to
provide some means for the treatment and oxidation of
this sewage before emptying it into these places.
The resolution was referred to the Executive Com-
mittee and subsequently adopted by the Association.
Management of Diphtheria Epidemics in Sural Dis-
tricts, by Dr. Charles A. Hodgetts, of Toronto. The
medical officer must exercise a personal supervision not only
over his patients but personally superintend the carrying
out of all orders, for upon the thoroughness of the work
depends to a very large extent the prevention of further
outbreaks in the district. He felt the inhabitants of the
rural districts should receive more attention from the
sanitary authorities than they had heretofore, and some
inexpensive system should be adopted for the more effi-
cient and prompt management of epidemics in those
portions of our country. Schools should be closed in
the district until such time as the inspector has satisfied
himself in the manner indicated that the household of
the individual scholars thereof are free from diph-
theria.
Practical Difficulties of Medical Health Officers and
Physicians in Dealing with Suspected Cases of Diph-
theria was the title of a paper read by Dr. Peter H.
Bryce, of Toronto. With every advance in our knowl-
edge we find that the practical benefits are often limited
by unforeseen difficulties, and that bacteriological results
bring into prominence the difficulties which the health
officer finds in dealing with cases of sore throat, and
which may be summed up as follows : 1. That according
to recent investigations made, at least twenty-five per
cent, of diphtheria cases are not caused by the Loeffler
bacillus. 2. That physicians endeavor to hide cases in
the supposed interest of the client, and conveniently
shield themselves behind the assertion that they could
not tell whether the disease was diphtheria or not. The
author drew special attention to the difficulty of differen-
tiating between cases of ordinary sore throat and real
diphtheria. It was impossible often to decide that cases
were really diphtheria without microscopic examina-
tion.
Dr. J. Ed. Laberge, of Montreal, read a paper in
French, entitled "Vaccination as a Preventive of Con-
tagious Diseases/' The paper was historical, it being
largely a review of Pasteur's experiments.
Innocuous Transportation of the Dead. — This paper
was read by Dr. J. D. Griffith, of Kansas City, Mo.
The author said that the age demands a far greater pro-
tection to the public health. He was convinced that we
owe to the travelling public that greater precautions
should be taken in the transportation of the dead body.
Heated as evidence of the virulence of a dead body that
in a Normandy village, twenty-three years after an epi-
demic of diphtheria, some of the bodies of those who died
of the disease were exhumed and an epidemic at once broke
out, first among those who opened the grave, and then
spread from those to many others. Other examples were
cited. Until the public are educated to the point of
the thorough sanitation of cremation, the transportation of
dead bodies by the railways is, and always will be, a source
of very great danger. The speaker urged that the atten-
tion of the different legislative bodies of the country be
directed by the Association to a subject of such vital impor-
tance. He urged, furthermore, that all railways cut cff
a small portion of their baggage cars for the transporta-
tion of dead bodies. The dead body should be placed
in a box lined with zinc, with a door very much after the
fashion of a large ice chest. This done, the lives of em-
ployees would not be endangered ; no broken or open
box could become infected, and no odor could escape
from the car.
Evening Session.
At this session addresses of welcome were delivered by
Dr. Robert Craik, the Lieutenant-Governor of the Prov-
ince of Quebec (Hon. J. A. Chapleau), the Mayor of
Montreal, Hon. L. P. Pelletier, Provincial Secretary,
and Doctor Gregario Mendizabal, of Mexico, after which
the President of the Association delivered his annual ad-
dress.
The President's Address. — He said the American Pub-
lic Health Association, since its foundation, now twenty,
two years ago, has never ceased to labor for the advance
ment of sanitary science ; for the promotion of measures
and organizations that should effect the practical accom-
plishment of the laws and principles of public hygiene.
It has thus realized the brightest hopes and most enthu-
siastic provisions of its worthy founders, and has ex-
tended its benefits and influence- over the whole ot
North America. To day it embraces the three gieat
countries that form this vast continent — the United
States of America, the Republic of Mexico, and the Do-
minion of Canada — all three working together in broth-
erly emulation, recognizing no political boundaries, and
striving to attain one unique and humane object — the
dissemination of all of the knowledge of public hygiene
and the development of respect for its decrees. Every
year the Association changes its place of meeting, and
this for good reasons. The spirit of its founders being
to establish a body for the diffusion and popularization
of public sanitary science, this object could not be better
attained than by extending to its greatest limits the in-
fluence of the Association; and for this purpose no
surer means could be found than the bringing together
of its distinguished members.
President Lachapelle in closing urged the creation by
the Government of a new department in their cabinets
—that of Public Health.
Second Day, Wednesday, September 26th — Morn-
ing Session.
The Executive Committee recommended, which was
endorsed by the Association, a new committee, to consist
of five persons, entitled " Steamship and Steamboat San-
itation."
Dr. E. Gauvreau, of Ste. Foye, Quebec, described in
a paper the process followed in his institution — the Vac-
cine Institute of Ste. Foye — for the culture and collec-
tion of vaccine lymph, showing that every care is taken
to insure absolute safety to the public using the points.
Restriction and Prevention of Tuberculosis, by Dr.
N. E. Wordin, of Bridgeport, Conn. He showed that
consumption was an infectious or communicable disease
and that the principal source of danger of its spreading
lay in the sputum ejected by a phthisical patient when it
had become dry. The breath of a consumptive contained
no bacilli, and was not infectious. If the spread of this
disease was to be prevented the sputum must be attacked.
Phthisis might be communicated by osculation, and
474
MEDICAL RECORD.
[October 13, 1894
among the hygienic commandments should be one for
the syphilitic and the consumptive, " Thou shalt not
kis." He considered that the most practical and the
quickest way of restricting the spread of tuberculosis
would be to put it on the list of infectious or communi-
cable diseases to be reported to the health officers.
Examination of the Milk-supply for Tuberculosis
in the State of Hew York, by Dr. F. O. Donahue,
of New York City. — He said that in May, 1892, New
York State took a step forward in authorizing its Board
of Health to make investigations in reference to the ex-
istence of tuberculosis in cattle. The relation of the
milk-supply to infant mortality from tuberculosis was in-
sisted upon by all health officers who had made it the
subject of systematic observation. That milk and its
product will convey tuberculosis had been proven.
When it is considered that milk is the principal aliment
during childhood, and enters largely into the diet of all
classes, it was a highly important question for consider-
ation. Statistics of New York State show that for a
period of eight years last past, every eighth death was
caused by tuberculosis. The State Board of Health
evolved the lesson that tuberculosis existed in the dairy
cattle to quite an extent, and that special legislation
was necessary to deal with it It is confidently expected
that future legislation in this regard will be enacted
carrying with it an appropriation commensurate with
the magnitude of the work.
Should, the Marriage of Consumptives be Discour-
aged ? — Dr. Paul Paquin, of Missouri, followed with a
paper on this subject. He held that the marriage of a
consumptive with a healthy person must lead to the infec-
tion of the latter, and that the children born of con-
sumptives are always naturally predisposed to tuberculo-
sis. Thus the centres of infection are increased and the
danger to society is made much greater. No consump-
tive should marry, and it is perfectly proper for science
to interfere and use all its influence to prevent such
marriages.
The Climatic Segregation of Consumptives. — Dr.
Henry Sewall, of Denver, read a paper on this sub-
ject He proposed the following plan for the treatment
of consumption in its early stages, viz., he would estab-
lish at favorable points in Colorado a series of cottage
sanatoria. The cottage plan was eminently the best in
its adaptation to the character of the climate, the people,
and the disease. The efficiency and feasibility of such
an institution had already been established in the Adi-
rondack Cottage Sanatorium of New York, which might
well serve as a model for extensive development. These
santoria should be located with careful regard to clima-
tological conditions, purity of water supply, beauty of
scenery, and accessibility to railways.
Dr. John T. Nagle, of New York City, in some re-
marks upon diphtheria, said that the Health Department
of New York City had been making strenuous efforts to
stamp out diphtheria, and with this end it has instructed
the bacteriological division to examine gratuitously the
cultures furnished it by physicians who attend sus-
pected cases of diphtheria. He said that Dr. Cyrus
Edson has great faith in the antitoxine treatment of
diphtheria, and it promises to be one of the most im-
portant discoveries of modern medicine, and, so far as
could be judged from the data at hand, will afford us a
means of not only protecting persons from diphtheria
who have been exposed to the disease, but also a certain
means for the cure of the disease when cases are sub-
jected to this treatment in the early stages. One of the
most important and significant features of the treatment
depends upon the absolutely innocuous character of the
remedy, it having apparently no influence, either favor-
able or unfavorable, in health or disease, excepting as to
its power of neutralizing the poison of diphtheria.
The afternoon was devoted to pleasure, the members
of the Association, many of whom were accompanied by
their wives and daughters, taking in the trip which had
been arranged down the Lachine Rapids.
Evening Session.
Dr. F. Montizambert, General Superintendent of the
Canadian Quarantine, gave an interesting sketch, illus-
trated by lantern slides, of the quarantine appliances at
Grosse Isle. He briefly explained the mode of boarding
ocean ships, the examination, disinfection, and hospital
treatment.
Some Points in the Hygiene of the Young in Schools.
— This paper was read by Dr. J. C. Cameron, of Mon-
treal. He pointed out that mind and body were de-
pendent upon each other, and consequently for the proper
development of the individual the body was to be con-
sidered and cared for as well as the mind. He referred
to the fact that the physical culture of school children
was in too many cases improperly cared for, though in
the case of boys, who engaged in out-door sports, the
effects were not so marked as in girls, who indulged less
in out door sports and were inclined to be more seden-
tary. Spinal curvature and pelvic deformity were liable
to result from assuming an improper attitude when sitting,
standing, or walking, and consequently it was of the ut-
most importance that school children should be taught to
sit, stand, and walk properly.
Sanitation in Plumbing. — By Mr. John Mitchell,
President of the National Association of Master Plumbers,
New York. The speaker advocated a semi-annual in-
spection of all houses for sanitary measures. The rule
that at present appears to be observed, he said, is to wait
for crape on the door before asking a question regarding
the sanitary arrangements.
Influence of Inebriety on Publio Health. — This paper
was read by Dr. T. D. Crothers, of Hartford, Conn.
The facts he wished to make prominent were :
1. The influence of inebriety on public health is of far
greater magnitude and more closely associated with the
various sanitary problems of the day than is realized at
present.
2. Our present conception of the extent, nature, and
character of inebriety is erroneous and based on theories
that are wrong. Our methods of dealing with inebriates
are most disastrous and fatal in not only destroying the
victim, but perpetuating the evil we seek to lessen.
3. These cases must be recognized as diseased, and be
housed in farm colonies, under military care and treat-
ment. They must be organized, employed, and placed
under hygienic surroundings and made self support-
ing.
4. The present duty is careful medical study of these
classes and full recognition of their needs and require-
ments. Public sentiment should be built up to sustain
rational means and measures in their treatment.
5. The sanitary problems that confront our civilization
are very closely associated with the inebriate class. One
of the central sources of peril to public health is inebriety.
This is the one fountain-head that must be corrected to
break up some of the evils of the present day.
Third Day, Thursday, September 27TH — Morning
Session.
A Journal of the American Publio Health Associa-
tion.— Secretary Watson read a short paper with this
title. He urged establishing a quarterly journal in
connection with the Association, to replace the annual
volume of Transactions. He expressed the belief that
the establishment of such a journal would increase the
influence and strength of the Association. The matter
was referred to the Advisory Council.
Vaccine and Vaccination. — Dr Ralph Walsh, of
Washington, D. C, read the paper. He summarized as
follows : So-called cow pox is simply modified variola.
The admixture of glycerine with vaccine lymph will de-
stroy all extraneous bacteria without injury to its peculiar
active principles. The admixture of glycerine with
vaccine lymph not only does this, but prolongs the ac-
tivity of the lymph. The selection of lymph and the
simple but important operation of vaccination had not
October 13, 1894]
MEDICAL RECORD.
475
received from the profession the attention they deserved.
The physician should see that each infant brought under
his care is successfully vaccinated during the first year of
its life, and again at sixteen, or better, to the point of
saturation during infancy. The accumulation of un-
vaccinated material, and consequently the increased
danger of outbreaks of small- pox, are caused by the
general practitioner failing to perform his duty at the
proper time.
Car Sanitation.— Dr. G. P. Conn, of Concord, N. H.
read the Report of the Committee on Car Sanita-
tion, of which he is chairman. The report maintained
that the railway companies are very negligent in this
respect The railway car is virtually and for the time
being a house on wheels, in which a varying number of
people are expected to make their homes for a longer or
shorter period, according to the distance which they may
be expected to travel. Therefore, like a house, it should
be constructed upon sanitary principles, in which venti-
lation, heating, and such conditions as will allow it to be
kept dean are paramount factors in every case. Unless
these sanitary principles can be carried out and made
permanent, then this house on wheels becomes unwhole-
some and unhealthy, and the conditions become favor-
able to disease, or of spreading it should a contagious
or infectious malady find a place within its walls.
According to investigations it had been found that
the atmosphere of the ordinary coach contained from
one to six times as much carbonic acid gas as public
assembly rooms, such as churches, theatres, and public
halls.
Prevention of the Spread of Yellow Fever. — Dr.
Feux Formento, of New Orleans, read the Report of
the International Committee on the Prevention of the
Spread of Yellow Fever. The report maintained that
this plague never originated in Louisiana, but is im-
ported from Cuba, Mexico, and Central and South
America. It recommended attempts to stamp out the
disease in the swamps in those countries, and the adop-
tion of thorough sanitary measures in the Southern
centres, where the disease is wont to become epidemic.
An effort to secure the co operation of the governments
of Cuba, Mexico, Brazil, and the Central American re-
publics was recommended.
Dr. N. £. Worden, of Bridgeport, read a paper on
"Disposal of Garbage," in which he advocated its de-
struction in an incinerator.
The Disposal of Garbage and Refuse.— The Report
of the Committee on the Disposal of Garbage and Refuse
was presented by Mr. Rudolp^l Hering, C.E., of New
York City. It dealt with the character of city refuse,
its collection and removal from a building to the place
of disposal, and the several methods in vogue for its dis-
posal.
Colonel W. F. Morse, of New York, dealt briefly with
the collection and disposal of the refuse and garbage of
large cities, describing what was being done in New
York in order to find out the best method of disposing of
its refuse and garbage.
Influence of the Climate of Canada on Health. —
This was the title of a paper read by Dr. W. H. Hing-
ston, of Montreal He touched briefly on the geographi-
cal situation and the topography of the country, and then
went on to show that after a residence in the country, of
shorter or longer duration, a change in the constitution
could be observed. The high color which flushed the
cheeks of some Europeans faded somewhat, and the skin
became less soft, the hair became darker and more like
the aboriginal type, and the muscles were less promi-
nent The hot weather did not last long enough to pro-
dace any great disturbance of the liver, and the cold was
exhilarating. The ratio of mortality in Canada was lower
than that of Great Britain, and, with the exception of
Malta, this country was the healthiest station of the
British army. Statistics gathered from the States showed
that all constitutions were healthier as they approached
the Great Northern Lakes.
Afternoon Session.
" The Advisability of Teaching Rules and Principle*
of Hygiene in the Primary Schools by Means of Object
Lessons," was the title of a paper read by Dr. Jesus £.
Monjaras, of San Luis Potosi, Mexico.
The Importance of Teaching Hygiene in Elementary
Schools. — Dr. S. Gauthier, of Upton, Quebec, followed
with a paper on this subject The speaker held that it
was through the teaching of hygiene to the school chil-
dren that we could eradicate the unfortunate prejudices
which directly caused the loss of so many who might
have been the strength, glory, and pride of our country.
The Hygiene of Vision in Schools.— Dr. T. D. Reed,
of Montreal, recommended the introduction into schools
of the suggestions of the Anthropometric Committee of
the British Association for the Advancement of Science,
in order to test the power of vision and color-sense. He
also recommended exercises for the development of the
power of rapid and accurate observation.
A Few Remarks on School Hygiene, by Dr. T. M.
Brennan, of Montreal. The points in this paper might
be summarized as follows : The rousing of the general
public to the necessity of propagating the study of hy-
giene ; the hygierfic education of children, whose teach-
ers must be proficient in hygiene. In each school there
should be a school commission endowed with power to
act. There should be some system of efficient general
supervision, and the general co-operative support of local
and general Boards of Health and the Board of Public
Instruction should be assured.
An Epidemic of One Hundred and Twenty Cases of
Paralysis in Children. — Dr. Andrew Macphail, of
Montreal, contributed a paper on this subject. The
paper contained an account of an epidemic of infantile
paralysis which occurred in the State of Vermont during
July, August, and September, and which the speaker in-
vestigated. He first stated that the belief was held that
it was an outbreak of cerebro spinal meningitis, but he
showed in a lucid manner that it was a true myelitis.
He quoted the notes of 91 cases out of the 1 20. In some
children the paralysis came on without any symptoms, in
others there was a preliminary illness of a few days resem-
bling indigestion. He described in detail the fatal cases,
of which there were 18, and 42 in which there was per-
manent paralysis. There were also notes of 6 cases in
adults, 3 of which ended fatally. He then referred to
the origin of the malady, giving full statistics of tempera-
ture, rainfall, and humidity, and geological factors.
There were, besides, 12 deaths from the same cause
among horses, and fowls were likewise affected. In con-
clusion, he dwelt upon the necessity for having in every
State a properly conducted laboratory and a competent
staff to deal with such outbreaks, and a Board of Health
with authority to investigate epidemics and perform au-
topsies. The paper had additional interest from the fact
that it is the first epidemic of the kind reported in
America, and the third which has occurred in any coun-
try. The speaker refrained from expressing any views or
propounding any theories till the pathological work
which he has in hand shall have been completed.
The Advances of Public Health in the City of Mon-
treal was the subject of a paper by Dr. L. Laberge,
Medical Officer of Health for Montreal The author
outlined the development of the several matters con-
nected with the public health of the city and the legis-
lation by which they were governed, such as milk inspec-
tion, meat-supply, ice-supply, drainage, and public baths.
He gave an account of the present state of sanitation in
the city, and concluded by showing that during the last
twenty years the death-rate had been reduced by 12.87
per thousand.
Myopia in its Relation to School Hygiene. — Dr. A.
A. Foucher, of Montreal, presented a chart which illus-
trated that myopia is more prevalent in the secondary
than in the primary schools. In the primary schools of
Russia it is fourteen per cent., while in those of Ger-
476
MEDICAL RECORD.
[October 13, 1894
many, Austria, France, Holland, New Zealand, the
United States, and Switzerland it is thirteen per cent ;
Norway, eleven per cent. ; England, Roumania, and Bel-
gium, thirteen per cent. In the secondary schools in
Austria it is thirty eight per cent. ; Switzerland, thirty-
six per cent. ; Germany, thirty-six per cent. ; France,
thirty-six per cent. ; Russia, thirty six per cent. ; Den-
mark, thirty-six per cent. In Italy it is thirty-eight per
cent. ; Sweden, thirty-four, and in England, thirty-
eight.
Or. G. Mendizabal, of Orizaba, Mex., gave some
" Observations on Yellow Fever in Vera Cruz, and its
Prevention,' ' and he was followed by Dr. }. I. Des-
roches, editor of the Journal d' 'Hygiene Populaire, and
member of the Board of Health of the Province of Que-
bec, who discoursed on hygiene in medical education.
Nomenclature of Diseases and Forms of Statistics.
— The day's session closed with the reading of the re-
port of the Committee on Nomenclature of Diseases
and Forms of Statistics, by Dr. S. W. Abbott, of Bos-
ton, chairman. The committee considered changes in
the nomenclature and classification of diseases and causes
of death ; uniform methods of reporting vital statistics ;
uniform methods of estimating population and death-
rates, and the adoption of a standard fif age distribution.
It is quite plain that a fair comparison cannot be made
of the death - rates of countries, cities, and towns in
which the age distribution is widely different ; hence the
importance of adopting some conventional standard to
which all populations may be referred, or with which
they may be compared.
Fourth Day, Friday, September 28th — Morning
Session.
A Plea for Vaccination.— Dr. M. T. Brennan, of
Montreal, Can., said vaccination should be performed
with all the precautions calculated to insure the action
of the pure lymph, free from all contamination and the
action of it. Each vaccinator should be provided with
— 1, pure lymph of a standard strength, if possible; 2, a
vial of distilled or boiled water to dilute the lymph ; 3,
a vial containing a solution of bichloride of mercury ;
4, a small alcohol lamp to sterilize the lancet, etc. ; 5,
Some sterilized absorbent cotton ; and 6, some steril-
ized gauze. All these take up but a small space, and
may be placed in a small satchel or metallic case. The
operation should be done under strict antiseptic precau-
tions ; all instruments, dressings, hands of the operator,
etc., should be clean.
Infection by the Bacillus Pyocyaneus as a Cause of
Infant Mortality.— Dr. H* Cameron, of Montreal, read
a paper on this subject. It was not until 1889 that this
bacillus was found to produce definite general infection
in young children. The author drew the following con-
clusions: 1. That the infant tissues are susceptible to
the invasion of this bacillus. 2. That the bacillus is dis-
tinctly pathogenic, setting up a disease peculiar to ex-
perimental pyocyanic disease. 3. That this disease is
characterized by a train of very definite symptoms, such
as diarrhoea, fever, rapid emaciation, rigidity of the legs,
and hemorrhagic and bullous eruptions. 4. That the
disease appears to be very fatal.
As this combination of symptoms occurs not infre-
quently in young children, especially when congregated
in nurseries and foundling asylums, the author ventured
to infer that a certain proportion of the deaths which
now appear upon our records of vital statistics under the
headings of gastro enteritis, purpura, or marasmus, were
in reality cases of generalized pyocyanic disease.
As to prophylaxis he had nothing definite to offer at
present beyond a strict observance of the laws of hygiene,
fresh air, suitable nourishment, and cleanliness ; but he is
inclined to consider that this disease is one eminently
suited for a trial of "serum therapeutics." It is a dis-
ease in which, experimentally, immunity can be easily pro •
duced in susceptible animals. This being so, it is proba-
ble that the serum of animals vaccinated against this dis-
ease, or substances obtained from such serum, will be
found, as in the case of diphtheria, to have curative effects.
The closing paper of the Convention was read by Mr.
J. W. Hughes, of Montreal. It was entitled " Evolu-
tionary Developments of Domestic Plumbing during the
Past Twenty- five Years.' '
Several papers were read by title, owing to the absence
of the authors.
The following resolutions were offered by C. O. Probst,
of Columbus, O., referred to the Executive Committee,
and adopted by the Association :
Resolved, That this Association approves the sugges-
tion for a co-operative investigation into the bacteriol-
ogy of water, and commends the efforts of the commit-
tee, in carrying out this work, to the officers of State and
Municipal Boards of Health, to the individual members
of this Association, and to all persons interested in the
purity of water-supplies for such special assistance as they
may be able to render.
By Dr. E. R. Campbell, of Bellows Falls, Vt. :
Resolved, That this Association records its protest
against the use of alcoholic liquor as a beverage, espe-
cially among the young, believing that such use is at-
tended with great danger to the health, the individual,
and society.
The Executive Committee failed to act on this reso-
lution.
By Dr. George Homan, of St. Louis :
IVhereas, It is the sense of this Association that the
pollution of potable waters in America has reached such
a point that the national governments should be asked to
take cognizance of the matter with the view of devising
means of prevention and relief; therefore be it
Resolved, That this Association memorialize the Con-
gress of the United States and ask that they shall author-
ize the appointment of a competent commission, clothed
with power to fully investigate the whole subject of the
pollution of rivers and lakes by municipal and manufact-
uring waste, and provided with sufficient means to en-
able them to conduct the examination in such a manner
as shall be deemed best, the results of said examination
to be published from time to time for the public informa-
tion.
The following officers were elected for the ensuing
year : President, Dr William Bailey, of Louisville, Ky.;
First Vice President, Dr. G. P. Conn, of Concord, N. H.;
Second Vice-President, Dr. G. Mendizabal, of Orizaba,
Mexico ; Secretary, Dr. Irving A. Watson, of Concord,
N. H ; Treasurer, Dr. Henry D. Holton, of Brattleboro',
Vt.
After a resolution of thanks, offered by Dr. A. L. Gihon,
of Washington, D. C, the Association adjourned to meet
in Denver, Col., at a time to be fixed by the Executive
Committee.
Menthol in Itching Affeotions of the Skin.— Dr.
Colombini strongly advocates this drug in cases of ec-
zema of the scrotum, vulva, etc. He uses the following
formulae :
3 . Menthol 5 to 10 parts.
Alcohol 100 parts.
Or,
$ . Menthol 10 parts.
Oil of sweet almonds 10 parts.
Or,
J) . Oxide of zinc .... 25 parts.
Starch powder 25 parts.
Vaseline 50 parts.
Menthol, from 5 to 8 parts.
Or,
9 . Oxide of zinc 10 parts.
Subnitrate of bismuth 10 parts.
Menthol 1 to 30 parts.
Starch powder 1 to 30 parts.
When the application is to mucous surfaces the mixt-
ure should contain a smaller proportion of menthol. —
La France Medicate.
October 13, 1894]
MEDICAL RECORD.
477
(tkrcvesvon&znce.
OUR LONDON LETTER.
(From our Special Correspondent)
DR. THORNE THORNE, CB. — APPRECIATION OF MEDICAL
WORK FOR THE STATE — THE DUKE AND THE ARMY
DOCTORS — CHOLERA — REPORT OF LOCAL GOVERNMENT
BOARD'S MEDICAL DEPARTMENT.
London, September 22, 1894.
Dr. Thorns Thorne, CB , has received from the Queen
an intimation of Her Majesty's appreciation of the ser-
vices rendered by the Medical Department of the Local
Government Board in the measures taken to prevent an
invasion of cholera. It is reported that the Queen has
all along manifested particular interest in the efforts to
prevent an epidemic, and this expression oi appreciation
of the work done will no doubt be gratifying to the
principal medical officers. To the profession it might
have appeared more satisfactory had the opportunity
been taken to give a step in the Order of the Bath.
There is always considerable reluctance to convert a
CB. into a K.C.B., especially in the case of medical
holders of the dignity. Perhaps this also is due to the
absurd jealousy of " military advisers/' a jealousy which
continues to work untold injustice. No one doubts that
the Duke of Cambridge has greatly injured the army
medical officers by his silly jealousy of the non comba-
tants, but he has lately had a lesson on the drift of pub-
lic opinion he would do well to take to heart. He has
been pushed into good things because of his birth, not
because of his knowledge or skill — the Crimea proved
that — and he should have some regard for those who make
their way by skill and knowledge only. If he continues
to persecute non-combatants {e.g. , the case of Dr. Briggs)
the day of reckoning may be nearer than he imagines.
To return to cholera. The disease has in some parts
of Europe been more severe this year than last, and the
danger which has threatened England has been greater,
too, as it has manifested a disposition to spread in differ-
ent directions. In Russia and Galicia it has been more
fatal, and still prevails. The returns from St. Peters-
burg, indeed, indicate that the epidemic is dying out
in that city, but in many of the provinces of Russia it is
unabated, and others are being invaded. The Prussian
frontier has been closed against Russia in all dangerous
directions, but not much is to be anticipated from the
old-fashioned methods in vogue.
What England has done to repel invasion is chroni
ded in the report of Dr. Thorne, which I have pre
viously noticed. In that report it is shown that the
inspection of our ports has been useful in stimulating
the control of vessels arriving from infected ports. In
1892 this method was perfectly successful, save in the
cases of thirty-five persons who landed during the period
of incubation or when the disease had set in. Last year
some cases occurred, as I reported to you at the time, in
persons who passed inland, and we were face to face with
the serious danger of an outbreak in several places at
once. Now that that peril is past it is satisfactory to
know that, besides the ports, these inland districts have
been carefully watched, and, moreover, that inspection
of other places exhibiting sanitary defects is being con-
tinued. The report contains some shocking examples
of neglect and recklessness on the part of some local
sanitary authorities, which deserve severe blame, and it is
certainly to be hoped that the danger incurred will be
brought home to all concerned. Dr. Thorne remarks
that it is no part of his duty in such cases " to appraise
the responsibility attaching respectively to electors or
elected," and he evidently thinks that great blame is
due to one, or probably both. It is, perhaps, a blot on
oar institutions that the densest ignorance does not dis-
qualify an elector, or, for that matter, an elected person,
and the representatives of ignorance are likely to be
reckless administrators in sanitary matters. It is, indeed,
a relief that the inspection of the Local Government
Board is a reality, and that its medical department is pre-
sided over by so capable an officer as Dr. Thorne Thorne.
The system of sanitary supervision he directs may claim
success so far, but no doubt many details require per-
fecting, and it is to be hoped that the suspicious villages,
and towns will continue under observation as well as the
ports which are specially exposed to danger. For we
are not out of the wood even in regard to the present
year, though some papers are already singing pseans at
our escape ; and not merely this year, but always and con-
tinuously, those precautions which have proved effectual
must be maintained. Even those who still hold to quar-
antine have accorded us the approval of our methods,
which its success necessarily extorted.
MUST THE PARSON PAY?
To the Editor of the Medical Record.
Sir : With your permission I would like to ask Minister,,
whose letter appears in your issue of June 9th, a few-
questions.
Is it not a fact that laboring men and clerks who re-
ceive a salary of forty dollars per month (some less), pay
their medical bills without a murmur ?
Is it not also a fact that the vast majority of physicians
do a great amount of work for which they receive not a
penny, in some instances even furnishing the medicine ?•
Who has the harder and more responsible duty to per-
form— the minister who prepares his sermon during the
week to recite on Sunday, and who visits the members of
his flock on pleasant sunshiny days ; or the doctor who
has to answer calls at all hours of the day or night, no
matter how tired and sleepy he may be, no matter how
much snow, ice, or mud he may have to plod through,,
and who, when he reaches the bedside, instead of repeat-
ing a prayer which he has learned by heart, has to call
into play all the resources of his medical knowledge, and
upon whom devolves the responsibility of restoring the
child to its mother, or the father to his family ?
And last of all, what do ministers do to merit medical
attention gratis? Truly I cannot understand it; and
while I would never hesitate to answer a call of charity
at any time, I fully concur with my friend of Durham,
N. C, that when one is able to pay one should pay,,
whether he be minister, lawyer, or laborer.
Yours very truly,
C. H. Carroll.
Pavaris, Fla.
SOME PRACTICAL OBSERVATIONS ON MAL-
ARIA NOT DUE TO DRINKING WELL- OR
SURFACE-WATER.
To tub Editor or the Medical Record.
Sir : The article on malaria, by Dr. W. H. Daly, ot
Pittsburg, Pa., which appeared in the Medical Record*
of September 15th, was especially interesting to me,
living in a malarial district (Twenty fourth Ward, New
York City). According to his observations, malaria is
due almost, if not exclusively, to drinking water con-
taminated by the germs to which the disease is attrib-
uted. That the mist, fog, etc., rising from marshy
ground ; the turning over of earth, incidental to filling
in and raising the grade of roads, are incapable of caus-
ing the disease ; and that no matter what may be the
condition of the soil and drainage, providing we do not
drink water containing the germs, we will not contract
the disease.
While I agree with Dr. Daly that surface-water and
that from contaminated wells are one of the prime factors
in causing the disease, I am compelled to differ with him
as to their being the distinct cause.
If he be correct in his deductions, how can the follow-
ing cases be accounted for ?
Some two or three months ago, for the purpose of
building sewers in my immediate neighborhood, the city
authorities have been filling in and raising the grade of
478
MEDICAL RECORD.
[October 13, 1894
one part of the road with earth obtained by lowering it
at other points. This work had not been going on very
long before I began receiving patients suffering from pro-
nounced chills and fever. During the months of August
and September (to date, the 2 2d inst., an unusually dry
spell), I treated twenty- three cases of chills and fever,
and nine cases with all the symptoms of malarial poison
excepting the chill.
Now, let us see what influence well- or surface water
had with their sickness. Close investigation resulted as
follows : Of the 23 cases where all the symptoms existed,
but 3 had drank water from wells, 2 from cisterns, and
the remaining 18 from the regular supply furnished
through the Croton Water Department pipes. Of the 9
cases where the chills were absent, only 1 case used well-
water, and the balance used Croton.
Furthermore, some of my patients came from families
consisting of from five to eight members, and in the ma-
jority of these cases they were the only members suffering
from the disease, notwithstanding the fact that the entire
family were using the same water-supply, and living, as
far as I could ascertain, under identical circumstances.
Admitting Dr. Daly's water theory, how did the cases
using the Croton water-supply contract the disease?
Admitting for the sake of argument that the Croton
water-supply for this district may have been contaminated
by malarial germs, how is it that the entire neighborhood
is not suffering, as we all use the same water supply ?
As to the drinking of contaminated water being one of
the prime factors, I can offer proof positive in the person
of myself. Some eight years ago, the house in which I
then resided had for its water-supply a cistern and a
well. After using this well-water for drinking purposes
for a f$w months, I suffered from a very severe attack of
chills and fever. Upon investigation I found the well
was receiving the leakage from an out house as well as
the surface drainage. Upon discontinuing its use all
symptoms disappeared.
In conclusion, while admitting the water-supply to be
a pronounced factor in causing malaria, it is not the dis-
tinct or exclusive cause. On the contrary, my observa-
tions point toward the mist, fog, etc., rising from swampy,
marshy ground, stagnant water, decaying of rank vegeta-
tion, and the turning over of great quantities of fresh
earth.
Further data upon this subject would be both interest-
ing and instructive.
Joseph S. Healky, M.D.
Kings Bridge, New York City, September aa, 1894.
IS BATHERS* CRAMP A POPULAR FALLACY?
To thb Editor op thb Medical Rhoobd.
Sir : It was with great interest that I read the article en-
titled " Bathers' Cramp, is it a Popular Fallacy " in the
Medical Record of September ist, and I should like to add
my small contribution to the much that has been already
said upon this subject. I have suffered from cramp not only
in the cold waters north of Cape Cod, but also in the
warmer waters south of it. Now the case quoted does not
seem to me to be one of genuine cramp, for if the attack
is severe it is quite impossible to move the members af-
fected, even in a " dazed or mechanical way. ' ' I have had
cramp at times in one and both legs, and in one or both
ankles. When attacked in one leg it was in warm river
water, and to get ashore was a comparatively easy mat-
ter. When attacked in both legs, it was in the warm
waters of New Bedford Harbor (Mass ) and it was
with great difficulty that I reached shore by swimming
on my back, both legs doubled up under me, and drag-
ging myself up on the beach with my hands.
This attack was very painful, the muscles of the legs
tightly contracted, violent pains in the head, and nausea.
Slight relief was experienced on the instant of dragging
the leg from the water, but the pain ceased only upon
prolonged and vigorous massage. Cessation of local
pain was followed by general debility, exhaustion, se-
vere headaches, muscular fatigue, and slight nausea for
two days.
I am absolutely certain that the liability to cramp is
increased by tight garters worn either above or below the
knee, tight shoes, or other obstructions to natural circu
lation. I have investigated several other cases, have
dragged one person so affected out of the water, and in all
there is a tendency to double up the legs, drop the head
forward and bend the arms (as in the attitude of writing) —
most favorable conditions to a death by drowning. I
believe the tight garter to be the cause of many such
deaths and would most strongly caution all those who
swim or bathe, against it. Hoping that these brief ob-
servations and remedies, which have certainly been effi-
cient in several cases of which I have had the treatment,
may be of interest and assistance to many others.
W. Louis Chapman.
Lynk, Mass-
PERMANGANATE OF POTASSIUM IN OPIUM
POISONING.
TO THE EDITOB OF THB MlDICAL RbCOKA.
Sir : Although it is not a pleasant task to harshly criti-
cise a confrere, yet I do not see how I could refrain from
applying the epithet illogical to the report by Dr.
McGuire of a case of morphine poisoning published in
the Medical Record of September 15, 1894. Accord-
ing to Dr. McGuire's statement, he came near losing his
patient by "relying" on potassium permanganate* A
brief analysis of the doctor's report will show the aston-
ishing unreasonableness of this statement One hour
after the patient had ingested the morphine, Dr. McGuire
began extending to hitn his medical aid. The following
three hours he spent in resorting to the usual methods
in vogue in the treatment of opium poisoning, not omit-
ting of course large doses of sulphate of atropine, and
incidentally giving 3 ss. of the fluid extract of ipecac,
which the doctor naively observes did its work fairly
well in an hour and a half. After the lapse of three
hours, or in other words, four hours after the morphine
had been taken, Dr. Earnest arrived on the champ de
batailU with a one-pound bottle of potassium permanga-
nate, out of which quantity the patient received three or
four grains per os. Twenty minutes later the patient
sank into a deep coma, and it was only with the greatest
difficulty that he could be roused again.
This is the resume of Dr. McGuire's report. The
reader will probably agree with me as to the peculiarity
of the doctor's claim " to have relied upon potassium
permanganate." I wish he had done so, for the timely
and judicious employ of the remarkable salt of perman-
ganic acid would have saved him a great deal of trouble
and anxiety. In the first place, it would be impossible
for anyone reviewing the doctor's report to know
whether the three or four grains of the antidote were
sufficient, even if they had been administered immedi-
ately, as we have no report of the amount of morphine
taken. Second : In my original article on the subject,1
I suggested the immediate use of from ten to fifteen
grains of the antidote well diluted, irrespective of the
quantity of morphine taken ; and by what peculiar ratio-
cination the doctor could have concluded that by admin-
istering three or four grains four hours later he was fol-
lowing my method, I am unable to understand. As an
analogue, if the doctor should prescribe a drachm of any
medicine to be taken at a certain time, and his patient
takes five minims three hours later, would the failure of
the treatment reflect at all upon the doctor's method ?
Now, Dr. McGuire followed my method to the extent
of using the antidote, but as regards time and quantity
he was wofully injudicious. As to the deep coma super-
vening twenty minutes after the administration of Mn,-
KtO„ it is out of the question that the permanganate
could have caused this. I have yet to find any thera-
peutist who would impute narcotic qualities to it. This
coma was only a relapse which, as the doctor is probably
1 Medical Record, February 17, 1894.
October 13, 1894]
MEDICAL RECORD.
479
aware, is not an unusual feature of opium poisoning.
However, it may have been aggravated in this particular
case by the large doses of sulphate of atropine which the
patient bad injected into him.
William Moor, M.D.
355 Boulevard, New York, September a8( 1894.
LEPROSY IN INDIA.
To thb Editor of the Medical Record.
Sir: On p. 699 of the Medical Record for June 2,
1894, in the review of the paper by Dr. White on the
subject of "Leprosy," it is stated that there are in
India two hundred and fifty lepers to day. This is
very far from the truth, as the number given by the cen-
sus of 1 89 1 makes the number 119,044, and this is not
quite complete, as it is rather above this number than
under.
In an asylum alone, not far from here, there are over
two hundred. In the asylum I have charge of there are
one hundred. Besides these two asylums, in the Pun-
jab alone there are over a dozen other asylums and places
where lepers voluntarily have congregated. Some of
these are under government or other control, while others
are simply places which the lepers make a stopping-place,
from which to go out daily, or for a few days at a
time, begging for their support.
I am sending you by tins mail reports of this asylum
for 1892 and 1893.
Yours very truly,
Th. B. Carleton, M.D.,
Superintendent Leper Asylum.
Sabathf, Punjab, North India.
TABLET TRITURATES.
To tub Editor of the Medical Record.
Sot: If space permits, will you allow me to point out a
matter that needs some correction. I think it will be
acknowledged that tablet triturates have come to stay, at
least for many years to come, they are certainly a " con-
venient and elegant " method of medication, but as pre-
pared at present I think they are, at times, far from
being " safe and accurate " as the manufacturers claim.
I have carefully examined samples from several differ-
ent manufacturers in various States and find the same
objection to all, namely that the ingredients are not
triturated but simply mixed. This might do very well
where the medicines are of a harmless nature, although
by no means commendable, but when tablets containing
arsenic, strychnine and the like are so carelessly made
that you can dig out the various combinations with a
sharp-pointed knife under the naked eye, I think it is
time to cry halt. I verily believe that I have seen evil
effects from several such tablets, and if I know of any
better make I should leave all the others alone, but, as I
said before, I find them all alike.
In my humble opinion all mixtures ought to be ground
and triturated so that the finished tablet should
exhibit one uniform color throughout the whole, and
that the individual drugs should not be distinguishable
even under a moderate magnifying glass. Only such
can be safe.
"Country Doctor."
East Eddihgton, Mb., September io, 1894.
A lew Salt in an Ammoniacal Urine. —Cases of per-
sistent and marked alkalinity of the urine, due to long ad-
ministration of much lime-water, will be found on ex-
amination to be instances of ammoniacal urine due to the
presence of a salt of carbamic acid. If, however, the lime-
water is given in large quantities and continuously, it will
lower the total output of ammonia as markedly as do the
carbonates of the fixed alkalies, though then lime-water
causes the appearance of free ammonia, which sodium car-
bonate does not do. — Abel.
Contagious Diseases — Weekly Statement— Report oi
cases and deaths from contagious diseases reported to the
Sanitary Bureau, Health Department, for the week end-
ing October 6, 1894.
Tuberculosis
Typhoid fever
Scarlet fever
Cerebro-spinal meningitis
Measles
Diphtheria
Small-pox
Cases.
Deaths.
129
84
«S
17
«4
4
0
2
18
4
112
21
9
1
The Typhoid Spine. — It is very probable that several
distinct sequelae of typhoid fever have been called "The
Typhoid Spine." Four cases of neurosis following en-
teric fever are described by Dr. William Osier in the fourth
volume of the Johns Hopkins Hospital Reports. In de-
fence of the neurosis theory he states that joint and
periosteal troubles are by no means rare sequences of ty-
phoid fever, but that such symptoms do not usually de-
velop after convalescence has been for some time well es-
tablished, and that the periostitis, which is seen more
frequently about the sternum and ribs, proceeds as a rule
to suppuration. Periosteal swellings may disappear with-
out suppuration, though periosteal thickenings protracted
through weeks and months usually develop abscesses.
Yet it is difficult to conceive of attacks of pain, lasting
for months, due to a simple perispondylitis, which in none
of the four cases passed on to suppuration. Though
neurasthenia may not be the cause of all cases of " The
Typhoid Spine," these four patients gave Dr. Osier that
general impression, and it seems to him as probable that
many of the cases are simply examples of the painful neu-
rosis known as "spinal irritation/9 and analogous to the
painful condition met with in the " hysterical spine," in
both of which the patients may have pains on the slightest
movements of the back or of the legs. In one of the
cases the rapid recovery in a few days, with the disap-
pearance of all the symptoms, was quite inconsistent with
a chronic perispondylitis. In the four cases of this sequela
of enteric fever, described by Dr. Gibney, of New York,
as "The Typhoid Spine," there was the production of
pain on the slightest movement, whether lateral or for-
ward, and the absence of any marked febrile disturbance
or neuralgia. All the painful backs after typhoid fever
may not be neurotic, however, as there is a possibility of
the existence of perispondylitis in some cases.
The Spirit of Quackery within the Pale of the Pro-
fession.— In an address delivered at the annual meeting
of the Midland Branch by Dr. J. West Walker, the au-
thor, after referring to the characteristics of quackery in
its barest and most uncompromising forms, proceeded
to inquire whether or no the enemy — quackery — had
gained an entrance within the profession. He animad-
verted upon the tendency on the part of certain dealers
to advertise proprietary preparations with an amount of
elaboration which appeared to him to be quite uncalled
for (The British Medical Journal). He then turned to
the attitude of consultants with regard to treatment,
taking occasion in the first place to pay a high compli-
ment to the diagnostic skill commonly exhibited, and
frankly admitting that assistance in treatment was often
obtained from them. But, he added, when I send to a
consultant I invariably ask myself what novelty shall I
have to procure, and this, notwithstanding it is the rule
to have my surgery well supplied with most of the estab-
lished therapeutic agents. The recently born mineral
water or proprietary dietetic, the endless variety of the
carbon derivatives with their break- jaw names, the latest
importation from America, some form, of course, of an-
tiseptic, the newest tabloid, capsule, or cachet, or some
480
MEDICAL RECORD.
[October 13, 1894
drag, it may be, not to be found in the Pharmacopoeia
nor the usual trade lists, but only to be obtained from a
particular chemist ; these and such like form a tempting
catalogue of choice novelties from which selection may
be made according to fancy. I make it a point of honor
scrupulously to carry out the consultant's plan of treat-
ment, but if the case be chronic, say of cardiac or renal
mischief, I soon find that one by one these addenda are
dropped and that the general management of the case
falls back upon the original adviser. He has to bring
into play all the skill and judgment he may be possessed
of to meet the various and varying symptoms as they
arise, aided and supported by the line of right principle
which he has received ftom his professional brother.
Bat more, our patients usually return to us loaded with
minute instructions as to diet and regimen.
Unfortunately, especially in the matter of diet, these
instructions are by no means uniform. Different advls
ers give different advice. Quot homines tot sententia.
The old adage that " what is one man's meat is another
man's poison " seems to be completely lost sight of, and
anyone whose inclination prompts him to do it can eas-
ily ride his hobby to death among the intricate bypaths
of dietary tables. Exact details, both as to quantity and
quality of the fish, oi the flesh, of the vegetable which
only are to be allowed ; nice distinctions as to what bev-
erages may be swallowed; careful directions as to the
time for the infusion of tea ; explicit rules as to meals,
exercise, and habits generally ; these and similar minu-
tiae are laid down and eo joined with great exactitude.
If the patient can be induced to have faith in this dog-
matism and obey it, if he adhere strictly to the diet and
regimen laid down for him, if he become afraid of the
taunts of kind friends on the least infringement of the
doctor's orders, benefit to health will generally follow.
If the patient who is in the habit of dining off half a
dozen courses and of making his other meals proportion-
ate, who freely partakes of beer, wine in variety, and
whiskey and soda — if such a patient can be induced to
forsake his gustful yet disgusting diet and daily to take
instead four pints of hot water and sundry messes of
minced beef, it is easy to see that good will be done by
the change, at any rate, for a time. And since the end
is usually greater than the means, and since the end of
professional effort must ever be the patient's good, some-
thing may be said in favor of means which conduce to
such a desirable end, even though they be a wee bit ir-
regular. May it not be well, however, to ask ourselves
and fully realize the answer to the question, How far are
these good results the positive effects of what we cause
our patient to do, and how far the negative effects of
what we cause him not to do? The removal of some
vicious habit, some worrying occupation, or some un-
healthy environment may really be the cause of good,
and our remedies only contribute to bring about the re-
sult by the oblique rather than by the direct method.
As before hinted, the oblique method may have some-
thing to commend it, and the practice of it may even, like
homicide, be, under some circumstances, justifiable. Let
not our eyes be dusty. If we strip this line of practice of
adornment, and look upon it in its nakedness, we in too
many instances recognize so many of the family features
that if we would call a spade a spade we can designate
it by none other than the family name. It may be that
stratagem in medicine, as in war, must still be occasion-
ally resorted to ; be ours the care lest we award to the
victory won by it glory in amount equal to that which
we bestow upon the result of a hand-to-hand encounter.
Returning again to the subject of new remedies, Dr.
Walker observed that a new drug which was really useful
required little advertisement. Of this the history of the
introduction of chloral and cocaine was sufficient proof.
He protested against the abuse, not the use, of adver-
tisement; while condemning credulity, he would not
favor its opposite — a dogged scepticism, which in an
inexact science, such as medicine, was perhaps even
more harmful than credulity. In conclusion, he uttered
a note of warning as to the practice of prescribing mixt-
ures in strong form, to be taken in doses of one or two
drachms or of so many minims. To prescribe concen-
trated mixtures of strychnine, of arsenic, or of mercuric
perchloride, and direct them to be given in various de-
grees of dilution was, he considered, a custom fraught
with danger. To place side by side on the nurse's table,
often in a dimly lighted room, two bottles of equal size
— the one containing sulphate of magnesia to be given
in doses of two tablespoonfuls, the other containing
chloral to be given in doses of one teaspoonful — was a
risky procedure, and one which, were the directions
never so explicit, paved the way for that terrible catas-
trophe— poisoning by misadventure.
Treatment of the Milk Teeth. — According to The
Lancet, Mr. Edmund 0*en read a short but interesting
paper on this subject at a meeting of the Odontological
Society. He asked the question whether it was always
the best plan to stop decayed milk teeth, and whether it
was really an advance in treatment. He thought that
in some other branches of surgery many so called im-
provements had in fact put back the dial of surgery, and
that dentists were carrying conservative treatment too
far, hesitating to extract from fear that the due develop-
ment of the jaws would be interfered with, or that the
second teeth would have to scramble for position after
premature loss of the temporary teeth ; but in his opin-
ion the development was due to the presence of the tooth-
sacs contained in the substance of the bone, and, with
regard to the crowding, should it take place, it could be
easily remedied by careful watching and weeding out if
necessary. He said : " There is one point in connec-
tion with the dental surgery of children's teeth which I .
am sure has not received the attention which it so ur
gently demands — it is that children's mouths should un-
dergo regular periodical inspection." Mr. Owen laid
especial stress upon the removal of carious teeth where
there was enlargement of a lymphatic gland in the neck,
which, hs said, so many dentists refused to do, probably
foreseeing some possible contingency in connection with
the eruption of the permanent teeth. Where the pulp
of a tooth was exposed it was an extremely painful and
difficult thing to do to clear out each fang thoroughly,
and unless this were done it was merely " rolling a stone
over a whited sepulchre," and further trouble was in
evitable. The very germ with which the dental surgeon
temporized in the alveolar region was often subsequently
encountered in a submaxillary glandular abscess, but Mr.
Owen thoroughly agreed with stopping milk teeth where
the carious cavities were small or could be rendered ab-
solutely aseptic.
A 8tatus to Thomas Sydenham was unveiled by the
Marquis of Salisbury at the recent meeting of the British
Association for the Advancement of Science, at Oxford.
The presentation was made by Sir Henry Acland, Regius
Professor of Medicine to the University.
Mineral Matter in Teeth and Bonos. — The framework
of the bones and teeth contains lime, phosphoric acid,
magnesia, potash, soda, carbonic anhydride, water,
chlorine, and fluorine. The water of crystallization
passes off at a very high temperature, but the constituent
water can be separated only by fusion with silicic acid. —
Gabriel.
Tobacoo and Fatigue. — Moderate smoking, in one ac-
customed to tobacco, neither increases the amount of
work done, nor retards the approach of fatigue. On the
contrary, it perhaps slightly diminishes muscular power,
and hastens the onset of fatigue, though these positive
effects could not be conclusively demonstrated. — Harley.
The Future of Children with Hip-disease. — Accord-
ing to Bruns, six per cent of patients under ten years of
age, who have been cured of hip disease, nine per cent,
of those between ten and twenty years, and seven per
cent of those above twenty years of age, succumb event-
ually to tuberculosis of other organs.
Medical Record
A Weekly youmal of Medicine and Surgery
Vol. 46, No. 16.
Whole No. 1250.
New York, October 20, 1894.
$5.00 Per Annum.
Single Copies, ioc.
<$rifiitml Articles.
CONSUMPTION: ROUGHING IT VS. THE COD-
DLING TREATMENT.
By CHARLES E. PAGE, M.D.,
BOSTON, MASS.
" Consumption " is the same bite noire to-day that it has
ever been. It is everywhere regarded as incurable, once
fastened upon its victim. And yet, the records of the
dissecting room prove that in numerous cases lungs,
" wasted to one-half of their normal size have been healed,
and after a perfect cicatrization of the tuberculous ulcers
have for years performed all the essential functions of the
sound organ" (Oswald). This fact, with all its great
significance, should be impressed upon the mind of every
medical student. It is doubtless true that in every in-
stance* of all who live to tell the tale of an inherited or
acquired tendency to pulmonary emphysema and of its
banishment, we would find a history of either an en-
forced or a voluntary change from an in door to an out-
door life, with some radical modification of the living
habits of the individual, especially in the matter of his
activities.
The writer recalls the case of a cousin who was killed
in California by being rolled down a mountain's side
under a drive of logs. Possibly the first log that rolled
over him did the business, but it was said by his com-
panions at the time that nothing short of that sort of
treatment could ever have killed this giant of 6 feet 3
inches, weighing 220 pounds, and noted for his muscular
strength. And yet, throughout his boyhood and to the age
of fifteen, he was about the poorest specimen of humanity
imaginable. No one believed that this cadaverous, y ellow-
white faced, round-shouldered, hollow chested lad, with a
"grave yard cough," would live to reach maturity, least
of all become a robust man. No news concerning my
cousin's condition reached me during an absence from
home of about two years, and one may imagine my
amazement when at our first meeting I looked up at the
face of a six- foot athlete claiming to be the cousin whom
I left in so sad a plight.
What had wrought this seeming miracle ? Simply an
enforced change from the life of a molly coddle to that
of a worker in the open air. My uncle was the ferryman
at N., a little village on the Kennebec, in Maine, and
owing to an illness his only son was compelled to take up
the work, which, though desultory, required the putting
forth of all the muscular power to which he could whip
himself, and exposure to all manner of rough weather.
Instead of dying outright, as his poor parents feared, it
was soon evident that his new life agreed with him ; he
began to mend, and it was doubtless owing to his father's
prolonged sickness that the boy got his start toward robust
health.
Instances more or less similar to the one just related
are constantly occurring, but their true lesson is appre-
ciated only by the few. Into another consumptive's
head there came in some way the crankish notion of be-
ginning the practice in summer of taking a cold plunge
and swim in the neighboring pond and of continuing
it throughout the year, breaking the ice in winter for his
morning bath. Result : A perfect cure.
Another case that came under my notice was that of a
young man who had as a clerk in a store fallen into de-
cline and was forced to resign his position. He con-
sulted me and was for a time under my care. He 1 ad at
first no appetite, little strength, an emaciated body, and
a distressing cough. He begun to improve somewhat,
but was greatly disturbed by his enforced idleness, with
all that this implied to a man with an ailing wife and
child requiring support, and one day he informed me
that a friend of his wanted a man to drive a milk wagon
and would give him the job, and by my advice he ac-
cepted. Hustling out of bed at 1 a.m. first in the fall,
and then throughout the winter, for a long drive, often in
bitter weather, regardless of rain or snow ; to jump off
and on the cart in the delivery of his wares, gave him a
boom toward health that resulted finally in making him
a robust man.
An acquaintance of mine, once wealthy, lost all of his
property except a " consumptive " horse that he had been
keeping " for the good he had done," and whose ill con-
dition had resulted from high living and a sedentary life.
His master finally started a little grocery business, and
at the risk of arrest by the agent of the Society for the
Prevention of Cruelty to Animals, he began delivering
groceries with the " patient." After a time the poor
creature began to show signs of picking up, and as busi-
ness increased, the work, of course, became harder ; but
the more he did the more he could do, and within a year
this hide bound victim of misplaced kindness was again
the plump, smooth, handsome creature that first attracted
his master's attention. At that time he was fat, and he
looked fat now, but this appearance was due to a fully
developed muscular system, the result of hard work and
enough to eat, with the natural improvement in digestion
and assimilation from plenty of exercise in the open air.
As an illustration of the benefits arising from chest ex-
ercise, we have the case of the consumptive who received
a wound in the leg and had to employ crutches. Find-
ing that their use seemed to relieve his cough, helped him
in the matter of "raising," etc., he got in the way of
hobbling about as much as his strength would permit, ard
this naturally meant more and more, until by the time he
could use his legs with freedom he was on the road to
high health, and he did become healthy.
A few years ago a prominent Connecticut physician
died, and an autopsy was made with the expectation of
viewing a " lung and a fraction," with which he had lived
for thirty years, after a prominent Boston doctor, in con-
sultation with the late Dr. Willard Parker, of New York,
had declared that he could not live a year. He had then
just graduated, and he took his case into his own hands,
and began a system of roughing it, out in all weathers,
eating freely of hearty food, for which he gained an ap-
petite by a nip of brandy at dinner. He became a robust
man, and died finally of chronic gastritis resulting from
sticking to the brandy habit I His lungs were both sound,
and the doctors' diagnosis was, therefore, absolutely
wrong ; but their prognosis would without a doubt have
proved correct but for his right about face and the
adoption of the bulldozing treatment, so to say.
The writer has long since adopted this principle in the
treatment of " consumption," which he regards as a dis-
ease of dyspeptic starvation. In its final issue, in cases
that terminate fatally, patients really die of fatty de-
generation of the lungs) so far as the local lesion is con-
cerned. There is utter lack of full, free exercise of the
lungs; the easygoing, loafing patient does not half
breathe, from lack of such physical exercise as would
482
MEDICAL RECORD.
[October 20, 1894
cause involuntary deep breathing ; and as a consequence
the lung tissues degenerate with fat, as is true also of the
entire muscular system.
Something like a dozen years ago, at a meeting of the
New Orleans Pathological Society, Dr. H. D. Schmidt,
whose researches had been extended and minute, made
an important microscopical demonstration for the pur-
pose of disproving Professor Koch's so-called discovery
as to the bacilli of tuberculosis. Professor Schmidt
claimed to demonstrate that the "bacilli" were simply
fatty crystals, but he at least succeeded in showing that
the condition of the lungs was one of fatty degeneration.
We know, however, that the diseased lungs do contain mi-
nute living organisms, but it is evident to my mind that
the bacillus is simply a natural scavenger of the decaying
tissue, and that its function is really life-conserving.
It has for years been my practice to treat consumptive
patients on the plan indicated in the foregoing para-
graphs ; the roughing, toughening, hustling plan, varied
according to the special needs of each individual, which
occasions a demand for a generous amount of wholesome
food, with appetite and digestion to correspond. The
result is as satisfactory when the treatment is prescribed
by an expert as when it is merely the outcome of acci-
dent, and I will venture to introduce here a couple of
instances of radical cure.
B. H , at present one of our noted American ar-
tists in Paris, came under my care in March, 1885, after
a three years' decline in Paris and London, and a return
to his native Philadelphia to die, as they all believed,
under the care of the old family doctor. The latter
ordered him to Colorado, as is still quite the usual cus-
tom in hopeless cases, to loaf away the remnant of his
life. He returned, however, after a few months' stay,
unimproved, and it was at this point of the case that he
wrote to me the history of his condition and asked my
advice. After a few weeks' correspondence H and
his wife came to Boston, that the patient might be di-
rectly under my eye. He had, meantime, made a slight
gain, and could do more rather than " crawl a mile on
level going," as he described his physical powers in his
first letter. He could manage a couple of miles without
extreme fatigue, and from day to day I cracked the whip
over his back, so to say, to secure something of a gain
in speed and distance at each trial, as well as in the
number of his daily walks, with ample rests between,
chiefly lying down. He was a brave fellow and he en-
tered into the plan with all the spirit he could muster.
Oq rising from bed he was directed, as a daily practice,
to take a quick dash of cold water all over, a good
towelling, and an air-bath of a half- hour or more, with
such all-around exercises as he could manage. After a
few weeks he would, naked, pull at the chest-weights for
an hour or more before breakfast, like a man sawing wood.
Light, low-cut, loose shoes, only, were worn. He went
barefoot several hours every day. Before the end of
summer he could do fifteen miles in the course of the
day, at several stretches, including a good bit of run-
ning, and was eating hungrily twice a day of pood plain
food. Three tonics only were exhibited: Fresh air,
fasting, and exercise. My counsel to him was what it
ever is to all classes of patients : Never eat unless hun-
gry. To eat without appetite is a species of self-abuse
inexcustble for the sick or well. Never eat when tired,
nor exercise actively soon after eating. Learn to dis-
tinguish between hunger and mere appetite ; let the test
be the least appetizing foods ; and if hungry enough to
enjoy such, one may partake of the more agreeable kinds,
as a steak or chop, a mellow ripe banana, new peas,
corn, string- beans, all of the seasonable fruits, berries,
melons, etc , but the consumptive, of all men, must
avoid gormandizing.
In October, affr seven months' physical training,
H and his wife returned to France, and within a
year thereafter he was enabled to report himself " as
sound as a dollar." I have heard from him every year,
and he remains still a typically healthy man.
R. T. S , aged twenty-three, a most unpromising
subject, weighing on my scales 99 pounds, came to this
town to be under my care, in February, 1887. His ap-
pearance was so pitiful as to almost excite disgust. His
weakness was so extreme that his brain was seriously af-
fected. But he setmed in dead earnest to get my ideas
on every point to carry them out to the letter. He kept
most of the time in the open air, regardless of the
weather, worked up gradually in his training, indoors
and out. but he grew restive from having nothing to do
but attend to himself. He finally conceived the notion
of canvassing from house to house for orders for provi-
sions as a means of keeping himself out of doors and his
mind occupied with something beside his own symptoms.
His success was largely due to the pity excited by his
forlorn appearance. He would get his orders, and then
visit the large markets and buy the meats and provisions
to fill them. He was therefore a merchant and had the
stimulus of looking for profits. All this work was on
foot in all weathers during March, and continuously
thereafter, and he began to gain in weight and strength.
In May he weighed no pounds, and the following year
he tipped the beam at 145, and was a bright, handsome
fellow.
In both these cases the patients at once, by my direc-
tion, abandoned the use of the heavy flannels they were
wearing when they consulted me, though they were, of
course, well protected from the cold when out of doors
by means of outer garments. The disuse of undei-flan-
nels as an important part of hygienic treatment will
doubtless fail to commend itself to most of my readers ;
but in a very busy practice during the past ten years I
have invariably urged the plan upon my consultants, and
I have succeeded in a large number of instances in in-
ducing them to abandon the use of underwear altogether,
not even compromising with light-weight, and I have
never had occasion to regret it ; but, on the other hand,
I have won the gratitude of every individual who has
given the plan a fair trial.
Is it not clear to every reflective mind that in all ordi-
nary homes we and our patients are living in summer
weather, so to say, even in mid-winter ? Why, then,
should we wear winter flannels in the house ? The em-
ployment of outer garments for out-door wear meets all
the requirements for comfort, and all the better when
the skin is not sweltered by flannels in the heated, often
over-heated, living-rooms ; and I have observed as an
invariable rule that those who have adopted the plan
here advised are the most indifferent as to the use of
outer garments when they do go out, even in winter.
It is the ones who swelter the skin with heavy flannels in
their warm dwellings, offices, stores, etc., who shiver
most in cold weather in spite of the heaviest sealskin
sacques or fur-lined top coats.
The writer has worn no flannels, winter nor summer,
since February, 1880, removing during this winter
month, the heaviest of Morley's Scotch undershirts and
drawers. For years he had, in his efforts after comfort,
selected his winter flannels from garments of heavier
weight each fall ; but all to no purpose, except, seem-
ingly* to make him subject to a kind of chills and fever,
very sensitive to cold when out of doors, and exceedingly
uncomfortable indoors at all times, ard also out doors in
moderate weather. He was subject to f equent " colds "
affecting throat and lungs, and a constant sufferer from
cold feet, and in fact was in a condition to sltfe into a
consumptive's grave, as had quite a number of his near
relatives who died in their flannels ! But now, at the
ape of fifty four, he is one of the most robust of men,
able to lead most of the young men in a cross country
run, not limiting the distance. And this change was
produced by the abandonment of th* coddling plan, re-
placing it with a rational application of the rough-and-
, tumble scheme outlined in this paper.
"It is not always realized that the abilitv of man to
carry his climate with him, or essentially modify it wher-
ever he chances to be located, is a power that can be
October 20, 1894]
MEDICAL RECORD.
483
used for harm as well as benefit/' says the Philadelphia
Polyclinic^ editorially. " When we depart from the
guidance of the immediate sensations and race instincts,
and shape our conduct according to definite ideas, we
accept a guide that may be better or worse than those of
nature ; and, in the matter of clothing, there can be no
question bat that incorrect ideas lead many into the very
disease and danger that they are striving to avoid.
"All observation shows that for individuals in com-
parative health, no possible regulation of environment,
either in the selection of a natural climate, in the con-
struction and heating of dwellings, or the choice of ma-
terial and amount of clothing, can supersede, or, indeed,
compare in importance with the influence of the physi-
ological mechanism for the regulation of heat production
and heat distribution, within the body.
"To keep this in the most perfect working order
should be the first concern of one who fears disease from
change of temperature ; and it cannot be kept in good
condition without opportunity for constant and consid-
erable exercise. The natural stimuli which provoke its
action, and which are essentially variations of heat and
cold, particularly properly proportioned shocks of cold
to the surface of the body, must be supplied or permitted,
and on the other hand, the nervous system, of which it is
an integral part, must be kept in good order by the
proper balance of physical and mental exercise and sleep.
Probably the persons who suffer most from ' colds ' are
those who, in their fear of such departures from health,
try hardest to avoid the changes of temperature that are
necessary to keep the heat-regulating organism in good
condition."
The person who, on rising from bed in the morning,
takes an air bath (as everyone should) in his unwarmed,
winter sleeping room, for ten to thirty minutes, with a
good towelling and hand polishing of the skin, prefaced,
perhaps, by a dash of cold water with the wet hands,
finding himself finally quite warm though naked, is in a
position to conclude that the single, ordinary suit, minus
flannels, will sufficiently "protect" him from cold when
he descends to the warmer living rooms ! His over-
coat and a brisk pace will do the business for him
when he seeks the actual winter weather without, and
this vastly better because of the freedom of the skin
indoors.
Chilliness, or that more or less vague, shivery feeling
that comes especially to all clothed animals, is apt to
mislead the inexpert. Who has not experienced it in the
evening, perhaps before a warm grate, temperature in the
room at 700 F. or over, the body clad in full winter cos-
tume, and on disrobing for bed in a cold room found
himself comfortably warm ? This seeming miracle would
happen to every shivering mortal if he would give the
skin a few active passes with his hands or a towel, in-
stead of dodging from his clothes into bed in cowardly
fear of " catching cold."
A leading question with me in every consultation, as a
means of ascertaining how bad the condition is through-
out the year, is, " Do you catch cold easily ? " In the
great majority of cases the reply is in the affirmative.
"Yes, I am seldom free from a cold," one will say; or,
" I catch cold if I even look out of the window." " I
don't know whether it will take more than one of the
air-baths you have prescribed to kill my wife," wrote a
correspondent, " for she usually gets a cold if a fly wings
past her ; still, live or die, she says she is going to obey
instructions." She began abruptly to take the air baths,
gave up flannels, and within six months this 91 j£ pound
woman wa? tramping barefoot three miles at a stretch in
the surf along the beach, and had gained a few pounds
of honest muscle, and was no longer a victim of the colds
delusion. Symptoms of ill condition she would from
time to time observe, due to some error in living habits,
but she has learned to call things by their right names,
at least some things.
Now and then a patient is able to declare that she sel-
dom has a cold ; and it always happens that she is one
of the few not given to the practice of bundling herself
up as a means of avoiding the disorder.
" How is it that I always catch cold when I put on my
winter flannels?" queried a patient, who was upon the
point of making his usual fall change of underwear. My
explanation was so convincing to him that instead of
putting on his thick flannels he took off his thin ones,
and in the spring he was able to declare that he had
never, since his unflannelled boyhood, passed a winter
with such immunity from the popular disorder, " colds."
He had, moreover, he said, enjoyed a greater average of
comfort than formerly with the inner suit.
An elderly lady, herself a victim of heavy flannels and
a "chest-protector," and who died, finally, from her
fourth siege of pneumonia, once remarked to me in the
presence of a little company at her hotel, that "there
might be a great deal in your theory about the mischief
of underwear, after all. Sam [referring to her husband
by his given-name] never wore flannels till the last win-
ter of his life. I had coaxed him to every fall, but he
would not give up till one fall he let me get him some
nice warm flannels. He seemed to have a cold all win-
ter long, and he died of pneumonia in the spring."
"Well," I replied, "you may have the sublime satis-
faction of knowing that you were responsible for Sam's
premature death ! " Twenty years having elapsed since
her investment in men's underwear, she was able to join
in the laugh that was raised by my somewhat brutal re-
mark.
The conviction has grown upon me from many years
of special study of the question, that a " cold " is really
a filth disease, and that, as that wisest of men, Dr. Ben-
jamin Franklin, wrote,1 " the causes of colds ate totally
independent of wet or even of cold." If this is not true,
how can we account for the efficacy of the barefoot cure
in certain disorders ? When an empress suffering from
neuralgia to the point of distraction finds complete cure
from going barefoot for several hours every day in the
wet grass about the palace grounds ; when Baron Roths-
child goes to Woreshofen and is pleased to pay a large
(voluntary) fee for similar treatment, under Kneipp;
when Dorothy Drew, the granddaughter of the " Grand
Old Man " of England, becomes " irrepressibly healthy,"
from " going barefoot all the year around, indoors and
out, in all but very muddy and the very coldest of
weather," is it not about time for us to revise the old-
time notions as to what constitutes really wise care in
the matter of clothing?
The skin is a breathing, as well as an excreting organ,
and both these functions are seriously impeded by the
second, or inner suit. Indeed, the employment of any
clothing at ail, at times when not absolutely required for
protection against cold, is a tax upon the animal organ-
ism, and against us in the search for health. This is
doubtless especially true concerning the care of the feet.
"Strip off your flannels, and you'll come out all right,"
was the advice for which an uncle of mine, in Australia
in 1853, paid a guinea, and which he afterward had rea-
son to believe would have been cheap at ten times the
cost ; for by obeying the level-headed old native doc-
tor's advice he escaped the "climatic fever " which cost
my brother his life there shortly after. The latter could
not divest his mind of the superstition, still prevalent,
that it is dangerous to keep comfortable in hot weather !
But how about our consumptive patient, shall he not
be allowed to dress comfortably in winter ? Cc mforta-
bly, yes, by all means ; but it is the greatest average of
comfort we have to secure. If he is to pass all of his
time in the open air, in winter, he may dress accord-
ingly, even to the use of underwear ; but as the average
patient does nothing of the sort he will be better off
without it. He will have chilly sensatiors at times
whether he does or does not wear flannels, but it is
vastly better for him, as for us all, to secure a feeling of
warmth by means of a little "shaking up" exercise, than
to try to secure comfort solely by means of excessive
1 See his Essays, p. 216;
484
MEDICAL RECORD.
[October 20, 1894
clothing. It is astonishing to one unfamiliar with the
experiment to observe the almost instantaneous glow of
warmth that results from a little arm-swinging, a few
sharp slaps along the sides of the legs, a bit of a jig-
dance, or even a few simple shrugs of the shoulders
alone ; and every little turn of this sort is in the line of
physical training, from lack of which, in ninety nine
cases in the hundred, our patient has fallen into decline.
Generally speaking, the consumptive is one who has
grown weaker and weaker, and, however slender he may
have become, relatively fatter from month to month, the
muscular system having steadily degenerated, because he
has exerted himself less and less, being forever encour-
aged in this course through the mistaken kindness of all
about him. He has, therefore, finally become " tired "
in a manner prohibiting all hope of rest this side of the
grave, except it be sought along radically changed lines.
Says Dr. Felix Oswald : l " A common catarrh will
not prevent a man from running upstairs or walking up-
hill for minutes together without anything like visible
distress; subjected to the same test, a person whose
lungs are studded with tubercles will pant like a swimmer
after a long dive, and his heart beats will most likely be
doubled in frequency. Combined with a hectic flush,
night-sweats, or general emaciation, shortness of breath
leaves no doubt that the person thus affected is in the
first stage of pulmonary consumption. If the patient
were my son, I should remove the windows of his bed-
room, and make him pass his days in the open air — as a
cow- boy or berry-gatherer, if he could do no better. In
case the disease had reached its deliquium period, the
stage of violent bowel- complaints, dropsical swellings,
and utter prostration, it would be better to let the suf-
ferer die in peace ; but, as long as he were able to di-
gest a frugal meal and walk two miles on level ground, I
should begin the out-door cure at any time of year, and
stake my life on the result. I should provide him with
clothing enough to defy the vicissitudes of the seasons,
and keep him out doors in all kinds of weather — walk-
ing, riding, or sitting, he would be safe : the fresh air
would prevent the progress of the disease ; but improve
he could not without exercise. Increased exercise is the
price of increased vigor. Running and walking steel
the leg sinews ; almost any bodily exercise — but especially
arm swinging, wood-chopping, carrying weights, and
walking up hill — increases the action of the lungs, and
thus gradually their functional vigor. The problem is
to make out door exercise pleasant enough to be per-
manently preferable to the far niente whose sweets seem
especially tempting to consumptives. This purpose ac-
complished, the steady progress of convalescence is gen-
erally insured, for differences of climate, altitude, of age
and previous habits, almost disappear before the advan-
tages of an habitual out door life over the healthiest in-
door occupations."
But, when he comes in- doors it must not be to find a
close atmosphere, such as at present the average home
provides ; for, as Dr. Pitcher remarks in his " Memoirs
of the Osage Indians," "the symptoms of consumption
(caused by smoking and confinement in winter quarters)
disappear during their annual buffalo-hunt, but reappear
upon their return to the indolent life of the wigwam."
And even an hour or two in the average theatre, church
edifice, hall, or dwelling will counteract the benefit aris-
ing from spending an equal length of time in the free
open air. In this fight for his life no patient can afford to
hazard his chances by any letting up in the " medicine."
At best, life is a struggle ; courage is demanded ; and in
no phase is this more absolutely true than in the consump-
tive patient's endeavor to secure a return of health.
"You'd hardly think to look at me, I guess, that I'd
been turned out to die of consumption before I came of
age," said a 200 pound man of good muscle, a sturdy
eater and sleeper, to a New York Sun reporter. " It's a
fact, though. I weighed 95 pounds when I left home.
My folks were poor, and they sent me to Kansas in a
» Physical Education.
prairie schooner, never expecting to see me again. I
began to pick up as soon as I got up on the rise of the
plains. I lived in a cabin that was wide open day and
night. Then I went into the army during the war, and
after that did a lot of work grading and surveying for a
railroad, and all the time I was living and sleeping with
only the sky for a roof. I have been farming it for the
last dozen years, and my windows are open day and
night. Air is the best medicine there is."
It is for a profusion of this medicine that people go
camping out. The consumptive patient must camp out
all the year around, as does the writer and his entire
family, practically. All one has to do is, in summer, to
run the curtains up, burn the smothering screens, open
wide the windows, top and bottom, and let the breezes
blow freely through the house ; in winter some degree of
modification of this free ventilation is admissible. This
means a lot of dust in summer, of course, and the fading
of the rugs and furnishings, but it keeps the color in the
cheeks, this " camping out at home."
" Beware of draughts," is the great cry of most writers
on health. In other words shun the running stream, drink
from a stagnant pool. "The only trouble about a
draught," says Oswald, "is that it is usually not big
enough ! " And rationally considered this means noth-
ing out of line of true hygiene. It does not mean that
even a well man should sit passively in a strong current
of cold air when he is fatigued or weakened from any
cause.
It does mean, however, that no dwelling, no sick-
room, can be sufficiently ventilated without a sufficient
current. For winter ventilation, probably no better
method can be devised — for the extremely cold weather —
than to mismatch a number of windows in each room by
means of a four inch board under the lower sash, which
allows, through the middle opening, and without
"draught," pretty free influx of fresh, and the passage
out of foul, air. Open grates are without doubt an ex-
cellent thing, but it should be borne in mind that they
let in no fresh air. The open windows must do this;
and in the warm periods of mid- winter they should be
freely opened throughout the house.
The consumptive patient on coming in from his outings
may well seek his chamber with its always wide-open win-
dows, and lie down with plenty of blankets for protection,
instead of sitting, as a rule. Sitting is altogether unnatu-
ral, and the less of it he does the better. He may well
avoid all unnatural practices until he finds himself safely
" out of the woods."
867 BovLvroN Stout.
The Temperature of the Electric Are is said to be
about 6,152° Fahrenheit.
Medical Valets. — Marcellin Pellet, in a work entitled
" Naples Contemporaine," says that the valets of the
leading physicians of that city always accompany their
masters on their professional rounds, and receive two
francs for each visit. They are paid no other salary, and
out of those fees have to meet certain charges, such as
that for lighting the house. — Mtdecine Moderne.
A Confinement that Didn't Confine. — A medical man
who had practised among the North Dakota Indians,
writes that their women as a rule had very easy labors \
in fact, it was no trouble at all for them to have children.
At one time he saw several women coming toward the
only store at the agency, across a wide open space in
front, each carrying on her back a bundle of sticks. Sud-
denly one stopped short, looked a little wild, dropped
her bundle of sticks, spread her feet apart, strained a mo-
ment, and then stooping, made a pass toward the ground
with her knife that she drew from its sheath, picked up
something which she wrapped up in her shawl, and leav-
ing her bundle of sticks for someone else to pick up,
passed on into the village. That was a confinement, and
the child was born then and there. — New York Medi-
cal Times.
October 20, 1894]
MEDICAL RECORD.
485
ACUTE BILIARY DISTENTION OF THE GALL-
BLADDER.
By BEVERLEY ROBINSON, M.D.,
CLINICAL PROFiSSOR OP MEDICINE, AT THK BELLEVUB HOSPITAL MEDICAL COL-
LEGE, NEW YORK.
It is always a subject of interest to clear up, if possible,
some of the obscure conditions pertaining to cases not
infrequently met with in general practice. Such an one,
at least in certain of its essential features, is the state to
which the title of my article refers. On two or more
occasions, during the past few years, I have seen in-
stances of the following kind : A patient is suddenly at-
tacked with intense pain in the epigastric region. Ac-
companying the pain, which is continuous and remains,
during the acute attack, limited to the epigastric region,
there is constant nausea and occasional vomiting. The
vomited matter is composed of the contents of the stom-
ach, or is pure bile. There is no rise of temperature.
There is marked local tenderness on palpation in the re-
gion to which pain is referred. Distention of the gall-
bladder is not clearly made out, but it is suspected and
probable, by reason of increased resistance and perhaps
local swelling in its vicinity. The liver is usually some-
what enlarged. Constipation is moderate. The motions
are dark brown, insufficient in quantity. The urine is
high-colored, but does not contain any bile. It is possi-
ble to have a sub-icteric hue of the scleroses, but there
is no other evidence of jaundice. There may be a history
of malaria, or lithsemia. The habits are occasionally re-
gular ; sometimes there are errors of diet or modes of life,
as to exercise and excitement. During the attacks a vom-
itive with ipecac, a stimulating enema, with a hot- water
bag applied locally over the stomach, will afford relief.
Usually, however, this relief is only slight in amount,
and the pain may last continually for several hours, and
be so intense as to require the use of morphine hypoder-
mically. For a day or two following these attacks, the
epigastric region is tender. Fluid diet, relative quiet,
counter-irritation over the liver, moderate catharsis with
Rochelle salts, or carbonate and sulphate of magnesia,
and the free use of Vichy water, will usually bring such
attacks to a favorable termination in a short time. They
recur at irregular intervals, usually after exposure, undue
fatigue, emotional disturbance, some imprudence in eat-
ing or drinking. They are not followed by jaundice ;
no gall-stones are passed. They improve very much at
first with free evacuation from the bowels of large, liquid,
dark colored, bilious stools, which gradually become
lighter in color as the individual improves in health.
After such an attack the patient is usually well for several
months, has no nausea, dyspepsia, epigastric soreness,
engorgement of the liver, or as a rule, other evidence of
ill health.
Occasionally, I have known sufferers from these attacks
to have ambulant neuralgic pains, principally in the
hypochondriac regions, but also in the thorax, abdomen,
and testicles. Shooting pains in the testicles, with a feel-
ing of weight and temporary swelling of the epididymis,
have been observed. Such attacks have been designated
gall-stones, acute dyspepsia, catarrhal jaundice, gastral-
gia. They are unlike all of these, and must be distinctly
separated from them. When the abdominal pain is acute
I have known appendicitis to be suspected. They are
obviously different from this disease. The subsequent
treatment of such cases, and between recurrent attacks,
is to be found in continuous moderate doses for several
wseks of phosphate of soda, sufficient in amount to
produce a laxative effect on the bowels. An underlying
malarial history has been clearly made out in more than
one instance, and yet quinine is of very little value in
these cases. Warburg's tincture may be helpful, but not
infrequently only renders the condition of the patient
worse. Arsenious acid, from -fa to ^ff grain, combined
with ignatia, has seemed to me to be the best and most
rational curative treatment. After stopping the phos-
phate of soda, or instead of it, small doses every other
night of podophyllin, or calomel, for a while have been
found very useful. I direct attention to these cases, al-
though not serious as to their immediate consequences in
my experience, because they are often confounded with
other affections, and because sooner or later, if not
properly cared for, I am of the opinion that they
lead directly to the formation and deposit of biliary
calculi.
Two cases that I have observed and treated — one of
them for many years — have occurred in young men be-
tween twenty ana thirty years of age. Both of them
lived an out-door life, were devoted to athletic sports,
and generally speaking, were careful as to their diet.
Similar, or analogous cases, occur more frequently among
men than women. I have seen them occasionally in
hospitals, but there they have been so much obscured by
complicating disorders that I have not felt so confident
in regard to my diagnosis. This diagnosis, which has
only been a suspicion for some time, has now become a
confirmed judgment in view of several more or less simi-
lar instances that I have taken care of. I am not aware
that this precise affection has been emphasized or in-
sisted upon by anyone else in quite the terms, nor in the
manner, which I have tried to make clear. Engorgement,
or congestion of the liver, does not fit such cases, as I
believe, although slight enlargement usually accompanies
the symptoms described. Besides, I have noted the
other symptoms more than once, when there was no en-
largement of the liver at all.
To my mind, these attacks of acute distention of the
gall-bladder with bile, are not unlike, in their analogy
with the development of calculous disease of the gall-
bladder, to what we have similarly defined, when we con-
sider the relationship of the pre albuminuric stage of
chronic Bright's disease with the development of nephri-
tis as a clearly formed malady.
To give a plausible explanation of the etiology of
these cases, I am almost forced to admit the existence of
a spasmodic contraction of the gall-bladder which is suf-
ficient to shut off in part temporary connection with the
cystic duct. I cannot believe in the extension of an in-
flammatory condition from the duodenum, as there are
none of the previous stomachal symptoms which are so
usual in catarrhal jaundice. Moreover, the jaundice it-
self does not occur as it would, unquestionably, if the
hepatic duct or common duct were occluded even for a
short time. Again, it is more than difficult to admit the
existence of an inflammatory state of the cystic duct which
would allow the common or hepatic duct to remain in-
tact or unaffected. Of course, the post-mortem revela-
tions in similar instances cannot be given, as such cases
are not fatal, and we are forcibly thrown back upon the
explanation which is most rational, and therefore most
satisfactory. Cases have been observed, or at least alluded
to, by Murchison,1 in which the organic occlusion of the
neck of the gall-bladder by a gall stone was such as to
allow entrance of bile into the gall bladder, but to
prevent its exit It is quite conceivable that a state may
be produced after a dynamic manner, which might ap-
proximate this condition, i e. , that of a plug valve, " and
where bile has in consequence accumulated in the gall-
bladder/'
It has occurred to me that cases like mine have occa-
sionally been confounded with gastralgia, which, how-
ever, differs materially from what I have described.
The latter disease is rarely so acute, is not accompanied
by any swelling or hypertension over the region of the
gall-bladder, is relieved frequently by pressure, or with
bromides and chloral internally, and the attacks are not
followed by copious and frequent bilious stools. In two
of my cases, so soon as the spasmodic condition of the
gall bladder was diminished, or suppressed, the symp-
toms of hepatic colic disappeared very rapidly and almost
completely. In other somewhat analogous instances, they
remained in a far less severe form for a few days. The
evidence in these acute cases of biliary distention of the
» Diseases of the Liver, 3d edition, p. 381.
486
MEDICAL RECORD.
[October 20, 1894
gall-bladder, is to the effect that the coloring matter of
the retained bile is not gradually absorbed, but quickly
eliminated by the bowels. Thus there is a radical differ-
ence with chronic cases of occlusion of the cystic duct
from calculus, or any other cause where the contents of
the gall bladder are an almost colorless mucous fluid. In
either the acute or chronic cases of occlusion of the cys-
tic duct, there need be no jaundice, nor clay colored
motions. By directing attention to the foregoing facts
I hope to throw some light on an interesting affec-
tion, which all general practitioners must occasionally
see, but do not perhaps designate or interpret as I have
done.
HYPOCHONDRIASIS.
By D. B. McCARTIE, M.D.,
NEWARK, N. J.
Historical Sketch. — Since the days of Hippocrates and
Galen this nervous disease has been known and written
on. Hippocrates wrote on hypochondriasis. The cerebral
nature of the trouble did not enter into the medical nosol-
ogy until much later. The ancient idea related to disturb-
ance of the visceral organs situated under the ribs, as
the name implies, and the gloom or depression accom-
panying the disease was ascribed as a result of deficient
action in the liver connected with the production of bile,
or in a perverted action in the spleen, whence the term
"splenetic." This pathological idea was held through
many centuries, and may have been popularly handed
down by such treatises as Burton's " Anatomy of Melan-
choly."
In the days of Cullen the malady began to assume a
new aspect and appear in its proper place as a cerebral
affection.
The disease presents itself in so many various forms, or
rather, its manifestations are so pronounced that these
have been called by special names, and even worthy
treatises have been written thereon. It is evident that
all these phases, so much written on at the present day,
are manifestations of the same disease ; but one symptom
standing out more prominently than others, the mental
aspect of the case being unobserved, has received a spe-
cial name, as " spinal neurasthenia/' " cerebral or spinal
hyperemia," rachialgia, or spinal irritation, etc. Promi-
nent authors have much differed about the nature and
causes of these terms. Many have placed the seat of the
trouble entirely in the cord. Griesinger places the mal-
ady in toto in the scale of insanity, observing minutely the
depression, and instancing his observations by advanced
hypochondriacal cases.. Again, other authors place such
signs as muscular asthenopia, motor weakness, cerebral
sensations, sensory sensations in the skin, etc., in a sepa-
rate class and call the trouble neurasthenia, leaving out
the mental perversion, thougtvsuggesting that the malady
occurs in hypochondriacal and hysterical patients.
Sir William Gull in his able article differs from Grie-
singer, and places the disease in a position midway be-
tween insanity and hereditary nervous disease, still re-
taining the indefinite name of hypochondriasis. He
observes its close connection with insanity and its pecul-
iar course, yet does not instance precisely phases of the
malady which are often prominent, and in the main
absorb all the other features of the disease, as ocular
weakness, neurasthenia, sensory hyperesthesia. Most
authors seem to think that a delusion as to being diseased
is the essential part of the disease, whereas this is often
wanting in definiteness, and motor weakness, irritability
of temper, want of sleep, and want of power to direct the
attention, or the so-called neurasthenic symptom, is often
the leading symptom, without the patient fearing disease,
though a mental " cloud " still hangs over the understand-
ing. Dr. Gowers places the disease in its proper category,
and observes on its various features, but does not com-
bine its symptoms. In speaking of neurasthenia he
simply refers to hysteria, neuralgia, hypochondriasis, as
its causes. He might as well have written an article on
hypochondriasis as on hysteria, and combined all these
symptoms, which undoubtedly refer to this peculiar and
frequent and much discussed disease. Dr. Gowers
touches, in various parts of his treatise, on some of the
features of the hypochondriacal malady, particularly in
the article on cerebral hyperemia, cephalic sensations,
neuralgia, hysteria, railway shock, etc. These symp-
toms connected together form the varying picture of hy-
pochondriasis.
It has, therefore, a mental aspect in all cases, and this
is probably the underlying morbid feature of the malady,
though it is often slight and unobserved, but again, often
so prominent as to place the case in the melancholic va-
riety of insanity. A better name than hypochondriasis
is manifestly wanted, as also a due connection of all the
symptoms with the mental defect, so that the cases can
be treated scientifically and the nature and course of the
disease mapped out. Unfortunately it is too plain that
it is so closely allied to the higher types of mental per-
version that its prognosis depends on uncertainty and
its treatment is tedious and non specific.
Definition. — The above name is badly chosen, since
it conveys an erroneous impression as to the seat of the
disease. Neurasthenia, which is so often a leading feat-
ure, is also an indefinite name, since debility, referring
particularly to the nervous system, is as much a symptom
as debility from fever or general disease. The term indi-
cates many obscure symptoms which result from nervous
disease, and should be known as a symptom of cerebral
affection and not as a disease in itself.
JStiology. — This relates almost entirely tp hereditary
effects, which are mostly untraced and indefinite in the
course of ages. A definite history of family insanity can
be obtained in very many cases, or other mental peculia-
rities or eccentricities. In fact the definition of insanity
as a perversion of the normal state of thinking, feeling, or
acting, applies very concisely to this condition, though the
perversion of thinking is often very slight and not much
noticed by the sufferer ; whereas in other cases the per-
version of thought is highly accentuated and hypochon-
driacal fancies abound. There are frequently histories of
epilepsy in other members of the family, as in an uncle or
aunt, and other nerve disease, as neuralgia, hysteria, cho-
rea, megrim, etc. The disease also occurs indirectly or in
connection with other diseases, a primary instance being
the effect of railway shock upon the mental action of
one prone to this disease.
The disease often occurs in young adult life, the first
symptoms being a slight dyspeptic attack or a trifling sen-
sation over the stomach region, which the patient takes for
dyspepsia. Ocular weakness often begins the disease, or
peculiar sensations about the head or extremit ies. Sperma-
torrhoea also gives the patient a cause for complaint, when
in reality the symptoms are due to the commencing cere-
bral affection. After this manner many slight and pre-
sumably local ailments are treated as if distinct, and in-
definite names, as nerve exhaustion, spinal irritation, etc,
are given to them.
The mental condition is unobserved, and these con-
current symptoms are found to be exceedingly intracta-
ble and obstinate of treatment.
Symptoms. — The term disease is very aptly filled in by
this nerve derangement, since both mentally and physi-
cally the patient is without ease. The symptoms admit
of no distinct delineation, since they vary in form, time,
and course. A leading symptom is motor weakness,
which has been mistaken as a special disease, since it often
predominates and is necessarily much noticed by the pa-
tient. This symptom is also called nerve prostration or
brain exhaustion, when generally the brain was not over-
taxed. In fact this sign is often predominant in cases
where no brain labor has occurred, and it is also unrecorded
where, when, and how the nerve- tissue would give way
under severe exertion.
Normally the brain acts without the cognizance of the
body. In this mental affection the mind is painfully
aware of its relation to the body, and kt'.a its want of free
October 20, 1894]
MEDICAL RECORD.
487
and healthy action. This morbid attention is a great
source of annoyance to the sufferer, and, if free from this
condition, the mere debility or neurasthenia would not be
more wretched or prolonged than in any ordinary case
of convalescence. The attention is also fixed on the
sensory sensations or nerve currents passing through the
body. From at first indefinite sensations in various parts
a fixed attention occurs, causing uneasy sensations, foci of
neuralgic pains, which are misconstrued into disease of
organs situated near the painful spot. Even when these
constant and annoying pains occupy the attention of the
patient he is also aware of mental uneasiness. These
pains are most common over the epigastric region, and
around the lower ribs, on top of the head, in the mucous
membranes, in the outer side of the limbs. They usually
remain in the skin, though often the deep nerves are very
painful to pressure. The motor nerves are also much af-
fected. These normal nerve-currents are perverted in
some way until great weakness results, flabbiness of muscle,
and much want of power and endurance. The patient
feels fearfully fatigued after trivial exertion. This is so
often a very prominent symptom that it has received the
name of neurasthenia ; but it is sufficient to prove it but
a symptom to remark that when the mind is easy and gay,
or the patient's attention sufficiently diverted, that the
sense of fatigue is forgotten ; or again, the weakness is
cared in a day, when the mental ailment of the patient is
dissipated, and he feels like a new man. Belonging to the
sensory phenomena are several lesser signs, as heat flashes
in warm weather and cold thrills in winter ; the hair often
becomes rough and falls out, and even the skin chafes in
places and becomes red. When the sensory sensations
are not marked enough to cause neuralgia, the attention of
the patient being called to them, according to his mental
aspect, forms them into disease of the organs beneath.
The mind being very diseased, hypochondriacal fancies
arise, whereas if the patient is only depressed, the sensa-
tions act as a hypersesthetic skin trouble, but none the
less fix his attention and give rise to extreme annoyance.
The loss of power he could tolerate, but the indefinite
sensation is ever prominent and occupies his attention in
spite of all his efforts.
The mental aspect of the case is probably more per-
sistent than all the other symptoms, if it be not the cause
of the entire nerve derangement. It would be difficult to
say whether the mental perversion keeps up the morbid
attention and brings about the motor weakness and sen-
sory phenomena, or whether these disease the mind ;
but most likely they are effects of a morbid fancy, for
almost all cases entertain erroneous ideas regarding their
condition. If all neurasthenic cases were looked into,
mental irritability, weakness, and evident mental distress
would be found, though it were not developed into
marked hypochondriasis, as it is in many cases. But since
one set of symptoms, as the painful neuralgic feelings, are
intensified at one time, and the mental ill or cloud at an-
other, it is likely they are parts of the same brain change.
They do not form a distinct chain of events, as in mi-
graine, though frequently there are distinct remissions and
intervals of improvement, the morbid condition lasting
much longer than the interval of quiet.
The disease brings with it a long train of varying
symptoms in the sensory, motor, and mental systems of
the brain, and probably affects its entire mechanism
rather than that the mental perversion should cause the
concurrent symotoms. The obscurer centres of the
brain are also affected — the heart often beats slowly and
wants force and tension. The respiration often appears
to the patient as if about to stop, and is painfully felt.
The sympathetic system suffers, various vaso motor flushes
and perspirations occur, dryness of the lips and alimen-
tary canal, loss of aopetite. and constipation. The kid-
neys often secrete much pale urine, and often a cloudy
deposit of phosphates ; sexual weakness is common, or
much sexual irritability occurs The mucous membranes
are often painful, neuralgic feelings attack the roof of
the mouth, the anal region, etc. The voice is weak, and
some patients notice a change in its character — it sound-
ing not like their own. The mental aspect is very diffi-
cult to investigate. Some patients are distinctly hypo-
chondriacal ; some, as those instanced by Griesinger, even
to insanity ; others have very indefinite hypochondriacal
ideas, the fancy often changing, and ever within the
bounds of possibility; others do not interpret their sen-
sations as disease, but complain of great weakness and
annoyance. They believe themselves to be suffering from
no delusions, but are restless, irritable, and a peculiar
mental cloud teaches them that they are not themselves.
They suffer from marked melancholia, avoid society, and
are weary of life. The mind is depressed, though there
is no false motion of disease. The patients are conscious
of a foreign element in their existence. It takes posses-
sion of their motor, sensory, and mental life. They are
restless and sleepless, fear things and persons — morbid
anticipation is often very marked, and weakness of will
to act. They are highly conscious of themselves. The
memory is poor, for want of exercise. The foreign at-
tention in despite of the patient's determination absorbs
all his faculties. Concentration of attention to work is
impossible. A hypochondriac, in the usual sense of the
term, cannot be reasoned with, his morbid fancies ab-
sorbing all his attention, but in the less severe forms
where advice is sought in reference to loss of nerve-power,
painful sensations, etc., it is always well to carefully ob-
serve the mental aspect of the patient, since we must hope
for a cure by acting on our knowledge of this mental
state, and not on the athletic means which are usually
prescribed for this class of patients, such as cold baths,
etc., which strike not at the real disease, which is a chronic
perversion of mind, marked by depression, accompanied
with uneasiness of sensation, loss of power, and other ner-
vous phenomena.
Treatment. — The treatment naturally changes with
the character of the case. The hypochondriacal patient
cannot be reasoned with. Those cases where perverted
mental ideas predominate are difficult to cure, and run
through years of treatment. The less serious forms, and
the common form which is designated by the word neu-
rasthenia, is best aided by means which aim at the mental
cure of the case, rather than to try and tone up the phys-
ical loss of power. The course of the malady is always
extremely chronic; the less mental derangement the
sooner the cure. In many cases the mental " cloud " is
so slight as to be almost unobserved by the patient, jet
he finds when this depression brightens up that all the
other symptoms lessen ; the neuralgias cease, the loss of
power returns, the patient seeks society. On this ac-
count the proper treatment would be to act on the per-
verted disposition, divert the patient's attention, etc.
As in more protracted and usually insane cases, when the
patient feels himself he is returning to health, so like-
wise in those less manifestvand slighter cases, all the
symptoms disappear when this feeling of nominal self re-
turns.
It is evident that up to the present day no medicine is
of any utility in cutting short this hereditary perverted
action of the brain, which is so curiously allied to the
more serious form of mental aberration.
The so-called nerve-tonics are of very little good, and
often cause distinct harm. Arsenic often flushes the
head and heightens the sensory irritability and hyper-
esthesia of the skin. The stimulants make the mental
thought more distressed, no hilarity occurring as in
ordinary brain action. The carbon-compound remedies
are useless toward a cure, but relieve the pain and give
sometimes a shade of more natural and peaceful brain
action and cheerfulness. Bromides and chloral relieve
sleeplessness best, and the former continued for one year
may do much toward a cure. Blisters or plasters ap-
plied to painful parts are of little service. The hot
bath is pleasant before bedtime, but depends more on
the patient's frame of mind than on any special efficacy,
as indeed do any other drugs employed. The paiient is
perhaps better left without physic. The bowels take
488
MEDICAL RECORD.
[October 20, 1894
care of themselves. The dyspeptic derangements are
vastly exaggerated and probably depend entirely on su-
perficial pains in the skin over the stomach region.
Headaches are often constant, and also depend on the
sensations in the sensory nerves in the scalp. The
weakness of sight recovers itself. Massage is undoubt-
edly the best remedy for the motor weakness and sen-
sory pains — the very rubbing drives, as it were, the pain
to other parts, and gives agreeable relief and sleep.
Massage continued judiciously for six months would
probably cure any ordinary case of so-called neurasthe-
nia if the patient is satisfied to wait till the developmental
errors of his brain aright themselves.
X08 BbLLBViLLE Avenue.
THE SUCCESSFUL TREATMENT FOR THE
RESTORATION OF THE INJURED FEMALE
PELVIC FLOOR.
Bv F. D. BRANDENBURG, A.M., M.D.,
CLEVELAND, O.
ACriNO PROFESSOR OF GYNECOLOGY, WESTERN RESERVE UNIVERSITY; GYNECOL-
OGIST TO CHARITY HOSPITAL; CONSULTING GYNECOLOGIST TO CITY HOSPITAL,
ETC.
The consideration of the most successful treatment for
the restoration of the injured female pelvic floor is of the
greatest importance, not only to the specialist in gyne-
cology, but also to the general practitioner. The dark
and gloomy picture of ever-increasing suffering and mis-
ery entailed by the neglect of injury to the pelvic floor,
in happy contrast with the bright picture of relief and
cure by its proper restoration, is so common, so apparent
to the eyes of all, that it is unnecessary for me to offer
any plea for its performance ; but rather, it is my object
to elicit a practical discussion, to call forth the opinions
of the miny able surgeons who are readers of the Rec-
ord, so that the pathway of duty may be clearer as to
what is the quickest and best method for the cure of a
condition whose import is among the greatest. In order
to fully understand the importance of this lesion, and also
to give the desired relief, it is absolutely necessary, first
of all, to have a due appreciation of what constitutes the
normal pelvic floor. A mitral regurgitant murmur will
have but little significance to the student who as yet
djes not fully understand the normal heart-sounds; the
stethoscope is faithful in transmitting both normal and
abnormal sounds, but we must know the first before we
can appreciate the second.
Relaxation of the pelvic floor may present no visible
lesion, but its importance may be far greater than a lesion
apparent to all. This can only be fully appreciated by a
study of the normal pelvic fascia and muscles. Allow
me to briefly mention a few of the more important struct-
ures involved in the pelvic floor. The pelvic fascia is
attached laterally to the brim of the pelvis, anteriorly to
the lower portion of the symphysis pubis, posteriorly to
the spine of the ischium, and to a tendinous band, the
white line, j >ining these points. At the white line the
pelvic fascia divides into the recto-vesical fascia and
the obturator fascia. The recto vesical fascia, arising
from the white line, extends downward and inward, cov-
ering the levatores ani muscles, and uniting in the median
line with its fellow of the opposite side, forms the true
fascial floor of the pelvis. This fascial diaphragm is
perforated by the rectum and vagina, to each of which
it is attached and gives firm support. The fascial floor
is the girder, acting as a framework for the support of
the various organs and complicated venous plexuses.
The pelvic veins are without valves, but by their exceed-
ingly tortuous course overcome the force of gravity. In
relaxation of the pelvic floor, injury affecting the fascia,
the blood vessels lose their support, become straighter
and at the same time more distended, thus increasing
the weight in the pelvis and giving rise to the dragging,
bearing-down sensation so common in patients suffering
from lesion to the pelvic floor. The levatores ani arise
anteriorly from the posterior aspect of the pubes, near
the symphysis ; posteriorly from the inferior and inner
surface of the ischial spine, and between these origins
from the white line that represents the point of division
of the pelvic fascia, they extend downward and inward
and are attached to the vagina, the rectum, to each other,
and to the tip of the coccyx by a ligamentous insertion.
These form the muscular floor of the pelvis. The only
other muscles which have any special importance are the
transversus perinaei, which arise from the tubero-ischii
and are inserted in the median line at the junction of the
levatores ani and the pelvic fascia. It is the function of
the transversus perinaei to keep the pelvic fascia tense
and assist in keeping the vaginal walls approximated;
but in a lesion to the pelvic floor their normal action is
apt to be perverted by retracting the torn ends, increas-
ing the gap, and making a bad matter worse. The fas-
cial tension is more or less lost, air enters and balloons
the vagina, causing sogging of the vaginal walls, followed
sooner or later by retroversion uteri, cystocele, urethro-
cele, rectocele, amd prolapse in its various stages.
Injuries to the pelvic floor may be incomplete or com-
plete. Under incomplete we have two varieties : First,
in which the fourchette or vaginal mucous membrane
may or may not be torn, perhaps no visible injury ; but
there is submucous injury to the fascial and muscular
floors causing relaxation of the pelvic floor. Second,
in which the muscular tissues are injured and lesion
visible. In complete laceration of the perineal body,
the sphincter ani is ruptured ; and possibly more or leas
of the recto- vaginal septum ; the ends of the sphincter
will be found widely distant according to the amount of
the fascial retraction, due to the perverted action of the
transversus perinaei ; the vagina and rectum being thrown
into one common passage according to the extent of the
lesion of the recto-vaginal septum. The pelvic fascia is
not elastic ; if tension is made in one direction, com-
pensation must be made in another direction, and when
this is not possible, rupture is the result.
In a remarkable case I found the perineum a hard
ligamentous mass ; there was present a large recto- vaginal
fistula, the anus being very patulous; on inquiry I as-
certained that the child had been born through the anus.
Injuries to the pelvic floor from the use of forceps usu-
ally begin externally, first rupturing the fourchette and
then the deeper parts; but when unaided the injuries
are apt to begin internally, and we may have the various
fistula resulting, and finally the loss of the perineal
body.
Another factor of great importance is that of subin-
volution of the vagina, the normal process of retrograde
metamorphosis being retarded, owing to laceration of
the cervix uteri, so apt to accompany severe lesion of
the pelvic floor. Here it is necessary to repair the injury
to the neck of the uterus, and thus assist nature in re-
storing again the uterus and vagina to something like
their normal condition before one is warranted in re-
pairing the lesion to the pelvic floor.
In the treatment of these lesions we must naturally
consider, first the incomplete and then the complete
laceration of the perineal body. Each case requires its
own separate and appropriate treatment ; no set rule can
be applied to all cases. After a careful study of the
normal pelvic floor, each case will readily suggest its
own proper treatment. I care not what operation is
used, so that the operator fully understands the amount
of lesion present, and by his method is able to restore as
nearly as possible the normal pelvic floor. Above all
errors, there is none more deceptive than that of produc-
ing a skin perineum. The patient has been subjected to
the inconvenience of an operation, but her condition has
not been one whit improved.
The repair of the pelvic floor cannot be learned from
text- books; it must be seen to be fully appreciated and
understood.
Again, the matter of diagnosis is sometimes obscure. I
was called to see a lady suffering from incontinence of
faeces ; she had been delivered of a child three months
October 20, 1894J
MEDICAL RECORD.
489
previous. Her family physician assured me there was no
local difficulty ; but on examination I found a complete
laceration of the perineal body, also a tear up the recto-
vaginal septum for fully an inch and a half, fully ac-
counting for all of the patient's symptoms. On restor-
ing the pelvic floor her disagreeable symptoms were at
once cared. I may also add that in this case, as in many
others, the baby was kept from the mother's breast for
twenty- four hours immediately following the operation,
and then again allowed to nurse ; this is very impor-
tant, as there is no agent more powerful to produce invo-
lution than that of nursing ; it is nature's way of pro-
ducing retrograde metamorphosis, and when this law is
violated the patient invariably pays the penalty. When
attending a case of labor always have your sutures
ready for any possible lesion which may occur ; having
trimmed off any tags that may be necessary, the sutures
can be readily and quickly introduced, for the parts are
then benumbed ; there will be union by first intention,
a normal restoration of the pelvic floor, involution
hastened, and the patient spared months or even years of
suffering. In tying your sutures they should be snugly
but not too tightly secured, and thereby avoid any diffi-
culty from the tumefaction of the reparative hyperemia;
this applies to any period. Avoid multiplicity of sut-
ures. Use as few sutures as possible consistent with the
proper coaptation of the torn parts. I have seen twenty,
thirty, and even still more sutures used in complete lac-
eration of the perineal body involving the recto-vaginal
septum. I have also seen failures which, I am fully con-
vinced, were due entirely to the multiplicity of sutures.
It is to be remembered .we are dealing with erectile
tissue, and with such a profusion of sutures how else
cap it be but that the circulation is disturbed ; an inter-
ference with the normal action of the vaso-motor
apparatus, and we have the classical symptoms, rubor,
calor, tumor, dolor, and functiolsesa. The consequent
abscess cavity is obliged to fill by granulation, and while
it may not lessen the strength of the pelvic floor, it is de-
cidedly annoying to the patient.
In preparing a patient for perineorrhaphy, especially
in case of complete laceration of the perineal body,
much of the success of the operation depends on the
previous attention to regulation of diet and action of
bowels. It is my custom to begin fully one week be-
fore the operation with regulation of diet. Three days
before the operation, calomel, ipecac, and soda tablets,
containing calomel, \ grain, are given hourly till one
grain is taken. Two days before the operation several
free movements of the bowels are secured by the use of
Rochelle or Epsom salts ; and the day before the opera-
tion the lower bowel is throughly emptied by enema.
For fully twelve hours or more before the operation the
bowels are perfectly quiet and remain so till three days
after the operation, as will be described later when speak-
ing of the after-treatment.
With the patient before you, anaesthetized and in the
dorsal position, map out carefully the extent of the
lesion, as indicated by the caruncles or scars ; with the
tenaculum picking up a point on the crest of the recto-
cele or central portion of posterior vaginal wall, and
bringing it down to the topmost caruncles on either side
as already noted, so that the slack of the posterior vaginal
wall will be taken up and become slightly tense.
Through this point in the posterior wall a suture can be
passed and be useful as a guide during the operation, and
then removed when sutures are in place. Beginning at
scar on left side, denude a strip at edge of the vaginal
mucous membrane, down along fourchette and up to
scar on right side ; then beginning again at same point
on left side, denude a strip across the left angle to the
point on the crest of the rectocele, and continue across
right angle till end of first denudation on right side is
reached. You have now mapped out before you the
ordinary butterfly diagram. Still the borders denuded
the intervening tissue can quickly be removed ; in de-
nuding avoid the vessels as much as possible, especially
the venous plexuses ; scissors and tenaculum being used
in the denudation. If the scar extends up either angle,
or there is marked relaxation, a triangular denudation
should extend up the same. Small spurters can easily be
controlled by the mere application of the artery forceps ;
but if a vein has been injured, it should be carefully
ligated and clot removed. When completed, the denu-
dation should be the same height on either side, and as
nearly uniform as possible. In suturing I prefer the fig-
ure-of-eight suture, using heavy silkworm-gut and the
Hagedorn gynecological needle, one-half or full curve.
If the angle has been denuded, a figure-of-eight suture
should be introduced, with the ends of the suture at base
of triangle, then using two figure-of-eight sutures for the
trefoil denudation.
Two sutures are sufficient for an ordinary laceration ;
if the angles are involved, then one for each angle. With
the left index-finger in the rectum as a guide, the sutures
should be buried as deeply as possible to catch up and
bring together the torn or relaxed ends of fascia and
muscle. Placing a small loop of thread on base of sut-
ure, it facilitates the removal of suture at end of eight
days.
Silkworm-gut commends itself for the ease with which
it can be made aseptic, and its lack of irritation to the
surrounding tissues.
It is very rare to have pus from its use, and it gives but
little pain to the patient. In securing the sutures, the
limbs, which had been strongly flexed, are now brought
forward, the knees being held tightly together. A tena-
culum is placed in the angle at the base of the denuda-
tion, and downward traction is made, thus lengthening
the denuded portion. The torn or relaxed pelvic floor is
now brought together to its normal position, and by thus
taking up the slack in the pelvic fascia, giving the blood-
vessels their necessary support, it also soon assumes its
normal condition. The successful performance of repair
for complete laceration of the perineal body is one of the
most difficult feats of plastic gynecology. All that has
been said about incomplete laceration of the perineal
body applies also to complete, with the exception that,
beginning at the retracted ends of the sphincter ani mus-
cle, careful denudation should be made about the rec-
tum, down to, but avoiding injury of, the rectal mucous
membrane. After the sutures already described are in-
serted, with the addition of a few transverse sutures if
the amount of lesion is very large, last of all I unite the
rectal mucous membrane, using a continuous suture of
small-sized catgut and one-half curved needle with smooth,
round point ; having tightened my first layer of sutures,
and the edges of the rectal mucous membrane being in
perfect apposition, I then use a second layer, and even a
third layer of sutures if necessary, bringing in surround-
ing tissues and strengthening the same ; lastly, with the
knees in the proper position, the remaining sutures are
secured as already described. In both classes of cases
the after-treatment consists in keeping the patient quiet
on dorsal position, giving hot douches, using Kiistner's
glass catheter if patient is unable to urinate easily. No
dressing is used on the perineum.
On second day after the operation, calomel, ipecac, and
soda tablets are given as before operation, and on third
day a saline cathartic is given. The first movement
should be soft and liquid, and especially so in cases
where the rectum has been involved : in those cases an
enema containing glycerine and Epsom salts should be
carefully given, using pressure with tip of syringe back-
ward toward coccyx, thus avoiding the slightest tension
on sutures.
Daily movements should afterward be secured by ap-
propriate medication. Union by first intention is se-
cured in these cases, and success will crown your efforts
if the proper care is exercised. In the treatment of a
case of complete laceration of the perineal body, just as
much care should be exercised as in the treatment of a
severe fracture. In the one we have exudate, in the
other callus. In both cases it takes time and rest for
490
MEDICAL RECORD.
[October 20, 1894
the parts to solidify and become strong. This should be
firmly impressed upon your patient Some surgeons pre-
fer daily movements of the bowels immediately follow-
ing the operation, by the administration of continued
small doses of a saturated solution of Epsom or Rochelle
salts. Others prefer constipation for a week or more,
even using opium to accomplish the same. In the first
instance the constant vermicular action is apt to prevent
complete union; and in the second, the accumulated
scybalae are apt to do damage to the newly united tissue.
The golden mean of Horace applies here as well as in
many other cases. The object attained is paramount to
the agency employed ; whether you are the disciple of
an American or a European, the speedy and thorough
restoration of the injured pelvic floor is the goal, par ex-
cellence, to be reached: I am happy to state it has now
reached a stage of development which insures not only
relief and cure to the patient, but also a reasonable degree
of satisfaction to our worthy leaders after their years of
tireless exertion.
99 Hukon Strsbt.
THE SECRETION OF HYDROCHLORIC ACID
BY THE STOMACH IN HEALTH AND DIS-
EASE.
By M. GROSS, M.D.,
NKW YORK.
According to Rollett and Heidenhain the difference be-
tween the gastric glands at the pylorus and the fundus
consists in the fact that the former contain only small
bright nucleated cells (Heidenhain's Hauptzellen=main
cells), while the latter have, in addition, the spherical
large cells adjoining the membrana propria (Heiden-
hain's Belegzellen = covering cells). Heidenhain as-
cribes to the main cells the formation of pepsin ; to the
covering cells, the formation of hydrochloric acid.
The elaboration of the gastric juice is divisible into
two separate acts : the supply of the raw material by the
blood to the points of secretion, shown by the vivid red-
dening of the gastric mucous membrane coincident with
the beginning of the secretion ; and the chemical trans
formation of a portion of this material into the specific
constituents of the gastric juice by the gland cells.
The mere fact that an acid secretion is formed from
the alkaline blood bears witness to the specific activity
of the gland cells.
In what manner is free hydrochloric acid formed in
the gland cells from the sodium chloride supplied by the
blood ? H. Schulz has shown that alkaline chlorides in
watery solution are decomposed by carbonic acid, small
quantities of free hydrochloric acid being formed. Since
the blood circulating around the glands contains large
amounts of free carbonic acid, the combined effect ot
this acid can liberate a small quantity of hydrochloric
acid from the sodium chloride. As it is probable that
the formed free hydrochloric acid is almost immediately
expelled from the gland, the carbonic acid can again
displace a small amount of hydrochloric acid and thus
the process of transformation may continue. While the
gland cells expel the liberated hydrochloric acid into the
efferent duct of the glands of the fundus, the carbonate
of sodium formed at the same time passes back into the
lymph and blood-current (J. Munk).
Under normal conditions, as has been proved in the
case of fistula, the mere contact of a foreign body with the
gastric mucosa stimulates the secretion over a circum-
scribed area corresponding to the surface of contact.
But the secretion occurring in consequence of the me-
chanical irritation is insufficient ; it becomes at once more
energetic and loses its circumscribed character if absorp-
tion, though it be only of water, takes place at the same
time. The glandular activity becomes general over the
whole of the stomach and assumes its normal degree when
the organ contains nutritive fluids, which seem to exert a
powerful influence on the secretion, probably in a reflex
way. It is a well-known fact that the swallowing of the
tube by sensitive individuals may be a sufficient stimulus
for starting the secretion.
The first phenomenon which we can demonstrate in
all normal gastric contents at the height of the digestive
process is their acid reaction, which is due chiefly to the
excreted hydrochloric acid and to a slight extent to the
acid salts present in the contents of the stomach. At
this period the acidity is greatest ; it rises gradually to
this point from the onset of digestion, and again slowly
decreases. At the moment in which the gland cells are
stimulated into activity by the ingesta the secretion of
hydrochloric acid begins, and the latter at first forms salts
or hydrochlorates with the inorganic and organic bases,
giving rise to chlorides and hydrochloric albuminates. In
testing these combinations litmus-paper will turn red,
but free hydrochloric acid cannot be demonstrated.
Sooner or later, however, saturation occurs, and as the
glands meantime continue to secrete, free hydrochloric
acid then appears, which reaches its maximum at the
height of digestion and then lessens (Ewald).
After Ewald's test breakfast (a cup [}4 litre] of tea and
a roll weighing 35 gm.) the maximum of the secretion of
hydrochloric acid coincides with the beginning of the
second hour, and the hydrochloric acid secreted about
this time amounts to 0.15 to 0.2 per cent ; after a plen-
tiful mixed diet the maximum of hydrochloric acid secre-
tion ensues later. Although these figures are not invari-
able, they are so nearly correct that great deviations above
or below them must be looked upon as pathological.
As opposed to the normal scretion of hydrochloric
acid (euchlorhydria), we speak — 1. Of an anomalous se-
cretion of hydrochloric acid when we have to deal with a
retardation or acceleration of the otherwise normal acid,
that is to say, when the maximum secretion occurs much
later or earlier than the time above given. 2. The se-
cretion of hydrochloric acid may be diminished (hypo-
chlorhydria. 3. The secretion of hydrochloric acid may
be increased (hyperchlorhydria). 4. Hydrochloric acid
may be completely absent (achlorhydria). 5. There
may be combinations of the above enumerated anomalies
of secretion.
If we bear in mind that disturbances in the secretion
of hydrochloric acid (defect or access) may occur (a),
when the quality of the blood is morbid, thus favoring
or impeding the secretion of hydrochloric acid ; (£), in
disorders of the glandular apparatus in consequence of
inflammatory processes, ulceration, etc. ; (c), in central
and peripheral disorders of the vago sympathetic system ;
(</), in combinations of the last- cited factors, we must
agree with Boas, who states that an anomaly in the se-
cretion of hydrochloric acid per se does not indicate
with any degree of certainty the existence of a disease of
the stomach.
The access or diminution of the secretion of hydro-
chloric acid is a symptom which indeed bears some rela-
tion to the different types of disease, inasmuch as some
have a decided tendency to increase the secretion, others
to decrease or suppress it altogether. But this takes
place only to the extent in which the various morbid
processes are associated with anatomical or functional
disturbances which naturally cause an alteration in the
production of hydrochloric acid ; hence it is the degree
of this factor in the morbid process which determines to
what extent the secretion of hydrochloric acid is in-
volved. Admitting that nowadays, owing to succes-
sively perfected methods of examination and daily in-
creasing clinical observations resting on a strictly
scientific basis, we are on a firmer footing in arriving at
a correct diagnosis or in recognizing the indications for
a successful treatment ; yet it is true to day, more than
ever, that only the most careful consideration and appre-
ciation of all the symptoms developing in the course of the
disease, aided by all the diagnostic auxiliaries, will make
clear the nature of the affection we have to deal with.
When we consider the anomalies of secretion of the
several diseases of the stomach we find in acute gastritis
almost exclusively a lack of hydrochloric acid ; the sour
October 20, 1894]
MEDICAL RECORD.
491
eructations and vomiting in this affection are usually due
to acetic, lactic, and butyric acids.
In chronic forms of gastritis we recognize above all
the law of pathology, that chronic inflammations restrict
or paralyze the specific activity of the respective organs.
In those cases in which, despite the inflammatory condi-
tion of the gastric mucous membrane, there is hyperchlor-
hydria, the inflammatory symptoms are of a secondary
nature, being merely sequels or concomitant phenomena
of the over- production of the secreting apparatus due to
other, usually nervous, causes. In such cases the hyper-
chlorhydria exists in spite of the partial lesion of a part
of the secreting parenchyma, as the expression of an in-
creased activity of the intact remainder (Ewald).
^ In simple chronic inflammation (gastritis chronica
simplex) the hydrochloric acid is always diminished;
in mucous inflammation (gastritis chronica mucosa) the
hydrochloric acid is usually completely absent; in the
atrophic form (gastritis chronica atrophicans) we note
complete absence of combined and free hydrochloric
acid, i.e., of all the hydrochloric acid which is physio-
logically active. In the chronic forms of gastritis, too,
we often find, in consequence of the formation of acetic,
lactic, and other acids, eructations and rising o£ acid
material which blunts the teeth and causes also a burn-
ing, scratching sensation in the course of the oesophagus,
the so called heartburn or pyrosis ; the latter sensation,
if confined to the cardia, is also called cardialgia. The
cases, however, which are associated with an intensifi-
cation of the acidity of the normal gastric juice, i.e.,
with hyperchlorhydria, and those periodical cases in
which the acidity and quality of the gastric contents are
normal, despite the symptoms of pyrosis, as shown by
MacNaught,1 should be, with few exceptions, included
among the neuroses, as indicated above.
In atonic conditions of the stomach, as I have had oc-
casion to prove,3 we find the secretion of hydrochloric
acid variable in accordance with the state of the gastric
mucosa.
In dilatation, however, the chemical composition de-
pends on the cause of the dilatation. In dilatation
of the stomach, in consequence of cicatricial stenosis
of the pylorus and atonic conditions of the muscular
structure, we find almost exclusively a normal or in-
creased amount of hydrochloric acid in the contents
of the stomach. The hydrochloric acid may vary in
the same patient on different days despite an un-
changed diet. In dilatation of the stomach we not rare-
ly find the condition called continuous acid hypersecre-
tion, in which the stomach, after being emptied in the
evening, contains the next morning often considerable
quantities of fluid charged with hydrochloric acid, a
point to be discussed hereafter. All this shows that
the stagnation of the gastric contents exerts no per-
ceptible influence upon the secretion of the gastric
mucosa, as long as its secreting elements in general are
preserved*
The diagnosis of ulcer of the stomach seemed to gain
greatly in certainty by the fact that it was thought an
excessive formation of acid could be demonstrated as a
constant symptom. The credit of having first em-
phasized the occurrence of an increased secretion of
hydrochloric acid belongs to Riegel. Ewald declares:
In ulcer of the stomach the gastric juice always con-
tains hydrochloric acid, often excessive in amount.
More recent experience, however, has proved that while
hyperchlorhydria is frequent in ulcus ventriculi, it is by
no means constant.
V. Korczynski, and Jaworski, too, found in some cases
also an untimely — i.e., occurring in the empty stomach
— so-called continuous acid hypersecretion. Removal
of the contents of the stomach will show that such acid-
ity disturbs the digestion, the protolytic being rapid and
complete, the amylolytic slow and defective;. in other
words, all the meat is often well digested, while of the
1 Medical Chronicle, January, 1885. "
9 Atony of the Stomach, Medical Record, March, 1894. '
starchy matters a greater or less residue is found. Gold-
ing-Bird 1 first described the state of the hydrochloric
acid in a case of cancer of the pylorus with dilatation.
Kussmaul and his pupils, however, were the first to treat
this question methodically, and have shown that in the
large majority of cases of gastric cancer free hydrochloric
acid is absent, although such absence in this disease has
no specific importance and possesses merely the value of
a secondary symptom. More recent investigations have
disclosed additional no less interesting points. When
the carcinomatous new-formation occupies a small region,
and the associated inflammation of the gastric mucosa is
slight, the secretion of hydrochloric acid may continue
to be sufficient ; a possible subsequent lack of hydro-
chloric acid may be the result of the slowly developing
cachexia. When the carcinoma springs from the bottom
of a gastric ulcer, there may be at first even normal se-
cretion of hydrochloric acid, or perhaps hyperchlorhy-
dria. In the majority of cases, however, as stated above,
there is not only an absence of free hydrochloric acid,
but also of that loosely combined with salts. Yet this
lack of hydrochloric acid does not depend upon the
carcinoma per se, but on the associated catarrhal in-
flammation or the atrophic condition of the gastric
mucosa.
Ewald describes a case which proves that when the
cancer is localized and the mucosa intact the secretion
of hydrochloric acid may continue until a short time be-
fore death. In this case carcinoma developing on an
ulcer could be excluded.
While some authors look upon hyperchlorhydria and
hypersecretion as an anomaly of secretion in consequence
of organic lesions, and only in a small number of cases as
a neurosis, Ewald, among others, maintains that in most
cases, excepting those above enumerated, we are dealing
with a pure neurosis of secretion. In the succeeding
sentences I am following mainly Ewald's deductions.
This author looks upon hyperchlorhydria and hypersecre-
tion of the gastric juice as a sensory neurosis of the
secretory sphere. Of these two conditions the hyper-
chlorhydria, which must be strictly separated from hy-
persecretion, consists in an increase of the normal hydro-
chloric acid secretion, this excessive activity being due
to the irritation of the ingesta. Van Norden found
hyperchlorhydria as a primary neurosis, i.e., indepen-
dent of an organic lesion, in melancholia; Jolly, in hys-
teria. It occurs temporarily as a reflex phenomenon
after gall stone colic and renal calculi.
Hypersecretion or parasecretion, Reichmann's "Ma-
gensaftfluss," is divided into the acute or periodical, and
the chronic or continuous form. The former occurs, as
a rule, without increased acidity. It appears periodi-
cally, usually after eating, rarely on an empty stomach,
but seems to have no direct connection with the in-
troduction of ingesta. The condition is a functional
disturbance of the nerves of the stomach, which oc-
curs independently or as a local symptom of other
neuroses.
In chronic hypersecretion there is a continuous forma-
tion of gastric juice, which is usually excessively acid, so
that even the empty stomach contains larger or smaller
quantities of a fluid which may vary greatly in the con-
tained free hydrochloric acid, but whose degree of acid-
ity is always increased. In this condition, too, while
the tongue is remarkably clean and the appetite good,
we find, as a consequence of the irritation due to the
acid fluid, heartburn, gastralgia, etc., which troubles
disappear temporarily after an albuminous diet, contrary
to the pyrosis resulting from acid fermentation, in which
albuminous diet has no ameliorating effect.
There is also a nervous anacidity (anachlorhydria) of
the gastric juice in hysterical and neurasthenic patients
in whom, therefore, an organic disease of the stomach
can be excluded.
The relations between the secretion of gastric juice
and the diseases of other organs of the body have an
1 London Medical Gazette, 1843, vol. ii., p. 391.
492
MEDICAL RECORD.
[October 20, 1894
importance which must not be underestimated, for there
is hardly any internal disorder in which gastric digestion
is not largely implicated and associated with functional
disturbances. This subject is so extensive that I must
dispose of it here in a few words.
In diseases of the heart, lungs, and liver it is mainly
the circulatory disturbances which lead to symptoms of
congestion and their sequelae, chronic catarrhal condi-
tions of the gastric mucosa.
Diseases of the heart per sc have no influence on the
secretion of hydrochloric acid ; it is the chronic catarrhs
resulting from congestion which cause a diminution of
the secretion of hydrochloric acid.
In diseases of the nose I have made investigations
with the mucopurulent masses from a purulent rhinitis
and have found that the digestive power of an active
gastric juice is weakened by the addition of such nasal
secretions; small amounts of hydrochloric acid may
thus be neutralized when the secretory activity is de-
pressed.
In chronic diseases of the lungs, in phthisis, emphy-
sema, in chronic forms of bronchitis, etc., in which, as
stated above, circulatory disturbances and their conse-
quences come in question with reference to their influ-
ence on the secretion of hydrochloric acid, it depends
entirely on the extent of the anatomical and functional
disturbance present in the concrete case to produce a
corresponding effect on the gastric glands.
Hildebrand found that the absence of hydrochloric
acid in phthisis coincided with the rise of temperature.
As regards diseases of the kidney l Fenwick proved that in
chronic renal diseases the gastric mucous membrane like-
wise excretes urea, and that the latter during the process
of elimination irritates the mucosa of the stomach and
leads to catarrh, with consequent diminution of hydro-
chloric acid. Bernacki found that during oliguria and
oedema the diminution of hydrochloric acid was greater
than after the re-establishment of the urinary secretion
and the disappearance of the oedema ; as the quantity of
urine increased, so did the hydrochloric acid.
As regards the disturbance of hydrochloric acid secre-
tion resulting from diseases of the sexual organs, E.
Fleischer found diminution of the acid during menstrua-
tion. Recently I treated a neurasthenic patient who
was attacked after nearly every coitus with nausea and
gastralgic pains, sometimes associated with vomiting;
the vomited matters always contained excessive amounts
of free hydrochloric acid.
Rosenheim found in a number of diabetic patients a
temporary absence of hydrochloric acid which he inter-
preted as a neurosis ; in other cases he found the hydro-
chloric acid constantly absent and ascribed the condition
to an atrophy of the glandular apparatus.'
In anaemia and chlorosis the activity of the gastric
glands suffers in consequence of defective blood supply ;
but there are cases enough in which the secretion of hy-
drochloric acid is normal or even excessive.
Lastly, with reference to the secretion of hydrochloric
acid in malaria, I have found among fifteen cases of
masked malaria — further details will be given in another
place — nine in which the hydrochloric acid was dimin-
ished, while lactic acid was markedly increased.
In conclusion, I shall give the shortest methods for
the qualitative and quantitative determination of hy-
drochloric acid. By means of Congo paper we ascer-
tain whether any free acid is present in the filtered gas-
tric contents ; paper impregnated with Congo red be-
coming violet in the presence of acids. To determine
free hydrochloric acid we employ Gttnzburg's reagent
and mode of procedure. The reagent consists of phloro-
glucin, 2 ; vanillin, 1 ; alcohol (eighty per cent.), 100
parts. Of this solution we place one or two drops in a
china saucer and add one or two drops of the stomach
contents to be tested. If free hydrochloric acid is pres-
ent, a carmine red ring forms at the point where the two
fluids meet when the saucer is carefully heated.
1 Virch. Arch., Bd. xviii.
For the quantitative determination of hydrochloric
acid Leo's method is the most reliable :
Any present organic acids having been determined
and removed, 10 c.c. of the filtered stomach contents
are mixed with 5 c.c. of a concentrated solution ot
calcium chloride (CaCl,) and its acidity is determined.
Then 15 c.c. of the filtrate are mixed in a dry vessel
with dry chemically pure powdered calcium carbonate
(CaCoa), and after stirring are run through a dry filter.
Of this filtrate 10 c.c. are measured off, and air is
passed through to drive off the carbon dioxide (CO,) ;
then 5 c.c of calcium chloride (CaCl,) is added and the
filtration is repeated. The difference between the first
and second filtration shows the physiologically active hy-
drochloric acid.
776 Madison Avsmuv.
fgKogtzBS at ^fit&icsCi £clmtz.
Putrefactive Oases as Predisposing Agents in Typhoid
Infection. — Dr. Alessi has made experiments which
throw some light upon this subject. Rats, guinea-pigs,
and rabbits were confined in boxes with perforated
bottoms, and these boxes were then placed over open
privies or cesspools, or over receptacles containing the
evacuations of the animals. Notwithstanding that they
continued to eat well, the animals lost their liveliness,
and gradually pined. They were inoculated in this state
with a small dose of typhoid bacillus, with the result
that they died in twelve to thirty* six hours. The
examination showed signs of hsemorraghic enteritis,
swollen Peyer's patches and spleen, and typhoid bacilli
in the blood, liver, and spleen. The same dose had no
effect upon the majority of the control animals; only a
few showed slight symptoms of illness, and one died.
These experiments go to show that animals are rendered
highly sensitive to the typhoid bacillus by previous in-
halation of the gases of putrefaction. Alessi next inves-
tigated the isolated action of the various gases produced
in putrefaction, to ascertain if any one were capable of
creating the predisposition referred to. The result was
in each case negative. The same held good as regards
certain mixtures of these substances. — Centralblatt JUr
Bakteriologic.
Toxicity of Scalded orjBurnt Tissues. — In 1880 Les-
ser made some experiments to ascertain the effects of in-
jecting the blood of a burnt animal into a healthy one.
He seems, however, to have succeeded only in producing
certain functional disturbances, never a fatal effect.
Vassale and Sacchi followed a similar line of investiga-
tion, and studied the effect of extracts of parts actually
burnt or scalded, and of the non-affected parts of the
same animals, on healthy animals of the same or allied
species. Their researches show clearly that the juice of
parts burnt has a much more toxic effect on animals of
the same species than that of the non-burnt parts of the
same animal. This last juice, in its turn, has a toxicity
much greater than that of the juice taken from corre-
sponding parts of a healthy animal, which is, in fact,
harmless. All the juices from a burnt animal are highly
toxic, and generally produce lethal effects whether in-
jected hypodermically or into the veins of normal ani-
mals. The chief pathological effects produced were
marked subserous hemorrhages, in one case especially
marked in the duodenum. Filtration through porcelain
somewhat diminishes but does not destroy the toxicity
of the juices; boiling, however, renders them innocu-
ous, which lends support to the view that the toxic prin-
ciple is an albumose, or some substance coagulable by
heat. These results are of interest as bearing on the
mode of production of the after effects of burns, at-
tributed by Fo£, as early as 1881, to a process of auto-
intoxication. Not long ago Kianitzin (Ann. di Chiw.
e di FarmacoLy 1892) examined the blood, organs, and
urine of animals suffering from burns, and by Brieger's
method obtained a substance from them which" was not
October 20, 1894]
MEDICAL RECORD.
493
to be found in normal animals similarly treated. When
injected into normal animals it produced torpor, somno-
lence, reduction of temperature, slow, shallow respiration,
diarrhoea, and death. The necropsy showed nothing but
hyperemia of the brain and kidneys. This substance
was classed by its discoverer with muscarin, neurin, and
peptoxin. More recently Reiss (Archiv fur Derma*
tohgie und Syphilis j i., 1893) studied the effects of subcu-
taneous injection of the urine of patients suffering from
burns. Such urine was very toxic, and it was found that
it owed its properties to the presence of bases of the
pyridin group. In cases of severe burn he recommended
the speedy removal of the sloughed parts so as to mini-
mize the absorption of poisons formed in the lesion.
Vassale and Sacchi are of a similar opinion. They also
recommend the employment of every possible means —
such as keeping the burnt limb as low as possible, and
the application of bandages— of preventing the too rapid
absorption of the degeneration products, the toxicity of
which they have so rally established. — The British Medi-
cal Journal.
The Hephritis of Typhoid Fever. — In a recent article
on this subject by M. L6once Bodin, the author re-
marks that the forms of nephritis that supervene during
the course of typhoid fever are well known clinically
(The New York Medical Journal, August n, 1894).
They occur most commonly in patients affected with the
clasical form of dothienenteritis, with high fever, diar-
rhoea, rose-spots, tympanites, enlargement of the spleen,
and a more or less pronounced typhoid condition. The
renal accidents usually make their appearance during the
course of the second week. Albumin appears suddenly
and more or less abundantly in the urine, and its appear-
ance is accompanied by general phenomena of variable
intensity. When these phenomena are violent, as some-
times happens, they deserve the name of acute uraemia,
being accompanied by almost complete suppression of
urine and by oedema, and almost always terminating
fatally by convulsions or coma. In another form they
are less violent, but they are always grave. There is
blood in the urine, which is diminished in amount, and
the uremic phenomena are less intense. Finally, and
more frequently, still less severe derangements are ob-
served, characterized especially by an aggravation of the
general condition, by dryness of the tongue, by pains in
the loins, by headache, and by the appearance of a slight
amount of albumin in the urine. It is particularly in
this third form, happily the most frequent, that there is
especially to be observed an exaggeration of the symp-
toms proper to the typhoid fever, but with a very clear
renal character easily recognizable. In these forms of
nephritis microbes are generally found in the urine, or,
but much more rarely, in sections of the kidneys. Or-
dinarily they are micrococci, with or without the bacillus
of Eberth, streptococci, and staphylococci, the last-
named being far the most common. As these microbes
are habitually found in the intestinal canal, it is very
probable that they gain entrance into the blood through
the intestinal ulcerations, which are an open door to all
secondary infections ; consequently, these cases of ne-
phritis of typhoid fever are most commonly cases of sec-
ondary nephritis.
But typhoid nephritis may present various guises, and
the case reported showed very special characters in its
evolution, so that it seems to the author to be an exam-
ple of a particular class of cases, both clinically and bac-
teriologically. The patient, twenty-three years old, was
a night nurse employed in the Trousseau Hospital. She
was admitted into the Saint-Antoine Hospital on June
1 st. For about a week she had suffered with progressive
loss of strength, great lassitude on the slightest exertion,
invariable fatigue on rising, progressive and persistent
impairment of sleep, and continuous headache which re-
sisted antipyrine. She had lost her appetite and had
vomited a few times, but had no diarrhoea or bleeding
from the nose. On examination, the abdomen was
found soft and not distended ; there was no gurgling in
the iliac fossa or pain anywhere on pressure ; the tongue
was lightly coated and pale, but neither red at the tip or
at the border nor tremulous. There were no rose-spots
on the abdomen* After a minute search two or three
doubtful eruptive spots were found on the back, between
the shoulder-blades and on the lumbar region. The
spleen seemed somewhat enlarged. The temperature was
102. i° F. in the morning and 104 20 F. in the evening.
The lungs were normal, and the patient's general condi-
tion was good — she had no stupor, but slight prostration.
The urine was normal. After hesitating between influ-
enza and typhoid fever, the latter was diagnosticated.
On June 5th it was noted that during the night the pa-
tient had vomited abundantly and that the matter vom-
ited was greenish ; also that her general condition was
aggravated and that there was some stupor, with severe
headache, lumbar pains, and dryness of the tongue. The
urine was of a deep red color and contained a notable
quantity of albumin. The temperature, which had at
first been kept down with quinine, had now risen to
104.30 F. Baths of the temperature of 66° F. were
prescribed every three hours. On the 6th many red
blood-corpuscles were found in the urine, also blood-
casts and epithelial debris. Albumin was found in the
urine until the 25 th, after which it was present only as a
slight trace for a day or two and then disappeared defi-
nitely and the patient was in full convalescence. M.
Bodin calls attention to the fact that during the whole
course of the disease at no time were the ordinary ab-
dominal and pulmonary symptoms of typhoid fever ob-
served, only a moderate prostration during the early days.
The temperature curve was that of typhoid fever of me-
dium intensity, but the onset of the symptoms of nephritis
had been very definite and had impressed upon the dis-
ease a particular aspect. The small amount of albumin
found in the urine and the absence of oliguria, save at
the outset, are to be contrasted with the very decided
uraemic phenomena present from first to last.
The bacteriological examination of the patient's fluids
was made as follows : Beginning with June 6th, the urine
was collected every second day, examined, and inoculated.
On three occasions the blood from the spleen was inocu-
lated. The urine was removed from the bladder with a
sterilized metallic catheter after a thorough cleansing of
the vulva and meatus urinarius with soap and a solution
of corrosive sublimate. The urine, received into steril-
ized tubes, was placed on a centrifugal machine and cult- '
ures were made in gelose, gelatin, or bouillon directly
from the deposit thus obtained. The blood was taken
from the spleen by means of a Roux's syringe boiled for
an hour, and after previous disinfection of the skin over
the spleen. It was ascertained that from beginning
to end the urine contained a very great abundance of
bacilli having all the characteristics of the Eberth-
Gaffky bacillus. The existence of this bacillus exclu-
sively in the urine is considered remarkable by the author,
for most commonly in analogous cases there are numer-
ous associated microbes, especially staphylococci. Fur-
thermore, from the complete absence of the ordinary
intestinal symptom? of typhoid fever, he thinks it prob-
able that in this case the intestine was but slightly if at
all affected, so that there could not have been a second-
ary infection by the microbes which are ordinarily found
in the alimentary canal. The author hazards the hy-
pothesis, which he confesses is somewhat forced, of a
primary nephritis from infection with the Eberth bacillus,
or nephro typhus accompanied by a general condition
and a temperature curve resembling those of typhoid
fever without any of the usual symptoms of typhoid fe-
ver pertaining to the alimentary canal, the lungs, etc.
Granting this to have been the case, the Eberth bacillus
would have acted in this case as the pneumococcus acts
in certain kinds of amygdalitis in which the thermometric
curve and the general condition of a frank pneumonia
are observed without the slightest local sign of pulmo-
nary inflammation.
494
MEDICAL RECORD
[October 20, 1894
Clinical gejrartraimk
FOUR CASES OF RETINITIS FROM CHRONIC
DIFFUSE NEPHRITIS.
By DAVID WEBSTER, M.D.,
PROPSfSOR OP OPHTHALMOLOGY IN THB NSW YORK POLYCLINIC AND IN DART-
MOUTH MKOICAL COLLBGK; SURGSON TO THB MANHATTAN BVB AND BAR
HOSPITAL, NEW YORK.
Case I. — Mrs. E. R , aged sixty-three, consulted
Dr. C. R. Agnew and myself oq December 2, 1879. She
had had poor sight for many years, but could read until
three months ago. During the last three months her sight
has deteriorated rapidly.
R. V. = ^q. ; no improvement with glasses.
L. V. = counts fingers at one foot
Ophthalmoscopic examination shows incipient cata-
ract of both eyes. The right has a large plaque of retinal
exudation in the region of the macula. The left has
neuro retinitis with numerous hemorrhages of various
sizes and shapes scattered all over the fundus.
All the urine Mrs. R passed in twenty -four
hours was sent to Dr. E. A. Maxwell for examination.
Dr. Maxwell reported as follows : 1, Medium and broad
hyaline casts ; 2, epithelial and granular casts ; 3, no
albumin ; 4, low specific gravity ; 5, large quantity of
urine. Chronic diffuse nephritis.
Case II. — June 25, 1880. James W , aged sixty-
eight, manufacturer and merchant, married, never saw
well in the distance. He can read at the ordinary dis-
tance without glasses. For the last two or three weeks
his eyes have failed in reading and he has seen motes
and black threads and dark spots floating before them.
He has had no pain in his eyes and no headache. He
has been troubled a good deal with dizziness on stooping
or on suddenly turning his head. He has had a cough
for four or five years, and is weak and short of breath.
R-v. = VW; ttwith-^.
LV. = 1«AF;«with-1V.
As his pupils were very small that of the right eye was
dilated by means of an atropine wafer, to facilitate oph-
thalmoscopic examination. We found floating bodies in
the vitreous and minute clusters of changes in the retina
at the posterior pole of the eye.
June 26th. — Since the atropine wafer was put into the
eye there has been smarting and sensitiveness to light.
His bovels are perfectly regular. Ordered iodide of
potassium, gr. v. ter in die.
On June 30th his urine was examined by Dr. E. A.
Maxwell, who reported as follows: 1, Concentrated
urine ; 2, no albumin nor sugar ; hyaline, hyaline and
granular casts, medium and narrow, six to eight on a
slide; 4, yellow, finely granular, tubular epithelium; 5,
altered blood - corpuscles, scanty; 6, spermatozoids,
scanty; 7, oxalate of lime. Chronic diffuse nephritis,
granular contracted kidney, general or localized.
Examination of a second specimen four days later
gave similar results.
Case III.— September 17, 1880. John T. R ,
aged sixty-eight, married, says that he did a great deal
of writing last February and from that time till five or
six weeks ago he had a great deal of difficulty in reading,
and since that he has not been able to read ordinary
print at all. He comes up stairs with difficulty, due, he
says, to rheumatism, which he has had, more or less, since
1868. He had it very badly at one time, but was never
laid up in bed with it. He has been, for two or three
weeks at a time, so crippled with it that he had to crawl
up stairs and slide down. He has a poor appetite, and
dizziness, and constipation, the latter for the last two
years. He seldom takes physic, however.
Ophthalmoscopic examination shows peripheral opaci-
ties in the lower parts of both crystalline lenses. There
are old corneal opacities of the right, and both have an
astigmatic look. There are changes about the macula,
and a large area in that region looks somewhat (Edematous,
or hazy. Both anterior chambers are markedly shallow.
R- V. = ,U; TVVwith + f
L- V. =^; f|with + |.
A specimen of his urine, examined by Dr. Maxwell,
shows: 1, Quantity and specific gravity normal; 2,
medium and broad hyaline casts ; 3, tubular epithelium ;
4, pigmented bladder epithelium; 5, no albumin nor
sugar. Chronic diffuse nephritis.
Case IV. — February 25, 1882. Thomas A , aged
seventy-one, married, merchant, complains of a blur
over his right eye with scintillations. He says he was
always near-sighted. He is the victim of rheumatic gout,
and his family physician says he has organic disease of
the heart.
R. V. = U with - |.
L. V. = || with - ^.
Ophthalmoscopic examination shows staphyloma pos-
ticum of both eyes, that in the right being very exten-
sive. In the right eye there are retinal exudations
occupying the whole macular region.
Dr. Maxwell examined his urine and found : 1, Light
color; 2, low specific gravity (1017); 3, no albumin
nor sugar; 4, abundant hyaline casts (10 or 12 on a
slide) ; 5, scanty, altered tubular epithelium. Chronic
diffuse nephritis.
It is worthy of remark that there was no albumin
present in the urine of any of these patients. The diag-
nosis of chronic diffuse nephritis was based on the pres-
ence of casts, and other abnormal constituents of the
urine.
A FEW WORDS IN REFERENCE TO CARYO-
CINETIC CHANGES IN THE RED BLOOD-
CORPUSCLES.
By WILLIAM MOSER, M.D.,
PATHOLOGIST TO ST. CATHARINE*S HOSPITAL, BROOKLYN, K. Y.
Ever since Luzet drew attention to caryocinetic changes
in the red blood-corpuscle in infantile pseudo-leucaemia
(Jaksch) the discovery has stimulated many to further
research. It is well known that in the blood of infants
nucleated red blood-corpuscles are common even in
health. They are like a nucleus when at rest, round,
and exhibit no property of caryocinesis. It is possible
that it has this property, but it has not yet been demon-
strated in healthy infants. In infantile pseudo leucaemia
mitotic changes in the red blood-cells are so constant and
occur in such large numbers that Luzet regarded it as
characteristic for that disease, as a means of differential
diagnosis from other forms of anaemia. If we have an
infant with an enormously enlarged spleen, and by ex-
amination of the blood find large numbers of red blood-
cells in process of caryocinesis we are justified in making
a diagnosis of infantile pseudo leucaemia. But from a
given specimen of blood without a clinical history the
diagnosis cannot always be made, hence it is not charac-
teristic for this disease. I base this statement from a
specimen of blood taken from a case which was diagnosed
as scurvy by Dr. Fuhs at St. Catharine's Hospital. The
specimen showed the nucleus at rest, accessory nuclei, ir-
regular shaped nuclei, the nucleus split in half, the ro-
sette-shape, and large numbers in which the cells were
filled with threads and dots ; (chromatic corpuscles), as
though the specimen had been " fixed " in Flemming's
solution. The specimen was examined fresh and can be
preserved as well as those which are " fixed " and stained.
Askanazy recently reported a picture similar to the one
described above in a case of pernicious anaemia. He saw
caryocinesis and what he terms " karyolysis " (retrograde
metamorphosis of the nucleus) in quite a number of the
cells. In a fresh specimen he even saw different phases
of caryocinesis in a single red blood-cell. The subject
is in its infancy, and much may yet be demonstrated.
The conclusion can be safely made that caryocinesis in
the red blood-corpuscles is not characteristic for any
given disease, and further research may prove it to be
more common than we now regard it.
158 Ross Strbbt.
October 20, 1894]
MEDICAL RECORD.
495
THE TEMPERATURE OF TWO CHILDREN DUR-
ING SPASMS.
By PHILIP S. ROY, M.D.,
WASHINGTON, D. C.
I offer these two cases to support the views of Landois
and others in relation to the probable proximity of the
heat centres to the motor centres in the brain.
Cask I — A white child, five years of age, in the sec-
ond week of typhoid fever commenced to have spasms
confined almost entirely to the right side. When I saw
her the left side was hot and dry, the right (the side of
spasms) was cold and covered with perspiration, the tern-
t perature of the left axilla was 1030 F., and in the right
axilla 105^-° F. ; after spasms were controlled the tem-
perature was the same on both sides. The right side
was nearly completely paralyzed. The child lived six
days after I saw her, but she was the patient of another
physician who returned to the case.
Case H. — A white child, aged four months, suffering
with marasmus, had general spasms, the surface was cold,
each spasmodic seizure lasted about three minutes fol-
lowed by a period of rest lasting ten to fifteen minutes.
I found by several trials that during spasms the tempera-
ture was 1080 F., and during the period of rest 1030 F.
I made my observations at different hours. The child
lived six hours after the first spasm occurred. Two cases
cannot go far in proof; but if the subject has not already
been investigated clinically they may suggest to others a
similar line of investigation.
RIGHT-HANDEDNESS.
By J. F. HERRICK, M.D.,
OTTOMWA, IA.
It is not my intention to discuss the motor functions of
the brain, but it seems necessary to say a few words on
that subject to make clearer my position further on.
The motor area for the left upper extremity on the
right side of the brain includes the paracentral lobule,
the anterior central convolution, and the upper part of
the posterior central convolution. On the left side of
the brain the motor area for the right upper extremity
includes the paracentral lobule, the three upper quarters
of the two central convolutions, and a part of the upper
parietal From this it is evident that the motor area of
the left half of the brain, which presides over the move-
ments of the right upper extremity, is greater than that
of the right, which presides over the movements of the
left upper extremity. So it is with the areas for the
lower extremities. On the left, besides the parts corre-
sponding to the motor area on the right which presides
over the leg, it includes the greater part of the parietal
lobule.
The centre for speech is located about and beneath
the lower part of the fissure of Sylvius, and is confined
almost entirely to the left side of the brain. The area
on the right side which corresponds to the speech-centre
on the left may be destroyed and the functions of the
vocal organs remain normal. On the other hand, if an
injury be received by the speech area on the left side,
speech may be entirely lost and its recovery depend, es-
pecially in adults and those advanced in life, on the re-
pair of the injury. Then we see that the motor areas of
the left side of the brain are beyond doubt much greater
than those of the right. The questions that occurred to
me are : Why are the motor areas of the left half of the
brain greater in extent and better developed than those
of the right ? and what connection has this development
with " right handedness ? "
I will answer the second question first by saying that
I believe the greater development of the motor area on
the left side of the brain is a satisfactory reason for people
using the right hand more than the left. We will suppose
that in the child the left hemisphere of the brain is even
slightly better nourished than the right. That better
nourishment would cause an earlier development and
result in an earlier and more perfect performance of
their functions by the organs presided over by that
hemisphere. This being true, the right hand would be
brought into use first, and that use would react on the
left motor area and cause further development, both be-
cause of the exercise and by education. Allowing this
to go on until adult life and we would have a full fledged
right-handed man. Physiological exercise of an organ
acts in two ways in perfecting the function of that organ :
First, by increasing its nutrition and weight ; second, by
educating it so that it responds more promptly and per-
fectly to impulses sent out from the centre of volition. I
believe that in the adult the motor area of the left half of
the brain has been educated to respond promptly to any
act of volition ; therefore the readiness with which the
right hand is thrust out when anything is to be done.
We will now return to the first of the two questions
raised above : Why should the motor area of the left
side of the brain be better developed than that of the
right?
If we recall our anatomy we will remember that the
left common carotid artery comes off directly from the
aorta, while the right is a branch of the innominate.
The axis of the left carotid is an almost direct continu-
ation of the axis of the first part of the aorta, so that
it receives almost the full force of the ventricular systole.
In the case of the right side we have the innominate
coming off at almost a right angle from the arch of the
aorta. The right common carotid is a branch of the in-
nominate, the remainder forming the right subclavian,
and the combined area of the two vessels is greater than
the area of the innominate.
It is evident that in getting the blood through the arch
of the aorta, the right angle of the connection between
the arch and the innominate, and then through another
angle into the right common carotid, there must be con-
siderable loss of speed. Therefore, if the blood is
pumped through the aorta at the rate of twelve inches
per second, we may suppose that its velocity in the large
branches is ten inches per second. That would be the
rate in the left carotid, while in the right, owing to the
obstructions named above, the velocity of the blood
would be reduced to, say, nine inches per second, or one
inch less than that of the blood in the left carotid.
Therefore the volume of blood sent through the left
carotid in a given time, the vessels being of the same
size, is greater than that sent through the right, and the
amount delivered to the left brain is greater than that to
the right. As further evidence that the left half of the
brain receives more blood than the right, I submit the
fact that cerebral hemorrhage takes place much more fre-
quently into the left hemisphere than into the right.
The arrangement of the vessels being as we have said,
from the moment the child begins to breathe and the fora-
men ovale is closed, the left hemisphere of the brain is bet-
ter supplied with blood, and, as was said above, the natural
consequence is the earlier and more perfect development
of the left half of the brain, and consequently the func-
tions of the right side of the body.
In conclusion I would say that right handedness is
primarily due to the anatomical distribution of the blood-
vessels ; and secondarily, in its perfection, as seen in the
adult, it is the result of the education of the motor
centres of the left brain, added to, and primarily depend-
ent upon, the anatomical distribution of the vessels. In
the case of left- handed persons the explanation may be
anomalies in the distribution or size of the vessels.
Alternating Constipation and Diarrhoea in nine out
of every ten cases, Professor Keen says, will mean either
tumor or cancer of the rectum or colon. — College and
Clinical Record.
The Old Men's Tobaeeo. — The Socialist deputies in
the French Chamber have introduced a bill to provide
the inmates of houses for the aged with smoking tobacco
and snuff at a reduced rate.
49«
MEDICAL RECORD.
[October 20, 1894
Medical Record:
A Weekly Journal of Medicine and Surgery.
GEORGE F. SHRADY, A.M., M.D., Editor.
Publishers
WM. WOOD & CO., 43, 45, & 47 East Tenth Street.
New York, October 20, 1894.
THE PHYSIOLOGY OF BICYCLING.
Dr. Philip Tissi£, of Bordeaux, has made a physiological
study of the performance of a certain bicycler named
Stephane, and has drawn from it some conclusions which
should be of interest to the physician and the 'cycling
world {Archives de Physiologic, October, 1894). M.
Stephane attempted to see how many kilometres he could
ride in twenty-four hours. He succeeded in travelling
620 during that time, getting back home in very excel-
lent condition. He fell in weight during his trip from
70 kilogrammes to 63.650, being a loss of about fourteen
pounds. His food consisted of cow's milk, of which he
drank 2.58 litres. Besides this he took of tea about one
pint, of rum three ounces, of mint seven ounces, of lem-
onade a pint, and of champagne about three ounces.
American trainers would not consider this a very good
diet, but M. Stephane, though he rode almost continu-
ously, did not suffer from any stomach trouble. The
amount of urine passed during the trip was 1,500 litres,
and its specific gravity was 1.023. During the succeed-
ing twenty-four hours the amount fell to 1,250, and the
specific gravity rose to 1.032. The total urea during his
work was 17.07 grammes, while next day it rose to 31.85.
The urates, phosphates, and sulphates also, while normal
on the trip, were much increased in the succeeding
twenty-four hours. The toxicity of the urine was greatly
increased. While riding, the urine secreted was so poi-
sonous that 10 ctm. killed a rabbit weighing 1 kilo-
gramme ; on the next day it took 20 ctm. to accomplish
the same purpose.
M. Tisste concludes that while milk is a good food it
is not sufficient for prolonged and violent muscular work.
There should be more hydrocarbons, the proper ratio
being about one of nitrogeneous to five non-nitrogeneous.
Every person whose food is insufficient is liable to what
Tisste calls acute autophagism, i.e., the body eats itself
up, and the laborer emaciates rapidly. Excito motors,
like tea, alcohol, etc., ought to be given very carefully.
Their effects are temporary and become weakened by
repetition. We should add that all experience shows
that alcohol is not a proper excito-motor at all except
perhaps at the very close of effort.
Fatigue of the voluntary muscles may occur without
cardiac fatigue, and vice versa.
Every person who subjects himself to violent and pro-
longed muscular exertion places himself ipso facto in a
state of autointoxication. This toxaemia may become as
high as it is in the severe infectious fevers. Hence it is
highly important that a person who takes such exercise
should have perfectly sound skin, liver, kidneys, and
heart. The respiratory capacity ought to be large, and
the ordinary maximum should be nearly as great as the
forced maximum. Thus in Stephane's case he expelled
in ordinary expiration four litres of air (!) measured by
a spirometer. In forced expiration he could expel only
4. 1 66 litres.
THE SERUM TREATMENT OF PHTHISIS.
The treatment of phthisis by the serum of asses is dis- ,
cussed at length by Dr. Arthur Gamgee {The Lancet),
who has personally investigated Dr. Viquerat's claims.
The theory upon which the treatment is based is that the
ass and the mule are almost absolutely immune to tuber-
culosis. Hence their serum will confer an artificial im-
munity against tuberculosis in man, as that of immunized
horses does against diphtheria. Viquerat admits that
asses may be inoculated with tuberculosis, but they have
the disease mildly and always recover. He increases
their immunity by inoculations of tubercle bacilli. On
the forty-fifth day, when spontaneous cure has already
been more than completed, the animal is used to supply
the curative serum. With this object it is bled, and the
blood is allowed to stand over ice, so as to allow it to
dot and to permit of the separation of serum. To this
serum from 0.5 to 0.75 per cent, of carbolic acid is
added, and it is then stored in stoppered bottles until
required for use. About twelve cubic centimetres aze
injected every third day. Viquerat states that when the
immunized serum of the ass or mule is injected every
second day into guinea-pigs, which have been fifteen days
previously rendered tuberculous by the inoculation of
active tubercle cultures, the tuberculous glands which had
become enlarged and perceptible rapidly become smaller
and disappear, while the animal, instead of dying four-
teen or fifteen weeks after the inoculation, regains perfect
health. Twenty-five cases of human tuberculosis are re-
ported, but the results of the treatment are not yet very
brilliant.
THE HYGIENE OF SORROW.
In a recent issue of a New York newspaper an article by
Dr. Louise Fiske Bryson formulates some distinctly mod-
ern views upon the views of grief. The attempt to act
as if nothing had happened after the advent of some
misfortune, and to conduct life exactly as before, is one
of the greatest possible mistakes. It is an outrage on
nature, which she resents sharply in the end. Pay-day
comes sooner or later; and the overthrow caused by
blinding catastrophe arrives, even if deferred.
The nervous system requires complete rest after blows
caused by sorrow. Recent medical observations (Fer6,
Bassi, Schule, Zenker) show that the physical results of
depressing emotions are similar to those caused by bodily
accidents, fatigue, chill, partial starvation, and loss of
blood. Birds, moles, and dogs, which apparently died in
consequence of capture, and from conditions that corre-
spond in human beings to acute nostalgia and " broken
heart," were examined after death as to the condition
of their internal organs. Nutrition of the tissues had
been interfered with, and the substance proper of various
vital organs had undergone the same kind of degenera-
tion as that brought about by phosphorus or the germs of
October 20, 1894]
MEDICAL RECORD.
497
infectious disease. The poison of grief is more than a
name. To urge work, study, travel, the vain search for
amusement, is both useless and dangerous. For a time
the whole organism is overthrown, and temporary seclu-
sion is imperative for proper readjustment.
After some bereavement the custom of wearing mourn-
ing has a distinct moral value. But its period of use
must be brief: a few weeks, months, perhaps a year;
otherwise dense black draperies become a burden, an
aesthetic blunder, and a source of depression in them-
selves. For a time they have a place, securing consider-
ation from strangers and silence from mere acquaintance,
since sorrow is one of the touches of nature that makes
the whole world kin.
When there is nearness of relationship to nature, ram-
bles in the open air, days alone with the sea, alone in
the forest, console as nothing else can. Quiet, silent
drives, or even short journeys by rail, will reveal a new
heaven and a new earth to one fatigued and worn by
sorrow. Music, when it can be borne, has a soothing
power beyond words. Books, too, have their place,
those gentle companions without speech whose calm
society helps annihilate time and space, and who always
receive us with the same kindness. The familiar faces
of newspapers and journals bring a stray comfort that
even the tenderest heart is powerless to bestow. The
care and companionship of children is another source of
strength. Children are not watching to see how the
afflicted are bearing up under sorrow, nor are they wait-
ing for some expression of sentiment or the overthrow
of self-control. A child is always the best comforter,
uttering no word of sympathy, yet rousing interest in
life because its nature is sweetness and light
Grief cannot be ignored, neither can it be cheered up.
It must be accepted, and allowed to wear itself away.
Readjustment comes slowly. Sorrow, grief, and all
great misfortunes should be regarded as conditions simi-
lar to acute infectious diseases, which they resemble in
result ; and later, as convalescence from such diseases.
Seclusion, rest, sleep, appropriate food, fresh air, sun-
shine, interests that tax neither mind nor body, these
are requirements in this class of illness. The care of the
condition following depressing emotion calls for the
same treatment in greater or less degree.
WATER-BAG BURNS.
It would scarcely be believed by one without subjective
or objective experience in the matter that an ordinary
rubber water-bag, filled with what usually passes for hot
water, would be capable, when applied to the human
skin, of producing an extensive and deep burn. All are
familiar with this effect from the careless use of the hot
water-bottle, and the surgeon seldom fails to see to it per-
sonally that a proper protection separates the glass from
the skin. Conditions of shock, lowered vitality, faulty
circulation, with exsanguinated and cold extremities are
those in which heat is most often sought to be externally
applied by this means, and it is just in these states of les-
sened power of resistance that the tissues are most apt to
suffer. Since it is not so generally known that the rub-
ber bag is possessed of decided powers for evil as well as
for good, it may be well for the trained nurse, no less
than the physician, to be reminded of it. At a recent
meeting of the New York Dermatological Society the
question was brought up for discussion by the report of
a severe burn with deep destruction of tissue extending
through the subcutaneous fat. An operation had taken
place, and the water-bag had been applied to the feet
while the patient was still under the anaesthetic. Sev-
eral of the members present at the meeting had been
consulted in similar unfortunate accidents, and as these
are just the cases which sometimes cause patients to think
they have grounds for legal redress, a note of warning
may cause us, conscious of having done no harm ourselves,
to feel beneath the covers and make sure that the nurse is
allowing none to be done.
THE CURE BY FAITH.
New Jersey has ever had an enviable reputation for fair-
dealing and quick justice. It is seemingly hard upon the
young New York doctor when the heat of July beats
down upon this side of the Hudson that he cannot freely
transpose the seat of his usefulness to Asbury or Spring
Lake without prolonging his journey to Trenton and
his agony in a three days' strict "Exam." The jus-
tice comes in when the quack, driven from our inhos-
pitable shore seeks to find a lodge in the vast wilderness
of Jersey City Heights.
The struggle to maintain the State's medical rights, in
the first place for Jersey physicians, and secondly for those
who are reputable, is beginning to show signs of suc-
ceeding. An indictment has just been found against a
faith-curist, who is to be tried under the new law, passed
through the efforts of the State Medical Board of Ex-
aminers, making it a misdemeanor for any faith-curist
or tnind-healer to practise in the State.
We do not take it that the Board denies the value of
faith or the great influence which may be exerted upon
disease by mental processes. They have, however, started
out to see to it that whoever wishes to engage in the
healing of the sick must show himself to be properly
qualified. Once the examination passed, the successful
candidate may employ faith, hypnotism, or any other
form of mind influence alone, if he and his patients
prefer it to the usual way of giving it mixed with
drugs.
The trial about to take place should attract some at-
tention, being the first since the act went into effect, and
it is said will be fought on the ground that it is not con-
stitutional.
An Order of Medical Monks has been founded in this
city in connection with the Episcopal Church. The
object of the order is thus expounded by Father John-
son : " The text of the order," he said, " will be « Heal
the sick, and say unto them, The kingdom of God is come
nigh unto them,' taken from St. Luke x. 9." The order
was the idea of Mr. Davidson. It is the intention to
found an order of medical monks, who will be connected
strictly with the church, and who will devote their time
to the poor and sick of the parish. The only compensa-
tion which the members of the order will receive will
be what the parishioners can afford to give them. The
members of the order will rank as deacons in the church.
There are at present two novitiates, of whom one is a
trained nurse, the other a medical student.
498
MEDICAL RECORD.
[October 20, 1894
fjst»s of Uxc W&ttfi.
Unveiling of the Sims Monument. — The ceremonies
of the unveiling of the statue of Dr. J. Marion Sims will
be held at 3 pm, on Saturday, October 20, 1894, in Bry-
ant Park, New York (Forty-second Street and Sixth
Avenue). Addresses will be delivered by Drs. George
F. Shrady and Paul F. Mund6, after which the statue
will be formally presented to the city of New York, on
behalf of the medical profession of this and other coun-
tries, and will be accepted for the city by Mayor Gilroy.
The medical profession and public are respectfully in-
vited to be present.
Soon after Dr. Sims's death, in 1883, the move-
ment for the erection of a bronze statue was set on
foot by the Medical Record, and the necessary funds
were subscribed by members of the medical profession
in this and other countries. American sculptors were at
first asked to compete in a design for the work, and
when all the designs submitted were rejected by the com-
mittee having the matter in charge, the commission for
the statue was awarded to Miiller, of Munich.
The House-warming of the Hew Bloomingdale Asy-
lum.— The patients of Bloomingdale Asylum were re-
cently transferred from the old site on Harlem Heights —
which had been occupied for almost three-quarters of a
century— to the new institution near White Plains. The
removal was made by easy stages, and without unpleas-
ant incident. The new establishment being in running
order, invitations were recently issued to members of the
profession likely to be interested in this line of medicine
to inspect the new building. A large number of New
York physicians accepted the invitation, and were shown
through the institution last Wednesday afternoon, and
pleasantly entertained by the officers of the Asylum. The
new Bloomingdale is located just on the outskirts of the
village of White Plains. The main building stands on a
broad hill-top, commanding a fine inland view. It
presents a very pleasing exterior, with little of the prison-
like aspect that usually characterizes asylum buildings.
Within, its appointments are all that intelligent study of
the prominent asylum plants in the world, backed by
abundant means, could make them. The building is
fireproof throughout, and the utmost attention has been
given to its sanitary features. It is supplied with water
from springs on the Asylum property. The sewage sys
tem connects with that of the neighboring village. The
Asylum has its own electric plant, ice machines, and the
like. A special feature of the institution is that most of
the peculiar advantages of the cottage system of archi-
tecture are secured without the sacrifice of the conven-
iences of the linear system. The entire main building
may be said to be under one roof, inasmuch as closed
corridors connect its various sections, yet these sections
are, for most practical purposes, independent and de-
tached buildings. One section of each wing has been es-
pecially constructed for hospital wards. In a word,
nothing has been omitted that could help to make
the new Bloomingdale strictly up to date in all its ap-
pointments, and the peer of any asylum plant in the
world. The credit for its many excellencies is very
largely due to the Medical Superintendent, Dr. Samuel
R. Lyon, who for many years has made hospital con-
struction a special study, and who drew the original
plans for the new Bloomingdale, and directed and super-
vised the work of construction with unremitting energy.
Whatever differences of opinion may exist as to the ideal
plan for an asylum, it must be conceded by everyone
that Dr. Lyon has succeeded in combining the best feat-
ures of the various systems to a remarkable degree in the
New Bloomingdale.
Dr. Charles H. Pinney, of Council Bluffs, la., died
from injuries received in a railroad accident, near Lin*
coin, Neb., on August 9th. He was Professor of the
Principles and Practice of Medicine in the Medical Col-
lege of Council Bluffs. During the Civil War he served
as surgeon in the Ninth Ohio Cavalry. Dr. Pinney was
fifty-two years old at the time of his death.
The State of Connecticut is agitating the question of
establishing a State Commission in Lunacy. " Don't"
Dr. Stuart Douglas, resident physician for the insane
at Bellevue Hospital, died on October 14th, of Bright's
disease. Dr. Douglas went to Alexandria, Va., about six
weeks ago to attend his father's funeral, and when he
returned to this city he complained of feeling ill.
Dr. Douglas was born in Alexandria thirty-three years
ago. His early youth was spent at Leesburg, Va. He
is a graduate of the academic and medical departments of
the University of Virginia, and came to this city in 188 1,
taking a post-graduate course at the College of Physi-
cians and Surgeons. He was appointed to take charge
of the insane at Bellevue on October 26, 1887, and was
the only salaried physician at the hospital. Dr. Douglas
was a member of the Southern Society, the American
Academy of Medicine, and the Society of the Alumni of
Bellevue Hospital, and Instructor in Mental Diseases in the
Post-Graduate Hospital. The last piece of work that he
did was the writing of an article on " The Treatment of
Melancholy" which appeared in the Post-Graduate.
Skunks and Typhoid Fever. — The skunk farm and ty-
phoid fever epidemic are two of the unpleasant things
with which the residents of Beadner, Wood County,
O., are now contending.
The Decreasing Death rate. — A statement prepared
by the Health Department shows that the death-rate of
this city has been lower this year than since 1884, though
then it was low as compared with the average of the pre-
ceding years. Moreover, the number of deaths, says
The Sun, has been less actually than in any year since
1890, though meantime the estimated population of New
York has increased by more than a quarter of a million,
or from 1,705,980 in 1890 to 1,957,452 in 1894. If the
mortality for the remainder of the year be the same as in
the corresponding period of last year, the total for 1894
will be less than in 1893 by more than 2,500. The
experience since January, and the present condition of
the city as to health, indicate the probability that this is
an overestimate of the mortality for October, Novem-
ber, and Decembef, and that actually the total number
of deaths in 1894 will be less than in 1893 by toward
three thousand, or not much above the total for 1890,
which was 40,103. This would make the death-rate, or
the mortality proportionately to 1,000 in the population
annually, about 21 in 1894, as compared with 23.51 in
1890.
October 20, 1894]
MEDICAL
Dr. John Y. McGay died on October 13th, at his home
in Brooklyn, forty years of age.
Sir Joseph Lister. — It is proposed to present Sir
Joseph Lister with a memorial on the occasion of his
retirement from active work.
Doctors as Companions. — The following passage from
Mr. James Payn's " Gleams of Memory," now appear-
ing in the Carnhill Magazine, will be interesting to
members of the medical profession : " Upon the whole,
and for a ' scratch ' companion, I prefer a doctor to a
man of any other calling. He may not be very good as
a conversationalist, but he is rarely very bad, like a
cheroot. He has had a genuine experience of life, and
has seen down to the depths of it ; a sick man does not
attempt to deceive his doctor, or put the best face on
his character, as he does with a priest. Moreover, what
is very unusual, your doctor knows more about you, pro-
fessionally at all events, than you know about yourself.
He does not tell you about it, it is true ; not a word of
that aneurism you carry about with you, and which will
some day kill you in half a minute, but your conscious-
ness that he may possess such knowledge makes him in-
teresting. The best suggestions I have had made to me
for plots for my novels have come to me from doctors,
to whom I have also had cause to be grateful for many
things."
The Perils of Football.— We have received from a
correspondent, in reference to the fact that many serious
accidents, and more than one death, have already, and
thus early in the season, been reported from the football
field, the following letter : " All lovers of football, both
players and spectators, would rejoice if accidents due to
football were of less frequent occurrence ; and I feel
sure that such would be the case if these suggestions were
carried out : 1. Give the linesmen, as well as the ref-
eree, power to stop the play for a foul charge or hack.
2. Let the spectators desist from such cries as ' Pay him
out,' etc. 3. Let the players wear tennis shoes, and not
boots with steel plates inside the toes, as I know the
modern boots are now made." We agree with our cor-
respondent's first two suggestions, and go further. It
has always been our cry — and we have been pleased to
see it taken up and echoed approvingly by our contem-
poraries, medical and lay — that the strengthening of the
authority of the referee, coupled with more drastic pen-
alties for the wrongdoer, must be the most practical
method of preventing accidents that arise not so much
from the essential laws of the game as from "bad
blood." And certainly such cries as " Pay him out "
are the very things to rouse the evil spirit. Our corre-
spondent's third suggestion is not so sensible. Firstly,
nailed and steel-shod footgear is not permissible by the
laws of the game ; and, secondly, india-rubber soles
would practically alter the game. — The Lancet.
The Attraction of Football for Intellectual Men. — In
an article on the present state of college football, Profes-
sor E. L. Richards, of Yale, speaks of the attractions of
the game for intellectual men as well as for the student
of muscular science. He says, speaking of the relative at-
tractions of football and other athletic games : " That
the game has had attractions for intellectual men in the
past is shown by the fact that the average scholarship of
men on the football teams has of late years been higher
RECORD. 499
than that of men in the other athletic organizations. In
the years 1879 to 1888 the average standing of men not
on athletic organizations was, on a scale of 4, 2.69 ; for
members of the university boat crew the average was
2.52 ; for members of the baseball nine it was 2.41 ; for
members of the football team it was 2.68. Track athlet-
ics were not in existence as an organization through the
whole decade, but for the few years when there was a
university team the average was 2.66. In the previous
decade, 1869 to 1878, it is only fair to add that the aver-
age of the football men was slightly below that of the
other athletes, it being 2.51 to their 2.56. I can only
account for the fact of the rise of the average in the sec-
ond decade by the change in the numbers of the team
from twenty to eleven — a change giving opportunity for
more skill, thus rendering the play more attractive to
men of mind. Notwithstanding the present style of
mass play, which puts a premium on physical strength
and weight, it was a surprise to me to find that the aver-
age scholarship of the sixteen men from the academic
department, including players and substitutes, was
higher than the average of any class which ever gradu-
ated. I cannot believe, however, that the high scholar-
ship of football players will always prevail, unless the
style of the game be changed to one which admits of
more open play. The present style of mass play and
momentum play puts a premium on weight and brute
force. The mingling men in masses make injuries more
probable than in an open style of play. The mass play
makes the game as little as possible a kicking game. It
eliminates a great deal of the element of skill. Skill
ought to be encouraged by setting some sort of premium
on it. Increasing the number of points scored by a
drop kick from the field might accomplish this some-
what Some changes in the rules regarding ' interfer-
ence ' would do more. If, again, ' the warnings ' for
' rough play ' were entirely omitted, and the umpire were
instructed to send a man off the field at the first offence,
captains would train their men to avoid these plays en-
tirely. Then the experts, in reforming the game, could
not do better than turn their attention to the umpires.
If a plan for training umpires could be devised it would
be a good thing."
Philadelphia as a Medical Centre. — According to the
Philadelphia newspapers that city is again asserting its
right to special prominence as a medical centre. The
census of the medical schools is as follows :
University of Pennsylvania, .... 875
Jefferson, 700
Hahnemann, 325
Medico-Chirurgical, 300
Woman's, 200
2,400
Physical Culture in Unhealthy Schools. — There are
one hundred and eighty sanitarily defective schools in
Chicago, and the city spends about £4,000 annually on
an athletic overstrain fad called "physical culture,"
whose chief purpose seems to be to provide " professional
foreigners" of the ward-heeler type with an occupa-
tion. The money wasted on this " physical culture "
humbug could be advantageously employed in rem-
edying the sanitary defects of a few schools. — Medical
Standard,
500
MEDICAL RECORD.
[October 20, 1894
%mixms and polices at Qoofos.
Pain in its Neuro-pathological, Diagnostic, Med-
ico-legal, AND NEURO - THERAPEUTIC RELATIONS.
By J. Leonard Corning, A.M., M.D., Consultant
in Nervous Diseases to St. Francis9 Hospital, etc.
Illustrated. Philadelphia: J. B. Lippincott Com-
pany. 1894.
As an aid to diagnosis in nervous disease the author
considers pain unique in importance. The insomnia
and melancholia induced by it are in themselves matters
of serious moment. The special therapeutics of pain are
given in detail and evince much conscientious research.
This work is one of marked originality and careful
thought There is in it much to interest the general
reader. In point of letter-press, binding, and paper,
the book presents attractions that the student cannot
fail to appreciate. The illustrations are clear, and add
to the value of the text.
The Care and Feeding of Children. A Cate-
chism for the Use of Mothers and Children's Nurses.
By L. Emmett Holt, M D., Professor of Diseases of
Children in the New York Polyclinic, etc. New
York: D. Appleton & Co. 1894.
This Catechism was originally designed for the pupils in
the Practical Training School for Nursery maids, estab-
lished in 1889, and compiled to meet the need felt for
some simple manual. A series of questions and answers
was made out, on matters of every-day practical observa-
tion and careful hospital work. The Catechism is now
given to the public, with the hope that it may serve a
useful purpose in other institutions, and be of value to
mothers and to the ordinary untrained child's nurse.
The essentials are strongly emphasized in the form of
questions and answers. The first part, devoted to the
care of children, treats of such subjects as bathing, eyes,
skin, mouth, clothing, nursery, weight, weaning, etc
The second part deals with infant feeding. And the
third is devoted to miscellaneous topics, as sleep, teeth-
ing, walking alone, convulsions, colic, contagious dis-
eases, etc. The advice given is excellent and perfectly
clear, and goes over all the ground concerning which
the doctor is so often questioned. If it could be fol-
lowed by those who read, it is safe to say that disease in
infancy would rapidly diminish and the happiness of
childhood be greatly increased. Sixty-six pages of good
advice are given, all for fifty cents. Less than seven
inches long and about five wide, Dr. Holt's Catechism
contains in most convenient form all the precepts of
modern nursery orthodoxy.
Small Hospitals, Establishment and Maintenance.
By A. Worcester, A.M., M.D.; and Suggestion for
Hospital Architecture, with Plans for a Small Hospital,
by William Atkinson, Architect. New York : John
Wiley & Sons. 1894.
This is one of the subjects that at present occupies the
public attention — the building and management of hos-
pitals in small towns and villages. Dr. Worcester's book
answers the questions that directly confront the promot-
ers of such schemes for public welfare. In Part I. full
directions are given for inaugurating the hospital and
for arranging its management. Part II. is devoted to
plans for buildings and hospital construction. While
thoroughly up to date and embodying the best principles
of such work, the book is not too technical for the gen-
eral reader. The author realizes that much as the suc-
cess of a hospital depends upon its medical and surgical
staff, even more does it depend upon its nursing service.
The best plan is to. have the nursing service done by the
student nurses of some training school, in order to se-
cure ambitious, capable young women who are by nature
fitted to undertake such work. There were no real
trained nurses until some years after the war. It will be
a great surprise to many to learn that in former times in
Bellevue Hospital the nursing was intrusted to women
who in the police courts chose a term of service as hos-
pital nurses when the alternative of a term of imprison-
ment was given them ! The book is earnest and well
written, and the plans offer the greatest possible economy
of space, together with convenience and harmony of de-
sign.
Diseases of the Skin. An Outline of the Principles
and Practice of Dermatology. By Malcolm Morris,
Surgeon to the Skin Department, St. Mary's Hospital,
London, etc. With eight Chromolithographs and
seventeen Wood-cuts. Philadelphia : Lea Brothers &
Co. 1894.
The clearness of this book, together with its good illus-
trations, careful arrangement, and the practical clinical
presentation of skin diseases that it gives, makes its prob-
able destiny one of general and well merited popularity.
All important schemes of classification are referred to,
and that of Unna followed in the main, die author feel-
ing convinced that whatever changes may come about in
the manner of looking at diseases of the skin, increased
knowledge cannot alter the principle upon which this is
based. The chapters on pathology and diagnosis are re-
markably interesting, the latter enunciating practical
principles of definite value. Affections of the skin de-
pendent on nerve disorder are next considered; then
artificial eruptions, eczema (thirty-four pages), pityriasis,
psoriasis, local inoculable diseases, general inoculable
diseases, diseases of the skin- glands and epidermic
appendages, new-growths, and malformations. In the
matter of treatment, which is always possible and unusu-
ally practical, great stress is laid upon the care of the
patient and his general condition, factors sometimes
overlooked in the supervision of abnormal states appar-
ently so definitely local as troubles with the skin. Of
convenient size and easy to handle, Dr. Morris's book has
everything to recommend it.*
Handbook of Obstetric Nursing. By Francis W< N.
Haultain, M.D., F.R.C.P. Ed.; Lecturer on Mid-
wifery and Diseases of Women School of Medicine ;
Obstetric and Gynecological Physician Royal Dis-
pensary; Examiner Royal College of Physicians,
Edinburgh; and James Haig Ferguson, M.D.,
F.R.C.P. Ed., M.R.C.S. Eng. ; Lecturer on Mid-
wifery and Diseases of Women School of Medicine ;
Obstetric Physician New Town Dispensary ; Examiner
Royal College of Physicians ; Late President Royal
Medical Society, Edinburgh. Second Edition, Re-
vised and Enlarged. With Thirty - three Wood En-
gravings. Philadelphia : J. B. Lippincott Company.
1894.
This is a well arranged handbook for the guidance of
monthly nurses and midwives, written in clear and sim-
ple language, very neatly printed, and of convenient size.
The authors are teachers who have had practical experi-
ence in the needs of obstetric nurses, and their book is
one that can be recommended. The illustrations are
instructive, and a good index facilitates reference.
The Jewish Method of Slaughter Compared with
Other Methods, from the Humanitarian, Hygien-
ic, and Economic Points of View. By J. A. Dembo,
M.D., Physician to the Alexander Hospital, St. Peters-
burg ; Member of the St. Petersburg Medical Society ;
Member of the Society for the Preservation of Public
Health, etc. Translated from the German, with the
Author's Amendments. London : Kegan Paul, Trench,
Trttbner & Co. 1894-
The basis of this book is the report of an investigation
into the Jewish method of slaughtering animals, by cut-
ting the carotids and other large vessels of the neck,
undertaken at the instance of the Russian Societies for
the Prevention of Cruelty to Animals. The author be-
lieves that such a method, used to-day we believe in New
York, inflicts a minimum of suffering upon the animals,
produces whiter and firmer meat, and, from the point of
October 20, 1894J
MEDICAL RECORD.
501
view of the purchaser, is the more economical. His
argument is well sustained, and certainly seems to prove
his point.
Inebriety or Narcomania. Its Etiology, Pathology,
Treatment, and Jurisprudence. By Norman Kerr,
M.D., F.L.S. ; Fellow of the Medical Society of Lon-
don ; President Society for the Study of Inebriety ;
Chairman British Medical Association Inebriates
Legislative Committee; Consulting Physician Dal-
rymple Home for the Treatment of Inebriety ; Vice-
President International Congress of Medical Jurispru-
dence; Corresponding Member Medico-legal Society
of New York; Corresponding Secretary American
Association for the Study and Cure of Inebriety.
Third Edition. London : H. K. Lewis. 1894.
This book is well known, through its earlier editions, to •
the large and increasing number of medical practitioners
who recognize in inebriety a disease, and not a vice, in
the common acceptance of the word, worthy of the same
serious study as any other physical or mental malady,
and one that is, in many instances, amenable to cure
through the institution of rational scientific treatment.
By the term inebriety is not meant simply an over-indul-
gence in alcoholic liquors ; the word is employed as an
inclusive term for all forms of drug addiction, narco-
mania, the particular kind of intoxicant employed being
accidental, determined by environment or other condi-
tions. The author defines the word as meaning " a con-
stitutional disease of the nervous system characterized by
a very strong morbid impulse to, or crave *or, intoxi-
cants." Most inebriates long for alcohol because that is
among us the narcotic in common use. The present
edition of the work contains a large amount of matter
not found in the former editions, including a study of
ether addiction, at one time very common in Ireland ; a
dissertation on the place of alcohol in therapeutics ; on
the relation of insurance to inebriety, and on the crimi-
nal responsibility of inebriates. The book is interesting
apart from the valuable lessons which it teaches, and we
can thoroughly recommend it as a safe guide to this most
important branch of medical science. The presswork is
all that could be desired, and a complete index makes it
a valuable work of reference.
A Treatise on the Principles and Practice of Med-
icine, Designed for the Use of Students and
Practitioners. By Austin Flint, M.D., LL.D.,
late Professor of Principles and Practice of Medicine,
Bellevue Hospital Medical College, New York. Sev-
enth edition. Thoroughly revised by Frederick P.
Henry, A.M., M.D., Professor of Principles and Prac-
tice of Medicine, Woman's Medical College of Penn-
sylvania. 8vo, pp. 1,143. Philadelphia : Lea Broth-
ers & Co. 1894.
To the old students of the late Professor Flint this new
edition of his classic work will be most welcome. Its
peculiar excellences and its breadth of conception have
made it a recognized authority from the time its first edi-
tion appeared. The author was a born teacher, an inde-
fatigable observer, a painstaking worker, and a thorough
medical philosopher. His clinical pictures of disease are
models of graphic description, minuteness of detail, and
breadth of treatment. To such as will see the work for
the first time there is an agreeable surprise in waiting.
This may appear to be high praise, but the work has so
well earned its leading place in medical literature that
but one view can be expressed concerning its general
character as a text-book. The editor has done his part
in bringing it up to date, not only in reference to treat-
ment and the adaptation of the newer remedies, but has
made numerous additions in the shape of the newly dis-
covered forms of disease, and has elaborated much in the
commoner forms which the recent advances have made
necessary. Among the new articles are those on Pulsat-
ing Pleurisy, Hereditary Chorea, Weil's Disease, Syringo-
myelia, Acromegaly, Raynaud's Disease, Anthrax, and
Glanders. The section on General Pathology has been
omitted, as in its old form it was obsolete, and its spirit
could hardly be maintained in any reconstructed form
as would consistently adapt itself to progress made since
it was first written. The classifications have been re-
tained, but some of the articles, such for instance as dys-
pepsia, indicating a series of functional disturbances, have
been treated under the different and now well- recognized
pathological conditions.
Although the doctrine of self- limitation of diseases so
well advocated by Dr. Flint still stands prominently
forth in the admirable natural histories he gives, the ele-
ment of treatment is by no means neglected, in fact by
the editor a fresh stimulus is given to this necessary de-
partment by a comprehensive study of all the new and
leading therapeutic agents.
Aseptic Surgical Technique. With Especial Reference
to Gynecological Operations. By Hunter Robb,
M.D., Associate in Gynecology Johns Hopkins Uni-
versity. i2mo, pp. 264. Philadelphia: J. B. Lip-
pincott Company. 1894.
The author of this little book goes into the subject of
asepsis not only from a bacteriological but from a sur-
gical point of view, and happily combines the functions
of each in making what may practically and theoretically
constitute the ideal operator. His treatment of the sub-
ject is thorough and fully abreast with the latest bacteri-
ological principles of wound treatment, and upsets many
of the cherished notions of wound irrigation by bichlo-
ride, carbolic solutions, and the like. The careful
descriptions of the most approved methods of asepsis by
sterilization of instruments, clothing, and dressings, and
the insistence of the elaborate ablutions of the hands as
practised at Johns Hopkins will impress the reader with
a minutia of detail which is fully in keeping with the im-
portance of doing the little things well in order to insure
the success of the greater. The work is practical from
first to last, and cannot fail to give the reader all the
really necessary information required for the practice of
asepsis in all the varied gynecological operations. The
illustrations are numerous and well executed, particularly
the plate which forms the frontispiece, and gives the dif-
ferent pathogenic microbes.
Text-book of Abdominal Surgery. A Clinical Man-
ual for Practitioners and Students. By Skene Keith,
F.R.C.S. Ed., Assisted by George E. Keith, M.B.C.M.
8vo, pp. 508. Philadelphia : J. B. Lippincott Com-
pany. 1894.
Abdominal surgery has grown since 1880 into such a rec-
ognized speciality, that any work claiming to be a sys-
tematic account of its present status and its future possi-
bilities will be warmly welcomed by progressive operators.
Considering the amount of literature upon the subject, the
authors have experienced no small amount of difficulty
in summarizing results and in reconciling the widely
varied views of investigators in this prolific field. But
the work, on the whole, has been well done, and stands as
a model of its kind for clearness of description, reasonable
minuteness of detail, and soundness of surgical principle.
Many of the supposed difficulties are simplified in a way
that is inviting to the student and assuring to the prac-
titioner. Altogether, it shows the present state of our
knowledge of abdominal surgery and creditably covers
the entire field, treating systematically of the various dis-
eases of the different organs below the diaphragm.
The first section comprises the surgery of the abdomen
from the standpoint of the general operator, while the
second section treats of the department of operative
gynecology. Under the former are described the dis-
eases of the stomach, intestine, appendix, liver, kidney,
and spleen, which may call for surgical treatment ; while
under the latter are discussed ovariotomy, diseases of the
ovaries and Fallopian tubes, uterine fibroids, and diseases
of the uterus generally. Each one of the various opera-
tions are described in sufficient detail, and all the neces-
502
MEDICAL RECORD.
[October 20, 1894
sary directions given for after treatment. Aseptic pre-
cautions are consistently advocated, and many very
valuable practical suggestions are offered for emergencies
away from hospitals and in remote rural districts. The
technique of the different operations is very satisfactorily
explained, as well as the methods of diagnosis and the
fundamental principles of after treatment. This is espe-
cially manifest in the discussion of intestinal lesions, the
choice of operations, and the cardinal symptoms upon
which a diagnosis is founded. The bugbear of intestinal
approximation is robbed of much of its perplexities and
difficulties by the description of the simple and effective
methods of the authors. In intestinal anastomosis Senn's
plates are uniformly advised, but, strange to say, nowhere
is even an allusion made to the Murphy button. Much
stress is laid upon electrolysis in the treatment of uterine
fibroids, which is good in its way, as offsetting the '
fashionable, formidable, venturesome, and unsurgical
proceeding of hysterectomy in such cases. The book as
a whole is a valuable clinical contribution, and is destined
to become authoritative on all principles upon which the
abdominal surgery of to day is founded.
History, Constitution and By-laws, and List of
Members of the Society of Alumni of Bellevue
Hospital. New York: De Vinne Press. 1894.
We learn from this little book that the Society of Alumni
of Bellevue Hospital of this city is in a very prosperous
condition. Its membership now numbers one hundred
and ninety-nine.
The American Institute of Homoeopathy. Section of
Materia Medica and General Therapeutics.
This is a report of the meeting of the Therapeutic Sec-
tion of the American Institute of Homoeopathy, held in
Denver in 1894. The proceedings consisted chiefly in
the discussion of the subject of how to treat and how to
learn materia medica. The little book contains numer-
ous half-tone portraits of many of the leading homoeo-
pathic practitioners in this country and England.
Macrobiotic, or Our Diseases and Our Remedies.
For Practical Physicians and People of Culture. By
Julius Hensel, Physiological Chemist. Translated
by Professor Louis H. Tafel, of Urbana Univer-
sity, O., from the Second Revised German Edition.
Philadelphia: Boericke & Tafel.
The author of this book attributes diseases to a dimin-
ished electric force, and proposes to prevent and cure
most ills by his "physiological saltwater." His no-
tions of pathology are interesting. Diphtheria, which
he calls "children's catarrh," begins, he says, "with
stagnation of the blood in the thymus gland, whence the
products of the putrefaction of the albumin of the blood
are spread with their infecting force over the whole vas-
cular system." The views set forth in other portions of
the book are equally sound and scientific.
Transactions of the South Carolina Medical Asso-
ciation. Forty-fourth Annual Meeting, held in Rock
Hill, S. C, April 25 and 26, 1894. Charleston:
Walker, Evans & Cogswell Co. 1894.
This volume of the Transactions for 1894 contains the
minutes of the meeting and the usual number of papers,
reports on special subjects, etc The next meeting of
the Association will take place in Columbia on the fourth
Wednesday in April, 1895.
Precis de Clinique THfeRAPEUTiQUE. Par le Dr. A. F.
Plicque, Ancien Interne des Hdpitaux de Paris, Lau-
rtat de la Faculty de M^decine, LaurSat des H6pitaux.
Paris: G. Steinheil. 1894.
The author of this little work says that it had its origin
in notes made for His own use during the early years of
practice. He found, in beginning his life-work, that the
conditions of private practice were very different from
those of hospital practice, and required often the exercise
of certain faculties and of a kind of knowledge not
gained in institution life. The work cannot pretend to
the dignity of a system of medicine, being, as its name
implies, simply a manual of therapeutics. But it is a
good manual, systematically arranged, and written in a
lucid style ; the directions are simple, and the reader is
not bewildered by a long catalogue of drugs for every
disease. Under each heading the indications for treat-
ment are briefly stated, and then the author mentions a
few of the best and tried remedies and gives directions for
their employment. The book deals with internal medi-
cine only, and does not touch upon surgical, venereal,
or cutaneous disorders.
A Handbook of Medical Microscopy for Students
and General Practitioners, Including Chapters on
Bacteriology, Neoplasms, and Urinary Examinations.
By James E. Reeves, M.D., Member of the Associa-
tion of American Physicians; Ex-President of the
American Public Health Association, etc. Phila-
delphia : P. Blakiston, Son & Co. 1894.
The author of this excellent little manual states in his
preface that his object in writing the book was to take
away from the practising physician all excuse for his neg-
lect of the microscope in his daily work. He says, and
very justly, that the time has now come when all pro-
gressive physicians and surgeons, general practitioners
and specialists alike, must either themselves possess suffi-
cient skill in microscopic technique for the faithful and
proper discharge of the high obligation which rests upon
them in the diagnosis and treatment of diseases, or else
be able to command the ready service of some accom-
plished microscopist and pathologist to do such necessary
work for them. The writer himself is a general practi-
tioner belonging to the former class, knowing by actual
experience the needs of those situated like himself, and
has the rare gift of being able to impart this self-acquired
knowledge to others. The work is not elementary for
the professional microscopist, but it is admirably adapted
to meet the work of the general practitioner, for whom it
was written.
Memoirs of the Boston Society of Natural History :
Volume IV., Number XI. A Bibliography of Verte-
brate Embryology. By Charles Sedgwick Minot.
Boston. 1893.
This bibliography appears to be a most exhaustive one,
containing 3,083 titles, all of which the author states have
been verified in the libraries of Boston and Cambridge, or
in that of the Surgeon-General's Office in Washington.
Gynacologische Anatomie. Die GeschwOlste der
EierstOcke. Von Dr. C. H. Stratz. Berlin : H.
Kornfeld. 1894.
This beautiful atlas of ovarian tumors consists of fourteen
colored plates, with fifty figures, delineating a great
variety of tumors of the ovary. The author has had a
vast amount of material to select from in Schweder's
Clinic, in the Frauenklinik of Berlin, and during his own
five years' practice in Java. He appears to have made
judicious use of this material, producing an atlas not only
of rare tumors, but also of those most commonly met with
in everyday practice. There are some forty pages of de-
scriptive text. The plates are well executed and printed,
and the work does credit to author and publisher alike.
Human Physiology. By John Thornton, M.A.,
Author of Elementary Physiography, Advanced Physi-
ography, etc. With 268 Illustrations. New York:
Longmans, Green & Co. 1894.
All the essential facts of human physiology have been
brought together in this handy manual of some 450 pages,
in a form convenient not only for continuous study, but also
for occasional reference. The author's style is as easy
and smooth as his descriptions are lucid. The illustra-
tions, some of them colored, are numerous and well exe-
cuted. To the general practitioner, who is not a special
student of physiology, we can recommend this little work
as one which will satisfactorily meet his needs in this
branch of science.
October 20, 1894]
MEDICAL RECORD.
503
Vade-Mecum du Praticien. Diagnostic et Traitement
des Maladies Internes. Par le Dr. Fernand Roux.
Paris: G. SteinheiL 1894.
This is a useful manual, giving the main points in the
diagnosis and treatment of non surgical diseases. The
subjects are arranged alphabetically, convenient for ready
reference, and the therapeutic suggestions are for the
most part sound, and in accordance with the latest dis-
coveries in this branch.
Transactions of the American Gynecological Soci-
ety. Vol. XIX. For the year 1894. 8vo, pp. 363.
Philadelphia: W. J. Dornan. 1894.
This valuable volume contains several admirable papers
on hysterectomy, others on face presentations, and a mas-
terly address by the President, Prof. Lusk, on the relative
value of the various methods of treating uterine fibroids.
Sharp's Tracts on Homceopathy. 14th Thousand.
8vo, pp. 232. Philadelphia: Boericke & Tafel. 1894.
This is a collection of tracts intended for the defence of
Homoeopathy, the theory of small dosage, the value of
the so-called provings, the advantage of single doses,
and the general advantages of the system. To such as
are interested in the subject this little book will furnish
much food for reflection.
A Treatise on Appendicitis. By George R. Fowler,
M.D., Examiner in Surgery, Surgeon to St. Mary's
and Methodist Episcopal Hospitals, Brooklyn. 8vo,
pp. 190. Philadelphia: J. B. Lippincott Co. 1894.
The present compact treatise comes at an opportune
time for the discussion of many questions bearing upon
the etiology, pathology, and surgical treatment of an
interesting and very frequent surgical disease. The
exceptional opportunities for observation which the prac-
tice of the author has given him are utilized in a practi-
cal and intelligent manner for the benefit of his many
readers. Many of the mooted points in the pathology
of the affection are discussed with becoming candor and
independence, and with a thoroughness eminently com-
mendable. Especially interesting are the views regard-
ing the etiology of the disease as bearing directly and
almost solely upon microbic influences. The clinical
reports which are inserted in the text are typical of their
kind, and serve their full intention of pointing questions
of pathology or illustrating lines of treatment. The
operative technique is very fully given, and the author's
methods are very intelligently described. The illustra-
tions are numerous and good, and the work altogether is
a great success.
An Illustrated Dictionary of Medicine, Biology,
and Allied Sciences, Including the Pronunciation,
Accentuation, Derivation and Definition of the Terms
used in Medicine, Anatomy, Surgery, Obstetrics, Gyn-
ecology, Therapeutics, Materia Medica, Pathology,
Dermatology, Pediatrics, Ophthalmology, Otology,
Laryngology, Physiology, Neurology, Histology, Toxi-
cology, Dietetics, Legal Medicine, Psychology, Clima-
tology, etc., etc., and the various Sciences closely re-
lated to Medicine, such as Bacteriology, Parasitology,
Microscopy, Botany, Zoology, Dentistry, Pharmacy,
Chemistry, Hygiene, Electricity, Veterinary Medicine,
etc. By George M. Gould, A.M., M.D., author of
" The Student's Medical Dictionary/' " Twelve Thou-
sand Medical Words Pronounced and Defined," "The
Meaning of the Method of Life," Editor of the Med-
ical News, etc. Based upon recent scientific literature.
Philadelphia: P. Blakiston, Son & Co. 1894.
This in many respects admirable work possesses a great
advantage over some of its recent competitors in that it
is in but one volume, and therefore much more conven-
ient as a work of constant reference. A commendable
feature is the grouping together of many correlated facts
in tables, of which there are one hundred and ten in all.
The type employed is of excellent size, the printing is un-
usually good, and the illustrations are judiciously selected
and not too numerous. The spelling adopted by the
editor is in the direction of the phonetic, the diph-
thongs being dropped from words of Latin or Greek
derivation, as also the final e of the name of alkaloids
and of certain other words, such as iodide, bromide,
iodine and the like, which Dr. Gould, following the
suggestion of the American Association for the Advance-
ment of Science, writes iodid, bromid, iodin, eta In
some of the words of this class the alternative spelling is
given, and in others, without any apparent reason for the
omission, it is not. The weakest part of the book is in
the matter of pronunciation. It is very well for a medi-
cal lexicographer not to be too dogmatic in cases in
which orthoepists themselves are not in accord, but his
diffidence should not go to the length of sanctioning
such errors as al'bumin, ab'domen, anemic diabe'tic,
asthe'nia, synechia, or such wretched cacophony as
making the final syllable of cocaine or leucomaine rhyme
with cane or mane. In the case of some words which
are frequently mispronounced, as the second one of the
term diabetes mellitus for example, the author gives no
sign to guide the would be orthoepist ; and the pronun-
ciation of the genitive or plural of several Latin words,
such as cervix and paries, over which even well educated
people so often stumble, is not given at all as for as we
have been able to discover. These are sins which some
may consider as venial, but we cannot so regard them.
They do not absolutely destroy the value of the book as
a work of reference, it is true, but they mar its perfection.
A dictionary should be an authority in matters of deri-
vation, spelling, punctuation and definition, and errors
in any one of these cardinal points are unpardonable.
A dictionary maker should be in these matters dogmatic,
and being dogmatic should be above all things accurate,
otherwise it is but a case of the blind leading the blind.
We have nothing but praise for the definitions, which
are clear and concise, or for the derivations, but the
spelling is peculiar and in many cases unsupported by
the best authorities, even by Whitney, whose phonetic
tendencies were so pronounced ; and as regards pronun-
ciation Dr. Gould is, as we have said, uncertain and in
not a few instances unsound. The author is already
well known as a maker of dictionaries, and we had
hoped that this, his latest work and the fruit of his ripe
experience, would prove to be the ideal lexicon for the
busy medical man. This, unfortunately, it is not, but it
comes very near to it, perhaps as near as anything human
can come to perfectibility.
Text-book of Medical and Pharmaceutical Chemis-
try. By E. H. Bartley, B.S., M.D. Third edition,
revised and enlarged. With 84 illustrations. Phila-
delphia: P. Blakiston, Son & Co 1894.
This excellent book contains, in the most concise form,
all the knowledge of medical and pharmaceutical chem-
istry. The present edition has been greatly enlarged,
and a new chapter on Physiological and Clinical Chem-
istry has been added ; the same deals with the chemistry
of nutrition, digestion, and the urine. This chapter is
treated in the most practical way, giving the principles
of feeding and diet, the clinical examination of stomach
digestion for diagnostic purposes, the easier methods for
the examination of milk, and a fairly complete guide to
the clinical examination of urine and urinary calculi. In
perusing the tests for sugar we miss those of Roberts and
Einhorn. The whole book reads admirably well, and
deserves the highest recommendation.
Diagnostik und Therapie der Magenkrankheiten.
Von Dr. T. Boas. I. Theil, 3te Auflage. Leipzig :
Verlag von Thieme. 1894.
The present edition of this so well- known book on dis-
eases of the stomach has been greatly enlarged and con-
tains the newest ideas and inventions in this field of
medicine. Boas has given his personal experiences on
many pathological anatomical conditions of the gastric
mucosa, illustrating them with figures of the correspond-
ing microscopic specimens. As to the early recognition
5°4
MEDICAL RECORD.
[October 20, 1894
of cancer of the stomach he puts most stress on the pres-
ence of lactic acid in the stomach contents, this being
much more characteristic than the absence of free hydro-
chloric acid. The book will be read with much profit
by every practitioner.
Transactions of the Association op American Phy-
sicians. Niuth Session. 1894.
This volume contains an unusual amount of interesting
material, and covers a wide range of medical subjects.
The papers are short and practical, and for the most part
bear upon the leading medical questions of the day.
Text- book of Practical Therapeutics. By Hobart
Amory Hare, M.D., B.Sc, Professor of Therapeutics
and Materia Medica, Jefferson Medical College, Phil-
adelphia. Fourth edition. 8vo, pp. 740. Philadel-
phia : Lea Brothers & Co. 1894.
The fact that the fourth edition of this work has appeared
within four years attests its value to the general prac-
titioner, and its appreciation by the medical student
Its wide application to the practical needs of everyday
medicine commended it from the first to the progressive
and working therapeutist. It is not only knowing what
to give, but when and where to give, and how the drug
will act in given conditions, that makes one a scientific
practitioner rather than an ignorant empiric. The book
in such respects supplies every need. It is divided into
four parts : I. General Therapeutical Considerations.
II. Drugs and their Properties. III. Remedial Measures
other than Drugs, Foods for the Sick. IV. The Thera-
peutics of Different Diseases, Tables of Doses, an Index
of Drugs and Remedial Measures, and an Index of Dis-
eases and Remedies. The author is well known as a pro-
gressive therapeutist, and it goes without saying that
all the new or valuable drugs receive their full share of
attention, and it is a great deal to say in this, as with
other features, that the book is up to date in everything
pertaining to the practical therapeutical needs of the
practitioner. The additions made are articles on Methyl-
ene-blue, Chloralose, Pyrogallol, Condurango, Conval-
laria, Duboisine, Hypodermoclysis, Enteroclysis, Lavage,
and several additions to the department of individual
diseases. The work has also been revised in such a way
as to make it uniform with the United States Pharmaco-
poeia.
Wann DCrfen Gonorrheische Heirathen ? Von Dr.
Edmund Saalfeld. Berlin : H. Kornfeld. 1894.
This is a little brochure dealing with the subject of the
marriage of men who have had gonorrhoea. The author
believes that the disease is curable and that when it is
once actually cured the man may marry with perfect
safety to his wife, himself, and their offspring, if any. 4 B
Der Alkohol als Gunss- und Arzneimittel. Von
Dr. A. Jaquet, Privatdocent ftir experim. Pharmakol-
ogie. Basel : Benno Schwabe. 1894.
An interesting and well considered lecture upon alcohol
as a beverage and as a therapeutic agent. The author's
views are very moderate, and he believes that the con-
sumption of alcohol in the so-called physiological doses
by adults is not prejudicial to health or to a long life.
A Manual of Hygiene. By Mary Taylor Bissell,
M.D., Professor of Hygiene in the Woman's Medical
College of the New York Infirmary for Women and
Children. New York: The Baker & Taylor Company.
Dr. Bissell has done a good work in preparing this stu-
dent's text-book on hygiene. Most works on hygiene
are of such size and deal with the subject so elaborately
that the student is repelled, being unable, indeed, to give
the time necessary for the study of such a formidable
looking work. In this book, which is, however, by no
means a superficial one, the essentials of the science only
are given, and the reader's attention is not distracted by
details of value only to the specialist. The book will be
found serviceable, moreover, to many practitioners as
well as to students.
jfocietg Reports.
NEW YORK ACADEMY OF MEDICINE.
Stated Meeting, October 4, 1894.
D. B. St. John Roosa, M.D., President, in the Chair.
The Stack Room Completed.— Dr. E. H. Grandin,
chairman of the Library Committee, stated that the stack
room had been completed during the summer and was
now the best in the country, not excepting that at Wash-
ington. It had a capacity of two hundred and fifty thou-
sand volumes, just five times as many as were now in the
library. He made a strong appeal for books from the
overflowing libraries of members, and for donations from
their wealthy clientele. The library was greatly in need
of an endowment fund of at least one hundred thousand
dollars. Money expended in this direction would prove
of far greater benefit to the public than if it were used
to build more hospitals and dispensaries.
Credit was given by Dr. Grandin to Drs. A. Jacobi and
A. M. Jacobus for careful supervision of the work done
in the stack room. Dr. Jacobi, who arrived later, at-
tributed all honor for the same service to Drs. Grandin
and Jacobus.
The President emphasized Dr. Grandin's remarks re-
garding the needs of the library, and expressed the belief
that if what was wanted were asked for, it would be given.
New York was ever ready to give for any worthy purpose
when made to appreciate its value and want, but the medi-
cal profession had been too modest, and the community
had come to regard their services as consisting only in
the administration of drugs and the use of the knife.
High and above all else was our duty as citizens of this
great nation.
Report of Committee to Constitutional Convention —
Dr. W. R. Pryor, one of the members of this committee,
made a preliminary report. The committee had been
received with courtesy, and, to a large extent, its sugges-
tions had been acted upon. The Convention had agreed
to abolish coroners, but refused to put doctors in their
place ; the Board of Regents had been incorporated into
the constitution, as desired by the committee, but their
objection to its being made a life tenure office had not
been heeded. The committee's recommendation to make
county instead of state office of charities and correction
in the counties of New York and Kings, and thereby
rendering the officers liable to removal by the Governor,
had not been accepted, as it affected too many official
heads.
Climate in Therapeutics. — The President, in intro-
ducing the author, Dr. C. Fayette Taylor, said he was
sure the Academy would be glad to know the conclusions
arrived at upon this subject by one who had had much
experience through travel and the reliability of whose
judgment had been demonstrated by enviable success
in another department of medicine, that of orthope-
dics.
Dr. Taylor said that his object in writing the paper
was to strongly impress the necessity for the profession,
in recommending a change of climate, to have a definite
purpose in doing so and more accurate knowledge of the
qualities and health influence of the particular climate
named. Some gave very indefinite advice, such as to go
to California, a State which was seven hundred and seventy
miles long, and embraced at least seven different climates.
The mean temperature of a locality meant nothing. It
might be the same in climates of greatest extremes in
their influence on the health. The mean temperature in
the different climates of California was nearly the same,
while the extremes varied greatly, as did also the phys-
iological effects. Moisture was a very important factor.
Yet, although it favored growth of micro-organisms, it
did not follow that an air dry enough to be almost free
from germs was necessarily healthier. Physicians had
found it necessary to send their patients, especially women
October 20, 1894]
MEDICAL RECORD.
505
and children, living in the dry, high air of the eastern
slope of the Rocky Mountains, to the moister valleys oc-
casionally, in order to avoid nervousness and loss of flesh.
He could not say whether the peculiar influence of such
air was due to increased action of the heart or the con-
stant hammering at the nerves by the wind and sunshine.
The author's conclusion on this point was that, while it
was important to live in an atmosphere as free from germs
as possible, it was even more important to live in one
which would give vigor to resist germ influence. It
seemed that heretofore the study of climatology had been
for the purpose of finding a place where consumptives
would not die. There was no such place. There was
no place where bacilli would not get in their deadly work.
A question of wider interest was, what climate was best
and in which we might spend the greater part of our
lives? There were many other diseases of which men
died besides tuberculosis. Moreover, ill health often de-
pended upon conditions and habits quite independent of
climate, and such as could be corrected without change
of place. A friend in New York had been almost re-
juvenated in three months by limiting his diet during that
time to oysters, fish, and clam broth. People went abroad
and were sent abroad by physicians in order, as it was
stated, to tone up. Yet in many instances the first step
toward toning up should consist in toning down. By
that the author meant to reduce the unnecessary ex-
penditure of energy which had become a filed habit of
life. Most of us were too prodigal with our resources and
squandered more than the occasion required. One
wisely answered, when asked how he succeeded in always
being so healthy, "Be comfortable/ ' We should learn
to sit down and be comfortable where we are.
Among the countries of whose climate the author
spoke from personal experience were California, Nevada,
other Western and also Southern sections of this country,
the West Indies, Spain, etc. He thought a visit to the
tropics from time to time would prove healthful in in-
ducing habits of reposefulness. Tropical heat was not
oppressive, as was generally supposed by those who had
not tried it. Wakefulness in the tropics was a rarity,
while the relief obtained from nervous tension and irri-
tability was delightful. The increased activity of the
skin freed the system of morbid material and gave rest
to the kidneys and lungs. It was a delusion born of
the constant assertion of advocates of negro slavery be-
fore the Rebellion to suppose that white people could not
work in the tropics. The Windward Islands were more
favorable for health than the Greater Antilles, being too
small to give rise to a land breeze and consequent im-
purity of air and change of temperature. A visit to trop-
ical points should be accompanied by a change of food.
One should live largely on native fruits. Hardly a
better climate could be selected than the southern part
of Spain, but one had to contend with lack of sanitary
arrangements in the cities. The author stated that peo-
ple from the South could stand northern winters better
than those from the North could stand the same season
in the warmer climates, and thought the explanation lay
in the fact that the former had not previously expended
their vital reserve in resisting cold. In visiting mineral
springs one should place himself under the care of a local
physician, and not ask, as many did, advice of the hotel
porter.
Finally, there was an abundance of climate in our own
homes if we would but open the windows and let it into
our living apartments, taking due precaution against
draughts and cold. Too many were taken away for a
change of climate in the last stage of disease to locali-
ties where they were deprived of comforts which could
only be had at home, and were brought back in a long
box by a baggage car.
Dr. Simon Baruch opened the discussion. For some
years past he had tried to simplify all problems in thera-
peutics and reduce them to first principles, as it was only
in this manner that we could succeed in combating dis-
ease. It seemed to him climatology was now in the po-
sition occupied by antiseptic surgery some years 8go,
when it was customary to surcharge the air of the opera-
tion-room with carbolized spray, while the surgeon's
finger-nails were left unclean. He was in agreement
with the paper, the most important point in which, he
thought, was the reference to climatic advantages of our
own homes, and our failure to utilize them. As an ex-
ample of what might be done, he mentioned the case of
a man with phthisis who was benefited by a visit to Min-
nesota, which was advised by Dr. Loomis ; but his cough,
hectic, and loss of flesh returned on leaving those parts,
and he consulted Dr. Baruch with regard to another lo-
cality. Dr. Baruch told him to remain in New York,
and arranged his rooms so that he practically lived in
open air and sunshine during the winter months, with
the result that in two months he gained twelve pounds in
weight, and lost his hectic and cough.
Three Principal Questions in Changing Residence.
— Dr R. C. M. Page thought that in considering a
change of residence we were met by three principal
questions at the outset : 1, The nature of the climate in
its widest sense, including elevation, extremes of tem-
perature rather than the mean, soil, drainage, winds,
dust ,- 2, accessibility, hotel and other accommodations ;
3, condition of the patient.
He believed that in the majority of cases it was the
change, in a general sense, rather than the particular cli-
mate to which benefit was chiefly due. Certainly, how-
ever, some places were to be avoided on account of ad-
verse climatic conditions, particularly by patients with
phthisis. A long, continuous, tiresome journey and sud-
den change of altitude were now guarded against in
Europe. Persons who were too sick to take exercise
should stay at home among friends.
Would Establish a Sanitarium for the Poor.— Dr.
Achilles Rose said that inasmuch as reference had been
made to Detweiler's establishment for consumptives in
Europe, he would point out the need of some similar re-
sort in this country where those could go with moderate
means and receive all the advantages of a well regulated
sanitarium. The locality should be accessible to the
great cities along the Atlantic coast, should be between
1,500 and 5,000 feet above the sea-level, and more south.
Dr. Sell, who had travelled a great deal and for a
number of years, cautioned against sending patients to a
place whose only recommendation might be its favorable
climate. The general advice to go to Egypt was like
sending one to California, without mentioning the par-
ticular part. He mentioned a number of places where
consumptives had had a cessation of their symptoms and
lived in health, but they were compelled to stay there
and not return to their place of nativity. Among these
was a place in Mexico, another in Texas, a third in Cal-
ifornia. There ought to be a teacher in climatology in
every medical school throughout the country.
Working up a Practice. — The following advertisement
appeared recently in an English lay journal : " Skin
Disease. — A Specialist, who cures every description of
Skin Disease, will give a liberal commission to ladies and
gentlemen who will introduce patients. Every informa-
tion given by addressing Specialist."
The Cholera appears, from the cable reports, to be
subsiding in Europe. It still prevails to a considerable
extent in St. Petersburg, Moscow, and Warsaw, and the
surrounding districts, but is rapidly diminishing in
Galicia and other infected provinces in the Austrian do-
minions. Twelve of these districts have been entirely
free since the middle of September. A despatch to the
State Department from Constantinople announces a re-
newed outbreak of cholera in that city and the outlying
districts. From Hamburg is reported the death of Dr.
Oertel, Assistant Superintendent of the Hygienic Insti-
tute in that place. His death occurred from cholera
contracted in the course of some experiments which he
was making with cultures of the comma bacillus.
5o6
MEDICAL RECORD.
[October 20, 1894
MEDICAL SOCIETY OF THE COUNTY OF
NEW YORK.
Stated Meeting, September 24, 1894.
H. D. Chapin, M.D., in the Chair.
nominations — [*ne following nominations were made,
the election to take place at the October meeting : For
President, Drs. H. D Chapin. E. H. Grandin, Robert
Abbe, V. P. Gibney; First Vice President, Drs. R. Van
Santvoord, H E. Crampton, A. Caille\ Wendell Phillips;
Second Vice-President, Dr. S. H. Dessau ; Secretary, Dr.
C. H Avery ; Assistant Secretary, Dr. W. H. Ballard \
Ireasurer, Dr. J dim S. Warren ; Censors, Drs. Seneca
D. Powell, Simon Baruch, C. L Gibson, George T. Jack-
son, E. D Fisher, R. W. Wilcox, A. M. Jacobus, E. N.
Liell, Charles H. Knight, William Stevens, C C.
Rice.
ffervous Dyspepsia.— Dr. Henry Illoway read the
first paper of the evening. Much literature had appeared
nnder the title " Nervous Dyspepsia," but analysis
showed that it was a jumble of many morbid states.
The author's purpose was to justify the classification and
to define the cases which properly belonged in it. The
views of German writers were cited, and disapproval was
expressed of including the cases under discussion under
the term neurasthenia gastrica. Neurasthenia had come
to be a well established morbid entity, with certain char-
acteristic symptoms, and where a dyspepsia was depend-
ent thereon it could be made to disappear with special
attention to the stomach itself. Nervous dyspepsia had
been appropriately defined as an ailment of the stomach
without any definite and fixed pathological or anato-
mico-pathological characteristics, depending solely upon
the nerves of the stomach. The stomach is primarily
affected. If any symptoms on the part of the general
nervous system present themselves they are the conse-
quence of irritation proceeding from the stomach, and
therefore only secondary manifestations. Treatment
must be directed to the stomach ; only in that way can
the disease be cured.
Symptoms. — The tongue in the morning is covered
with a thin transparent coat, the red being visible
through it ; the patient complains of lack of hunger, but
when he begins to eat he can eat as much as anybody,
but when he stops his misery begins. He complains of
feeling bad at the stomach, of a feeling of heaviness and
distention, of eructations of gas, which, however, are at-
tended by some relief and differing from hysterical eruc-
tation in not being continuous. The most unpleasant
feeling is the one described as general irritability ; a de-
sire to have a row with somebody. There might be a
feeling of pressure and irritability of the brain. Such
feelings lasted an hour and a half usually, sometimes
three hours, and were renewed after the next meal.
The bo*els were usually undisturbed, although an inac-
tive life might lead to constipation. The patients were
incapable of prolonged work, and preferred light litera-
ture. Sleep was usually undisturbed. Alcoholic bever-
ages were not well tolerated, although frequently pre-
scribed by physicians.
Etiology — There were two chief causes — mental
shock and tobacco smoking. Where mental shock was
the cause, as loss of friends or of property, the whole
force of the blow seemed to be expended upon the stom-
ach and not upon the general system, as in neurasthenia
depending upon a like cause. Where tobacco-smoking
was the exciting factor the symptoms would come on
after the use of perhaps a single cigar, and were not due
to excessive indulgence and poisoning of the system
thereby. The patients could digest nitrogeneous foods
well, and us lally there was a sufficient amount of hydro-
chloric acid and pepsin in the gastric secretions. In the
author's experience there had been no atony of the stom-
ach, yet the symptoms seemed to point to inhibition of
muscular action in that organ and disappearance of the
same when action was re established. The vagus sup-
plying the stomach seemed to be in a state of hyper-
excitability, and the irritability might be so great as to
cause most of the food to be rejected as soon as taken.
In differential diagnosis the author thought it only
necessary to exclude neurasthenia gastrica, and this he
believed not to be a difficult matter. In this affection
the patient felt bad when the stomach was empty, and
after eating felt much stronger and better, while the re-
verse was true in nervous dyspepsia. In nervous dys-
pepsia the food tasted good, while in neurasthenia gas-
trica there was no desire to eat. In the latter the in-
testines were affected, they were not in the former.
Neurasthenic patients awoke frequently, complained of
sensations of hot and cold, and sometimes as if suffering
from malaria, differing in these regards from patients
troubled with nervous dyspepsia.
Many had said the prognosis was unfavorable, but the
author had found it quite favorable. Even cases of ner-
vous dyspepsia of long standing would recover nnder
proper methods. He had seen no sequelae although he
suspected the condition might in time lead to melan-
cholia and insanity. Nor had there been complications
except a slight eczema on the chin. The treatment was
not considered in this paper.
A Brief Study of the Physiological Epochs that Pre-
dispose to Insanity, with Observations on the Manage-
ment of Each. — Dr. William P. Spratling, in a paper
with this title, spoke of six epochs predisposing to insan-
ity, all of which were physiological except one, namely,
heredity. In the order named they were — the epoch of
childhood, of puberty, of maternity, heredity, the men-
opause, and senility.
The peculiarity of the epoch of heredity was its varia-
bility, embracing the period when ancestors who were
inclined to insanity exhibited signs of the disease. The
last epoch, or that of senility, was pathological rather
than physiological.
Regarding the first epoch, Gowers had stated that one-
eighth of all cases of epilepsy, which not infrequently led
to insanity, began during the first three years, and with
rickets as a combined cause, seventy- five per cent, were
due to infantile convulsions ascribed to teething. Gen-
uine epilepsy, however, probably never arose from den-
tition, but the convulsions occurring at this time might
finally take on all the characteristics of epilepsy. Any-
thing which interfered with the nutrition of the child's
brain was a serious matter, for this organ acquired its
chief growth the first seven years. Besides dentition as
a starting cause, he mentioned blows, fevers, and other
conditions which changed the physiological processes of
childhood into pathological, and thus laid the basis for
insanity.
Pubescence, from the fifteenth to the twenty second
year, was more dangerous to the female than to the male.
In the former the change from childhood was almost at
a bound, while in the latter it was very gradual. The
female was liable to show melancholia, mental enfeeble-
ment, bodily inactivity, later along systematized delusion
which pertained chiefly to self. The prognosis was good
when there was no history of hereditary taint. Nourish-
ment should be given in an easily assimilable form,
and the secretory and excretory functions should receive
particular attention as they were inclined to be sluggish.
Give hypnotics or sedatives only when urgently needed.
The best form of iron for the anaemia was the carbonate.
Insanity during maternity occurred more frequently
in women about to give birth to an illegitimate child.
Infanticide and suicide were common. To produce sleep
the author preferred paraldehyde. As showing the in-
fluence of heredity, the author knew of a family mem-
bers of which had shown insanity during four generations
on reaching a certain age.
The insanity of the menopause was of the depressed
type, frequently with suicidal impulse, yet the prognosis
was favorable where there was no hereditary taint. Out-
of-door life and change of climate were recommended.
The most common form of insanity of the last period
was that of senile dementia. It was rather a retrogres-
October 20, 1894]
MEDICAL RECORD.
507
sion of the mind. In senile melancholia seventy- five per
cent, of the cases showed suicidal tendency. The author
had found most satisfactory results from opium, and at
this period there was little danger of the opium habit.
In discussing the paper Dr. William Leszynski said
he had never felt satisfied that the physiological epoch of
childhood had much to do with the development of
insanity, although it was a settled fact that hereditary
predisposition was a prime element. Puberty in the boy
also had little influence since the change was so gradual.
Dr. E. D. Fisher said women at puberty were par-
ticularly subject to nervous disorders, as hysteria, men-
tal depression, etc., and required a change of surround-
ings, for their chances were not good if treated at home.
He endorsed the author's recommendation of opium in
senile dementia.
Dr. Collins thought some of the divisions made in the
paper somewhat artificial, although they might serve to
make the subject clear.
The epoch of childhood as predisposing to insanity
particularly seemed artificial, and that of old age was very
variable, and pertained to degeneration of the arteries.
In the insanity of the puerperal period the time had ar-
rived for laying more stress on infection as a cause.
Dr. Van Fleet thought the term heredity a misnomer,
that it had been much abused ; but the basis of his belief
seemed to be fear of its influence on the imagination of
those giving a hereditary history.
Dr. Bryson related two instances to show the injuri-
ous effects of the same physical conditions enforced upon
women as upon men in attaining an education. She
thought the same mental training could be acquired and
yet allow for differences in physiological processes.
The usual collation was served.
(&0VXC$VQU&ZUtZ.
OUR LONDON LETTER.
(From our Special Correspondent)
SANITARY CONGRESS — PRESIDENT'S ADDRESS — HEALTH EX-
HIBITION CONFERENCES OF OFFICERS OF HEALTH, SAN-
ITARV INSPECTORS, ETC — OVERCROWDING OF HOUSES —
DR. &LEIN ON TYPHOID — DEATH OF DR. GREENHILL,
THE SCHOLAR OF THE PROFESSION— OPENING OF THE
LONDON MEDICAL SCHOOLS.
London, September 29, 1894.
This week we have had another congress, viz., the four-
teenth of the Sanitary Institute, which met in Liverpool.
On Monday the members were received in the town- hall
by the Lord Mayor, and the President, Sir Francis Pow-
ell, Bart., M P., delivered his address. He passed in
review the progress made in the last few years, especially
in connection with the Acts of Parliament which dealt
with the subject. It was with a note of intense satisfac-
tion, if not of exultation, that he surveyed the progress of
the last twenty years, in which more than fifty-six million
pounds had been expended under the sanction of the
Local Government Board, while local acts had author-
ized the expenditure of a further sum of more than sixty-
seven millions. He then passed to the question of quar-
antine, and showed how much better we have fared with-
out it in regard to cholera. On vaccination he pointed
out that it is the part of true wisdom to be guided by
those best qualified to judge, and that those who were in
doubt might be reassured as to the harmlessness of the
preventive measure by the increased care and precautions
which are taken to secure the safety as well as the efficacy
of the operation. Among other subjects noticed were
the dissemination of phthisis, the alleged increase of in-
sanity, food adulteration, factory legislation, the smoke
nuisance, river pollution, and pauper children. A cor-
dial vote of thanks was given to the President. In the
evening an exhibition of sanitary appliances, etc., was
opened by the Lord Mayor. This exhibition was kept
open and musical selections given each afternoon and
evening. Here also demonstrations in cooking were
given.
On Tuesday the several "conferences" began their
work. That of the Medical Officers of Health was pre*
sided over by Mr. C. £. Paget, the able officer of Sal-
ford, whose address dealt fully with the questions of the
Health Acts and diplomas in public health. He spoke
freely of the imperfections he had observed in the ad-
ministration of the acts, but while admitting we might
not be able to remove them for a time, urged that their
continuance cannot rob us of the stimulus to exertion
afforded by the labors of those who have gone before.
Moreover, we may live up to those records and make the
imperfections we protest against more and more glaringly
manifest until those beyond our profession see them and
insist on their amendment, so that if we fail to win re-
form we shall pave the way for others to secure it.
In the evening Dr. G. B. Longstaff, gave a lecture on
the overcrowding of houses on land, illustrated by pho-
tographs of the Hamburg slums.
On Wednesday Dr. Klein presided over the Section of
Sanitary Science and Preventive Medicine. His address
was on typhoid fever, as to which he held that sanita-
rians might continue to regard the disease as specific, and
derived from case to case ; not, as some had suggested, a»
originating de novo through the bacillus coli communis.
This does not render the duty of preventing sewage con-
tamination less urgent, for although the typhoid germ
without the bacillus coli communis might not be capable
of causing typhoid fever, the presence of that bacillus in-
dicated excremental contamination in which possibly
specific typhoid germs might be present.
The conference of sanitary officers was presided over
by Mr. Vacher, F R.C.S., and that of domestic hygiene
by the Lady Mayoress. In each of the sections inter-
esting papers were read and discussions carried on.
Needless to say that hospitality and entertainments were
to the fore, and that the members had reason to feel sat-
isfied with a pleasant visit to Liverpool combined with
a show of zeal in the cause of sanitary progress.
Dr. Greenhill is no more. He died on the 19th at
the ripe age of eighty-one. He was one of the greatest
scholars in our profession. William Alexander Green-
hill graduated at Oxford in 1841, and was recognized
everywhere as an ornament of that ancient seat of learn-
ing. Even your younger readers will remember his
name as the editor of the best edition of Sir T. Browne's
" Religio Medici." Others will call to mind his Latin
edition of Sydenham, his translation of Rhazes, or his
critical edition with Latin version of Theophilus.
These alone should suffice to show that the profession
has lost in him a scholar of high order, but those who
came into contact with him felt that he was much more
— a true gentleman, sincere friend, a devout Christian,
a sanitary reformer, destitute of self-interest, and withal
crowned with the deepest modesty and generous inten-
tions. He went to Hastings in 1851, and practised
there until he retired some years ago, and devoted his
remaining time to his literary work, on which he was
employed up to the date of his decease from syncope.
In Hastings his noble figure was familiar enough, and he
was naturally regarded with reverence on the one hand
by those who had been his patients, on the other by
those who were aware that he was perhaps the greatest
scholar which our profession has produced during the
century.
London, October 2, 1894.
The custom of opening the session of the medical
schools with an " Introductory Lecture " addressed chiefly
to freshmen — though giving way further to dinners and
conversazioni — is still kept up at some of our hospitals,
and where the lecturer is fitted for the post has much to
commend it. Formerly, October ist was regarded as
an event in the annus medicus which every institution and
every student ought to observe, and old practitioners,
whenever they could, visited their alma mater on that
5o8
MEDICAL RECORD.
[October 20, 1894
day, and renewed friendships and friendly intercourse.
The invasion of the dinner is, in this respect, to be re-
gretted, besides which the lecture afforded the oppor-
tunity of words of warning and advice to young men
which the teachers have seldom the opportunity of giv-
ing.
Yesterday several schools opened with the old " Intro-
ductory." At the Westminster Hospital Mr. Hartridge
congratulated the students on choosing the profession
which called for their highest intellectual powers, brought
them into contact with suffering and pain, and called
forth those deep feelings of sympathy which united man
to man. N;> other profession could stand on the same
basis for usefulness. Look at the immense amount of
work which was so freely given by the members of their
calling ; all the hospitals depended upon it for their ex-
istence. Look also at the health of this great city,
with its millions of people, and they would have some
idea what medical science had done in the department
of preventive medicine. If it was the noblest and most
useful, it was at the same time the most arduous, the
most difficult, and one which received the least notice
and reward from the state and the public ; the former
only recognized those who were able to support its
claims. Most of them were not politicians ; they were
not a powerful body to be conciliated, able to turn the
tide of an election or decide the fate of a Cabinet.
Much of this was their own fault, because it was a duty
they owed both to their profession and their country, to
take an interest in politics. He anticipated the time
when they should be fairly represented in both Houses
of Parliament, and when they would have a Minister of
Health in the Cabinet. To the students he would say
that much benefit would accrue by raising the standard
of the entrance examinations. He should like to see
Latin and Greek replaced by modern languages and sci-
entific subjects, which would be equally effectual as a
mental training, and far more useful. Working too
much was almost as bad as working too little. In regu-
lating their study hours they must be careful to look
after their general health. Medicine was a study which
should be approached in a scientific spirit, and they
could always make their work scientific, in whatever
branch they were engaged, by training the mind in the
power and habit of accurately observing facts, and should
always have the courage to do what they considered
right, and allow the consequences to take care of them-
selves. Referring to the success of " quacks and charla-
tans" who advertised so largely, he said these advertise-
ments were hardly a credit to journalism ; most were of a
flagrant character and without a vestige of truth, out of
which certain papers made a rich harvest. The so called
religious papers were the worst offenders. But of all
irregular practitioners the bone-setter was the one whom
the public held in the highest esteem. He knew noth-
ing of anatomy, had never been in a dissecting room,
but was supposed to be born with special gifts as regards
bones and joints. To the bone-setter every injury was a
bone out of place. He wound up by saying that adver
tising quacks, protected by diplomas, were far worse than
the unqualified man. and a disgrace to the bodies whose
diploma they held, and their existence a disgrace to the
legislation of a civilized country.
At St. George's Hospital Dr. Isambard Owen took for
his subject the importance of mental training in medical
study. Accurate observation, he said, was the founda-
tion of all medical work ; to it there was no royal road
— only the old fashioned way of constant, close, per-
sonal observation of case after case, under skilled super-
vision and systematic reduction to written or graphic
records of what was observed* He urged that if school
children were systematically trained into more exact
habits of arithmetical perception and expression more
would be done to render the rising generation scientific
than the suppression of Latin in favor of biology could
possibly effect. Adverting briefly to the position of the
London University and the Gresham Commissioners'
scheme, he said that while a tribute of sincere gratitude
was due to them for their painstaking labors, the merits
of the scheme itself were matter of controversy, and that
he had never concealed his own sense of the danger to
soundness of medical education with which certain parts
of it were charged.
At Middlesex Hospital Dr. Robert Boxall touched
upon the steady increase in the number of doctors in
recent years, and, by a series of statistical tables and
diagrams, showed that the ranks of the profession in
England and Wales had been gradually swelling out of
proportion to increase in population. Drawing deduc-
tions from statistics, he said it was manifest that the
outcry which had been raised against the out patient de-
partments of the large general, hospitals was unwarranted
— at least, in comparison with what might be said of
more recently established institutions, most of which
had no teaching function to fulfil. It was an undoubted
fact that in all the hospitals the number of out patients
had increased, but so had also the number of in-patients,
and an outcry against the one was no more justified than
an outcry against the other. But, inasmuch as medicine
was in itself a progressive science, it would be a wonder
indeed if the medical charities of Great Britain, which
had long been the admiration and wonder of the whole
civilized world, failed, as years rolled on, to enlarge
their walls and to increase the scope of their utility.
At St. Thomas's Hospital an address was delivered by
the Rev. Dr. Merry, Rector of Lincoln College, Oxford,
who spoke upon the half-serious, half-jesting strictures
passed by Plato on the practice of medicine in his own
time, a subject which the great philosopher humorously
introduced in the form of a criticism on medicine as
practised in the days of Homer. Plato professed to feel
the greatest satisfaction in the rough and ready treat-
ment of the heroes who fought under the walls of Troy.
The degenerate system of coddling Plato strongly con-
demned, as tending to the survival of the unfittest, and
the production of sickly children, whose presence was
not to be endured in his commonwealth. The very ex-
istence of hospitals, said the philosopher, was a proof of
a degenerate age, when men had impaired their health
by intemperance and indolence. No one had a right to
be an invalid, and the " coddling " process would never
have been introduced if the profession had not been de-
moralized by wealthy patients, who bribed the doctors
to prolong their miserable and useless lives. Passing
from this humorous criticism, the lecturer quoted a more
serious sentence from his author, recommending that the
physician should not be in robust health, and should
have known what illness is in his own person. Rightly
interpreted, it contained the golden maxim that the phy-
sician must not only bring his skill, but his sympathy, to
bear upon his patient. The world at large was taking a
growing interest in medicine, and men were looking in
high hopes to the progress of medical science.
At University College Professor H. R. Spencer said
that the treatment of wounds on antiseptic principles had
revolutionized surgery and obstetrics, and he believed his-
tory would record it as the grandest achievement of the
century. In medicine, too, great advance had been made
in diagnosis and treatment, as a result of the employment
of the experimental method of research, which only the
ignorant condemned. As to legislation, which was ur-
gently required for the benefit of the public as well as the
profession, he said that autopsies in cases of unnatural
or suspicious deaths should be only performed by expert
medical jurists and pathologists. Practice by unqualified
persons and by medical men whose names had been
expelled from the Register should be absolutely forbid-
den. And the law should be severe on those unprincipled
persons who risked the lives of the ignorant poor by cir-
culating among them the cruel slander that patients were
experimented upon in hospitals. Adverting to the
abuse of hospitals by well-to-do patients, he thought
hospitals should be able to recover fees from persons ob-
taining gratuitous treatment by fraudulently representing
October 20, 1894J
MEDICAL RECORD,
509
themselves to be poor. In conclusion, he said the pro-
fession they had chosen was an arduous one, and yet it
was the most fascinating of all. No social class could
look down upon those to whom such sacred interests as
reputation and life were intrusted. Greater trust hath
no man than this, that he trusted his life to his friend.
At St. Mary's Hospital Dr. Scanes Spicer took for his
subject, " Medicine as a Profession." Its social ad-
vancement, he said, of late years had been remarkable,
and had been parallel with the wide general culture and
interests of the average modern doctor, who was some-
thing more than a mere prescriber of physic. Doctors
were more and more finding their way into Parliament,
the Privy Council, and the national government. It
was a grievance with the profession that it was not di-
rectly represented in the House of Lords, where the
counsel of medical men would not only add to the effi-
ciency of public work, but signalize the national recog-
nition of the value of medicine to the community. The
increase and development of specialism was one of the
most striking facts in the medical history of the latter
part of the nineteenth century. Specialism was destined
to play an even more important part in the development
of medical art. He defended it from the charges of
shallowness, self sufficiency, and unscrupulousness that
had been brought against it. Attention was drawn to
the remarkable development attained in less than forty
years in the specialty of diseases of the throat and nose,
due chiefly to the truly marvellous results of local treat-
ment. On the Continent there was hardly a university
without one or more professors of this specialty, and
well-appointed clinics ; a marked contrast to the indif-
ference and neglect which this branch met with in the
United Kingdom. Specialism now enjoyed, more than
ever before, the respect of thinking members of the pro-
fession and the public ; but there was need for still fur-
ther rapprochement between specialists and the general
body of the profession, in the interest of both. Each
was necessary for the other, for no one could be an all-
round specialist.
At the London School of Medicine for Women, Miss
Maida Sturze, M.B., London, alluded to the need of
cultivating from the first the scientific habit of mind,
seeing that its possession was invaluable to the medical
practitioner. The importance of general culture and ex-
perience as an aid to the right understanding of others,
and as a help in the individualization of treatment was
pointed out. The wisdom of devoting time to learning
something of the natures and abundant vitality of healthy
children was dwelt upon, as the only means of fully un-
derstanding their needs when ill, and probably in the
future the profession would regard with surprise the fact
that in the nineteenth century sick children were so
often admitted into hospitals instead of carrying them
into the fresh air and sunshine outside cities.
THE ESQUIMAUX AND THEIR TEETH.
To the Editor of the Mbdical Record.
Sir : It has long been a disputed question as to what
effect diet, climate, and mode of life have upon the
structural formation of the teeth of mankind. Desiring
to make my observations among a people who fitted the
conditions of such an investigation as nearly as possible,
I chose the Eskimo as my most available subjects, and
with that end in view I eagerly seized the opportunity to
become one of a number who visited the icy shores of
Greenland last summer. Of the interesting people who
inhabit this arctic region, the pure Eskimo are fast dis-
appearing through marriage with the Danes ; the pres-
ent generation being known as Greenlanders, or Danish
Eskimo. The men are taller and lighter in color than
the native Eskimo, shading from bronze to dark tan.
Their hair is black, generally straight, long, and un-
kempt, and, falling over their faces, presents a savage ap-
pearance. Their eyes are small, round, and very sharp,
with large deep wrinkles extending from the outer edge
of the eye to their high cheek-bones. These wrinkles
are caused by the habit of constantly squinting to shade
their eyes from the intetse glare of the ice during the
long arctic day. The women are short, rather stout,
and comely looking. Their skin is lighter in color than
the men's. Their eyes are clear, bright, and similar in
shape to the Chinese. Their hair is twisted in a haid
knot on the top of the head, held in a place by a ribbon
or a rag, the color of which denotes their station in life.
Blue for a married woman, red for a single woman,
black for a widow with the addition of a narrow strip of
white if desiring to marry again. The unfortunate or
fallen women of the tribe are designated by a green rib-
bon bound around the hair. Their food, which consists
wholly of fish and flesh, of the various animals which in-
habit this region, together with the fat and oil obtained
from them, is generally swallowed or bolted without
mastication. Their teeth, which articulate squarely upon
the cutting edges of the incisors, are worn off in many
cases nearly to the gums, giving the appearance of
double teeth all around. Caries is not common, al-
though in several cases the first molar teeth were de-
cayed, while all other teeth in the same mouth were
sound. In color their teeth have a yellow cast; the
structure is more like ivory. The palatal arch is broad
and shallow, the mouth large, with firm lips, and jaw
square shaped.
From twenty-eight impressions taken in modelling com-
position, I made as many plaster- of Paris casts of the up-
per and lower jaws and teeth, which were unfortunately
lost, together with a valuable collection of Eskimo
curios, weapons of the chase, skin, and fur garments,
kyaks, etc. , when our vessel was wrecked off the Green-
land coast, near Sukkertoppen. Despite the unfortu-
nate termination of our expedition, I trust it will be my
fortune to again visit the Arctic region, and make a
similar collection of casts and notes, to add to the large
number now on exhibition at the Medical Museum in
Washington.
Roswell O. Stebbins, D.D.S.
55 West Foety-fipth Steekt, New York.
APEX CATARRH OR TUBERCULOSIS?
To the Editor or the Medical IUcokd.
Sir : In your issue of September 2 2d I notice a short
paper on " Diseases of the Ear and Upper Air passages
in Apex Catarrh," by Dr. Howard S. Straight, of Cleve-
land, O. If I may be permitted the use of a small space in
your journal, I want to object to the use of this expres-
sion " Apex Catarrh." If Dr. Straight will make care-
ful, and if necessary, repeated examinations of the sputa
in these cases of so- called apex catarrh, I think he will
find that they are nearly all cases of more or less early
tuberculosis. Acute simple catarrhal affections of the
chest — "cold," " bronchitis," etc. — do not limit them-
selves to the apices, and I think that the existence of
subacute and chronic affections of the apices of a simple
catarrhal character is more than doubtful. In one of
the cases cited by Dr. Straight as apex catarrh it was
certainly so, for he states that a few days later the pa-
tient, a boy aged twenty, died " from a profuse hemor-
rhage from the lungs."
Post mortem records prove conclusively that tubercu-
losis is a much more common and at the same time a
less to be dreaded disease than is generally supposed,
since a large portion of the dead from all causes show
healed tuberculous lesions. If this view is correct, and
limited apex catarrhs are tuberculous in character, it is
certainly a great gain to call them by their proper
names and to avoid the use of terms which are mislead-
ing and calculated to give rise to a sense of false security-
very dangerous to the interests of the patient. This
view accords very well, too, with what the doctor has to
say upon diseases of the ear and upper air passages in
such cases, since it is a matter of general experience that
the existence of even a slight tuberculous affection in the
5io
MEDICAL RECORD.
[October 20, 1894
lungs renders disorders of the ear, nose, and throat much
more refractory to treatment. Physicians in phthisical
health resorts have been trying for years to arouse in the
profession at large an active appreciation of the impor-
tance of recognizing tuberculosis in just these early be-
ginnings. In no other way, I believe, is it possible to
save them. Palliation can be had at almost any time,
but cures can not.
Yours truly,
H. B. Moore, M.D.
Colorado S things, September ad, 1894.
Hetxx Instruments*
THE
APPLICATION
METHOD TO
OF THE GRAPHIC
HEARING.
By W. HARVEY SMITH, AM., M.D., CM.,
WINNIPEG, MANITOBA,
The graphic method, when employed to demonstrate
physiological or pathological variations from the normal
or to express relations and ratios between different bodily
functions or conditions, is recognized by the medical pro-
fession as an invaluable adjunct to diagnosis. The chart
here shown has been devised for the purpose of applying
this method to hearing, and thus to provide the otologist
with a means of representing the results of tuning-fork
and other tests in a form more intelligible than that com-
monly used.
In this chart the hearing power is expressed in percen-
tages which are based upon the results obtained from the
use of Hartmann's tuning forks, the acoumeter, the voice,
and the watch. The percentage line on each side of
the central columns is numbered from o to 200, the
100 line being the line of normal hearing for all tests.
The percentages employed are based upon the averages of
a large number of tests made upon normal ears, and mod-
ified by comparing them with Hartmann's results.
These averages have been printed in the middle col-
umn opposite the different tests. Spaces for marking
the percentages of aerial and bone conduction ^^^
are provided, one above the other, opposite the [4
different C's. The aerial conduction is repre- v_y|
rented by joining together the consecutive
aerial percentages with black lines, while red
lines are similarly used for the bone conduc
tion. At the bottom of the chart is shown the result
of the Weber test and the percentages of hearing for the
acoumeter, the voice, and the watch ; and in the spaces
to the right and left of the middle column the height of
time or distance at which (in figures) the standard sounds
are heard. A rapid calculation of the percentages can be
made from the percentage table which is printed on the
back of each chart.
It is obvious to those who possess a practical knowledge
of otology, that, owing to the influence of constitutional
and other factors, the results obtained from any or all
hearing-tests can give but an approximate idea of the
condition of the auditory functions. This being true,
how essential it is that that system should be adopted for
the expression of hearing-power which will afford infor-
mation in the most intelligible and rational form !
By applying the graphic method to hearing in the
manner described, the slightest deviation from the normal
can be perceived at a glance, and the comparative differ-
ences between the aerial and bone conduction, and the re-
sults of the acoumeter, the voice, and the watch tests can
be more readily appreciated than by using the numerical
system at present in vogue.
These charts can be obtained from Mr. E. B. Meyro-
witz, of New York.
A NEW SNARE,
By WILLIAM A. MARTIN, M.D.,
PROFESSOR OP LARYNGOLOGY, S\H FRANCISCO FOLYCLXNZC.
The snare described in the following lines is a combina-
tion of the meritorious principles found in other snares,
rendered possible by the shape of the handle designed
by the writer. Most of the snares in present use have
one or more objectionable features, the principal one of
which to the writer is the time lost in rewiring. This is
particularly the case in polyclinic practice, where one
either has to have a number of snares prepared for use, or
must have an assistant with an extra snare at hand.
The only original principle in the snare is in the shape
of the handle. It was designed in this manner in order
that the stiff rod into which the wire is threaded could
be used, and at the same time prevent the obstruction of
the view by the hand of the operator.
The following are a few of the numerous advantages
of the snare. One can have any desired number of
cannulas with the contained rod wired ready for use. The
time occupied in taking out one cannula and replacing it
with another is not more than half a minute. The same
loop can be shoved out and used again and again, as
often as six or seven times.
The economy in wire is not a minor consideration,
especially in polyclinic practice. The loop can be turned
and held in any desired plane by simply revolving the
rod. Anyone who uses the snare for removing tonsils
will appreciate this principle. A loop of larger size than
permitted in any other snare may be used when the finger-
rings come to the end of the slide; the winged screw
may be loosened and the rings slid forward on the rod
and reclamped, a procedure which in the ordinary snare
is awkward and occupies considerable time. The loop
may be placed around the part to be removed and drawn
taut before attaching to the handle, a desirable feature
in post-nasal growths where one has to use both hands.
The handle is threaded as in the Bosworth snare, so that
the loop may be slowly tightened when desirable. The
same handle could be used with the Schrotter laryngeal
instruments, it being similar to the Streck handle ex-
cepting the double bend. The same handle could also
be used for ear instruments, both for cutting instruments
as well as for a snare. Since designing the above snare
I see that a similar bend for ear instruments is advocated
by Barclay,1 of St. Louis. In his instruments the angles
are not 900, but by prolonging the shaft of the instru-
ment and the handle they meet at an acute angle.
The snare is made according to my directions by E.
B. Meyrowitz, in the most satisfactory manner, and he
has also kindly furnished the accompanying cut.
An Italian Hospital has been established in Tunis for
the benefit of residents of that nationality.
1 Archives of Otology, vol. xxii., No. a.
October 20, 1894]
MEDICAL RECORD.
5"
AN IMPROVED PHOROSCOPE.
By WILLIAM F. AIKEN, M.D.,
SAVANNAH, CA.
In using the ordinary rod-test for heterophoria, the
writer has always been inconvenienced by the narrowness
of the opening. About a year ago it occurred to him to
substitute a series of parallel rods for the single rod, and
a crude self manufactured instrument has since then done
excellent work. Recently, Mr. E B. Meyrowitz, of New
York, has constructed from drawings an extremely pretty
instrument, as here illustrated. In practice, the elongated
images produced by the sev-
eral glass cylinders fuse into
one long, continuous, and
very brilliant bright band.
This band is so long, indeed,
that when so placed as to be
vertical, it extends from floor
to ceiling.
Apart from the increased
length and brilliancy of the
image produced, the instru-
ment possesses the great ad-
vantage of a large square opening before the pupil. If,
owing to faulty adjustment of the trial frame in which
the instrument is placed, the pupil fails to correspond
with the exact centre of the opening, it makes no differ-
ence, any point within the square affording a perfect
view of the image. This large working space saves the
annoyance of carefully adjusting a heavy trial frame, the
light single frame being more convenient, and more com-
fortable for the patient. Moreover, the efforts patients
make to see through the stenopeic slits and openings of
other tests add a dynamic factor to what should be a
purely static finding as regards the muscular equilibrium ;
with the large opening no moving about of the head or
eyeballs is excited, the eyes resting quietly in their natu-
ral position.
It should be noted that the instrument is a phoroscope,
not a phorometer. The amount of deviation shown has
to be measured with prisms. Using a rotary variable
prism in the other side of the trial frame, however, makes
the most efficient form of phorometer, as both eyes look
through large openings, and either instrument may be
used separately. Mr. E. B. Meyrowitz has suggested,
nevertheless, that the two instruments can be combined,
making a single phorometer, in case of demand for such
an arrangement. I wish to state my indebtedness to Mr.
Meyrowitz for his courtesy and readiness in conceiving
and executing my idea; likewise for the accompanying
cut.
i^sflical Sterna.
Contagions Diseases — Weekly Statement. — Report of
cases and deaths from contagious diseases reported to the
Sanitary Bureau, Health Department, for the week end-
ing October 13, 1894.
Tuberculosis
Typhoid fever
Scarlet fever
Cerebro-spinal meningitis
Measles
Diphtheria
Small-pox
Cases.
Deaths.
106
99
35
10
53
4
X
1
18
3
119
30
1
0
There are no Public Baths in Rome, according to a
statement recently made by Professor Celli.
The Oldest Physician in Great Britain is Dr. Salmon,
of Penllyn Court, South Wales. He was born in Wick-
ham Market, Suffolk, in 1790. He is also the oldest
Freemason in the country, having joined the order over
eighty years ago.
The Pain of Inoperable Cancer has been found by
Aikmann to yield in many cases to salicylate of sodium
in doses of ten grains three times a day.
The Cholera Bacillus becomes attenuated, it is said,
by exposure to direct sunlight, and will then serve as a
preventive vaccine.
Illegal Sale of Patent Medicines.— Grocers in Eng-
land who sell patent medicines are being prosecuted, on
the complaint of the apothecaries, under the law prohib-
iting the sale of poisons without a special license.
Mrs. Sarah Thomas, of Buryport, South Wales, re-
cently celebrated the completion of her one hundred and
sixth year. The Princess of Wales sent her a letter of
congratulation and a check for one hundred and six
shillings, a shilling for each year of her life.
Delinquents in Olympia. — The publisher of our
esteemed contemporary TaXrjvos has been compelled to
print a black list of subscribers to the journal who are in
arrears for three years. Of these there are eight, two of
whom live in Olympia.
The Face as a Guide in Diagnosis. — The physiog-
nomy of the sick presents innumerable shades ot expres-
sion. These are certain facial lines and wrinkles which
are of positive value in diagnosis, but in the use of these
it is important that we discriminate between those natu-
ral to the face, and those which are developed by disease.
In childhood, however, there are few or none of the
acquired lines found in adult life. We may therefore be
quite sure of our indications in this class of cases. 1 he
more important of these are as follows : The transverse
rugae, the oculo- frontal rugae, the oculo- zygomatic line,
the linea nasalis, the linea labialis, and the linea collat-
eralis nasi. The first two are situated upon the fore-
head, the first of which, the transverse rugae, are formed
by the action of the occipito-frontalis muscles, and are
believed to be indicative of great pain from causes out-
side the cavities of the body. The next, the oculo-
frontal rugae, are vertical lines extending from the fore-
head to root of nose ; they are formed by the corrugator
supercilii muscles; they express distress, anxiety, and
extreme pain from some internal cause, cranial, thoracic,
or abdominal. They oftentimes indicate an imperfect
crisis, and in acute diseases often a fatal termination. I
have observed this many times, and whenever I see these
peculiar lines I am very solicitous for my case. In ex-
cessively severe headaches these two described rugae may
exist simultaneously, and when during the course of an
acute disease the two meet abruptly, they denote a de-
veloping serious lesion of the brain or some of its cover-
ings, and when I meet a case where this condition exists,
I feel justified in advising of the grave nature of the dis-
ease and a consequent grave prognosis, a lingering case,
if not fatal. The linea oculo-zygomatica extends from
the inner angle of the eye down and outward, crossing
the face below the malar bone. This is believed to in-
dicate a cerebral or nervous affection in children, in
adult life masturbation or venereal excesses, and is fre-
quently a very valuable aid in this class of cases.
The linea nasalis extends in a semi curved direction
from the upper border of the ala nasi downward to the
outer margin of the orbicularis oris muscle ; this line we
find very marked in advanced cases of marasmus, inani-
tion or such diseases as these simulate; in adult life,
phthisis and atrophy. Where only the upper half, the
linea nasalis proper, is present, it is quite a reliable indi-
cation of intestinal disease, typhlitis or entero colitis ; it
may be present in severe colic, although not marked, as
the attack is remittent and of short duration. When the
lower half, or linea buccalis, is alone present, it indicates
some disease affecting the stomach. It is quite promi-
nent in chronic dyspeptics, and when the two, as last de-
scribed, together with the linea oculo zyg^matica. appear
conjointly, they may be regarded as positive evidence of
worms, and if the circumscribed red cheeks, the pallor
of face around the mouth inside the linea nasalis, to-
5"
MEDICAL RECORD.
[October 20, 1894
gether with the bright, fixed, and wild expression of eye
are present, no further evidence of the presence of these
pests is necessary. The linea labialis extends from the
angle of the mouth downward without marked termina-
tion till lost in the lower portion of the face. It is usual
in those diseases which affect respiration, and is a more
important diagnostic sign in childhood than in adult
life ; it may be observed in croup, both true and fake,
in acute laryngitis and capillary bronchitis; in adults
most prominently in asthmatic subjects The linea col-
laterals nasi extends in a semi-curved direction from the
ala to the chin. It is situated further out, outside the
lines just described, and is a reliable guide to diseases of
the thoracic and abdominal viscera ; in fact it may be
considered as positive evidence of a lesion in one of these
regions, and when with the above is coupled the painful
expression about the mouth, together with the peculiar
fold on either side the mouth, we may be almost posi-
tively certain that the lesion is abdominal. It is very
marked in typhus abdominalis, also phthisis abdominalis.
The above described are the more important and most
frequently met by physicians, and to those who have not
studied the physiognomy in this manner I would say,
carefully note these lines, wrinkles, and expressions;
they will aid you in the diagnosis of many an obscure
case, assist you in a prognosis that oftentimes will seem
little less than inspirational to your patients or their
friends. — Dr. S. M. Spalding.
Hitrate of Cobalt is said, by Dr. Antal, a Hungarian
chemist, to be an effective antidote to cyanide of potas-
sium. He has tried it in upward of forty cases of poi-
soning by this substance, in every instance with success.
In One Thousand Towns in Minnesota the people
live and die without the help of a homoeopathic physi-
cian, so says a contemporary in that State.
Phthisis is one of the most common diseases of sailors,
more seamen dying from that than from either accident
or heart disease.
Dr. Y. May Kin, now practising in Kobe, Japan, was
the first Chinese lady to receive a medical decree in
America, and the first scientifically educated female prac-
titioner in Japan.
Combined Carbolic Aeid and Chloroform in Typhoid
Fever.— The experiments of Werner, at St. Petersburg,
in 1890, showed that a one-half per cent, solution of
chloroform will kill the bacillus of enteric fever. In
1892 Mclntyre, of Glasgow, proved that carbolic acid
controls the development of this bacillus, and also exer-
cises an antiseptic action on the intestinal contents.
Acting on these hints, Dr. R. H. Quill, of the British
Army Medical Staff, stationed at Hirkee, India, has
treated with a combination of carbolic acid and chloro-
form all his cases of typhoid fever for over a year, and
reports in the British Medical Journal of April 28th
that perfect recovery has followed in each case, without
the advent of any severe symptoms. In India the mor-
tality of enteric fever is much greater than is usually ex-
perienced in temperate climates, which fact increases die
value of the test. He used a mixture of thirty six minims
of pure carbolic acid, two fluidrachms of spirit of
chloroform, three fluidrachms of compound tincture of
cardamon, two fluidounces of sirup of hemidesmus, and
added chloroform water to make twelve fluidounces.
Every two hours the patient was given two tablespoon-
fuls of this carbolic mixture in a like quantity of iced
water. On the first visit three grains of calomel were
given to the typhoid patient. On the next day, five
doses of the mixture were given, and ten doses on the
third and following days until there was a fall of temper-
ature, and the general condition of the patient was dis-
tinctly improved, the doses then being gradually re-
duced to seven, five, and three in the twenty - four
hours. To prevent a relapse, the mixture should be con-
tinued for at least a week after the temperature is nor-
mal, giving from three to five doses each day. Twelve
of the patients were in the station hospital, and one took
two fluidounces, in all, of pure carbolic acid and the
same of chloroform, while another took one and one-
half fluidounce of each, the urine occasionally becom-
ing high colored, but never black.
Carbolic acid combined with chloroform reduced the
average duration of typhoid fever, with a continuous de-
pression of the febrile temperature. The tendency to
diarrhoea was checked, the abdominal distention kept
under control, and the stools were almost completely
deodorized. There was early cleansing of the tongue,
dryness of which was rare and brief. There was no ten-
dency to stupor or delirium, and the patient retained
the usual clearness of intellect. The few relapGes were
of short duration, and secondary complications did not
occur. The food was always well digested and assimi-
lated, and convalescence was rapid. In the past, carbolic
acid has not been generally adopted as an intestinal an-
tiseptic, probably on account of the small doses given.
Full doses, at short intervals, freely diluted and suitably
combined, must be given to make carbolic acid efficient
in enteric fever.
The Pennsylvania Hospital is to be renovated, its
drainage being said to be very defective.
Asparagus causes a reduction in quantity, and in-
creased concentration of the urine, according to Dr.
Elliot Daunt.
Dr. Beaven Bake, whose death occurred in Trinidad
on August 25th, succumbed, as we surmised in a previous
notice, to yellow fever, which has been epidemic in Port-
of-Spain during the past summer.
Dr. Henry Hoffmann Donner died in Frankfort-onthe-
Main on September 20th, aged eighty-three. Although
a skilful physician, he was better known to the world at
large as a poet and humorous writer. His best known
book was " Struwelpeter," which ran through no less
than one hundred and fifty editions in Germany, and was
translated into every European language.
The Influenza has been very prevalent in Buenos
Ayres during the four months just past, which constitute
the winter season in that latitude.
The Cult of the Rotten Calf is the gentle term applied
to the prevention of small-pox by an English anti- vacci-
nationist.
A London Anti vivisection Journal publishes these pa-
thetic lines :
TO A VIV1SECTOR.
Oh, cruel man, how dost thou dare,
With selfish ends in view.
To torture thus a creature fair,
Who never injured you ?
Do you not know the God of love,
Whose are the creatures all,
Looks down from His high throne above,
And hears them when they call ?
He sees the hand with blood-stained knife,
He hears the piteous cry !
Then spare, oh spare, that poor beast's life,
Oh do not make him die !
The God who made him made you too,
For He did all things make;
Then show much love in all you do.
For your kind Maker's sake.
If the gentle author had a child ill with diphtheria; we
wonder if he would consent to the use of the diphtheritic
antitoxin, a product of the vivisectionist's work on
horses. And does this poet eat capon, ride the gelding
or hunt the fox ?
Taking the Case. — Patient : Showing her arm badly
bitten.
Doctor : Bitten by a dog, madam ?
Patient (with withering dignity) .- No, sir. By an-
other lady 1
SUPPLEMENT TO THE MEDICAL RECORD. October 27, 1894.
BRONZE STATUE OF THE LATE DR. J. MARION SIMS ERECTED IN
BRYANT PARK AND PRESENTED TO THE CITY OF NEW YORK, ON
SATURDAY, OCTOBER 20TH, BY THE SUBSCRIBERS TO THE FUND.
Medical Record
A Weekly yournal of Medicine and Surgery
Vol. 46, No. 17.
Whole No. 1251.
New York, October 27, 1894.
$5.00 Per Annum.
Single Copies, ioc.
DR. J. MARION SIMS — SURGEON AND PHI-
LANTHROPIST.
An Address Delivered October 20, 1894, in Bry-
ant Park, New York, on the Unveiling of the
Statue of Dr. J. Marion Sims.
By GEORGE F. SHRADY, M.D.,
MEW YOUC
Ladies and Gentlemen : We have met on this occasion
to do honor to a medical man, and through him to show
a becoming appreciation of the labors of his fellows.
Strange as it may appear, in consideration of the mo-
tive which has actuated this recognition of valuable
services to mankind, and the previous opportunities that
have been, from time to time, offered for conferring
similar honors on the profession, this is the first instance
in this country in which an heroic statue has been erect-
ed to a member of that fraternity.
Heretofore Fame has restricted her tributes to achieve-
ments in every other line of high human endeavor —
War, Poetry, Music, Literature, Art, Patriotism, States-
manship, and Philanthropy have in turn mounted the
pedestal, while the Genius of Medicine, with finger upon
closed lips, has humbly and mutely awaited the verdict
of an appreciative humanity.
This new departure which we this day inaugurate can
be hailed, from many points of view, as an omen of good
import, as the beginning of an end in which cherished
traditions shall no longer hamper the well directed efforts
of such as work in other spheres of human usefulness.
The public, however, is not so much to blame for lack
of a general appreciation of the work of the doctor as
would at first appear. It has in reality no means of es-
timating distinctive merits. It was, therefore, proper,
in order to initiate such a movement as the present one,
that the profession itself should take the lead, and indi-
cate a fitting subject for such an honor. This was done
by the Medical Record, which made an appeal to the
profession in this and other countries for funds with
which to erect a monument to the memory of one of its
acknowledged leaders.
A committee was appointed, of which the late Dr.
Fordyce Barker was chairman, which comprised leading
specialists from every part of the United States. Our
own city was represented by Drs. T. Gaillard Thomas,
Thomas Addis Emmet, William T. Lusk, William M.
Polk, Paul F Munde, the editor of the Medical Record,
and Mr. William H. S. Wood, as treasuier of the fund.
The subscriptions were mostly limited to one dollar
each, and coming as they did from members of the pro-
fession in every part of the civilized world, attested, in an
unmistakable manner, the good name and great fame of
the American surgeon.
This distinction came, then, from his peers, who were
best able to judge his qualifications for it, and who with
one accord were delighted to honor him.
It was eminently fitting also that such a tribute should
be paid to American surgery in general, through one of
its chief representatives. He was a product of the soil
as well as the exemplification of one of the principles
which has placed American surgery where it is to day,
holding the Sceptre of the world.
Nothing in all the line of progress during the century
has acquitted itself so creditably as this very science of
life saving by operative procedure. And America spe-
cially points with pride to her great achievements in this
noble art, to her notable discoveries in alleviating human
suffering, her successful efforts in prolonging human life,
and in the accuracy, skill, and daring of her brilliant op-
erators,
America gave ether to the world, invented the new
sleep which numbs the touch of sharpest steel, brings sweet
peace in the eternal war with agony, and wafts pain to
oblivion on the drowsy wing of night. She opened new
fields for exploration within the human body, made ab-
dominal surgery with its brilliant successes the possibil-
ity of the age, and with dauntless blade and master hand
snatched victory from the long-hidden entrenchments of
death. In fact in every department of surgical proced-
ure the American surgeon has left his impress for good
either in the invention of new methods or in the modifi-
cation of old ones ; and has given American surgery a
world-wide recognition for originality of conception,
boldness of execution, and success of practice.
In his own department Sims, a born and typical
American, was a leading worker. He established a
school of his own, which has now won fame through-
out the world. Indeed, it is safe to say that Sims's
name is associated with more original operations and
more new instruments for making such operations
successful than that of any other American surgeon.
His was the germinal thought implanted in a disposition
for untiring work, which changed impossibilities into
triumphs, restoring health and happiness to countless
numbers of suffering womanhood.
If it be true that no fame is lasting unless founded on
labors which promote the happiness of mankind, the
name of Sims must live as long as generations succeed
each other, and will punctuate the progress of history
by its cherished memory.
But Sims, although ambitious, did not seek for fame.
When it came to him he viewed it with an innocent sur-
prise. When it was all done, when during his tour
of the capitals of Europe, operating in the large hos-
pitals and before the renowned surgeons of the day,
his breast studded with the starry decorations of France,
Portugal, Spain, and Italy, he could not understand why
he was so cordially noticed, forgetting that he himself
was the focal point toward which all the then great
lights centred.
Indeed, it was said of Sims that he could practise and
earn his living in any city of Europe, by virtue of what
became for him a cosmopolitan reputation.
He was, however, virtually alone in his conviction of
ultimate success. His few professional friends, who
were at first enthusiastically hopeful, became, in the face
of his early failures, mistrustful and discouraged. While
they admired his ardor they pitied his delusion. In his
darkest hours came confidential advice from his brother-
in-law : " When you began these experiments/ ' said he,
" we all thought that you were going to succeed at once,
and that you were on the eve of a great discovery. We
have watched you and sympathize with )OU, but your
friends here have seen that you are breaking down with
overwork. And besides, I must tell you frankly that
with your young family it is unjust to them that you
continue in this way. You have no idea what it costs
you to support your hospital, now for over three years,
5H
MEDICAL RECORD.
[October 27, 1894
and my advice is to give it all up." His answer came
quickly and to the point : " My dear brother, if I live
I am bound to succeed. I am as sure that I will carry
this thing through as I am that I now live. I have done
too much already. I am going on with these experi-
ments to the end, it matters not what it costs, if it costs
my life."
The destiny of discovery forced him against many ap-
parently overwhelming obstacles to finally fulfil his
mission. Thus a backwoods doctor of Alabama, strug-
gling for his daily bread, hampered by sickness, working
for the work's sake, his ardor glowing in the very
ashes of his hope, with desperate cases forced upon him,
compelled to follow in a given line, and conscious of a
duty he owed to his poorest patient, was ever busy in his
long and lonely drives in devising the newer means of
relief. Turning to account a trivial circumstance in the
treatment of a patient, what was before a perplexing
problem became a solved discovery. A new method of
operating was thus suggested, and with an almost over-
powering enthusiasm in the possession of the principle
he eagerly put it to the test. His first operation was
upon a female slave. It failed, as did others upon simi-
lar subjects. Bit there was enough of encouragement
in each to prick his ambition and spur his purpose. He
must have suitable means to the end, so he equipped a
little hospital of his own, and with the humblest of poor
patients accomplished the greatest of triumphs.
The stitches used in his operation were necessarily so
deeply placed that they could not be securely tied, and
were themselves a source of infection. And then another
step was taken. He had been lying awake for an hour
wondering how to tie the suture, when all at once an
idea occurred to him to run a perforated shot along the
string, and when the suture was tightened to compress
the shot, thus making the knot secure. He became so
elated with the discovery that he lay there until morning
performing in imagination all sorts of operations upon the
patients in his little hospital. But the shot did not answer
every purpose, for the silk of the suture still made union im-
possible. Just at this time he was walking from the house
to his office when he picked up a piece of fine brass wire.
"A wire is the thing," said he. A neighboring jeweller
made him a fine wire of silver, and with it the thirtieth
operation was performed upon the long suffering yet
* hopeful slave and the principle was forever established.
These incidents are merely sketched to present an out-
line of some parts of his character ; how the greatest
ending may have the most insignificant beginning.
Whenever a great discovery is to be made the idea of it
compasses the individual round and about, it possesses
him by day and by night, at all hours and in all places,
until the misty conjectures form the rainbow of promise,
which frames the prospect of a world beyond. Thus
Sims found fame waiting with her chaplet From little
things to great ones is the lesson of every invention.
With Sims ail the successes of his great operations hinged
not only upon the wide utility of the famous instrument
now inseparably associated with his name, but upon the
accidental suggestion of a cast-off suspender wire.
So ilso the little hospital maintained by himself from
the limited income of a poor, sickly, and hard worked
practitioner, with its beds occupied by bondwomen, was
the germinal conception of the present Woman's Hospi-
tal in this city, the only institution of its kind in the
world, and an eternal monument to the ardent zeal and
lofty purposes of its brilliant founder. Thus while here
the statue preserves the memory of the good man, of the
faithful worker, of the great inventor, oi the broad phi-
lanthropist, the Woman's Hospital becomes for him and
all of us an ever living principle, extending its charity,
widening its influences, perfecting scientific skill, and
fulfilling its divine mission of alleviating suffering and
saving the lives of waiting generations of stricken woman-
hood.
Bat Sims was not only a leader in his own department
but was always ready to devise new methods of treatment
in the broader domain of general surgery. As a striking
instance of this he was the first to boldly advocate the
operative invasion of the abdominal cavity for gunshot
wounds of that region. When the lamented Garfield
was shot, Dr. Sims, in a cabled interview from Paris, ad-
vised that such an exploration should be made. Aston-
ishing as it was, and as much criticism as it then pro-
voked, it would be the first of all expedients at the
present day.
But I must not dilate on points that will be more fully
touched upon by the distinguished speaker who is to fol-
low me.
Suffice it to say that every man having his place, Sims
has found his. If brains, opportunity, environment,
and energy fit him for great things, he is singled out as
a memory of good accomplished, as an emulation for kin-
dred spirits, as an exponent of the progressive idea, and
as an acknowledged benefactor of his race. The reali-
zation of such a position for Dr. Sims is manifest in the
reverential duties of this hour, which consign his lovable
memory to the heritage of a grateful humanity.
DR. J. MARION SIMS— THE FATHER OF MOD-
ERN GYNECOLOGY.
Being an Address Delivered October 20, 1894, in
Bryant Park, New York, on the Unveiling of
the Statue of Dr. J. Marion Sims.
By PAUL F. MUNDfi, M.D.,
Mr. Chairman, Ladies, and Gentlemen : You have
heard from my distinguished friend, the preceding speaker,
who and what manner of man Dr. Sims w s. To me has
been delegated the honor of enlightening you as to the
reasons why he was selected for the peculiar distinction
of having a statue erected to his memory. I say " pecul-
iar distinction " because, while in our parks and squares
are found the statues of soldiers, statesmen, poets, mer-
chant princes, and clergymen, nowhere until to day, so
far as I am aware, does there stand a statue of a physi-
cian. There have been several public monuments and
busts erected to prominent physicians in other cities,
notably a monument to Dr. Ephraim McDowell, the dis-
coverer of ovariotomy, in Lexington, Ky. ; a bust to Dr.
Benjamin Rush, in Philadelphia, and a monument to the
" Discovery of Anaesthesia," the heroes of which are not
mentioned in the public garden of Boston. But this statue
to Dr. Sims is the first of its kind erected in this country.
And why has this great distinction been awarded him ?
Simply and solely because, among the many eminent
physicians and surgeons whom America has produced, he
stands pre-eminent as the man through whose genius, per-
severance, and energy a special branch of medical science
and practice was so renovated, improved, and elevated as
to create an era in medicine and raise America from the
place of the docile and receptive pupil to the proud po-
sition of the teacher of older nations.
This claim is allowed Dr. Sims without dispute, even
by those European nations who are most jealous of their
own achievements in medical science.
Up to fifty years ago the special branch of medicine to
which Dr. Sims devoted himself, as soon as sufficient op-
portunity offered, had made comparatively little progress.
About the middle of the present century three men in
Europe, by their individual efforts, each in his own land,
raised this branch of medicine to the dignity of a spe-
cialty, and placed it on a sound scientific basis. These
men were Simpson, in Great Britain, Recamier, in
France, and Scanzoni, in Germany. But in spite of their
efforts the treatment of these diseases advanced but little,
and the one needful factor, the knife, was rarely used.
Then, like a meteor, appeared the genius of Sims 1 In
the Southern town where he had for many years followed
the practice of a successful general surgeon, as my prede-
cessor has already stated, accident caused him to stumble
October 27, 1894]
MEDICAL RECORD.
5*5
on a method of operating and curing a hitherto practi-
cally incurable injury. Strange to say, the instrument
which enabled him to achieve this success, and which
remains indelibly associated with his name, owed its ori-
gin to the happy thought of a bent kitchen spoon 1 An
ordinary man would not have grasped the situation ; but
the genius of Sims at once comprehended the immense
value of his discovery, and led him on to improvement
after improvement, until the whole procedure was per-
fected.
The field of Montgomery, Ala., then became too nar-
row for his ambition, and in 1853 he came to New York.
His one great object here was to establish a hospital for
the exclusive treatment of the diseases peculiar to the fe-
male sex ; and long and hard did he work, until, after
much opposition from physicians and laymen, and many
a disappointment, in 1855 he was at last able to form
the Woman's Hospital Association. On the opening,
in 1856, of a temporary hospital in Madison Avenue,
among other speakers to commemorate the occasion, Dr.
Valentine Mott, who was the foremost surgeon of his
time both at home and abroad, made the following re-
marks : " Go on, Dr. Sims, in your work of charity and
benevolence ! Although no marble urn or inanimate
bust may tell of your honor and renown, you will yet
have in all coming time a more enduring monument ;
and that monument will be the gratitude of woman."
The latter part of Dr. Mott's prophecy has long since
been fulfilled. And to-day we are assembled to cele-
brate the unveiling of the statue which Dr. Mott scarcely
expected to see erected.
The limited accommodations of the hospital soon
proved insufficient, and after many delays funds were se-
cured for the erection of the first pavilion of the present
Woman's Hospital, at Forty -ninth Street and Park
Avenue, the land for which was given by the city. Since
then one other pavilion and a number of cottages for
tumor operations have been donated by private citizens.
This Woman's Hospital, founded by Dr. Sims, was
the first institution of its kind in the world. Its work
became world-known under his teachings, and those of
his colleagues, Emmet, Thomas, and Peasiee. And
from its walls have issued scores of young physicians,
and thousands of professional visitors, who carried what
they had there seen and acquired to the four corners of
the globe.
A sojourn of several years in Europe made Dr. Sims's
name familiar to the medical profession abroad, and
many opportunities were there afforded him of dem-
onstrating his peculiar methods of operating. But his
name became particularly well known after the ap-
pearance, in 1866, of the only book of any magnitude
which he ever wrote, the originality and boldness of
which aroused admiration and surprise all over the pro-
fessional world. By the older physicians it was even
regarded with more or less distrust and incredulity.
This was particularly the case in Germany, then so very
conservative in this branch of medicine, but now the
boldest of the bold in her daring achievements with the
knife. I well remember how, in 1867, Scanzoni, the
Nestor of German gynecology, whose assistant I then
was, brought a copy of the translation of Dr. Sims's
book, which had just appeared, to the clinic, and em-
phatically expressed to me his opinion that, original
and ingenious as Sims's views and methods were, he
still was only an enthusiast, whose illusions were not
capable of realization. And that was less than thirty
years ago I And in these thirty years these very " illu-
sions " of Sims, subject, of course, here and there, to the
modifications of increased experience, have become the
accepted rules of practice all over the world. It may
truly be said that this book of Sims made a revolution in
modern gynecological practice. The era of what must
properly be called " modern " gynecology, that is, oper-
ative gynecology, dates, so far, at least, as the world out-
side of the New York Woman's Hospital is concerned,
from the year 1866. Many of Sims's views have re-
mained uncontested or unchanged, others have been
modified, and others, again, disproved. But the fact
must always be admitted that the impulse of active sur-
gical interference given by him to the, before him,
largely conservative treatment of the diseases of women,
has resulted in the enormous advances which this spe-
cialty has made during the last twenty five years.
With Sims came the revolution which upset the con-
servative " do little " methods, and opened wide the field
of active, radical, scientific, and rational treatment by
surgical means of the diseases and malformations which
formerly were merely palliated or left unrelieved. As
the exponent of a new system in gynecological thera-
peutics Sims may truly, to use the term of the clergyman
who delivered his funeral oration, be looked upon as an
" apostle." Without disparagement to the patient labors
of previous workers in the same field, I must insist that
the greatest triumphs in this specialty have been achieved
since Sims first taught us how to use his speculum, the
scissors, the knife, and the needle for the cure of the
diseases to which he paid particular attention. J. Mar-
ion Sims may, therefore, with all propriety, be called
The Father of Modern Gynecology, and it is to this
universally admitted claim that he owes the distinction of
being the first physician to whose memory a statue has
been erected.
The genius of Dr. Sims was not limited to the specialty
with which for all time his name will be connected.
Quite early in his career he wrote an article on " Con-
vulsions in Infants" (Trismus nascentium), in which he
advanced the very plausible theory, borne out by later
experiences, that these convulsions could be prevented
and relieved by removing the pressure exerted on the
brain through the soft skull of the child by the simple
plan of placing it on its side, instead of permitting it to
lie constantly on the back. Again, he was among the
first, if not the first, to recognize an abscess of the liver
and open it by a free incision. Obstruction of the gall-
bladder was also the subject of an article by him, in
which he described the operation of opening that organ,
and thus relieving the symptoms. One of Dr. Sims's last
original achievements has already been referred to by
the preceding speaker — I mean his criticism of the
treatment of the wound of President Garfield. I well
remember how vehemently his views were opposed by
the leading surgeons of this city, who insisted that it was
presumptuous for him, a surgeon in an entirely different
line of practice, to offer such radical suggestions to them.
But Sims's views soon gained ground, and to day, only
twelve years later, the correctness of his prophetic asser-
tion is so well recognized that any surgeon who would
fail to carry out Dr. Sims's advice to at once open the
abdominal cavity in case of injury by gunshot or other
perforating wound, and suture the wounded organs,
would be considered criminally negligent ! If only one
such case out of one hundred is saved by this practice,
it is so much gained, since without the operation death
is inevitable.
I hope I have been successful in demonstrating why a
statue has been erected to the memory of Dr. Sims. It
certainly is not my object to deliver a fulsome eulogy of
this great man. He needs no flattery. The record of
his deeds speaks for itself. His memory, and the recol-
lection of what he has done for suffering mankind will
be far more enduring than his statue or the granite on
which it stands. Let his life be a shining example for
us to follow !
Insolated Cholera Cultures. — Dr. Palermo, of Rome,
has succeeded in producing an attenuated cholera virus
by the action of sunlight. This agent does not destroy
the bacilli, but modifies their biological character.
Guinea-pigs inoculated with cultures which had been ex-
posed to the sunshine for more than three and a half or
four hours not only presented no symptoms of the dis-
ease but were also found to be immune, resisting inocu-
lation with the most virulent cultures.
5i6
MEDICAL RECORD.
[October 27, 1894
SOME UNUSUAL CASES OF ABDOMINAL SUR-
GERY, WITH COMMENTS.1
By CLINTON CUSHING, M.D.,
PROFESSOR OF GYNECOLOGY, COOPER MEDICAL COLLRGK, SAN FRANCISCO.
In January, 1893, * was asked to see the wife of a medi-
cal man, who had been suffering for several years with
occasional attacks of fever accompanied by a disturbed
condition of the digestion and by marked emaciation.
The attack lasted from six to ten weeks, the temperature
varying from ioo° to 105 ° F. Following the attack she
would slowly return to her normal state of health. There
was no marked pain to indicate local disease, inability to
take and digest food being the most pronounced feature.
Professors L. C. Lane and J. O. Hirschfelder saw the
case in consultation, but aside from a diagnosis of chronic
indigestion, no decision was arrived at.
Upon examination the patient was found in no pain,
much emaciated, and without distention of the abdo-
men. Abdominal and pelvic organs apparently normal,
analysis of urine negative ; heart and lungs in good con-
dition, pulse weak. After the examination I told the
husband that I was unable to form a definite opinion as
to the nature of the case, but that the probability lay be-
tween a commencing tubercular peritonitis and a small
collection of pus somewhere in the peritoneal cavity.
I advised an exploratory incision as the best means of
settling the question. On February 4, 1893 (with the
assistance of Professor Steele), the abdomen was opened
in the usual way below the umbilicus in the linea alba,
the hand and arm introduced, and all the abdominal or-
gans carefully examined.
Everything was found normal except an enlarged gall-
bladder, filled with gall-stones, on the right side beneath
the liver. I advised the removal of the bladder with the
stones.
The opening in the central line was closed, and the
abdomen laid open just below the ribs on the right side,
the gall-bladder drawn out and ligated close to the liver,
and the whole removed.
The recovery was uneventful, the fever disappeared,
and since that time there has been no recurrence of the
trouble.
A question of importance now comes up. What re-
lation, if any, was there between the gall-stones and the
fever and emaciation ?
If the gall-stones were the cause of the fever, it would
appear to me probable that they produced a reflex irrita-
tion of the stomach and thereby an indigestion of a suf-
ficiently severe character to account for the fever. I am
the more inclined to take this view on account of a sim-
ilar experience six years ago in a case where I stitched
the gall-bladder to the skin and drained it after removing
a quantity of calculi.
In this last case all the symptoms were at once re-
moved by the operation. In both cases the gall-bladder
could not be felt by palpation, and it was not suspected
that there was any fault with this organ.
In any event, the prompt relief of the symptoms, and
the subsequent good health, leads me to the conclusion
that the disorder of the gall-bladder was the cause of the
sickness. Since the existence of the gall-bladder is not
essential to the health of the individual or to the function
of the liver, I believe its removal, when diseased, is better
surgery than to drain it, or to secure an artificial open-
ing between it and the pylorus.
In April, 1893, I **w, "* consultation with several
well known surgeons, a case of stricture of the rectum in
a woman, aged twenty-eight, the mother of two children.
The stricture was about a finger length above the anus,
and the contraction of the gut would not permit the in-
troduction of the first joint of the finger.
* Read before the Medico-Chlrurgical Society of San Francisco,
Cal., September 3, 1894.
The consensus of opinion was that the disease was
probably malignant, and the majority of those present
opposed any surgical procedures owing to the inaccessi-
bility of the disease.
Professor Lane and myself advised an operation on
the ground of the youth of the patient and the possibil-
ity of a cure, and that the real facts in the matter could
only be determined by an effort to remove the disease.
On April 22, 1893, with the assistance of Drs. Still-
man and Rixford, I performed Kraske's operation,
which consisted of the removal of the coccyx and the
lower segment of the sacrum, the breaking up of the at-
tachments of the sigmoid flexure of the colon to the pel-
vic wall, the drawing the detached gut do*n, the re-
moval of six inches of the gut, including all the diseased
portion, leaving about two inches of the rectum next the
anus in situ, as it was apparently healthy. The upper end
of the gut was then drawn down and carefully sutured to
the end next the anus, and the large wound in the back
closed with silk- worm gut sutures. On account of the
escape of some of the contents of the bowel between the
stitches, suppuration took place in a portion of the.
wound. A small recto- vaginal fistula formed at the up-
per end of the vagina immediately behind the cervix;
with the exception of the fistula the wound. healed read-
ily, and she was enabled to return to her home at the
end of two months much increased in weight and in
good general health. She returned to San Francisco in
November last, when I closed the recto- vaginal fistula,
which healed readily. There was left at the site of the
sutures a decided narrowing of the rectum, but the strict-
ure permitted the passage of a Wales's soft rubber bougie
an inch in diameter. At this time her physician writes
me that after the lapse of fourteen months her general and
local condition remain excellent.
A microscopical examination of the removed specimen
demonstrated that it was an epithelioma.
One who has never witnessed this operation cannot
easily conceive how thoroughly the parts are exposed to
view as the operation proceeds, no vessels ligated, haemo-
static forceps being sufficient. A large sponge with a
cord attached was passed up into the pelvis and protect-
ed the intestines from injury.
It is yet too soon to say that a permanent cure has
been made, but the outlook is good and we have at least
given the patient a year of comparative health, with
good prospects of a continuance.
In this case the disease was situated almost exactly in
the centre of the pelvis, and could be reached through an
abdominal opening only with the greatest difficulty, and
from below only by sacrificing the lower end of the gut
with its sphincters unless, as in this case, the opening was
made as Kraske advises. Had I to deal with a similar
case in the future, I would make a trial of the Murphy
button for uniting the ends of the gut, as much time
would be thereby saved and the shock lessened. ''
Mrs. G. H , the wife of a medical man and the
mother of three children, applied to me for advice re-
garding an enlargement of the abdomen. She was in
good general health except that she was unable to stand
long upon her feet without a feeling of weight, and a
bearing down sensation in the lower part of the abdo-
men. She was about thirty six years of age. An ex-
amination demonstrated a bad laceration of the cervix
and perineum. There was marked hyperplasia of the
uterus, and a smooth elastic tumor in the region of the
right ovary which was pronounced an ovarian cystic
tumor, and an operation advised.
On February 25, 1893, the patient was placed under
ether, the uterus thoroughly curetted, the laceration of
the cervix and perineum repaired, and afterward the
abdomen opened in the usual manner. What was sup-
posed to be an ovarian cyst proved to be a colloid cyst
growing from the retroperitoneal tissue just below the
right kidney, and the inner wall of which was made up
in large part of the outer wall of the ascending colon.
The tumor was about the size of a child's head at term.
October 27, 1894]
MEDICAL RECORD.
5i7
The wall of the sac was covered by peritoneum about
the thickness of card-board. The sac was tapped, but
the colloid mass had to be removed by the hand ; mani-
festly the sac could not be removed without sacrificing,
or, at least, greatly endangering, the wall of the colon,
so the cut edges of the sac were stitched to the abdomi-
nal wall and a drainage-tube inserted and fastened into
the abdominal wound.
There was no shock and the recovery was uneventful.
At the end of a year there was still a slight discharge
from the fistulous opening, and the narrow tract was
syringed out with a solution of nitrate of silver, sixty
grains to the ounce, and the fistula then closed. The
ovaries were found to be normal. The plastic operation
on the cervix and perineum had yielded a perfect result.
I report this case, for retroperitoneal tumors of this
kind are uncommon, if we are to judge by the fact that
we seldom see one reported in the medical journals.
The error of diagnosis is easily understood when it is
remembered that the cyst was movable and was in direct
contact with the ovary, and that the patient's abdomen
was well loaded with fat. However, mistakes in diagno-
sis in abdominal diseases are so frequent that they have
ceased to cause surprise.
Dr. Hennessy, of Napa, sent a woman to me February
last, with a history of pelvic inflammation ending in a
discharge of pus from the rectum and from the bladder.
She also passed gas from the bladder, from time to time.
She was much emaciated and suffered a good deal
from pain in the region of the left ovary. Upon exam-
ination an immovable and tender mass was found in the
region of the left ovary, and the diagnosis was made of
a pus-tube opening both into the rectum and bladder.
On March 3, 1894, assisted by Dr. Hennessy, the
abdomen was opened and the diagnosis verified. The
whole left broad ligament was distended and filled with
cheesy pus, and the remnants of a pus-tube were in evi-
dence. The tube was ligated with catgut and removed,
and the pus cavity in the broad ligament thoroughly
curetted and afterward mopped out with a mixture of
equal parts of carbolic acid and compound tincture of
iodine, and a rubber drainage-tube passed through from
the abdominal wound into the vagina.
There is still a fistulous opening in the abdominal wall,
bat the patient has grown fat and hearty, and bids fair
to make a perfect recovery. This case is somewhat out
of the ordinary.
In this connection I would like to call the attention
of the. members of the Society to a practical matter of
undoubted value, and which I put in practice for the first
time in this case.
In order to avoid fistulous tracts caused by leaving in
the abdomen silk ligatures that have become infected
with pus, I prefer in pus cases to use catgut, but a seri-
ous objection to catgut is, that in handling it with wet
hands, and when it is soiled with blood and pus, it be-
comes slippery, and when a knot is tied down in the bot-
tom of the pelvis, I do not feel sure that it will hold.
It occurred to me that, after the catgut had been kept
in sulphuric ether for ten days in order to get all the ani-
mal oil out of it and render it antiseptic, if it were put
into a mixture of an ounce of common rosin to a pint of
alcohol, it would preserve the catgut and make it sticky
so that it would stay tied, whether wet or not.
The experiment was a success, and the catgut stayed
tied, and I can recommend it as an improvement.
Two years and a half ago a patient, aged about thirty-
five, brought me a letter from Dr. Henry O. Marcy, of
Boston, asking me to give her such attention as might
be needed. She was exceedingly nervous, and was suf-
fering from pain in the region of the ovaries. She was
a widow and had never been pregnant. Upon examina-
tion the ovaries were found more than usually sensitive,
and slightly enlarged. I advised measures to improve
the general health and the use of the continuous current
of electricity to be passed through the ovarian region by
means of large pads made of potter's clay. She did not
return for treatment and I heard nothing more of her for
two years. Last spring she came to my office again for
advice, stating that after leaving me over two years ago,
a surgeon had performed laparotomy and removed the
left ovary and tube, but with no benefit to the trouble-
some symptoms.
Upon examination she was found to have a ventral
hernia the size of a small cocoanut in the line of the ab-
dominal incision. The right ovary was about the size
of a duck's egg, and extremely tender, the right Fallopian
tube was enlarged to the size of one's thumb. Behind
the uterus there was what appeared to be a mass of hard
fecal matter in the rectum which prevented my making
a satisfactory examination, and I instructed her to go
-home and take a large rectal enema and to return for
further examination.
'Upon her return the mass was still felt in the same
place and a digital examination per rectum demonstrated
the fact that the mass was in the lower part of Douglas's
pouch, and through the thin wall of the gut, I could
make out the outline of a round flattened mass something
like the end of a spool, but further consideration led me
to the conclusion that it was a finger-ring, and I so in-
formed the patient.
She then told me that she had learned since the opera-
tion that a valuable ring had been lost at the time and
that it had never been found. This only confirmed me
in my original opinion that the mass in Douglas's pouch
was a finger-ring buried in lymph.
On May 24, 1894, assisted by Professor C. N. Ellin-
wood and Dr. £. W. Thomas, the abdomen was opened
and the right ovary, which was a mass of cysts, and the
enlarged Fallopian tube, were removed ; an attempt was
made to dissect out the mass in Douglas's pouch, but on
account of the cartilaginous hardness and the imminent
danger of making an opening into the rectum, the effort
was for the moment abandoned. The fibrous sheath of
the rectus muscle was next dissected free along the edge
of the incision in the abdomen and, after the usual sutures
of silk- worm gut were introduced through all the tissues
composing the wall, interrupted buried sutures of heavy
silk were used to bring together the fibrous layers that
had been dissected out, and finally all the structures were
brought together by the deep sutures of silk worm gut,
the buried sutures being introduced to prevent, if possi-
ble, the recurrence of the hernia. The patient was then
turned upon her side and Douglas's pouch laid open from
below, when the gold ring with an emerald setting, as
bright and clean as the day it was made, came into view,
and with a pair of strong forceps and long-handled scis-
sors was quickly removed from a firm bed of lymph where
it had laid for two years. As a consequence of the dis-
section a rather free hemorrhage followed, and a sponge
in the grasp of a long-handled forceps was left in the
opening for six hours, which effectually controlled the
bleeding. The recovery was slow but uneventful, and
she left the hospital at the end of four weeks. I am con-
fident she will now be restored to health.
It is of interest to know that so small a body could
be detected after being in the peritoneal cavity for over
two years, but this can be understood when it is remem-
bered how thin the rectal wall is.
Had she been free of the ovarian and tubal disease, and
not suffering from hernia, I doubt that the simple pres-
ence of the encapsulated ring would have warranted a
serious operation for its removal. Nevertheless Douglas's
pouch is one of the most sensitive points in the human
body, as can be proved by passing a sponge down upon
it during an abdominal operation. Other manipulations
are borne without a sign of suffering, but if Douglas's
pouch is touched, the patient begins to struggle.
The following case is reported by Dr. Rixford, and is
a valuable contribution to the literature of abdominal
surgery, for it illustrates some of the difficulties attending
diagnosis, and shows what may be done in the way of
exploratory incision in serious conditions, without caus-
ing untoward symptoms :
5i8
MEDICAL RECORD.
[October 27, 1894
R. L. Jump, a physician, has enjoyed generally good
health. On April 18th he felt perfectly well, though
for ten days or so previously he had been troubled with
constipation, a very unusual condition for him. During
the night of April 19th, he had abdominal pain sufficient
to keep him from sleeping, situated in the right iliac and
umbilical regions. The pain was constant, and resembled
that experienced in several similar attacks which occurred
during the last three years, though it was not so severe.
In one of these attacks the pain persisted a week or more.
During the evening of April 20th he was slightly fever-
ish, and more so the following evening. Sunday morn-
ing he felt well, and walked to the ferry, but by night he
was feeling badly and chilly, and had a temperature of
102. 50 F. by the mouth. He took ten grains of calo-
mel and confined himself to milk diet, but did not go
to bed.
The temperature came down to 99.80 ?. on the 23d,
to 99 50 F. on the 24th, but rose again on the 25th to
1 00. 50 F. He took a second dose of calomel, after
which the temperature fell to 990 F. On the 26th, 27th,
and 28th he took long buggy rides and felt well. Friday,
the 27th, the temperature was normal night and morn-
ing, and continued so for three days. During this week,
from the 23d to the 30th he had no pain.
On Saturday, the 28th, he returned to the city feeling
welL Sunday he felt as well as ever, and ate with relish
meat and vegetables. That night he slept well. On
Monday afternoon, April 30th, he began to feel badly
again ; he had some uneasiness in the abdomen, but ate
as usual. Temperature 102° F. Next morning he-took
an ounce of Rochelle salts, vomiting part of it. That
night he took five grains of calomel in divided doses.
Temperature 1030 F. He passed a sleepless night, and
Wednesday morning, May 2d, went across the bay. The
abdominal pain had returned worse than before. Tem-
perature, 10 40 F. At times he complained bitterly of the
pain, and asked for an exploratory incision.
On Thursday, May 3d, the temperature reached 1050
F., followed by a remission to 1030 F. Friday morning.
Five grains of phenacetine brought the temperature down
to 101.50 F. The pain was so severe that morphia was
given. On this day there were several fluid stools,
which were thought to be due to the beef extracts with
which he had been fed for two days.
The rectus muscle on the right side was quite rigid,
and a decided tumefaction was felt just below and to the
right of the umbilicus. This point was very tender on
pressure. There was moderate tympanites. One year
and a half ago he had had an extensive pelvic abscess,
which was incised deeply through the perineum. In
view of these facts, together with the patient's request,
and the history of several attacks of abdominal pain
mentioned above, and the rapidly increasing severity of
the symptoms, the attendants decided upon an explora-
tory incision, it being thought that there was present an
abscess, probably of appendical origin.
On Saturday afternoon, the 5th, Dr. Cushing, assisted
by Drs. Stiliman, Rixford, and Huffaker, made an ab-
dominal section through the body of the rectus muscle
immediately over the tumor. The appendix appeared
in the wound and was quite normal. The lower eight
inches of the ileum were moderately congested, and in
violent peristalsis. The mesenteric glands of this region
were greatly swollen, some being as large as almonds,
and of a purple color. The total mass of the glands was
sufficient to be felt through the abdominal wall, and
accounted for the tumor. One of the glands was shelled
out for examination.
The case was evidently one of typhoid fever, in spite
of the clinical history. Typhoid fever had been dis-
cussed several times before the operation, and was
strongly suggested by the rapidly increasing fever and
the fluid stools of May 4th, but it was excluded on con-
sidering the history of previous abdominal trouble, the
period of defervescence and return to normal health, the
severe pain, the excessive tenderness, the muscular spasm,
the chills, and the absence of the typhoid eruption and
stupor, for the mind was bright as ever.
There was considerable dark-colored fluid in the peri-
toneal cavity. A glass drain was inserted. The wound
was closed with silk-worm gut sutures, and dressed with
carbolic acid and glycerine. There was no. shock follow-
ing the operation, and no vomiting.
Soon after the operation delirium became profound,
and continued to May 18th. It was peculiar in that the
patient knew those about him, and offered rational sug-
gestions concerning his treatment.
On the next day after the operation the patient's
pupils began to dilate, and the dilatation soon became
extreme. Then strabismus occurred, lasting several
days. The head was retracted, and a certain degree of
opisthotonos was present. With these symptoms the
pulse-rate increased to 120 and 140. Subsultus tendi-
num was excessive. Beginning as usual in the hands, it
extended seemingly to every muscle in the body ; the
arms and legs were thrown about, and the thoracic and
abdominal muscles contracted spasmodically.
The drainage-tube was withdrawn after forty- eight
hours, and the stitches were removed on the fifth day,
the wound having healed by complete primary union.
On the sixth day, while the attendant's back was turned,
he tore off the adhesive strips and opened the lower third
of the wound. No evil resulted other than the some-
what delayed healing by granulation of this portion of
the wound.
Tympanites was excessive at times. The typhoid
eruption appeared after the operation, and was marked
on the abdomen and chest, and a few petechias were
present even on the extremities.
At no time was the diarrhoea excessive, nor was there
blood in the stools. Prostration was extreme, and the
discharges were involuntary for a week or more. The
greatest care was necessary to prevent the formation of
bedsores, and, notwithstanding the patient was turned
from one position to another every twenty minutes, and
air cushions and cotton rolls were used, several small
bedsores did form.
The temperature, taken by the rectum, ranged from
1020 to 105 ° F. from May 2d to 14th, when decided
remissions took place, and defervescence set in. On
May 2 1 st the temperature was 990 F., and thereafter re-
mained normal. Great distress was caused by drying of
the secretions of the throat. Several times complete
casts of the pharynx had to be forcibly dislodged.
The case is remarkable in a number of respects. Few
cases of typhoid are accurately observed at as early a date
as this. There occurred an interval of complete defer-
vescence following vigorous purgation with calomel and
restriction to a milk diet, and complete return to health
for three days. After this, the fever rose rapidly but
continuously for four days. Several explanations of this
have been suggested ; one, that the disease really began
about April 19th, and that by the prompt administra-
tion of calomel it was aborted, to be lighted up afresh on
too early return to ordinary diet Another is, that the
symptoms were due to an error in diet during the pro-
dromal stage, and were relieved by the removal of fer-
menting intestinal contents by the calomel.
The exploratory incision yielded a number of valuable
observations besides those mentioned ; viz., the localized
congestion, the violent peristalsis, the dark fluid in the
cavity, the enlargement of the mesenteric glands early
in the disease. Dr. S. M. Mouser, to whom was sub-
mitted the excised mesenteric gland, reported that Es-
march tubes inoculated from it showed only the typhoid
bacillus in pure culture. This fact is almost proof posi-
tive against ulceration of the intestines having occurred,
for a break in the continuity of the mucous membrane
gives entrance to a great variety of bacteria with which
the intestinal contents swarm. From the violence of the
peristalsis in the lower end of the ileum as the coil lay ex-
posed, the explanation of the colicky pain was evident.
The remarkably severe nervous symptoms deserve some
October 27, 1894]
MEDICAL RECORD.
5*9
attention ; meningitis and frightful subsultus and violent
delirium, which made it at times most difficult to give the
patient food ; all this in a case which progressed to con-
valescence without the slightest evidence of intestinal ul-
ceration, and which was followed by a rapid return to
perfect health, once convalescence was established.
Dr. Jump is Assistant Demonstrator of Anatomy in
Cooper Medical College, and a most enthusiastic and
thorough student of his subject. Believing that he was
suffering from appendicular trouble, and knowing the
dangers attendant upon it, he insisted that an exploratory
incision be made without delay. He said, " If I should
die without operation, and it be found that the disease
could have been removed by surgical means, I want put
on my tombstone, ' A victim of conservative surgery.' "
THE RATIONALE OF HYDROTHERAPY.1
By SIMON BARUOH, M.D.,
NSW YORK.
AllEMlMMG rHYSKIAN TO MANHATTAN HOSPITAI, MKW YORK JUVBNILB ASY-
LUM, rrc.
Recently a professional friend suggested that, by devot-
ing too much attention to hydrotherapy, my usefulness
as a member of the profession would be impaired owing
to a one-sided view of therapeutics. This suggestion has
" given me pause/' but upon reflection I regard it as
originating in a mistaken view of the duty of the physi-
cian to his colleagues, and to humanity at large. I take
it that the physician's first duty is to cure disease, his
second duty, but not less important, to garner up his
dearly bought experience and offer its deductions to his
fellow-laborers for criticism, study, and, if worthy, for
imitation.
Through all my professional life I have been more
deeply interested in therapeutics than in any othe*
branch. Hence my contributions, whether medical,
surgical, or gynecological, have been to the treatment of
disease. My having spent the larger part of my profes-
sional life, like many of yourselves, in village and coun-
try practice, may account for this predilection for a
branch of the profession which is to day too much neg-
lected at home and abroad.
A young Viennese doctor recently told me that he
knew nothing of therapeutics, because his teachers were
engrossed in the diagnosis of living patients, and in
autopsies of the dead ones, far more than in saving the
former from the fate of the latter.
To search out a rationale for therapeutics has ever
been my aim, because only by this means may therapeu-
tic methods be firmly established in the minds of the
profession. This is the reason that has led me to the
investigation of water as a remedial measure. Here was
a field that opened a valuable mine for exploration.
How inexhaustible and rich this mine is, I have daily
reason to observe. If I am persistent in offering to the
profession the results of my explorations in this direc-
tion, the explanation rests in the fact that I have dis-
covered the same surprising inattention to, and conse-
quent unfamiliarity with, hydrotherapy in the large
majority of the profession, which was a painful discovery
in my own case. As the value of this much neglected
remedy dawned upon me in a somewhat extensive experi-
ence gathered in private and hospital practice, the ques-
tion presented itself: Is it not a duty to agitate this
subject in the medical societies, until its merits and
objections are thoroughly canvassed ?
From the earliest medical times water has been
applied in medicine. In his work " De Aquaet Locis,"
Hippocrates laid down principles in hydrotherapy which
are so sound and practical, that it would be a blessing to
suffering humanity were medical students indoctrinated
in them to day.
1 Read before the North Carolina State Medical Association, April
17. 1894.
The average medical man goes into practice with the
idea that warmth stimulates, and cold depresses. And
yet Hippocrates himself taught the reverse, which is the
truth. One of the first lessons we are taught in surgery
is that when a limb is frost-bitten we should avoid heat,
and apply cold. The reason is obvious even to the tyro
in medicine ; but when this tyro becomes a full-fledged
doctor, and hears the cold bath suggested in typhoid
fever, he at once objects to it as a depressing agent.
To overcome this prejudice, which is as deeply rooted
as it is irrational, has been exceedingly difficult, even for
some of the greatest intellects, and most influential phy-
sicians, whose lives and works have illumined medical
history. Asclepiades, of Prusa, the bosom friend of
Cicero, was a warm advocate of water. Indeed he in-
sisted upon being called a water doctor, and he was the
man who founded the school in which were equipped for
practice such illustrious men as Antonius Musa, the phy-
sician who saved the lives of the Emperor Augustus and
of the poet Horace ; Cornelius Celsus, the bosom friend
of Ovid, and also Galen. All these men remained true
to and exemplified the teachings of their preceptor, ap-
plying water successfully in many acute and chronic dis-
eases ; and yet water fell from the high estate to which
they had brought it. Paulus iEgeneta, the greatest
physician of the seventh and eighth centuries, was the
discoverer of the use ot the cold douche in sunstroke.
Cheyne, Huxham, and Currie, men well known in Eng-
lish medicine, and Hufeland, the renowned German
medical philosopher, were enthusiastic advocates of hy-
drotherapy, as was in later times that grand teacher Nie-
meyer. These representative men are mentioned to
demonstrate that hydrotherapy never was, and is not
now, a medical fad, that it must surely be founded on
correct rationale and on practical results at the bedside,
if it enlisted the advocacy of such men.
When I am charged with undue enthusiasm in this
matter, I am proud to be able to point to these men, and
men like Ziemssen, Semmola, Charcot, Draper, and Pea-
body, as confreres and collaborators.
One of the reasons why water has not become fully es-
tablished as a remedy despite the advocacy of able and
conscientious men, is that its rationale has not until re-
cently been studied with care and precision. To Pre*
fessor Winternitz, of the Vienna University, we owe the
first attempt to invest it with some scientific accuracy.
As a follower and student of this clinician, I have endeav-
ored to impress upon my American colleagues the impor-
tance of not accepting water as a remedy only upon em-
pirical grounds.
If it is to take a permanent place in therapeutics, a
place from which the whims and fancies, the prejudices
and fashions of coming generations shall not again displace
it, the rationale of its action must be clearly established.
In this essay it is impossible to furnish anything
more than a brief outline. The more succinctly princi-
ples are formulated, however, the more readily they may
be accepted or controverted. The rationale of the inter-
nal application of water will be omitted, because this is
very simple and generally appreciated. That diuresis,
for instance, is enhanced by free drinking of water, is a
trite observation, as is the cleansing effect of stomach
lavage, and intestinal irrigation.
Although the external application of water in disease
has been carefully studied by capable physiologists and
clinicians, it has not obtained such universal recognition
among practitioners as its positive effects deserve.
The action of water upon the human organism is de-
rived from its physical and mechanical effects.
The physical qualities of water are utilized in hydro-
therapy because it is an excellent vehicle for conveying
the thermic and mechanical effects aimed at.
Water absorbs and gives up heat readily ; it may be
used in solid, liquid, or gaseous form ; it may be applied
to any limited part of the body or to its entire surface.
Hence its physical property alone makes it a most
flexible therapeutic agent.
520
MEDICAL RECORD.
[October 27, 1894
Thermic agents, as is well known, affect living tissues
in the most pronounced manner.
Smooth muscular fibre contracts under cold, and ex-
pands under heat, and its contractility may be entirely
destroyed by an excess of either.
By the conveyance df cold or heat by means of water,
we are therefore enabled to produce striking effects upon
the vital processes which depend upon muscular activity.
As cold and heat are irritants, their reflex effects conveyed
through the nervous system also become valuable thera-
peutically. Applying these axiomatic principles, we find
that circulation, respiration, tissue change, and heat-pro-
duction may be positively influenced by the application
of water as a medium of conveyance of cold and heat,
that abnormal conditions of these functions may be rem-
edied and their healthy equilibrium restored.
That the application of cold to the cutaneous surface
produces pallor and cutis anserina, is a well- known fact,
as is also the rmtioncUc thereof. The circular fibres of
the cutaneous vessels, and the elastic tissue surrounding
the cutaneous capillaries are contracted, and thus they
are made to contain less blood. Stagnation occurs in
the arterial capillaries, while the venous, being less eas-
ily contracted, remain filled ; the part becomes cyanotic.
If this stage be prolonged under extreme cold, necrosis
of the tissues lying in immediate contact ensues. On
the contrary, if the application of cold be of brief dura-
tion reaction takes place, the part is aglow.
In the first instance we have a paralysis of the inhibi-
tory nerves, which allows the vaso-constrictors to exert
full sway ; while in the latter the inhibitory nerves are
stimulated, and tonic contraction and relaxation ensue.
The deeper vessels in the muscular tissue are more slowly
affected. The local hyperemia produced by this reac-
tion both on the cutaneous surface and in the deeper
parts, is therefore not a passive congestion, as has been
too often assumed. It is not a congestion like that pro-
duced by the application of warmth, but is the result of
a vital process, reaction which is the physiological se-
quel of the preceding depression. Admitting these
trite physiological facts, you perceive that an immense
field for therapeutic effect is at once opened.
The blood which is driven out of the cutaneous and
muscular vessels must be taken into the general circula-
tion, and thus produce hyperemia in other more or less
distant parts; arousing increased activity in organs
whose circulation has been impaired by disease ; remov-
ing the result of abnormal tissue change which the slug-
gish organ has been incapable of unburthening ; stimu-
lating it to more normal function.
That such' effects are really produced, laboratory experi-
ment as well as observation at the bedside has again and
again demonstrated.
In a valuable essay before the recent International
Medical Congress at Rome, Professor Winternitz, of
Vienna, offered some practical observations upon the
changes produced by thermic agencies upon the circula-
tion of the blood and upon its composition in health.
He ascertained positively that all applications of cold
which involved the entire surface of the body, or a con-
siderable part thereof, resulted in an increase of the num-
ber of leucocytes ; the percentage of haemoglobin and
the specific gravity of the blood were also increased.
This remarkable change in the blood was more or less
enduring, its extent varied according to the technique
employed, and sometimes it did not entirely disappear
even after a tolerably prolonged period of observation.
Only in those cases in which no reaction ensued, as
manifested by cutaneous hyperemia, did this effect upon
the blood fail.
Indeed, in such cases the erythrocytes, and often the
leucocytes, also were diminished. Sometimes the red
corpuscles were diminished while the leucocytes were
increased.
Locally the application of cold, when followed by re-
action, almost invariably increased the cellular elements,
specific gravity, and haemoglobin of the blood, while a
diminution of all these ensued in distant parts. After
flowing foot-baths, for instance, blood taken from the
toe showed an increase, while that taken from the finger
or ear lobe showed a decrease. Warmth mostly pro
duced a diminution of the cellular elements, haemo-
globin, and specific gravity of the blood. A comparison
of the composition of the latter in the normal condition
of health, even showed that blood distribution is quite
unequal ; for instance, while blood taken from the point
of a finger furnished 4,955,000 red corpuscles, and ninety-
one per cent, haemoglobin, blood drawn from the ab-
dominal skin showed 7,366,000, and a hundred and fif-
teen per cent, haemoglobin. When, after this examination,
a cold compress well covered was applied so as to en-
velop the whole abdomen, the blood drawn from the ab-
dominal skin and tip of toe an hour later, was found to
present a still greater difference from that of the finger-
tip drawn at the same time ; and while the cell- elements
were decidedly diminished in the latter, that drawn from
the former, underneath the compress, showed an enor-
mous increase of erythrocytes and haemoglobin, some-
times amounting to 2,000,000 of corpuscles, and over
thirty per cent, haemoglobin.
Up to the present time all our observations upon the
effect of cold compresses and poultices were conjectural
and empirical. But these valuable observations demon-
strated them upon a clear rationale.
That these effects may be utilized to explain the
rationale of cold applications in disease, was demon-
strated last year by Thayer, of Johns Hopkins Univer-
sity, who observed that the blood drawn from the lobe of
the ear of a typhoid fever patient after a Brand bath, con-
tained three times the number of leucocytes which re-
sulted from a counting previous to the bath. Since this
enormous increase could not be the result of new pro-
duction during the fifteen minute bath, the conclusion
is inevitable, in view of Winternitz's observation just
<cited, that the increased activity of the circulation in-
duced by the changing anaemia and hyperemia of the
cutaneous surface resulting from the cold bath and fric-
tion, has driven these cells from their hiding-places on
the outskirts of the blood-stream and elsewhere, and
brought them into active service.
Thus we have a brilliant explanation of one of the
most important effects of the cold bath in typhoid, of
the mildness it impresses upon its course, which may be
charged to the phogocytic action of the leucocytes when
actively mingled with the blood-current, where they
must come into living contact with Eberth's bacilli and
other pathogenic organisms. How different this physio-
logical method of stirring up a sluggish circulation is to
that produced by medicinal agents, every practitioner
may learn by comparing the impotence of the latter with
the demonstrable results of the former. Another result
of the application of cold to the periphery is the in*
creased blood pressure produced. The contraction of
the arterial capillaries induces a more rapid flow of blood
into the veins, while the deepened inspiration, which is
also a well known incident of the application of cold to
the surface, accelerates the circulation in the smaller
vessels, causes the blood to flow more rapidly into the
left auricle, the contraction of the ventricle becomes
more vigorous. Thus blood-pressure is enhanced.
Cold improves the muscular tone of the vessel, in-
creases tension, but warmth relaxes them, causing passive
dilatation and loss of tone. Although both produce a
hyperemia, one is the result of reaction and is tonic,
while the other is the result of relaxation and is atonic.
This trite fact is sadly disregarded in practice. Its more
general recognition will do much to neutralize and re-
move the fear of shock from cold applications in atonic
conditions. Before entering into the rationale of the
clinical application of these effects, the reflex action of
cold and heat as irritants may be briefly referred to
here. That the idea of the direct derivative action of
irritants like blisters is fallacious, has been clearly shown
by Naumann and others. Naumann severed all the
October 27, 1894]
MEDICAL RECORD.
521
connections of a frog's head from its body, except the
spinal cord, and then severed one leg from the body after
tying the vessels (to prevent bleeding) except by its
sciatic nerve. By applying irritants to the severed leg
the blood in the lungs and mesentery was made to flow
more rapidly; when the irritant was withdrawn it
flowed more slowly. From this experiment he deduced
laws which are of so much importance in the rationale of
hydrotherapy, that I may be pardoned for summarizing
them here: " The action of irritants is reflex and potent
on the circulation ; feeble irritants stimulate the latter,
and intense irritants depress it; effects continue after
withdrawal; relaxation ensues after the stimulation;
cooling follows the warming effect of the increased circu-
lation."
That the circulation of the blood in distant parts is
reflexly influenced by thermic irritants, has been plainly
demonstrated by the classical experiments of Max
Schueller upon trephined rabbits.
Having the circulation in the pia mater directly under
his eye, he found that any irritation, such as pressure
upon the belly, was followed by filling of the veins.
The application of cold wet compresses upon the
belly of the rabbit was followed invariably by dilatation
of the blood-vessels in the pia, and increased and slowed
pulsation and deepening and retardation of the breath-
ing.
••The application of warm wet compresses to the belly
of the rabbit was at once followed by a contraction of
the vessels of the pia, a diminution of cerebral pulsations,
and a more rapid and shallow breathing.
Very hot compresses were followed by the same effect
as cold compresses. And right here I may call atten-
tion to a point not sufficiently appreciated, that extremes
of heat produce temporarily the same effect as extreme
cold.
By dipping the rabbit into cold or warm water, i.e.,
giving it a bath, the same effects were produced as by
compresses of the same temperature.
Many other valuable points of practical interest were
ascertained by these experiments, whose results are sus-
tained by others, all tending to demonstrate that the
various hydriatric procedures produce positive effects
which medicinal agents are incapable of accomplishing.
It is not difficult to demonstrate that the thermic ac-
tion of water upon the human organism is capable of
influencing its every part and function in the most pro-
nounced manner.
Beginning with the skin, we know that this is an organ
of protection by reason of its external layer ; of excre-
tion and heat regulation by reason of its glandular and
vascular supply ; of sensation by reason of its harboring
terminal nerve-fibres. Hence the skin is the great out-
post of the human body. As a stimulant to all these
functions water has long earned a well-deserved position.
That by warmth or cold conveyed through it we may
increase or diminish any or all of these functions of the
skin, need not be enlarged upon before this audience.
By reason of its action upon the glands of the skin we
may enhance excretion of products of tissue-changes, as
in uraemia by warm baths and hot packs ; by reason of
this action we may increase or diminish the heat of the
body, which is regulated chiefly by giving off moisture,
and which may be powerfully influenced by direct cool-
ing of the blood as well as by reflex effects from the nerve-
centres. That soothing or stimulating manifestations
may be produced by warm or cold baths is also so com-
mon an observation that it requires only an enumera-
tion in this category.
Next to these powerful effects upon the skin proper, let
us consider the effect of hydriatric procedures upon the
heart and circulation. The first impression of cold upon
the sensory cutaneous nerves is rapidly conveyed to the
brain. Rapid contraction of the cutaneous vessels en-
sues, causing an increased vascular tension, which is fol-
lowed by slowing of the pulse. This continues so long
as the individual rests, but the pulse-rate increases with
continuance of high tension if exercise be taken after
the hydriatric procedure. The effect of cold applica-
tions upon the respiration is to deepen and slow it; the
normal frequency is, however, soon resumed; but the
deepening effect continues. Hence it is wise to send
anaemic and other patients requiring increased supply of
oxygen, at once into the open air after cold hydriatric
applications.
The influence of cold applications upon constructive
and destructive metabolism is demonstrated by the in-
crease of urinary specific gravity and of urea which en-
sues, and which continues several hours, as shown by
Juergensen and others, also by the increased excretion
of carbon dioxide, discovered by Liebermeister and
Voit after cold baths. Warmth produces the opposite
effect.
Having now briefly pointed out the powerful physical
and thermic effects of water upon the human body, it
remains to refer to the mechanical effect
Friction alone has been shown by Pospischl to pro-,
duce a great increase of heat loss. And Winternitz has
demonstrated that when active mechanical irritation is
combined with cold baths, the temperature of the pa-
tient is more readily reduced.
Indeed Winternitz has announced it as a law that the
amount of compensatory heat increase which is incidental
to all cold baths is not influenced by the absolute
amount of heat abstraction, but by the degree of actual
cooling of the peripheral terminal nerve- fibres which
govern the production of heat by reflex action.
Mechanical irritation, as friction during a cold bath,
prevents tremor and that intense tonic contraction of
the muscles which always results in the production of
heat. These facts are beautifully utilized in the Brand
bath, whose efficiency depends not any more upon its
temperature, 65 ° F., than upon the active but gentle sur-
face friction:
Aside from the reflex effect produced by the mechani-
cal aid utilized in hydriatric procedures, the actual press-
ure with which water may be applied enables us to
vary its effects.
In a full tub bath respiration is more difficult, be-
cause of the pressure of the water upon the thorax.
The effect of a douche delivered under pressure of one
or two atmospheres is stimulating to the cutaneous results
at the points of impingement.
The exact experiments of Maggoira, and Vinaj l demon-
strated that the mechanical effect of water applied under
pressure of two atmospheres increase threefold the work-
ing capacity of the muscles, as mathematically ascer-
tained by means of the ergograph of Mosso, which cor-
rectly and automatically registers muscular resistance.
The mechanical massage produced by a good douche
sets diseased structures into a vibration which cannot be
approached by simple manual massage. This mechani-
cal effect is constantly utilized most effectively in feeble
patients, to whose condition it may be graded and
adapted.
Locomotor-ataxia patients may be greatly injured by
cold baths and douches, hence in these cases we utilize
advantageously the tonic effect of hot douches by com-
bining more or less the mechanical effects of pressure,
gradually increased and adapted to the case.
This brief outline of the rationale of the action of water
upon the human organism may be fitly concluded by
explaining the manner in which it may be applied thera-
peutically.
We have several — indeed numerous — methods of ap-
plying water externally, all of which aim to deduce some
curative or palliative result from the application of those
principles of hydrotherapy which have been briefly for-
mulated under the term rationale.
But we are capable of applying water in the treatment
of disease with greater accuracy and more extensive lati-
tude in resultant effect than is possible from the applica-
tion of medicinal agents. J do not say this in depreca-
1 Blaetter: fuer Klin. Hydrotherapie, January, 1892.
522
MEDICAL RECORD.
[October 27, 1894
tion of the latter, whose value no one is more ready to
acknowledge than myself.
To substantiate this proposition, allow me briefly to
point out that we have three elements of increasing and
diminishing the therapeutic effect of water upon the or-
ganism, viz., temperature, duration, and pressure.
That the temperature is capable of modifying the
effect of water is well known. A very high or a very low
temperature produces destruction of tissue, while moder-
ately hot water produces a rubefacient effect.
The difference in the effect of a bath or other hydriatric
procedure at ioo° F., and one at 450 F., need but to be
mentioned to be appreciated, and it cannot be denied
that every five degrees more or less between these two ex-
tremes must produce a different effect in the same indi-
vidual.
That the duration of a bath or other procedure is capa-
ble of modifying the effect of the latter is also known.
It would be easily appreciated by the experiment of dip-
ping one hand into water at 400 F. for two seconds, and
drying it with friction ; and then putting the other hand
into the same water for ten minutes, and drying with fric-
tion. In the first case we would obtain the stimulating effect
with a fine glow and well filled, ruddy, cutaneous vessels ;
while in the second instance we would have a shrivelled
skin, of a cyanotic hue, cold and clammy, which many
minutes, if not hours, of friction would be required to
react from.
It may not be so evident that every second of time of
exposure to a hydriatric procedure of the same tem-
perature may alter its effect. But this is really a fact, of
which anyone can be convinced by personal observation.
Pressure. — Although the modifying influence of tem-
perature and duration is usually recognized, the effect of
pressure is not so generally appreciated.
A pressure of four atmospheres driving a stream of
water of any temperature through a very minute opening
produces destruction of the skin upon which it impinges.
During one of the meetings of the staff of the Monte-
fiore Home a good deal of amusement was created by
drilling small apertures into the thumbs of some very
skeptical colleagues, by means of the douche fiUforme of
Lauriat.
Driving water at the same pressure through a larger
aperture will produce a rubefacient effect, while a stream
of still less pressure will produce a temporary blush only.
Thus we may produce the destructive effect of a caus-
tic, or blister, or the rubefacient effect of mustard by
simply varying the pressure with water of the same tem-
perature.
When a stream of water at 50° F. is driven upon the
body under a pressure of two atmospheres, the depress-
ing (chilling) effect of the low temperature is counter-
acted by the massage and friction due to the forcible im-
pact.
The skin emerges from such an application in a glow.
If the same individual be bathed by the pouring of the
water oyer her body from a sponge, the effect would be
depressing (chilling), and so much greater reactive capa-
city would be required on the part of the individual that
an attendant would be necessary to aid it by friction.
It is plain, therefore, that we have a safe latitude of
seventy degrees (400 to no° F.) in temperature; a safe
latitude from one second to many minutes in duration ;
a safe latitude up to thirty pounds in pressure, by means
of which we may modify the effects of hydriatric proced-
ures.
Besides these mathematically ascertainable elements of
a hydriatric prescription we have various modifications
in hydriatric technique, as baths, packs, ablutions,
douches, etc., by means of which we may again render
the effect very flexible.
One who has had occasion to observe this flexibility of
hydriatric measures cannot fail to be convinced that no
similar effect is deducible from medicinal agents.
It id difficult if not impossible (selecting a powerful
remedy for illustration) to ascertain by any reliable test
if there be a difference in the effect of strychnia upon
the pulse, respiration, digestion, or tissue-change pro-
duced by any non-toxic dose (from say ^ grain to -fa).
I am not aware of such facts having been ascertained.
All the so-called physiological effects described by
Horatio Wood and others are predicated upon poisonous
doses, not upon medicinal doses.
The same observation may be made upon many other
valuable agents. Unless toxic doses, or doses closely ap-
proaching these be used, there is no definite clinical or
rational difference ascertainable.
Hydriatric procedures, on the contrary, are so flexible,
they may be administered by such a variety of methods,
that their effect may be definitely dosed, as it were, and
correctly ascertained.
In conclusion, I would offer some illustrations of the
rationale of a hydriatric procedure.
Place a patient suffering from any severe infectious dis-
ease, with high temperature, into a bath of 700 F. for fif-
teen minutes, practise active friction, and observe the re-
sult.
Elevated temperature, rapid and perhaps feeble pulse,
shallow respiration, dulled intellect, lost appetite, con-
centrated and scant urinary and other secretions indi-
dicate that the nervous system is overwhelmed by the
products of infection. So soon as he enters the water
he gasps. The shock and subsequent stimulus to the
cutaneous surfaces are conveyed to the nerve-centres
and thence reflected to the heart, lungs, and the other
organs.
Observation at the bedside at once renders these effects
patent. The first effect is a refreshment, an enlivenment
of the cerebrum. The eyes are opened ; the face loses its
apathetic stare ; consciousness returns after one or more
baths; the inspiration is deepened ; expectoration is fa-
cilitated ; the widening of the peripheral vessels and the
stimulation of their coats relieve the heart ; blood press-
ure is increased, and the laboring organ becomes as
quiet as does a sea-tossed ship in the hands of a skilled
mariner. The secreting glands are aroused to activity.
Moreover, the temperature is reduced, not so violently
as by medicinal agents, but more definitely, more in ac-
cord with normal tendencies. In brief, all the manifes-
tations of the disease are favorably influenced because the
normal standard is slowly but steadily and lastingly ap-
proximated under the influence of repeated judicious
bathing.
Even the most exacting demands of the most recent
ideas are met by this treatment.
Metchnikoff has shown by his interesting studies that
inflammation is the phagocytic reaction of the organism to
an irritant. Cells are phagocytes, hungry to devour any
toxine or microbe that may find entrance into the blood.
We may successfully aid the system in this " reaction
against toxines " by endowing its main vitalizing agent,
the nerve-centres, with vigor, by furthering elimination
from the skin and kidneys, by removing hyperemia of
the organs, and facilitating the passage of phagocytes into
the tissues ; but more especially by rendering the blood
more alkaline, and thus more favorable to the phago-
cytes.
A lack of recognition of these principles involved in
the Brand bath in typhoid fever leads to disappointment
and disaster.
If, for instance, the temperature and duration are not
properly adapted to the case, the shock and subsequent
stimulus are modified ; if the frictions of the surface are
omitted, the widening of the peripheral vessels is pre-
vented and cyanosis will result, instead of the ruddy hue
of the skin, with consequent depressing effect upon the
heart. The latter, instead of being aided by the tonic
widening and responsive elasticity of the cutaneous ves-
sels, will remain contracted, and thus embarrass the
heart.
Collapse ensues, with feeble pulse, Cheyne-Stokes-like
breathing, an effect so rare after the application of this
bath according to its correct rationale that I have never
October 27, 1894]
MEDICAL RECORD.
523
seen it, but an effect of which we often hear, in discus-
sion, attributed to the cold bath, instead of its improper
application.
That there is need for a good deal of missionary work
on this subject I have frequent opportunity of observ-
ing. As an example, allow me to briefly cite a case in
point. Two months ago I was asked to see, in consulta-
tion with an intelligent and experienced colleague, a
child of two years, in the latter part of the third week of
scarlatina. Desquamation was proceeding. The child
was suffering from enormous cervical glands, jactitation
with partial stupor, very high temperature, feeble pulse —
in short, a clear case of sepsis. The attendant recited
the difficulty of controlliug the temperature by aconite,
phenacetin, quinine, and concluded with the statement
that even baths, against which he claimed to be preju-
diced, had proved ineffectual because the child collapsed
in them.
On inquiry I learned that the baths were applied fif-
teen minutes, beginning with a temperature of no°F.,
and reducing gradually to 8o° F. ! If a correct rationale
had been followed, such a bath would not have been
ued
The object in view was to lull the patient to rest, to
reduce temperature and improve the heart's action. That
a temperature of uo° F. would produce the opposite ef-
fect it would seem patent enough even to one who has
not studied the rationale of hydrotherapy.
But to disturb a child in this condition by the splash-
ing and noise necessary to reduce the bath to 8o° F., to
allow water at such a low temperature to come into con-
tact with a tender partially denuded skin, even by slow
degrees, is entirely opposed, as you will perceive, to the
rationale I have offered. A bath of 95 ° F. for eight min-
utes fulfilled the indications effectively.
A few days ago a phthisical patient in my wards at
the Manhattan Hospital, who was receiving considerable
benefit from a dry pack, followed by ablutions at 80 ° F.,
reduced daily until 6o° F. was reached, was asked how he
liked the cold ablutions. His reply was that he liked the
treatment, and that he had received it in another hospital
where they had even put him in tubs of ice-water.
Patients subjected to improper hydriatric procedures
fortunately do not die from them, they do not even suf-
fer materially in most cases, but the remedial effect is
neutralized, if not entirely thwarted, by a disregard of
the true rationale f and thus hydrotherapy comes into
unmerited disrepute.
This is my chief reason for bringing this subject to
your attention. I ask you to give the same clinical study
to the remedial uses of water which you have devoted to
the study of medicinal agents (not, however, to the neg-
lect of the latter). I ask you not to condemn this valu-
able agent until you have tried it fairly according to the
principles which are briefly pointed out in this paper,
and which will amply repay more elaborate investiga-
tion. Having mastered these principles you will find
that the clinical application of water will afford you not
only an auxiliary to the ordinary treatment of diseases,
especially those which have become chronic and intrac-
table, but in many desperate cases it will prove a last but
effective resort.
In chlorosis that has resisted iron, in the various obsti-
nate digestive troubles, in phthisis, chronic rheumatism,
and neuralgia, in neurasthenia and other functional neu-
roses, in the faulty nutrition of many organic diseases, I
have been able to confirm the opinions oi Draper, Sem-
mola, Erb, Charcot, Leyden, and other clinicians, that we
have in hydrotherapy an agent of great power which is
not sufficiently recognized by the profession. I have
come to regard no case as hopeless until a judicious and
methodical application of water has proven ineffectual.
Dr. Heinrich Pasehkis has assumed editorial manage-
ment of the International Klinische Rundschau of Vi-
enna, formerly edited by Dr. Arthur Schnitzler.
THE ACTION OF ELECTRICITY ON THE
SYMPATHETIC NERVOUS SYSTEM.1
By A. D. ROCKWELL, M.D.,
The influence exerted by electricity upon the sympa-
thetic system of nerves is a subject of exceeding interest.
There can be no question in regard to the phenomena
that attend the direct applications of either current in
physiological investigations, and it is not surprising that
those who first witnessed these phenomena regarded them
as significant of the possibilities of this agent in the
treatment of diseased states of the central nervous system.
Unfortunately, external or percutaneous applications of
electricity — galvanic or faradic — failed in great measure
at that time to substantiate the hopes entertained, and
the therapeutic results in those cases where the sympa-
thetic was supposed to be involved, were altogether un-
satisfactory. We do not have to seek far for the causes
of this failure. They are to be found in an incorrect
appreciation of the relation of electricity to the human
body, based upon an imperfect knowledge of the physics
of electricity, and the lack of suitable appliances and in-
struments of precision.
In view of the wide field opened to us, in case it can
be demonstrated that in therapeutic doses electricity can
be made to appreciably affect the deeper nerve struct-
ures, it seems to me most desirable to gather together
some of the facts bearing upon this interesting question.
This seems to be the more necessary because there are
many who honestly doubt the possibility of electrically
stimulating any part of the central nervous system by
ordinary percutaneous methods of application. Cer-
tainly no one who has witnessed an execution by elec-
tricity can doubt its power to directly influence the most
distant organs ; and if fifteen hundred volts will instant-
ly paralyze every bodily function, would it not be strange
if fifty volts, or one-fiftieth of the power necessary to
kill, possessed no influence on the brain and the deeper-
seated nerve- structures? Reasoning from analogy, the
facts are all in favor of this probability, for in the admin-
istration of drugs far less than one fiftieth of the dose
necessary to destroy life is often productive of* appreci-
able therapeutic effects.
We possess^. very few pathological facts in support of
the sympathetic origin of disease, and therefore, in study-
ing this question, and the one that I am about to briefly
consider, viz., the action of electricity on the s)mpa-
thetic, it will be instructive to refer, 1, to the effects of
electrization on the exposed sympathetic, and to a few
of the ascertained facts in regard to the influence of the
sympathetic on the functional activity of various or-
gans ; 2, to ascertain phenomena observed after per-
cutaneous applications in the neighborhood of the s)m-
pathetic; 3, to clinical observations illustrating the
effects of applications of electricity to the neck in cer-
tain conditions supposed to be dependent upon disordeis
of the sympathetic
Beginning with the original experiments of Claude
Bernard as far back as 1832, we find that division of the
sympathetic causes a multitude of phenomena. The
cornea flattens, the pupil contracts, the globe of the eye
retracts, the palpebral fissure decreases in size, the con-
junctiva reddens, and there is a very positive elevation
of temperature due to a general dilatation of the vessels
of the head and neck on the side operated upon. Elec-
trical stimulation of the cephalic extremity of the severed
nerve, on the contrary, causes the vessels to contract, and
all the various phenomena to disappear for the time being.
The influence of the vaso- motor nerves of the eye was
made evident a century ago by the investigations of
Pourfour du Petit. The vessels of the iris dilate on di-
vision of the sympathetic, followed by immediate con-
traction when the peripheral extremity of the nerve is
submitted to electrical excitation.
> Read before the American Electro-Therapeutic Association, Sep-
tember as, 2894.
524
MEDICAL RECORD.
[October 27, 1894
Brown Sequard, experimenting upon guinea-pigs and
rabbits, by dividing the cervical sympathetic, found after
the lapse of a few months an appreciable atrophy of the
brain of the same side.
That the intercranial blood pressure is in some degree
regulated by the cervical sympathetic, seems altogether
probable on account of the anatomical relationship.
The nerves of the pia mater, and those associated with
the vessels of the cortical substance, are traced back to
the sympathetic plexus, irritation of which causes im-
mediate contraction of the cranial vessels. Perhaps the
most conclusive experiments in this direction were made
by Fisher1 in 1875. With the aid of a hsemato-dyna-
mDmeter, he was enabled to show that faradization of
the exposed sympathetic of a horse resulted in a con-
stant increase of arterial pressure, as well as increased
tension of the arterial walls.
Intestinal peristalsis is undoubtedly more or less under
the influence of the sympathetic; the movements of the
intestines in animals being arrested on irritation of the
splanchnic nerve, while the thoracic and abdominal
sympathetic impart accelerating influences to these
movements. The uro genital apparatus also, including
the bladder, the ureters, seminal vesicles, and the uterus,
respond to experimental irritation of the sympathetic
plexus of the abdominal cavity.
The secretory processes of the body depend largely
upon the influence of the vasomotor branches of the
sympathetic, the secretion of the gastric juice being car-
ried on automatically by the ganglia situated in the walls
of the stomach. The nutrition of the mucous membrane
must in a measure be dependent upon this system of
nerves, since extirpation of the solar plexus is followed
by hyperemia, extravasation of blood, and ulceration.
Stimulation and extirpation of the abdominal sympathet-
ic plexuses, affect the intestinal secretion, the evacuation,
and the general nutrition of the intestines. The vaso-
motor nerves of the liver are derived from the sympathet-
ic. These nerves have their origin near the floor of the
fourth ventricle of the brain, entering the sympathetic,
and thence with the blood-vessels pass to the gland it-
self. Puncture of these vasomotor nerves produces
paralytic dilatation of the vessels and the production of
sugar — the same results that follow puncture of the floor
of the fourth ventricle itself. These effects were supposed
to be produced by stimulation, but the experiments of
Cyon and Aladoff, in 187 1, made it quite evident that the
appearance of sugar in the urine came not from stimula-
tion, but from paralysis, of the sympathetic. Not only
did they find that removal of the cervical ganglia of
the sympathetic was invariably followed by diabetic symp-
toms, but also when the nerve-branches, central and
peripheral, with which it is connected, are divided. In-
terference with the function of the sympathetic affects
the excretion from the kidneys in more ways than the
elimination of sugar. Albuminuria, hematuria, with
quantitative and qualitative changes in the urine, to-
gether with disturbances in the nutrition of the kidney
and suprarenal capsules, have often been observed. The
spleen and the entire genital apparatus also have inti-
mate connection with the sympathetic through their
nerve-supply, irritation of which produces marked circula-
tory disturbance in both the spleen and penis.
Burckhardt2 and Ziemssen's8 experiments upon the
dead body indicate the possibility of directly affecting
the cervical sympathetic through percutaneous applica-
tion of the galvanic current. They thrust partially insu-
lated needles into the sympathetic from behind, con-
necting their free ends with a sensitive galvanometer.
Electrodes connected with a galvanic battery were
placed, one near the angle of the lower jaw, and the
other at the manubrium sterni, and when the circuit was
closed the movements of the needle indicated the ac-
tion of an electric current on the nerve itself.
1 Deutsches Archiv fur Klinische Medicin.
"Ibid., 1878.
* Die Electricitat in der Medicin.
Again, if one electrode, the anode, is placed at the man-
ubrium sterni, or in the neighborhood of the alio- spinal
centre, and the cathode at the inner border of the sterno-
cleido muscle, a little below the auriculo-maxillary fossa,
and a current of sufficient strength employed, the pupil
of the same side may be made to instantly dilate on clos-
ing the circuit, followed by a gradual contraction. The
difficulty of demonstrating this phenomenon in most per-
sons is due to their susceptibility to the action of the
current, many suffering from extreme vertigo, and even
nausea and faintness, before the current is sufficiently
strong to produce contractions visible to the unaided
eye. By the aid of the pupillascope, however, it has
been found possible to detect these changes in the eye
with even exceedingly weak currents. Changes in the
pupil so slight as to escape direct observation, are yet as-
sociated on the retina with what are called dispersion
circles, the character of which accords with the degree of
contraction or dilatation of the iris. While it seems to
be entirely probable that the dilatation and subsequent
contraction of the pupil on closing the circuit, are due
to the action of the current on the sympathetic pupillary
branches, nevertheless, it is impossible not to take into
consideration the fact that reflex influences are potent
factors frequently in the movements of distant parts, and
therefore in these experiments there is some ground for
the claim that pupillary changes may be reflex in charac-
ter.
The circulation is unmistakably influenced by strong
and prolonged applications of electricity to the neck and
neighboring parts, and the reason why the test fails ex-
perimentally in so many cases, is because of the inability
of the ordinary subject to endure the necessary strength
of current.
In the many tests that I have made to determine
whether or no it is possible to get any appreciable elec-
trical effect upon the sympathetic by percutaneous ap-
plications, I have occasionally met with interesting and
suggestive results. Everyone who has much to do with
the medical application of electricity, is aware how
varied is the susceptibility to its effects. The two fol-
lowing records are interesting illustrations of this fact,
and of the probability of direct electrical stimulation of
the sympathetic by external applications.
Case I. — Male, aged thirty- one, with a normal pulse
of 75. An electrode of plastic sculptor's clay, 3 ctm.
in diameter, and connected with the positive pole of a
galvanic battery, was applied to the hollow just above
the clavicle, at its juncture with the sternum. The cur-
rent was gradually increased to 75 m., which caused a
decrease in the frequency of the pulse of ten beats in less
than one minute, and this decrease in the rapidity of the
heart's action continued so long as the electrodes re-
mained in position. On removing them the pulse
would almost immediately increase to its normal fre-
quency, and also the respiration, which was invaria-
bly affected equally with the pulse. The results in this
case clearly depended for the most part on stimulation
of the inhibitory fibres of the pneumogastric, and the
fall in the heart-beats may have borne no relation what-
ever to the sympathetic system. None the less, how-
ever, was the test of value in demonstrating the possi-
bility of influencing the deeper seated nerve-structures
by currents of sufficient strength. Only occasionally
can a person be found who can endure such a strength
of current through small electrodes, and placed as indi-
cated ; but few opportunities, therefore, have been af-
forded of getting so striking a result. I have observed
the good effects of electricity in chloroform poisoning,
but not through the use of the galvanic current, the
tendency of which is undoubtedly to inhibit the action
of the heart. The induced current, as ordinarily ap-
plied, certainly does not affect the inhibitory fibres con-
trolling the action of the heart, and its undoubted influ-
ence over respiration must be ascribed to the action of
the current on the accelerating fibres of the vagus and
sympathetic that refer to the respiration. The induced
October 27, 1894]
MEDICAL RECORD.
525
current of electricity, therefore, does good in chloroform
narcosis in increasing respiratory activity, the strength
of current necessary for this purpose being insufficient
to materially interfere with the movements of the heart
through its action on the inhibitory fibres of the vagus
that control it.
The next record, as compared with the first, illustrates
how varied are the susceptibilities of different indivi-
duals to the effects of electricity.
Case II. — Female, aged twenty-three, with a normal
pulse of 72. Electrodes of the same size and applied as
in the previous case; and yet 15 to 20 m., was all this
patient could possibly bear without a tendency to faint-
ness and nausea. Confining the strength of the current
to a point below the production of these symptoms, it
was most interesting to note its very positive effects
upon the pulse. This effect was not immediate, as in the
former case, when currents of far greater strength were
used; but by keeping the electrodes in position for
several minutes, it was found that the pulse would inva-
riably sink to 65. I have at the present time under
observation a young man aged twenty-two, with a
remarkably torpid circulation. His pulse seldom rises
above 48, and under the influence of a strong current it
can at will be reduced to 43. If these effects upon the
pulse are due, as is probably the case, to a stimulation of
the inhibitory function of the pneumogastric, it is only
an additional argument in favor of electrically influencing
the sympathetic ; for if the vagus is influenced by per-
cutaneous applications, the sympathetic ought also to be
affected as the threads of current pass from pole to
pole.
Exophthalmic Goitre. — In support of the sympathetic
origin of exophthalmic goitre, we have the well known
fact that division of the cervical sympathetic in animals
is followed by a train of symptoms that are most sugges-
tively in accord with those of Basedow's disease, and
the further fact that in a certain limited number of cases
pathological anatomical changes have been found in the
sympathetic after death.
Among the many special phenomena that point to
this causal relationship, there is one of special interest
referable to the eye. It is a common observation that
ordinarily, when the plane of vision is altered, the move-
ments of the eyeball upward or downward are closely
followed by the upper eyelid. In exophthalmic goitre
the eyelid does not follow the movements of the eyeball,
and the cause of this deficient mobility Von Graefe as-
cribed to innervation of Muller's unstriped ocular mus-
cles, which receive their nerve-supply directly from the
sympathetic nerve. To my mind, however, one of the
strongest arguments in favor, not only of the sympathetic
origin of this disease, but also of the possibility of di-
rectly influencing the sympathetic by the galvanic cur-
rent, relates to my personal experience in the treatment
of exophthalmic goitre.
I published in the New York Medical Record of Sep-
tember 30, 1893, an article on the treatment of this dis-
ease, based on 45 consecutive cases, in which the results
of electrical treatment were so pronounced in a large
proportion of the cases, that, admitting the disease to be
dependent on sympathetic disturbance, there can be lit-
tle question but that these results were in the main due
to the action of the current upon the sympathetic. The
following case furnishes very strong evidence in support
of this assertion.
Case III. — Miss C , aged twenty-three, came to
me in September, 1893, with the three cardinal symp-
toms of exophthalmic goitre quite distinctly present. The
pulse was 115, the eyes prominent, and the thyroid con-
siderably enlarged. These symptoms had been coming
on for about three years, and in connection with the pro-
tuberance of the eye, the patient called my attention to
a marked dilatation of the pupil of the right eye, which
she only observed a few weeks before, and shortly after
the occurrence of a feeling of pressure in the neck and a
slight feeling of suffocation. The tumor was highly vas-
cular, made of tortuous blood-vessels, and not of firm thy-
roid tissue.
It was evident that the oculo-pupillary fibres of the
sympathetic were involved, and that the irritation caus-
ing the well marked and persistent mydriasis must be
due to the pressure of the enlarged blood-vessels upon
the sympathetic. Applications of the galvanic current
were soon followed by some appreciable amelioration of
the symptoms, but the point most interesting was the
fact that the pupil began immediately to decrease in size,
and became entirely normal, before there was any change
in the prominence of the eyes, the rapidity of the pulse,
or even in the size of the thyroid itself. Such pressure,
however, as had been sufficient to produce this oculo-
pupillary symptom had been relieved, and this could have
only come through a contraction of the enlarged vessels,
and through treatment having a direct influence over
the sympathetic.
We have in this case an illustration of a simple irrita-
tion as distinguished from a paralyzed condition of the
sympathetic. I am aware that damage to this nerve
more frequently produces a paralysis with myosis than a
simple irritation with mydriasis, but it has been shown
that those causes that produce ultimately a paralysis of
the sympathetic, may primarily induce only irritation.
A case was reported by Ogle of an abscess of the neck
which, as it enlarged, occasioned extreme dilatation of the
pupil; the dilatation disappearing after a quiet sleep.
Subsequently the pupil became much contracted, but
upon the abscess being opened and the pressure relieved,
the pupil became normal. The explanation offered of
these phenomena was this : The inflammatory exudation
and suppuration associated with the development of
the abscess, at first stimulated the pupillary fibres, pro-
ducing mydriasis. The secondary or prolonged effects
of the compression, however, lessened the conducting
power of the nerve fibres, inducing paralysis and myosis.
In the case which has just been related the condition
was primarily one of irritation, which might have merged
into one of paralysis, had there been any material increase
in the arterial dilatation.
Unilateral Hyperidrosis. — Unilateral hyperidrosis is
not of such rarity as to entitle it to special comment,
without it offers points of therapeutic or pathologic inter-
est. Notwithstanding the well* known experiments in
which severance of the sympathetic in horses produced
a profuse unilateral perspiration, the pathology of this
somewhat unique symptom has not been definitely set-
tled. Cases of unilateral hyperidrosis, many of them,
indicate not the slightest evidence in other respects of
sympathetic disturbance, but a few cases have been placed
upon record,1 which seem, with considerable certainty, to
point to paralysis of the sympathetic as, in some instan-
ces, the cause of persistent unilateral hyperidrosis. A
case reported by Seguin 2 indicated on examination no
change to the naked eye, but microscopically there
seemed to be an abundant granular pigment filling the
ganglionic cells, although both sides were alike in this
respect. A case reported by Ebstein8 revealed more
definite and pronounced pathological changes. The pa-
tient, a man of sixty, suffered from paroxysms of angina
pectoris, accompanied by hyperidrosis of the left side.
Microscopic examination of the ganglia of the left sym-
pathetic revealed varicose and dilated vessels, with per-
fectly normal nerve tissue upon the right side. Ebstein
therefore claimed that hyperidrosis depended on a tem-
porary or permanent compression of the sympathetic
nerve-elements, resulting in paralysis.
The case that I herewith report is of value, not only
because of the associated symptoms indicating an involve-
ment of both the vasomotor and oculo-pupillary fibres of
the sympathetic, but because the results of treatment gave
further evidence of the sympathetic origin of the disease.
» Eulenburg & Guttman : Sympathetic System of Nerves, p. 58.
■ American Journal of the Medical Sciences, October, 1872.
» Virchow's Archiv, 1875, Bd. lxii., p. 435, quoted by Eulenburg and
Guttman. _,
526
MEDICAL RECORD.
[October 27, 1894
Case IV. — Mr. M , aged sixty-five, was referred
to me by Dr. John H. Demorest, of New York. This
patient was greatly enfeebled, was suffering from diges-
tive disorders, and in addition I found a profuse unila-
teral hyperidrosis, involving the right side of the head,
face, and trunk of the body, the right arm, and to a less
extent the right leg and foot. While the left side was
abnormally dry at all times, the right was always moist;
the median line, front and back, sharply defining the
two conditions. The right ear was also hotter and red-
der than its fellow, and with it was associated a persist-
ent congestion of the conjunctivae. In addition to these
vaso thermic phenomena there existed a considerable
degree of myosis, suggestive of paralysis of the oculo-
pupillary as well as the vasomotor fibres of the sympa-
thetic. This patient was subjected to thorough and
persistent treatment by both the galvanic and faradic
currents of electricity, and with results of the most pro-
nounced character. The patient did not regain perma-
nent health, nor strength, and, indeed, finally died from
exhaustion ; but the hyperidrosis lessened very consider-
ably after each treatment, and would occasionally almost
entirely disappear, while, in an equal degree, the pupil
dilated and the heat and congestion decreased. On the
whole, it seemed to me a very satisfactory test of the
efficiency of electricity in directly influencing the func-
tion of the sympathetic.
Hemiorania. — The following case of hemicrania is
still another interesting example of the probable part
played by the sympathetic as a causative factor in dis-
ease, and strengthens one's belief in the power of elec-
tricity to directly affect the sympathetic.
Case V. — Mr. F , aged thirty-three, had for some
years been subject to frequent and violent attacks of
right hemicrania. Whatever tended to raise the blood-
pressure in the head greatly aggravated the distress.
Daring the attacks the temporal artery became hard
and tense; the face pale and the eye sunken, with a
narrowing of the palpebral fissure. The patient had in-
termittent attacks of nausea, with alternations of un-
natural dimness and clearness of vision ; while as the
paroxysm subsided, the face became abnormally red,
and both the eye and ear considerably injected. The
initial and prominent symptoms, such as the condition
of the temporal artery, the paleness of the fact, and the
depressed and altered condition of the eye, all pointed
to a persistent contraction of the muscular coats of the
vessels on the side supplied by the cervical branches of
the right sympathetic nerve ; while the nausea and sud-
den changes in the character of the vision indicated
contemporaneous changes in the intra-cephalic blood-
pressure, due to repeated changes in the calibre of the
small blood vessels. We find also a rational explanation
for the secondary injection and increased heat of the
face, eye, and ear, in the changes from a condition of
tetanic spasm to a state of relaxation and dilatation of
the overstrained vessels. Such a very positive condition
of tonic vascular spasm could be due only to some dis-
turbance of the sympathetic nerves.
I refer to the treatment of this case by the galvanic
current, not because of any very remarkable therapeutic
effects, for all efforts were futile in entirely overcoming
these paroxysmal attacks, but as an evidence of the
possibility of directly affecting the sympathetic. A cur-
rent strength of fifty m., when applied to the neck
during a paroxysm of pain, gave appreciable relief so
long as the treatment was continued, and for a consider-
able time thereafter. No sooner were the electrodes in
position — one on the cilio-spinal centre, and the other
below the auriculo maxillary fossa, and the current
gradually increased until 20 m. were registered, than the
pain abated, and as one electrode was moved down
toward the manubrium sterni, and the strength increased
to fifty m., there was still further relief and change of
symptoms. The face on the affected side, which was so
pale and sunken, became almost normal in appearance,
and appreciably warmer, the ear redder, while the af-
fected eye opened widely; the eyeball standing out as
prominently as its fellow. This treatment was often
repeated, but with only temporary relief. The tendency
to these attacks of hemicrania was not materially weak-
ened, as had been somewhat confidently expected on
account of the very marked immediate effects of the
treatment.
Progressive Facial Hemiatrophy.— From the fact
that this disease has been known to follow mechanical
injury of the cervical sympathetic, it seems not improb-
able that it may be related to the sympathetic, rather
than to the trigeminus, with its vasomotor nerves of
nutrition.
While, so far as I am aware, there are no recorded cases
of cure, or even material benefit, following galvanization
of the sympathetic, yet Brunner reports a case where the
galvanic current caused a reduction in the rapidity of the
heart's action, dilatation of the pupil, with redness and
perspiration of the face. Eulenburg and Guttman also
report a case of this kind, where galvanization of the
neck caused a reddening of the affected side of the face
that lasted some hours.
In confirmation of these reports, I recall a case seen
some years ago at the clinic of the New York Post Gradu-
ate School, in which strong galvanization of the neck
quite perceptibly increased the heat and redness of the
atrophied side.
geognesB of iJfcedical Scimtz.
Treatment of Peripheral Neuritis. —Professor Ley-
den believes that in the case of neuritis following acute
specific diseases, care during convalescence as to nourish-
ment, rest in bed, and avoidance of over-exertion con-
tribute to prevent its occurrence. " Etiological treat-
ment " (removal of the cause) in neuritis due to alcohol
or lead, and treatment of the primary malady as in dia-
betes, is of the first importance. There is no specific
remedy for multiple neuritis, and treatment by drugs
does not play a very important part. Owing to the fact
that rheumatism is not infrequently an element in the
etiology, salicylate of sodium and other anti-rheumatic
drugs had been used, without producing any good results
in the majority of cases. Iodide of potassium was of use
only now and then, and mercury was of doubtful value.
Antipyrin, phenacetin, exalgin, euphorbia, and methy-
lene blue were sometimes of use for the relief of pain,
but it was often necessary to resort to morphine, chloral,
sulphonal, etc. Strychnine, formerly much used, but
lately fallen into the background, deserved to be tried ;
by increasing the excitability of the affected muscles it
favored the return to normal function and nutrition ; it
ought especially to be resorted to in progressive cases
in which the respiratory movements were threatened.
Leyden prefers to use it as a subcutaneous injection,
gr. Vxf to gr. ^ twice daily. Massage and baths were
valuable auxiliaries which were indicated, especially the
latter, in the later stages of the disease. General
hygienic treatment was of much importance. Rest — as
a rule rest in bed — was of the first importance in the
early stage; in the later stage, feeding. Finally, in the
latest stages of all, moral suasion, rousing the patient's
latent energies, was often of great value. Passive move-
ments and encouraging the patient to make active
movements, were generally attended with better results
than massage in this stage. Electricity, formerly used
too much, was now used too little, but its usefulness was
greatly limited by the fact that in many cases the pain
caused was too great to permit the treatment to be con-
tinued.— Berliner Klinische Wochenschrift*
Our Present Knowledge of the Cure of Malaria by
Means of Quinine. — According to Professor Binz so
long as twenty-six years ago he opposed the then gener-
ally accepted theory that the curative action of quinine
October 27, 1894]
MEDICAL RECORD.
527
in malaria is developed through the nervous system, and
propounded the theory that quinine in all probability
acts as a protoplasm poison on the pathogenic micro-
organism, at that time undiscovered, which is at the
root of all paludism. It has now been discovered that
all forms of malarial fever are brought about by organ-
isms of the genus amoeba, which penetrate the bodies of
the red blood cells, at whose expense they increase in
size, finally sporulating and destroying their host. Lav-
eran, who first discovered and described the parasite of
tertian ague, also investigated the action of quinine on
that organism, and found that when microscopical prep-
arations of the parasite were treated with quinine, the
vitality of the disease-germ was speedily destroyed, a
feet which has been substantiated by Marchiafava, Celli,
Grassi, and Feletti. The influence of quinine on the
malaria parasites has also been studied by examining the
blood of malaria patients before and after the exhibition
of the drug. In this instance the investigations of Lav-
eran, Romanoffsky, Bacelli, Golgi, Marchiafava, and
Bignani established the fact that the parasites were killed
by the quinine absorbed into the blood.
Dr. Mannaberg, who has recently investigated this
question in the malarial districts of Dalmatia, Lstria, etc.,
finds, among other things, that about three hours after
the exhibition of from seven to fifteen grains of quinine,
the amoeboid movements of the amoeboid form of the
parasite of tertian ague slacken to a very perceptible de-
gree, and that after a lapse of a further period of three
to six hours, the number of parasites in the blood of the
patient greatly diminishes, while many of those still left
are torn and mutilated. On the full-grown parasite of
tertian ague quinine either produces a complete cessa-
tion of all movement in the pigment, whereby the para-
ate acquires a glittering, cloddy appearance, as though
coagulation had set in, or else dropsical swelling is set
up, or, finally, the parasite falls to pieces. Shortly after
the exhibition of quinine, medium-sized parasites of ter-
tian ague develop intense activity. It appears that qui-
nine possesses a stimulating action before causing coagu-
lation and immobility. This phenomenon has also been
observed by Bacelli. According to Golgi, the medium-
sized parasites of quartan fever acquire a glittering ap-
pearance and tendency to shrivel when the patient re-
ceives quinine internally; the large forms, however,
become distended, their pigment exhibits lively oscilla-
tory movements, and they frequently contain vacuolse or
abortive spores. About three hours after the exhibition
of a dose of seven and one- half grains of quinine, the
nucleoli of some of the amoeba of the milder forms of
true quartan had either partially or entirely lost their
tinctorial characteristics. After twelve hours of the
treatment stainable nucleoli were hardly met with at all,
most of the parasites having broken up into irregular
fragments. From these and other experiments it is evi-
dent that the amoeba of malaria is not only visibly en-
feebled by the presence of quinine in the blood, but that
its capacity for producing viable spores is greatly dimin-
ished.. In those forms of malaria which are not curable
by quinine that drug has no effect whatever on the para-
sites present in the blood. Bacelli, however, has found
that many such severe forms which defy the ordinary
method of treatment may be speedily cured by injecting
the usual dose of quinine into a vein.
In spite of certain differences on minor points, Man-
naberg and the other investigators one and all agree that
quinine is a direct poison for the malaria parasite, and
that the therapeutic doses employed are non injurious to
the cells of the human organism. Any assistance from
the nervous system in the process of cure is neither evi-
dent nor necessary. With regard to the prophylactic
action of quinine, it is to be noted that the drug disap-
pears very gradually from the blood and in an almost
unaltered condition. By this means any young amoebae
and spores are kept in constant contact with the drug,
and are thereby checked in their further development.
As to the part played by the leucocytes, it appears that
phagocytism is prominent in cases of spontaneous cure
of malaria, but not when quinine is employed. — Provin-
cial Medical Journal.
The Halation of Bacillus Coli Communis to Typhoid
Fever. — According to Dr. Kellogg it will be remem-
bered that in 1887 Hueppe called attention to the pos-
sible pathological importance of the colon bacillus, hav-
ing found this organism in nearly pure cultures in cases
of cholerine. In 1889 Roded and Roux made extensive
investigations of this bacillus in relation to typhoid fever
in which the conclusion was reached that the typhoid
germ is a modified colon bacillus. Several investigations
have been recorded of outbreaks of typhoid fever result-
ing from the use of the water from a common source,
usually a well, from which no typhoid bacillus could be
found, but the colon bacteria were present in large num-
bers. The claim that is made at present by certain bac-
teriologists is that the colon bacillus, which ordinarily
possesses very little pathogenic power, can be made suffi-
ciently virulent to produce an effect similar to that of the
Eberth or typhoid bacillus.
Another interesting fact is the observation that the
colon bacillus becomes increased in virulence during an
attack of typhoid fever. Vallet has shown that rabbits
that were inoculated with the filtrate from vaults con-
taining excreta from typhoid-fever patients were pro-
tected to an appreciable degree against the inoculation
of the typhoid bacillus. This experiment serves to ex-
plain the fact, so often noted by sanitarians, that visitors
to an infected locality are more likely to suffer from the
disease than the residents who are accustomed to drink
the contaminated water. After certain experiments,
which are too lengthy to record in full, Kellogg draws
the following conclusions, based upon his own work and
the results of other investigations: 1. The bacillus
coli and the bacillus of Eberth are so* nearly identical in
their biological characters that none of the numerous
methods proposed for distinguishing them can be relied
upon as giving constant results, a. The bacillus coli
gives in inoculation experiments identical pathological
effects with those produced by the bacillus of Eberth.
3. The bacillus coli acquires, by passing through the
body of an animal, biological characters closely resem-
bling those of Eberth's bacillus. The bacillus coli
found in vaults is much more virulent than the bacillus
coli of the intestines or Eberth's bacillus. 4. The
bacillus coli is much more resistant than the bacillus of
Eberth, and thrives in vaults, while the bacillus of Eberth
quickly dies under the same conditions. 5. The study
of epidemics, and the bacteriological study of waters
which have given rise to typhoid fever, lead to the con-
clusions that the bacillus coli at least shares with the ba-
cillis of Eberth the property of producing typhoid fever
under certain circumstances, and that the bacillus of
Eberth may be only a variety or modified form of bacil-
lus coli. 6. The contaminations of milk with the ex-
creta of cows is a possible source of infection with the
bacillus coli and with typhoid fever. 7. The same care
ought to be observed in the protection of water used by
cows kept for milking purposes from contamination from
excreta, as for that used by human beings for drinking
purposes. 8. Since vaults and cesspools constitute
depots in which the comparatively innocuous bacillus
coli acquires malignancy and virulence, rendering it
highly destructive to human life, these convenient
nuisances should be prohibited by law, and the destruc-
tion or disinfection by proper agents, or conveyance to
a safe distance from human habitation, of all alvine dis-
charges, should be compulsory as one of the most im-
portant means of conserving the public health. — Medical
and Surgical Reporter.
A Hew Convalescent Hospital — Mr. Yarrow, the
English builder of torpedo-boats, has recently given
£600,000 to build and endow a hospital for convalescent
children at Broadstairs.
528
MEDICAL RECORD.
[October 27, 1894
Medical Record:
A Weekly Journal of Medicine and Surgery.
GEORGE F. SHRADY, A.M., M.D., Editor.
Publishers
WM. WOOD & CO., 43, 45, &. 47 East Tenth Street.
New York, October 27, 1894.
THE SIMS' STATUE.
The dedication, in this country at least, of an heroic
statue to a medical man marks an important era in med-
ical history. Dr. James Marion Sims, dead over ten
years, comes again to us in the earthly immortality of
bronze and granite. He once more looks at us as of old,
with gentle persuasiveness and calm conviction, the in-
dex of a life well spent, the unchangeable impersonation
of a living principle. When the present generation shall
have passed away, he will remain through coming seasons
and fleeting years, for unborn eyes to look upon and com-
ing tongues to speak his praise. The benediction of his
good works will thrill the enthusiasm of future workers in
every line of human progress. It is pleasant to think that
his example can hi constantly with us and continuously
extend into the beyond. The lesson of his life is now
written, the lovable memory of his past struggles, and the
cordial recognition of his final triumphs, are new incen-
tives for lofty purposes and noble emulation for persistent
endeavor. He was the founder of a new medical faith,
and his works live after him. As the father of modern
gynecology, he becomes the exponent of a living thought
constantly widening and progressively extending.
Time has now so softened the asperities of criticism,
and calm judgment has so cooled the temper of envy,
that no one will now question his genius or doubt his
talents. The statue as it stands is the final vindication of
his faithful work, and the lasting tribute to his duty done.
It is, therefore, with no small degree of pride that
the Medical Record recalls its initiatory efforts to do
him honor, and likewise does it congratulate the many
subscribers, in this and other countries, who through its
columns so promptly and generously contributed to the
fund. The heartiest thanks of the many friends and
admirers of Dr. Sims are also due to the distinguished
gentlemen who have so long served on the committee,
and who have so faithfully discharged the duties of
their high office. In evidence of this is the statue itself*
which is acknowledged by competent authorities to be
the best conceived and most artistically executed of any
in the city. That the contributors to the fund, and the
members of the profession throughout the world, may
judge of this fact for themselves, we have the pleasure of
presenting in this number of the Medical Record a
full-page illustration of the statue as it now stands in
Bryant Park.
In completing the history of the monument, it is proper
to add that the receipts and expenditures on account of
the fund, submitted to the committee by William Wood &
Co., treasurers, have been duly audited and found to be
correct. And thus endeth our loving part in memory of
an old friend.
COLLEGE ATHLETICS.
At a recent meeting of the Boston Society for Medical
Improvement, Dr. W. M. Conant read a paper on the
" Educational Aspect of College Athletics," and it was
discussed at length by a number of prominent physicians
and laymen. The net result, we must confess, is rather
disappointing ; for no particularly new facts were brought
out, and there was a most placid unanimity of opinion to
the general effect that college athletics form a beneficent
factor in education. It hardly requires a special meet-
ing of savants to determine this point. What one
would like to know is the amount of evil connected with
athletics, and how this can be prevented. The directors
of gymnasia, trainers and physical educators, furnish us
interesting reports showing the increase under training
of the circumference of the arm and the expansion of the
chest. But they do not tell us of the hypertrophied
hearts, crippled limbs, and lowered scholarship. Among
the 3,000 students at Harvard, we gather from Dr. Co-
nant that about 400 engage actively in college athletics.
He gives us a list of about 70 foot ball injuries per
year among some of the latter. These are rather inade-
quate data. It has often been urged that one evil of
competitive athletics lies in the fact that the system
practically puts on the shelf the weaker men, who have
no special aptitude or inclination to athletics, but who
especially need physical culture. All that is left to
these are the inanities of wooden dumb-bells, wands, and
clubs, things which no self respecting intelligence will
long put up with.
It is admitted that college athletics tend to disparage
scholarship, but to what extent no one seems to know.
In fact, the only suggestive thing in the whole discus-
sion is a remark by the Mayor of Cambridge, who ex-
pressed surprise that college authorities do not personally
supervise and teach athletics, since they admit that physi-
cal culture is of so much importance. The exercises of
intellectual culture are rigidly controlled, but physical
culture is left largely to the student's inclinations or
whims.
THE DOCTOR AND THE BICYCLE.
Shall the doctor ride a bicycle ? It is too late for an
answer to this question. He already does it. The
wheel has evidently come to stay, as a source of recrea-
tion to the busy physician, if not used by him as a means
of locomotion in making his rounds. It is probably
even too late for us to discuss the advisability of the pro-
fessional sister striding the two- wheeled steed. She has
not only taken to it most kindly in common with many
of her sex, but has already begun to give them practical
information concerning the proper way to ride, so as to
gain the greatest benefit with the least danger of injurious
effect. We have already called attention to Dr. Laura
Liebhardt's discussion of the question before the Colorado
State Medical Society, in which the advice is given, among
other things, not to mount during the first days of the
menstrual flow, or at least only for short hill less rides.
Undoubtedly injury may be inflicted upon the perineal
October 27, 1894]
MEDICAL RECORD.
529
region by a faulty saddle-pressure too long kept up and
accidents en route; but taking into consideration the
amount of bicycling now indulged in, it must be admitted
that the physician is not often called upon to prescribe
for any results of injudicious riding. On the other hand,
those who have carefully watched this mode of exercise
from its therapeutic side, must have observed the bene-
fit derived from its proper use in many conditions of
non-health. In its present perfected state, the pneu-
matic-tired " safety ' ' is a very different machine from the
" velocipede " of the sixties and the " ordinary " of the
transition period of its evolution ; and it is now, for the
first time in the history of two-wheeled travel with the
rider as the propelling force, that the serious attention of
the medical profession is demanded.
In just how far we are justified in prescribing or for-
bidding it— especially for young girls; what are the
dangers to warn against; at what point does benefit cease
and injury begin ? These are questions for the physician
to decide — not from his own narrow views and precon-
ceived ideas as to the fitness of things, but from a true
scientific study of the question. For himself he can de-
cide whether he considers it dignified or judicious to visit
his patients awheel. If the distance is too great for him
to arrive in a presentable condition, he had better stick to
his chaise. If the case is one of urgency and he can
get there quicker, he need not fear the condemnation of
the anxious sufferer.
But whether he goes adriving, ariding, awheel, or
a foot, the doctor must bless the bicycle, for it has done
more, and probably will do more, for the cause of good
roads throughout the country than any other one thing,
and no one knows better the necessity of good roads
than the doctor.
PHYSIOLOGICAL EPOCHS THAT PREDISPOSE
TO INSANITY.
At a recent meeting of the Medical Society of the
Coonty of New York, a paper read by Dr. William M.
Spratling, on the " Physiological Epochs that Predispose
to Insanity, with Observations on the Management of
Each," presented in clear and definite form certain facts
too often overlooked and ignored by the general prac-
titioner and the public at large. The grave responsibil-
ity of treating insanity in its incipiency rests in greater
degree upon the physician in general practice than upon
the specialist in diseases of the mind. The family doctor
sees usually the first signs of incipient mental disorder,
when its early recognition and proper treatment may se-
cure the happiest results.
Mercier concisely sums up the causes of insanity in
this way : Insanity is, in mathematical terms, a function
of two variables ; that is too say, there are two factors,
and only two, in its causation ; and these factors are
complementary. Both enter into the causation of every
case of insanity ; and the stronger the influence of one
factor, the less of the other factor is needed to produce
the result. These factors are heredity and stress. A
study of the various states of mental instability arising
directly from physiological epochs, proves conclusively
and without variation that heredity and stress, with their
subdivisions, constitute the only etiological factors.
There are six distinct epochs at which insanity may ap-
pear, all but one being strictly physiological in the order
and nature of their occurrence. This one, the epoch
of heredity, may be called patho-physiological. Early
childhood, puberty, maternity, the epoch of heredity,
the menopause, and senility, are these fixed times in
which stress may serve to destroy mental health. Early
childhood is the period of life beginning with the sev-
enth month and ending with the beginning of the sev-
enth year, and may be in itself said to predispose only
indirectly to insanity through its accidents and inci-
dents. Puberty in the female extends from the thir-
teenth to the fifteenth year; in the male, from the four-
teenth to the sixteenth. The third physiological epoch
covers the entire childbearing period, from the fifteenth
to the forty fifth year. Insanity occurs more frequently
during the first than during the latter half of this period.
The epoch of heredity has not had special attention
called to it by writers in this country, though it is an
important and variable one. It embraces that critical
period of the life of any individual whose ancestors have
been accustomed to exhibit evidences of insanity on
reaching a certain age. Regis uses the term phrenasthe-
nia to designate and include all forms of inherited in-
sanity. The fifth epoch is that of the climacteric, from
the forty-third to the forty-fifth year. Exceptionally, the
time may be extended a little either way. The changes
that now occur are the most clearly perceptible of those
of any epoch, and lead oftener to mental instability.
Senility is the last epoch, old age ; and it is interesting
to note that, when the preceding epochs have not been
strictly physiological, pathological conditions of mind
are apt to appear in extreme old age.
Early childhood presents the possibility of many acci-
dents and incidents that may serve to render the child
mentally unsound in the future. Gowers is authority for
the statement that one-eighth of all the cases of epilepsy
begin during the first three years of life ; and adds that,
with rachitis as a combining cause, seventy-five per cent,
of all cases of epilepsy that begin during the first three
years of life are due to infantile convulsions ascribed to
teething. Here the various tendencies of an inherited
taint change a perfectly physiological process, that ought
to be free from danger to the child, into a period fraught
with influences of a most pernicious kind. Syphilis,
chronic alcoholism, insanity, or epilepsy, in the parent,
stamps on the child's nervous system a congenital insta-
bility that unfits it to pass unscathed through the seri-
ous disturbances that mark the steps of growth and de-
velopment. Dentition alone is probably never a cause
of genuine epilepsy; what it does give rise to are epi-
leptiform convulsions that in time take on the character
of true epilepsy. That insanity often follows epilepsy is
well known. Clouston states that cases of prolonged de-
lirium ending in idiocy, and arising out ot the ordinary
convulsions of dentition have come under his observa-
tion. And such cases have also ended in true epilepsy,
followed by insanity. Adolescent insanity has appeared
so often, as well as other forms, iff persons earlier the vic-
tims of epilepsy, that it is impossible to regard the two as
coincident.
In the Journal of the American Medical Association
for August 18, 1894, Wilmarth gives some interesting
facts concerning idiocy, epilepsy, imbecility, and in-
sanity, as he studied them at the Pennsylvania Institute
for Feebleminded Children. Out of one thousand
53Q
MEDICAL RECORD.
[October 27, 1894
admitted to the institution, he found that there
were three hundred and twenty-two whose condition re-
quired medical treatment before entering, and whose
afflictions were of such a nature as to indicate that medi-
cal treatment would possibly bring about a cure. In this
list, all cases not amenable to medical treatment are ex-
cluded, together with cases in which congenital defect
was noted before the sixth month, or just before the com-
mencement of dentition. In seventy-five cases out of the
three hundred and twenty- two, the disorder had developed
during the spasms of dentition ; in two cases, before
the sixth month; in twenty-nine, between the sixth and
twelfth ; in twenty-five, between the twelfth and eighteenth
months; and between the eighteenth month and the
twenty-fourth, nineteen cases are recorded as first show-
ing evidences of mental disease. The growth of a little
child's brain is rapid up to the seventh year, and anything
which interferes with its nutrition is a serious matter.
Besides dentition, traumatism, blows or falls on the head,
the effects of excessive heat, mental shock, fevers of specific
origin, and structures and malformation of the genital
organs, are causes that act unfavorably upon the organ-
ism and threaten to disarrange its more highly developed
parts.
The excito motor exaltation during the first dentition
has its parallel in the explosive condition of the nerve-
centres, in the higher plane of cerebral activity, during
the evolution of the generative function and of the sex-
ual divergence of early adolescence. Such epochs may
be characterized as the search- lights of psychiatry, since
they serve to reveal weak spots in the mental organiza-
tion. The mental disorders that so frequently develop
at this age, are due to indirect stress of internal origin.
Pubescent insanity may develop anywhere between the
ages of fifteen and twenty-two. The epoch of puberty
is attended with more danger to the female than to the
male, the time is shorter, and the shock is greater. In-
sanity in the female at this epoch is essentially an acute
neurosis, acute mania being its commonest form.
Acute mania is also the commonest form of puerperal
insanity. Hallucinations appear in about one-quarter
of the cases in both sexes, those that are visual and
aural predominating. Delusions of poisoning exist fre-
quently, and spiritual delusions are not uncommon.
When uncomplicated by hereditary taint, the prognosis
is good. Nearly four-fifths of persons thus afflicted re-
cover. Early removal from home is best. Nourish-
ment easy of digestion should be given, and the secre-
tory and excretory organs should receive special
attention, since they are liable at this period to sluggish
action. Sleep must be secured by open-air exercise and
by hypnotics; and narcotics and sedatives avoided.
Menstrual irregularities, anaemia, etc., require the strict-
est hygiene, and the use of carbonate of iron, extract of
nux vomica and rhubarb in pill form, malt extract,
etc.
Pregnancy, labor itself, and lactation, have more im-
portant relations to insanity than other physiological
epochs. Insanity during pregnancy is more frequent
among women about to give birth to an illegitimate
child. Mental anomalies vary all the way from simple
morbid appetites to well-marked melancholia with suici-
dal impulses. Transitory frenzy during labor appears as
the forerunner of puerperal delirium. Infanticide and
suicide are acts common to the subjects of this condition.
Mental derangement may come on suddenly after child-
birth or develop gradually after evidences of nervous
exhaustion, most frequently appearing as acute mania.
Begin treatment with a saline aperient, and search for
and remove causes of fever. The condition of the
blood may require iron ; but none of the chalybeate
preparations should be used till all traces of acute excite-
ment have subsided. The infant must be removed from
the mother's care. The mother's diet must consist of
milk, beef-tea, broth, and eggs, administered in small
quantities at frequent intervals. To secure sleep, the
following may be used : chloral, bromide of potassium,
sulfonal ; paraldehyde, two-drachm doses, or more if
required, in a small quantity of port wine. Warm
baths often suffice to produce refreshing sleep, and,
whenever possible, deserve a trial before drugs are given.
The fifth physiological epoch is the menopause.
Psychic manifestations are well marked. Whenever
there is inherited tendency to mental disease, or when
there have been eartier attacks of insanity during one of
the former epochs, the menopause has added dangers.
Climacteric insanity, Skae characterizes as a monomania
of fear, despondency, remorse, hopelessness, passing oc-
casionally into dementia. Over half of all cases are of
the depressed type. Treatment consists mainly in a
tonic regimen, out-door life, strict attention to diet, and
change of surroundings. Iron and arsenic are required,
artificial feeding is often necessary, and sleep must be
secured by hypnotics. Chloral hydrate, in a single
large dose, and paraldehyde, are the best. Senile mania
and senile melancholia occur as distinct disorders. The
most satisfactory drug for the treatment of insanities in-
cident to old age is opium, beginning with small doses.
The danger of establishing the opium habit is less than
if the patient were in the prime of life. Persistent in-
somnia and great restlessness are overcome by opium,
which seems to have as powerful an influence over human-
ity in its second childhood as it has during humanity's
earliest years.
MEDICAL UNIVERSITY EXTENSION.
Wb have often wondered why some active and philan-
thropic mind did not devise a scheme for applying
"University Extension" to medicine. And now we
find that it has been done by an association of eminent
English physicians, including Drs. Clifford Allbutt, Sir
W. H. Broadbent, John Cavafy, J. F. Goodhart, T. H.
Green, Hughlings Jackson, S. Wilks, Sir James Paget,
Sir J. M. Humphrey, and Mr. Jonathan Hutchinson.
They term their movement the "Clinical Research
Association." It proposes, as we understand, to furnish
the general practitioner a convenient means of having
all forms of bacteriological, chemical, and microscopical
information made accessible to him and his patients.
THE RECOGNITION OF MERIT.
The Germans have their jubilees, and the English their
"presentations." We notice in a recent issue of The
Lancet, that Dr. Walter Murray was presented with a
clock for his bravery in going to the rescue of a police-
man. Also, that Dr. Symington has been presented with
a tea-tray for causes not stated. The habit of giving some
October 27, 1894]
MEDICAL
formal recognition to conspicuous merit or long profes-
sional service, is surely a most praiseworthy one. We
wish that in this country something of the kind might be
done. With us the doctor gets recognition sometimes
alter he is dead, but that is, after all, not so satisfactory
to the person most concerned.
THE CZAR'S DISEASE.
To such medical men as have studied the symptoms of
the disease of the Czar, as they have been reported in
the vague and meagre official bulletins, it must be appar-
ent that the only way to reconcile seemingly conflicting
accounts, and draw reasonable conclusions therefrom, is
to assume that the diagnosis made by Professor Leyden
is the correct one. Contracted kidney, as is well known,
is a very common affection in persons addicted to the
pleasures of the table and the excesses of the cup. The
general condition of the distinguished patient, his cor-
pulency, and attendant lack of vital energy, make him a
fit subject for this form of renal disease. The distressing
symptoms of paroxysmal cardiac dyspnoea, due to feeble-
ness of compensatory cardiac effort, the pulmonary com-
plications associated with pleuritic effusion, and the gen-
eral weakness and anasarca caused by the lowering of
arterial pressure, are of ominous gravity, and tend in the
direction of a probably speedy dissolution. Under the
circumstances, it will not be surprising to learn of the
appearance of apoplexy, convulsions, or coma, or of an
equally sudden termination in syncope, or pulmonary
oedema.
A NEW CURE FOR PERNICIOUS ANiEMIA
AND LEUCOCYTILEMIA.
"While sitting alone, and in profound sorrow, in my
library, on Sunday morning the 29th of April last, I sud-
denly saw a great light." It is in this somewhat dra-
matic way that Dr. I. N. Danforth, whose wife was suf-
fering from pernicious anaemia, begins his description
of a new method of treating that disease. The light
which he saw was reflected from the following paragraph
in a London journal : " Professor Frazer, of Edinburgh,
read a paper to the Section of Medicine " (of the Elev-
enth International Medical Congress, at Rome) "on
the Effects of Bone Marrow in Pernicious Anaemia,
which attracted considerable attention. He gave par-
ticulars of a case in which at the beginning of the dis-
ease the haematocytes numbered 1,000,000 per cubic
millimetre, and the haemoglobin twenty* five per cent.
After a month's treatment, first with iron, then with
arsenic, afterward with salol, no appreciable improve-
ment was manifested. At the end of that time bone
marrow was administered with remarkable results. The
patient gradually improved, and in two months the blood
had a composition of 4,000,000 haematocytes, and the
haemoglobin had risen to eighty per cent. This case
shows, so far as a single case can, that in bone marrow
we may perhaps have an effective remedy for what has
hitherto been practically held to be an incurable dis-
RECORD. 531
once began to improve, and in four or five months was
comparatively well.
After a time, instead of giving the marrow in its nat-
ural state, he cut up several ribs and allowed them to
soak in glycerine. He then made the following mixt-
ure:
9* Liq. potas. arsenit 3 ijss.
Acid phosphate J iij.
Ext. bone marrow. ad | viij.
M. Sig. : 3 ij. after each meal
The addition of the arsenic robs the bone marrow of
some of the credit. This addition was not made, how-
ever, in Professor Frazer's case.
We note also that Dr. W. G. Bigger reports, in a
London journal, a case of leucocythsemia in a boy aged
twelve. The patient was given three or four slices of
bread daily, on each of which the raw bone marrow was
thickly spread. The improvement in the boy's condi-
tion after the first week was " little short of marvellous."
The anaemia and jaundice disappeared, and the skin and
mucous membrane acquired a healthy color. The symp-
toms due to the anaemia at the same time passed off, and
in three weeks the boy was able to walk about without
shortness of breath or palpitation. The temperature also
became normal, and has remained so. Pari passu with
this improvement in the general symptoms, the spleen
diminished in size, so that by the end of a fortnight the
lower edge had receded to a level with the anterior spine
of the ilium, and the inner edge did not extend beyond
the middle line.
The boy eventually became entirely well. Both the
cases reported are apparently examples of cures of ob-
stinate and dangerous diseases. If we have a remedy
for them in bone marrow, therapeutics has made a re-
markable advance.
Dr. Danforth immediately got some bone marrow and
began feeding it to his patient, whose condition, despite
everything that had been tried, was desperate. She at
A NEW WAY TO ADVERTISE.
The following candid announcement appears in The
Texas Health Journal. " To the Medical Profession of
Texas. — I have devoted many years to the exclusive
treatment of diseases of the eye, ear, nose, and throat.
That I might feel doubly assured of my ability to treat
these diseases with the best possible skill known to the
profession, I spent the last winter, spring, and summer
in New York and Europe, where I received the special
clinical instructions under the most distinguished spe-
cialists in the world. My many months of clinical work
at the greatest hospitals and clinics in the world, to-
gether with the new instruments and apparatus I pur-
chased in Europe, regardless of price, cost me nearly two
thousand dollars. I now respectfully ask that the general
practitioners of Texas who have not the time and instru-
ments to successfully treat such cases, kindly consider
my recent advantages and complete armamentarium, and
intrust to me the responsibility of treating such cases.
If this courtesy is extended to me, I will be true to the
trust confided. Besides, I will make it especially advan-
tageous to every physician who kindly refers cases to me
for treatment ; try and see if I do not ; a hint to the
wise is sufficient. Furthermore, I will take pleasure in
treating any member of a physician's family, absolutely
free. I will also treat any charity case free referred to
me by a physician. My present large paying practice
532
MEDICAL RECORD.
[October 27, 1894
enables me to do this without loss to myself; besides,
the pleasure of curing those unable to pay is sufficient
remuneration to me. I have opened an elegant new
office in the North Texas Bank building; rooms 316,
317, and 318. Call and see me while in the city.
" Fraternally submitted. "
A letter of this kind is in our opinion a legitimate re-
sult of the approval given by the American Medical As-
sociation to the plan of sending out cards with the
words "practice limited to" eye diseases, gynecology,
etc. Instead of distributing cards to the profession, the
specialist puts it in a medical journal, and naturally adds
to it a modest account of his unusual experience and
skill. The next step would be for the general practition-
er to put in an announcement of his special skill in the
common run of diseases, and request the specialists and
incidentally the public to send him their patients. Very
soon, as the examples of these announcements increase,
their language must become stronger. For example,
there are in Texas a good many physicians who have had
a larger experience in eye diseases even than the writer
of the above quoted letter. If his conduct is approved,
what will be left to them but to imitate him, or rather
surpass him, in an attractive presentation of their accom-
plishments. The results must be disastrous to profes-
sional dignity, personal veracity, and mutual confidence.
Medical men cannot afford to enter the field of the
advertising agent. The old way is often criticised, and
it is not perfect. The man must become known through
his works. The profession is not so dull but that it can
recognize merit, and it estimates a man's abilities fairly
well by his writings and by contact with him in scienti-
fic and social meetings. The recognition thus gained
comes slowly, but special skill also is acquired slowly, and
matters adjust themselves with a good degree of equity
in the end.
We hope that the profession of Texas will not endorse
the methods adopted by the enterprising young oculist
of their State.
%zxo% at VUt WLteb*
County Medical Society Election. — The Medical So-
ciety of the County of New York held their eighty-
ninth annual election October 2 2d. Dr. Egbert H.
Grandin was elected President ; Dr. Richard Van Sant-
voord, Dr. Wendell C. Phillips, and Dr. S. Henry Des-
sau were elected Vice-Presidents ; Dr. Charles H. Avery,
Secretary ; Dr. William E. Bullard, Assistant Secretary ;
and Dr. John S. Warren, Treasurer. The Censors
elected were : Drs. Seneca D. Powell, Edward D. Fisher,
George T. Jackson, Charles H. Knight, and Charles L.
Gibson.
Conference of Hospitals for Insane in New York.—
The Eighth Joint Meeting of the Managers and Medical
Superintendents of the Hospitals of the State of New
York was held, under the auspices of Honorable Aus-
tin Lathrop, at the Matteawan State Hospital, at Fish-
kill Landing, Thursday, October 18, 1894. Delegates
from the different asylums were present. After an in-
spection of this model institution and congratulatory
remarks by the gentlemen present, Dr. H. E. Allison,
the medical superintendent, read a paper on the " Care
and Treatment of the Criminal Insane. ' ' Remarks were
made by Judge Graham, of Utica ; Professor Stephen
Smith, of New York ; Dr. Carlos F. Macdonald, Presi-
dent of Lunacy Commission ; Dr. S. H. Talcott, of Mifi-
dletown, N. Y. ; Senator Amasa J. Parker, of Albany ;
C. W. Pilgrim, of Poughkeepsie ; C. G. Wagner, of
Binghamton; G. Alder Blumer, of Utica; and Dr.
George F. Shrady, of New York.
The Monument to Villemin. — On September 30th
the monument erected to the memory of Villemin, the
discoverer of the infectivity of tuberculosis, was unveiled
at Bruygre-en-Vosges, in the presence of a distinguished
assembly. Dr. Viger, the Minister of Agriculture, who
is a member of the medical profession, represented the
Government, and delivered an oration.
The Late Professor Billroth.— The letters of the late
Professor Billroth, of Vienna, are about to be published,
with the sanction of his widow, under the editorship of
Dr. Georg Fischer, surgeon to the Hanover City Hos-
pital. Dr. Fischer asks any English correspondents who
may have preserved letters of Billroth's to send them to
him at 22, Warmbuchenstrasse, Hanover. Any letters
forwarded in response to this request will be copied and
returned without delay.
Antidote for Fungi Poisoning. — Dr. Thomas Taylor,
chief of the Division of Microscopy of the Department of
Agriculture, speaking of recent deaths in this city from
eating poisonous fungi, says : " The mushrooms eaten in
this case were undoubtedly the Amanita verna, which,
and Amanita muscaria, are the most poisonous mush-
rooms known. There is but one antidote known for
amanitine or muscarine poison, and that is sulphate of
atropine. The use of atropine, as has been fully demon-
strated, will quickly neutralize the effects of muscarine
and amanitine on the nerve-centres of the human system,
as well as those of the lower animals. The dose may be
administered either by means of hypodermic injection or
by the mouth in the usual way."
Anti-toxin and Diphtheria. —The Deputies of the
Lower House of Hungary proposed to vote 50,000 flo-
rins to be used in treating diphtheria with Behring's
serum. At the Government's request the vote was post-
poned pending the reports of medical inspectors sent to
France and Germany. In Buda-Pesth the use of the se-
rum has given excellent results.
The anti-toxin treatment of diphtheria is the topic
of the day in Berlin. The Children's Hospital (Kaiser u.
Kaiserin Friedrich-Kinder-Krankenhaus is its short and
euphonious name) has published in the daily papers an
appeal for subscriptions — signed, among others, by Ru-
dolph Virchow, Skrzecska, and Siegmund — in which it
is stated that of 169 diphtheria patients treated in the
hospital with antitoxin, all recovered, except those that
came under treatment at an advanced stage of the dis-
ease ; that, in fact, the percentage of deaths had been
reduced from 42 to 17, and that the results of protective
inoculation performed on the sisters and brothers of the
diphtheria patients had also been most satisfactory. It
must be said, however, that here and there voices are
heard warning against too enthusiastic hopes. It is said
that a much longer period of observation must elapse
before a final judgment on the treatment can be given,
October 27, 1894]
MEDICAL RECORD.
533
and that possibly the present cases of diphtheria are
none of them of the severest type, and that it remains to
be seen whether antitoxin will stand the test of one of
the severe epidemics — the foudr&yant cases, that carry
off their victims in a few days. — British Medical Journal.
Cholera Decreasing in Europe. — The latest advices
received by the Marine Hospital service show that chol-
era is on the decrease everywhere, amounting in the
case of Austro Hungary to nearly fifty per cent The
decrease in Russia is remarkable, and it is hoped that the
advent of cold weather will put an end to this epidemic
entirely. There are still many cases reported in Hol-
land, Belgium, and France, but '.they seem mostly of a
sporadic nature, and nowhere assume an epidemic form.
The health of Marseilles is now so satisfactory that the
medical inspection of all vessels sailing thence has been
discontinued.
A Vow German Hospital.— The corner-stone of the
new German hospital, at Stanhope Street and St. Nicho-
las Avenue, Williamsburg, was laid October 2 2d, by
Mayor Schieren, in the presence of nearly one hundred
societies and several thousand people. A parade of all
the societies preceded the laying of the stone. Twenty-
seven lots, bounded by St Nicholas Avenue and Stock-
holm and Stanhope Streets, were purchased, and a few
months ago ground was broken. The cost of the hos-
pital when completed will be about #250,000.
American Aoademy of Railway Surgeons.— The first
meeting of the American Academy of Railway Surgeons
will he held in the parlors of the Grand Pacific Hotel,
Chicago, November 9 and 10, 1894.
Status and Pay of Japanese Army Surgeons. — The
Surgeon-General of the Imperial Army has the rank of
major-general and the same amount of salary, 300 yen
per month, the yen being equivalent to about 75 cents
of our money. Surgeon-inspectors, whose position is
analogous to that of colonel and assistant surgeon-general
in the United States Army, have the rank of colonel and
a salary of 193 yen per month, or 3 yen more than a
colonel of cavalry receives, and 15 more than a colonel
of infantry. Surgeons of the first class rank as lieutenant-
colonel, and their pay, 143 yen, bears the same relation
to that of a regimental lieutenant-colonel that the pay of
an inspector does to that of regimental commanders.
Surgeons of the second class, with the rank of major,
draw 93 yen monthly. Assistant surgeons of the first
class, and pharmacists of the same grade, have 52 yen, or
the pay of a captain. Assistants and pharmacists of the
second class rank as first lieutenants and have the pay of
that grade, 32 yen. Assistants and pharmacists of the
third class have the rank and pay, 26 yen, of the second
lieutenant. These medical, like other officers of the
army, have increased pay when assigned to special duty ;
those on duty in the War Department, for instance, hav-
ing an increase amounting to about one third of the
regular salary of their grade.
Vermont State Medical Society. — The annual meet-
ing was held in Montpelier, October nth and 12th.
The following officers were elected : President, Dr. J. H.
Linsley, of Burlington ; Vice-President, Dr. F. F. Chaffee,
of Stratford ; Secretary, Dr. D. C. Hawley, of Burlington ;
Executive Committee : Drs. J. H. Linsley, D. C. Hawley,
and F. R Stoddard, (of Shelburne). Publication Com-
mittee : Drs. D. C. Hawley, J. B. Wheeler, and H. C.
Tinkham. Zictnte Censors : Drs. E. S. Albee, C. M.
Ferrin, and H. S. Brown. The attendance was the largest
in the history of the Society. Dr. Frederick C. Shattuck,
of Boston, read a valuable paper on " The Modern Treat-
ment of Typhoid Fever," and Dr. John C. Irish, of
Lowell, Mass., presented one on the "Surgical Treat-
ment of Uterine Neoplasms." The annual banquet was
spread at the Pavilion Hotel at 10 p.m. Thursday, and
was enjoyed by about a hundred and fifty, including the
members of the Society, the Governor of the State, V.
A. Woodbury, of Burlington, also the Speaker of the
House of Representatives and other officers of the Legis-
lature. The Anniversary Chairman was Dr. A* P. Grin-
nell, of Burlington. The next annual meeting will be
held in Burlington.
Hew Ruling by the Illinois State Board of Health. —
The Illinois State' Board of Health will not recognize
Dental, Pharmacy, or Veterinary Colleges as entitled to
recognition for any part of a medical college course.
Some Recollections of Holmes. — Mr. Ernest Hart
gives entertainingly some recollections of a visit which
he paid to the late Dr. Holmes a year ago. " We fell,1'
says Mr. Hart, "to talking of his visit to London in
1886, and of our meetings together and our mutual
friends. He recalled a brilliant dinner party at the Re-
form Club on the night of his arrival, and spoke sympa-
thetically of his host, Sir Morell Mackenzie, and some
others of the party who were now no more, and of his
daughter who had charge of him, whom also he had lost.
Laughingly he reminded me of the ' lesson in English '
he had received in the hall. During dinner the talk had
turned on provincial and American slang. Speaking of
one of his latest poems, of which he recited a passage, he
had said in banter that he did not think it his worst,
adding: 'I tried it on a dog, and the dog didn't die.'
He confessed that the 'American language,' about
which there was some discussion, was not always identi-
cal with the English, but 'it was none the worse for
that.' At any rate, he prided himself on talking pure
English. As we came away and were taking leave, he
said to me, apropos of an engagement for the next day
when he was coming to lunch with me : ' But you must
give me your ticket.' In handing it to him I could not
help saying: 'We English call it a card.' He an-
swered: 'I don't know that it is a better word.' 'I
did not quite relish then,' he said to me, ' being taught
English by a cockney on the first day of my arrival, and
I have not forgotten it; but you see I bear no malice.'
Speaking of his student life in Paris Dr. Holmes said :
' It was in the days of Louis Philippe, in 1833-35, that
I followed the classes of Louis, who was the loadstone of
all the young American students, and there I first met
Gairdner, of Glasgow, with whom I still sometimes corre-
spond.' 'Bigelow,' he said, 'used to go over once a
week to London to hear a lecture, but that was uniquely
enterprising.' He claimed for Bigelow, afterward a
medical professor in Boston, that he was one of the
greatest of modern physicians, and that ' a single lecture
which he had published on " Self limited Disease " made
" a revolution in medicine." It anticipated Gull's doc-
trine of " Expectant Medicine," and laid bare the secret
of the temporary success but the self-evident folly and
534
MEDICAL RECORD.
[October 27, 1894
failure of homoeopathy.9 When a practioner boasted to
him that he had 'cured a disease/ he would say:
'Young man, take care; are you sure that you cured?
If so, perhaps to morrow you may kill, but then you will
only say that the patient died.1 "
Dr. Holmes on Walshe, Watson, and Paget.— Dr#
Oliver Wendell Holmes thought Dr. Walshe, of Univer-
sity College, an early contemporary, " the most philo-
sophic of the physicians of our day ; " Watson, " the
most eloquent;" but Paget, "the most persuasive.
Persuasive, but not always convincing. He is truly the
Gladstone of Medicine, and left often in my mind a
doubt whether his reservations and distinctions might
not to-morrow lead him to a variation from the convic-
tion to which almost he persuaded you to-day. . . .
But that is the infirmity, perhaps, of my dim perception
rather than of his circumspect intellect."
A Cyclone Struck the Insane Asylum at Little Rock,
Ark., on October 2d, demolishing three stories of a
wing containing two hundred and sixty patients. Dr.
Ingate, one of the medical staff, and formerly of Mobile,
Ala., was killed. Two of the patients were killed also.
Castration for Masturbation.— Dr. Pilcher, Superin-
tendent of the Institution for Imbeciles and Weak-
minded Children, at Winfield, Kan., has been bitterly
denounced by newspapers in Winfield and Topeka for
castrating several boys — inmates — who were confirmed
masturbators. His predecessor, Dr. Wile, had treated
these boys five years without benefit, and Dr. Pilcher,
taking a rational view of the subject, performed the
operation for the same reason he would perform any
other surgical operation — for its curative effect. There
is a strong probability that he will be ndicted for may-
hem, to the everlasting disgrace of the civilization of the
nineteenth century. — Texas Medical Journal.
A Pathetic Appeal.— October is the month of cotton,
calves, colds, and collections. We are not interested in
any of these " forces " (four c's) except the latter, and
we do earnestly hope and expect that our good friends
will not forget our patience and long suffering (nor their
patients and their long suffering) when they go out in
quest of cash. — The Texas Medical Journal.
Anti-Handshaking Society. — We hear that a society
for the suppression of hand-shaking has been established
at Baku, in Russia.
The Golf "Cure" for Insomnia.— A writer in the
Scotsman, commenting upon the Marquis of Salisbury's
recent address to the members of the British Association
at Oxford, expressed regret that his lordship should be a
victim to the modern and very prevalent disorder of in-
somnia. He went on to appeal to the medical profes-
sion for some prompt and effective remedy for that dis-
tressing ill. " Would that the noble leader of the Con-
servative party would take a three months' course of golf ' '
was the inward exclamation of one who had himself suf-
fered from insomnia, and was at the time rejoicing in a
succession of nights of profound and refreshing sleep.
Golf is the game for the exhausted brainworker at any
stage of his life. No junior is too young, no senior is
too old to learn it ; to learn it and to enjoy it. The
proof of the pudding is in the eating. On the golf links
of St. Andrews the man of seventy looks fifty, and the
man of fifty has the appearance of thirty-five. Sleepless-
ness, so far as the writer was able to discover, in a three
weeks' sojourn at St. Andrews, is absolutely unknown to
the regular golf-player. One may almost say it is im-
possible. Living, as he does, in the open air, and tak-
ing several hours of daily exercise without unpleasant
fatigue, and with a mind constantly, but not laboriously,
interested, he eats well and so the brain is adequately
nourished. The only trouble with the remedy is that a
man must be a person of leisure in order to take it.
A Bureau of Autopsy. — In the year 1881 there was
founded at Milan a unique and curious institution,
which has been at work ever since. This was the Loria
Bureau of Autopsy. It was founded, and placed under
the direction of Professor A. Verga, for the use of the
inhabitants of Milan. That is to say, either courts of
law or the family of a deceased person can have a com-
plete examination and report in cases where a death has
occurred under suspicious or strange circumstances. All
autopsies are recorded, and may be consulted for pur-
poses of study. The Bureau is intended to serve two
purposes — the advancement of knowledge, and to remove
one objection to cremation raised on the grounds that
crime may be less easy of detection when the deceased is
effectually placed beyond the reach of examination.
The River Seine " Catch " of 1883.— The following
figures are published as a result of the attempt to keep
the River Seine clear of cadavera for the year of 1893.
There were withdrawn from the river 5,652 dogs, 3,307
cats, 9,108 rats, 1,720 fowls and 3,942 other birds, 4,209
rabbits, 789 pigs, 7 calves, 4 hedgehogs, 33 horses, 15
sheep, 2 colts, and 13 monkeys.
Death of Dr. Virginias A. Turpin. — Dr. Virginius A.
Turpin died at his residence in New York, October nth,
at the age of seventy* five years. He was a Virginian by
birth. For many years he was regarded as a high au-
thority on the subject of cholera, and during the epi-
demic of the disease in the year 1866, he was called by
the Board of Health of St. Louis to assume the direction
of the cholera hospitals of that city. A considerable
portion of his life was passed in Chicago, where he en-
joyed a high reputation and had an extensive practice.
About two years ago he removed to New York, and since
that time his health has been gradually failing.
An Appeal to the Pity and Better Matures of the Edi-
tors and Publishers of the British Medical Journal and
the Lancet — You know, gentlemen, that the paper upon
which is printed the " foreign edition " of your otherwise
splendid journals, is simply inexpressibly vile. It is at
once thicker, and yet more mushy and rotten than tissue-
paper, and is, therefore, properly fit for no purpose what-
soever— absolutely none— of civilized or unregenerate
man. We can only explain its use on the ground of a con-
tempt of us, the reason of which dates back to Revolution-
ary times, or perhaps to Simian ages. You certainly would
not, and could not, treat residents of the British Islands
thus. We beg of you to remember that however remote
the relationship we are at least your Teutonic brethren,
and that it is your duty to help on the cause of Anglo-
Saxon civilization. Please do not forget that even an
American can sometimes grumble, and even revolt, after
prolonged indignity and injustice. — Medical News.
October 27, 1894]
MEDICAL RECORD.
535
UNVEILING OF THE SIMS STATUE.
The ceremonies attending the unveiling of the statue of
Dr. J. Marion Sims and its presentation to the city of
New York were held in Bryant Park on Saturday last,
October 20th, at 3 p.m.
A number of representative medical men, with female
members of their families, occupied places upon the
elevated platform, which was decorated with flags and
which faced the statue, also draped in the American flag.
The fine October weather enabled the large audience in
the Park to comfortably compose itself upon benches
provided for the purpose.
On the stand were : Dr. H. Marion Sims and Master
Marion Sims Wyeth, the little grandson of the original
of the statue. Others present were Dr. D. B. St. John
Roosa, President of the Academy of Medicine; Dr.
Abraham Jacobi, Dr. Lewis A. Sayre, Dr. E. L. Keyes,
Dr. J. A. Wyeth, Civil Justice Stiner, Mr. and Mrs.
Edwin Gould, Dr. A. R. Robinson, Dr. and Mrs. Will-
iam M. Polk, Drs. Robert W. Taylor, O. D. Pomeroy,
Y. R. Goffe, W. G. Wylie, Mrs. G. F. Shrady ; Drs. O.
D. Pomeroy, D. H. Goodwillie, Robert C. Myles, S.
Waterman, A. G. Gerster ; Dr. and Mrs. T. R. Price,
and Dr. W. H. Pancoast, of Philadelphia ; Mrs. P. F.
Mund6 and Miss Bertha Mund6, Medical Director E. S.
Bogert, U. S. N., and Hon. A. B. Tappan, who, as a
member of the Board of Park Commissioners, accepted
the statue for the city. Among the spectators in the Park
there were also delegations from the New York Academy
of Medicine, the New York Pathological Society, the
American Gynecological Association, the Medical So-
ciety of the County of New York, the New York Poly-
clinic, and the New York Post-Graduate Medical School
and Hospital.
The Jefferson Medical College of Philadelphia, from
which Dr. Sims was graduated in 1835, sent Dr. W. W.
Keen and Dr. Theophilus Parvin to represent the Fac-
ulty.
Letters of sympathy with regrets of inability to be
present at the ceremonies were received from Professor
J. M. Da Costa and Dr. Richard J. Dunglison, of Phil-
adelphia ; Dr. George J. Englemann, of St. Louis ; Pro-
fessor A. P. Grinnell, of University of Vermont, Burling-
ton, Vt. ; Dr. J. C. Reeve, of Dayton, O. ; Dr. B.
Bernard Browne, of Baltimore ; Dr. M. C. Baldridge,
of Huntsville, Ala. ; Dr. R. Stansbury Sutton, of Alle-
gheny, Pa. ; Dr. A. Webb, of Collierville, Tenn. ; and
Dr. Henry Dickson Burns, of New Orleans, La.
There were not only a goodly number of ladies occu-
pying seats on the platform and in the general audience,
bat many were seated in carriages which lined die ad-
joining streets.
The committee in charge of the ceremonies consisted
of Dr. George F. Shrady, Dr. William T. Lusk, Dr.
William M. Polk, Dr. Thomas Addis Emmet, and Mr.
William H. S. Wood.
General Addresses. — Dr. George F. Shrady made the
opening address, in which he sketched the character of
Dr. Sims as a surgeon and philanthropist (see p. 513).
Professor Paul F. Mund6, M.D., followed with an ad-
dress on Dr. Sims as the gynecologist, the founder of the
New American School (see p. 514).
Presentation of Statue to the City of Hew York.—
On the conclusion of Professor MundeVs address Dr.
Shrady, as chairman of the committee, made the follow-
ing presentation :
" Commissioner Tappan : I have the great honor, on
behalf of the many friends and admirers of Dr. J. Marion
Sims, and in the name of the medical profession of this
and other countries, to present this beautiful statue to the
city of New York, with the assurance that it will com-,
pare favorably with others of its kind in our parks and
squares, and in the hope that in this Park, which is here-
after to be devoted to the meritorious recognition of dis-
tinguished services in literature, art, and science, it may
take its worthy place."
During these remarks the string was pulled by Master
Marion Sims Wyeth, the five- year- old son of Dr. J. A.
Wyeth, and the covering fell from the figure, amid the
cheering applause of the multitude assembled.
The Acoeptance for the City by Hon. A. B. Tappan.
— Park Commissioner Tappan, on behalf of the city,
made the following speech of acceptance :
" * Whether on scaffold high or in the battle's van,
The noblest place for man to die is where he dies for man 1'
" These words of the poet apply, with slight change,
to Dr. Marion Sims. His life exemplified the saying
that the ' noblest life a man can live is where he lives
for man.' A citizen of high repute, a benefactor of the
human race, a man who reached the most exalted place
in his profession, it is due to his memory that all who
knew him professionally, and all who knew him by repu-
tation, should stop by the wayside of the busy field ot
our daily life and shed a tear to the memory of his many
virtues and his most distinguished services.
" Dr. Sims had, indeed, a most exalted career as a
citizen and as a professor of the art of preservation of
the human race and of the laws of life and health. No
eulogy can do justice to his merits, and in erecting this
heroic statue to his memory those who knew him, and
by whom this work was created and is erected, are doing
themselves high honor.
" The city of New York feels most proud of the citi-
zenship of its distinguished men in every department of
active life. The profession of which Dr. Sims was a
most prominent member has a just pride in the deed of
to-day in 'erecting this statue. I repeat that it is an
honor, not merely to one who has filled and finished
an exalted career and has gone to his reward, but to
those who participate in the ceremonies of this occa-
sion.
" Mr. Chairman, I might add much, very much, to
these brief remarks, deputed as I am by the public
authorities of our city to speak on this occasion ; but
that task has been better performed by others. The
work and all that it is intended to perpetuate are now a
part of the history of our metropolis, and is accepted
with all the high honor accorded to contributors that so
justly belongs to them. One word more and my agree-
able duty is finished :
" 4 Count that day lost whose low, descending son
Sees no good deed or worthy action done.'
" Gentlemen, this day has not been lost. The deed
in which we are all participating will mark it in our
calendar as a day well spent and always to be remem-
bered. We thank you for your public spirit in offering
a statue of high excellence in its workmanship, and
claim it now as an additional ornament to the city at
large, and especially to Bryant Park, the scene of these
ceremonies/
The statue is the work of Mailer, of Munich. It is of
bronze, in full length, and of heroic proportions. It
stands upon a pedestal of brown granite. On one side
is the inscription :
J. Marion Sims, M.D., LL.D.
Born in South Carolina, 1813.
Died in New York City, 1883.
Surgeon and Philanthropist
Founder of the Woman's Hospital, State of New York.
His brilliant achievements carried the fame of
American Surgery
Throughout the civilized world.
In recognition of his services in the cause of
Science and Mankind
He received the highest honor in the city of his countrymen,
And decorations from the Governments of
France, Portugal, Spain, Belgium, and Italy.
On the opposite side the inscription recites that the
statue was " Presented to the city of New York by his
professional friends, loving patients, and many admirers
throughout the world."
536
MEDICAL RECORD.
[October 27, 1894
(IPtitticat geprartttuetit
TWO COMMON FORMS OF ALOPECIA, WITH
THEIR TREATMENT.
By ELLICE M.ALGER, M.D.,
NEW YORK.
CLINICAL ASSISTANT IN DERMATOLOGY NKW YORK POST GRADUATE SCHOOL:
The premature falling out of the hair is a trouble that
causes a great deal of mental disquietude in young people
and not infrequently leads to certain more serious ills.
It is exceedingly common, and yet comparatively few
cases are brought to the physician's notice, for it is gen-
erally understood that the family doctor knows little and
cares less about such a trifling matter.
It should not be so, for a little study in this direction
will be more profitable, both for him and his patients,
than a profound research into "thyroid feeding" or
leprosy.
In a certain number of cases of alopecia no sufficient
cause for the hair- fall can be found, even on careful ex-
amination. These idiopathic cases begin, generally, in
individuals between twenty and thirty, with a very grad-
ual loss of hair from the vertex or sides of the forehead.
At the same time a progressive decrease in the size and
vigor of the hairs can be plainly seen, till after a certain
length of time the vitality of the hair follicle is exhausted
and complete baldness ensues. The time required for
this process to be completed varies from two to ten
years, and is usually much shorter in patients who lead
sedentary lives.
In looking for predisposing causes it is often found
tfiat early baldness has been a family trait for one or
more generations, and this influence in many cases seems
to be transmitted along sexual lines ; the daughters of a
bald father do not on that account suffer as much as
though the mother were prematurely bald. Another un-
doubted factor is the wearing of hot or tight-fitting head-
gear, since it is argued that a hat tight or heavy enough
to compress blood-vessels must interfere with pilary
growth and nutrition. The frequent soaking of the head
which many people seem to think necessary, is undoubt-
edly injurious.
Just how nerve-strain should cause early loss of hair
cannot be satisfactorily explained, but it is beyond ques-
tion a factor in many cases.
Women are apparently much less subject to alopecia
than men, probably because they wear different head* gear
and are naturally provided with a more abundant layer
of subcutaneous tissue. Also they pay much more atten-
tion to the condition of the scalp, and are more skilful
in concealing their losses by artificial means.
The prognosis in these idiopathic cases is bad, the
gravity increasing as the layer of subcutaneous fat
becomes less, and as age increases. The rate of progress
is best indicated by the size of the individual hairs and
their clipped ends in men, and their length in women ;
these indicating whether they have matured and fallen
naturally, or come out while immature. A constant fall
of lanugo hairs would indicate an advanced and grave
state of the trouble. The indications for treatment are
first prophylactic. The general health has a direct bear-
ing on the case ; the scalp should be frequently brushed
with a moderately stiff brush and any deficiency in the
oily secretions should be artificially supplied. If the
trouble seems caused by a lack of the hair-forming ele-
ments in the body, a generous diet must be insisted on
and supplemented by tonics, iron, hypophosphites, etc.
Locally, stimulants are called for and remedies which
shall cause an unusual supply of blood in the scalp.
Tr. cantharides, Tr. nucis vom., Tr. capsic, and quinine
all have more or less value. They can be used in oily
excipients if the scalp be very dry, or in alcohol if the
sebaceous secretion is sufficient
The following will give some idea of the local treat-
ment:
9. Tr. cantharides,
Tr. capsic,
Tr. nucis vom.,
Ol. ricini ftft 3 ij.
Alcohol J ij.
Spts. rosmarini J j.
M. Sig. : Apply to scalp night and morning.
Another very good thing which should be carefully
used is muriate of pilocarpin, either hypodermically or
according to Lassar's formula as follows :
9 . Pilocarp. muriat gr. xv.
Vaseline | ss.
Lanolin f ss.
M. Sig. : Rub in carefully twice daily.
But in another and much larger class of cases an unmis-
takable cause appears in the presence of a larger or
smaller amount of "dandruff," which gives the name
alopecia furfuracea. Clinically this dandruff takes on
two forms, which are probably due to the same cause.
The common variety consists in the constant shedding of
dry scales. European writers would have us believe that
this is parasitic in origin ; that the irritation of parasites
results in the shedding of epithelial scales while yet im-
perfectly formed, and that the falling out of hairs and the
succeeding atrophy of the follicles occur because they
form only parts of the epithelial covering and are event-
ually subject to the same processes.
In another form, the so-called seborrhosal eczema of
Unna, the scalp is covered with adherent crust and scales,
frequently taking the form of circular patches and show-
ing a marked tendency to spread over the face and body
if undisturbed. These patches are inflammatory in char-
acter, especially on their margins, and are very greasy.
This seborrhoeal eczema is most common from puberty
to about thirty, that being the time when the sebaceous
glands are most active, and it has been demonstrated by
the experiments of Lassar and Bishop that the cause is a .
parasite, but whether the crusts are the result of sebaceous
or sudoriferous hypertrophy is still a matter of dispute.
At any rate, owing to parasitic irritation, one of two
things takes place. Either the cells formed in the glands
and hair follicles are shed while yet imperfect, taking the
hair with them, or from the constant production of
sebum a hypertrophy of the glands results, followed by
atrophy of the hair from pressure.
In this variety of alopecia the prognosis is better than
in the idiopathic form, but the treatment is quite differ-
ent. To begin with a stimulating treatment would ag-
gravate instead of alleviate the difficulty, and this is the
mistake commonly made. The first thing to do is to
remove the crusts, and this is first accomplished by soak-
ing the scalp thoroughly with some bland oil at night-
time, and cleaning it thoroughly in the morning. A
nice way of accomplishing this is to shampoo the head
with a mixture, made of egg-yolks beaten up in lime-
water, washing the scalp thoroughly afterward. When
the crusts are pretty well gone we can apply anti-para-
sitic treatment. This requires patience, and application
must be made long after the trouble is apparently gone.
The remedies at command are numerous. Perhaps the
most universally serviceable is sulphur in one form or
another, for it is a parasiticide and a good stimulant to the
hair growth, supplying elements which contribute di-
rectly to its growth. It can best be used in ointment
form. One of the nicest preparations is that devised by
Dr. Jackson, called sulphur cream. The formula is :
$. Cera alb 3 viij.
Ol. petrolat 5 v.
Aq. rose 5 ijss.
Sod. biborat gr. atxxvj.
Sulphur 3 vij.
M. Sig. : Apply night and morning.
Resorcin is another valuable remedy. It can be used
in ointment in strengths of from five to ten per cent., but
a more agreeable preparation is the following:
October 27, 1894]
MEDICAL RECORD.
537
9. Hydrarg. bichlor gr. j.
Rcsorcin 3 ij.
Alcohol,
Aq afi J jss*
M. Sig. : Apply night and morning.
Ichthyol and naphthol, thymol and many other reme-
dies have their advocates and values. The treatment
must be persisted in as long as any traces of seborrhoea re-
main, the frequency of applications being gradually di-
minished. Afterward the hair thickens up, its growth
being assisted, if necessary, by the stimulating remedies
advised under alopecia idiopathica.
335 East Nimbtbbmtk Strkbt.
SEWER-GAS A CAUSE OF PNEUMONIA.
By THEODORE ZANGGER, M.D.,
LATB ASSISTANT PHYSICIAN, UNIVERSITY HOSPITAL, ZURICH, SWITZERLAND.
In his interesting paper on "Sewer -gas a Cause of
Throat Disease/' in the Medical Record of September i,
1894, Dr. Robinson has written on a subject of no small
import. Perhaps the following two cases, which I had
under my care at a health-resort in the Bernese Oberland,
may help to throw some further light on the subject.
Case I. — Miss O. T , aged fifteen, of healthy pa-
rents, pale, anaemic, who had undergone an operation for
adenoids six weeks before, sickened with acute pharyngitis
and tonsillitis without any formation of membrane,
fever remittent, normal or rather subnormal in the
morning, and rising to 1020 F. and 102. 50 F. in the
evening; no lung symptoms except slight bronchial
catarrh. After three days the patient developed a cir-
cumscribed pneumonia of the lower lobe of the left lung.
Recovery in three weeks. The drainage of the chalet
was in a very bad state, nauseous odors spreading all
over the house ; the drains were immediately seen to, and
no other member of the household (five adults, four chil-
dren) showed any illness.
Case II. — Miss Z , fifteen years of age, weak and
anaemic, still suffering from albuminuria subsequent to
scarlatina, four months previous. Three weeks later
than Case No. 1, she was attacked with acute tonsillitis
and subsequent pneumonia of a portion of the lower
lobe of the right lung. Temperature remittent, the fever
never exceeded 1020 F.; great prostration. Recovery took
place in a fortnight. No other cases among the one
hundred and twenty guests of the hotel. Drainage very
defective, nauseous odors rising at night up to the win-
dows of the patient's bedroom.
At the same time, but at another hotel, there was one
case of severe erythematous tonsillitis, and one of follicu-
lar tonsillitis simulating diphtheria in all its symptoms.
Both recovered in from three to five days. There were
no other infectious diseases at the time among the three
hundred visitors and the sixteen hundred inhabitants of
the village.
These cases, occurring at an Alpine resort four thousand
six hundred feet above the level of the sea, among pa-
tients of the better classes who were accustomed to pay
every attention to hygiene of the body, point to the pos-
sibility, or rather, I would say, the probability, of sewer-
gas as causation. The form of pneumonia, localized as it
was and limited to a small portion of the lobe of one
lung, the remittent type of the fever, and perhaps the un-
due amount of prostration in both cases, are striking. I
can explain this only by considering the " causa agens "
to be the same in both cases : micro-organisms contained
in and disseminated by the sewer- air and affecting just
these patients as being in a low state of general health.
The similarity of the cases may even point to the simi-
larity of species and similarity of virulence of these bac-
teria, just as we see patients suffering from typhoid fever
or diphtheria due to the same source of infection, offer
curious analogies as to the severity and the complications
of the disease.
jfoctetg Reports.
NEW YORK ACADEMY OF MEDICINE.
SECTION ON SURGERY.
Stated Meetings October <?, 1894.
B. Farquhar Curtis, M.D., Chairman.
Election of Chairman. — The resignation as Chairman
of Dr. Charles A. Powers, he having removed to Denver,
was accepted with regret, and Dr. B. Farquhar Curtis
was elected to fill the vacancy.
Hernia Treated by the Wire Mattress Method.— Dr.
A. M. Phelps presented a young man to illustrate the
treatment of hernia by the method which he had de-
scribed some months ago, one of the chief features of
which consisted in weaving silver wire in the foim of a
mattress into the layers of muscle when closing the
wound, with a view to offering a stronger barrier .against
recurrence. While there had been no recurrence in the
several patients treated in this manner, yet it was too
early to speak of a permanent cure, and he showed this
patient simply to prove that the presence of the wire in
the tissues caused no inconvenience after having been
worn seven months. In one or two cases there had
been a little superficial suppuration, but not of conse-
quence ; the cases which he had treated had been severe
ones, the opening large.
Hernia Afflicted. — The Chairman, Dr. Curtis, pre-
sented a man who had had double inguinal hernia, the
McBurney operation having been done on one side, the
Czerny on the other. Both had given way, the McBur-
ney first, after which it had been followed by Macewen's
operation, which still held. Four weeks ago Dr. Curtis
performed Basini's operation on the other side.
Bending of Neck of the Femur. — The Chairman pre-
sented another patient, a young man, who had been ad-
mitted to St. Luke's with the diagnosis of tubercular ar-
thritis at the hip of fifteen months' duration ; but when
Dr. Curtis came to operate he found, on reaching the
neck of the femur, that it was healthy in appearance, but
bent, bringing the head down on a level with the tro-
chanter. The neck appeared also to be somewhat short-
ened. He at once closed the wound, and it healed by
primary intention. The case belonged among a class of
which Hoffmeister had collected about forty, of soften-
ing of the neck of the femur, resulting in bending and
consequent shortening of the limb, and more or less
mechanical limitation of motion and pain on use. The
trochanter projected more than on the sound side.
Dr. Royal Whitman presented two patients, a young
man and a boy, with the same trouble. In the first there
was bending of the neck of the femur in both limbs, pro-
ducing the deformity known as scissors legs, the two
limbs crossing each other at thq knee. In this case the
diagnosis of softening of the neck was made before there
was scarcely any deformity, but his advice was not taken,
the patient continued at his work, saw various physicians
who made the usual diagnosis of hip-joint disease, and
finally of paralysis, because of his awkwardness. Dr.
Whitman intended soon to divide the femora and over-
come the crossed position of the legs. Flexion and ex-
tension were almost free, but power of abduction was
very limited ; rotation was also limited. In the second
case there was bending of the neck of the femur only on
one side, and the symptoms were like those in other
forms of knock- knee. There was only limitation of ab-
duction in this case, and the shortening amounted to
half an inch. No case yet reported had occurred after
the twentieth year.
Fracture of Ulna and Radius. — Dr. Jacob Teschner
presented a boy who had fractured the ulna and radius
from a fall in July, and when seen soon afterward was
found to have the end of the lower fragment of the
radius in contact with the end of the upper fragment of
538
MEDICAL RECORD
[October 27, 1894
the ulna. Four short splints, one on each of the four
aspects of the forearm! were applied, and over these a
longer splint with a webbing, extending two inches be-
yond the fingers, to give sufficient extension to prevent
the fractured ends from slipping past one another. The
result had been perfect.
Enormous Sarcoma of Ilium Treated Successfully by
Inoculations. — Dr W. B. Coley presented the young
man whom he had first shown to the section last spring,
through the kindness of Drs. George F. Shrady and F.
Kammerer, when there was an enormous sarcoma of the
ilium on the right side. The patient's health was de-
clining rapidly, an operation was entirely impractical,
and under these circumstances he had, with the consent
of the gentlemen named, undertaken treatment by in-
jections of the combined virus of erysipelas and the bac-
terium prodigiosus. The injections were kept up over a
month, during a part of which time, and for some weeks
after cessation of treatment, the tumor sloughed and dis-
charged in great masses. While the sloughing was
going on, the patient's condition became critical, but
afterward he regained flesh and strength. At present
there was only a slight discharge from one of the sinuses,
around which there was moderate inflammatory thicken-
ing. The ilium had resumed nearly its normal size. In
a paper which he had read at Washington last spring, he
had reported five other cases which could be pronounced
cured by this method, the total number so treated by
him having been twenty-five at that time. Since then
he had had two other cases. The percentage of suc-
cesses had been about one in five.
Dr. George F. Shrady remarked that he had watched
this case and the treatment with great interest from the
time it first entered his wards, and had been perfectly as-
tonished at the result. It was clearly an inoperable case,
as an operation would have involved resection of the
ilium and division of the man into two parts. He had
very little faith that anything could be done by way of
toxin treatment, but knowing that this was an age of
progress he asked Dr. Coley to kindly come into the
wards and try that method. The result seemed to be
that the patient was cured. He could not recognize any
of the original growth, and there was reason to hope
there would be no recurrence. He believed now that
there was a great future for this toxin, and should never
be discouraged in inoperable cases until it had been tried.
It gave one reason to hope that something might yet be
found equally efficient in cancer.
The Chairman referred to a case in St. Luke's Hos-
pital, of very large secondary sarcoma of the clavicle, the
growth of which had ceased after using the injections two
weeks, but the treatment had to be discontinued on ac-
count of deposits in the lungs, and haemoptysis. The
effect of the injections had also been shown in the regular
rise of the temperature every day or two, just as had oc-
curred in Dr. Coley's case.
Resection of Knee for Charcot's Disease. — The Secre-
tary showed, in behalf of Dr. Willy Meyer, a man with
locomotor ataxia with so-called Charcot's disease of the
left knee, which had been resected by Dr. Willy Meyer
in 1887. Although the spinal disease had progressed,
there had been no further trouble with the affected knee.
Bony union had not taken place. There was slight mo-
tion, nature having formed a sort of condyle and socket.
Dr. Syms was not convinced that this patient was bet-
ter off than he would have been without an operation.
At the same time that Dr. Meyer was about to operate,
he had himself a patient on whom he wished to excise
the knee for Charcot's disease, but the patient refused,
and afterward partial bony anchylosis formed and left a
better joint than probably would have resulted from any
effort to bring about artificial anchylosis.
Improved Osteoclast. — Dr. W. M. Phelps presented
a Grattin osteoclast which he had modified in a way to
obviate breaking of the skin and producing compound
fracture. The new instrument was also stronger and
easier to operate.
Multiple Heurc-flbromata. Dr. C. N. Dowd read a
brief paper in which he described two cases of this affec-
tion. The first was in a man aged thirty- three, who dur-
ing the past two years had had probably as many as two
hundred tumors on the surface of the body, most of them
freely movable on the underlying tissue but attached to
the skin, the surface having a red angiomatous appear-
ance. On removing one it was found to be a fibroma of
the variety known as neurc-fibroma. Such tumors were
ordinarily benign, and caused trouble only by their me-
chanical irritation and disfiguration.
The second case was in a man aged thirty-five, who first
noticed a tumor over the olecranon of one arm, and
afterward others over various parts of the body, varying in
size from a pea to a horse chestnut. They had the ap-
pearance of the tumors in the other case, except that in
some there was a tendency to necrosis. There was no
history of syphilis, yet mercurial inunctions caused the
tumors to disappear, proving their syphilitic origin. Re-
plying to a question, he said there was no neurotic history.
NEW YORK PATHOLOGICAL SOCIETY.
Stated Meeting, September 26, 1894.
George C. Freeborn, M.D., President, in the
Chair.
Report of the Microscopical Committee. — Dr. E. K.
Dunham, on behalf of the Microscopical Committee, re-
ported the results of the examination of the specimen pre-
sented to the Society on February 20, 1894 — supposed
gumma of the heart. Because of the presence of certain
bodies closely resembling giant cells, this specimen had
been referred to the Committee. The special object was
to make a differential diagnosis between a possible tuber-
cular or syphilitic causation of the growth. At that
meeting the opinion was advanced by one of the mem-
bers of the Society, that the bodies resembling giant-
cells were derived from the muscular fibres of the heart.
Further microscopical examinations had confirmed that
view, as it had been found possible to select a series of
transitional forms explaining the changes. In order to
distinguish between tuberculosis and syphilis, a luge
number of sections were examined for tubercle bacilli,
but none were found. The sections also failed to show
any reason for regarding the growth as of tubercular
origin. In support of the opinion that the growth was
of syphilitic origin, were certain appearances in the
blood-vessels which seemed to indicate a beginning
thickening of the vascular wall. The results of the mi-
croscopical examinations were therefore confirmatory of
the original diagnosis.
Giant-Cells in Epithelioma^. — Dr. George P. Biggs
referred to a specimen of epithelioma, which he had pre-
sented to the Society last November, in which there
were giant- cells. The tumor had been removed from a
man sixty years of age, who had given a history of hav-
ing received a compound fracture of the inferior maxilla
five years before. Following this, a tumor developed in
the floor of the mouth, which proved to be an epithe-
lioma. A small nodule was said to have recurred in the
scar left after the operation for the removal of the
growth. Later, a growth appeared in the submaxillary
region on the same side, and this had grown steadily for
four months previous to his coming under observation.
The specimen referred to, which was a typical epithe-
lioma, contained large numbers of giant-cells of peculiar
character, some of them very large, and containing a
great many nuclei grouped near the centre rather than
at the periphery. The specimen had been submitted to
the Microscopical Committee, and Dr. Dunham, after
examining a number of sections stained in various ways,
was able to demonstrate that these giant-cells had been
formed from epithelial cells.
He desired at the present meeting to present a simi-
lar specimen, which had been removed at the New
October 27, 1894]
MEDICAL RECORD.
539
York Hospital by Dr. Stimson, from a man fifty years of
age who gave a history of progressive loss of voice, and of
some pain on swallowing, for four years. For five or six
months previous to the operation, he had suffered from
dyspnoea, which had become so severe that an opera-
tion was undertaken. The family history was tubercular,
but there was no personal history or symptoms of tuber-
culosis. The operation consisted in opening the larynx
and removing from its interior a large part of the mu-
cous membrane and a new-growth. Examination of the
latter showed it to be a typical epithelioma. In this
specimen also were giant-cells apparently of the same
nature as those found in the first specimen referred to.
Some of these cells were large, others had only three or
four nuclei, sometimes grouped in the epithelial struct-
ure and sometimes by themselves. Some of them were
round, while others were irregular in shape. Tubercle
bacilli were searched for, but not found. Since then, in
two other cases he had seen similar cells, but not as dis-
tinct as in the microscopical specimen just presented.
They seemed more prone to form in epitheliomata of
alow growth. The literature of this subject was very
meagre.
Dr. Thomas H. Manley asked the clinical significance
of these cells — in other words, whether their presence
was to be considered an element in the prognosis. We
know that, as a rule, cancerous growths, particularly on
the tongue, were rapidly fatal, and that sarcomata in this
region often did not recur for a considerable time after
their removal. He recalled one or two illustrative cases
which had occurred in his own practice.
D*. Biggs replied that he had not seen a sufficient
number of cases to admit of his stating definitely in re-
gard to their possible clinical significance,-but in those
ises he had reported the growth had been quite slow.
The Society then adjourned.
NEW YORK COUNTY MEDICAL ASSOCIATION.
Stated Meetings October jjf, 1894.
Samuel B. W. McLeod, M.D., President, in the
Chair.
1, Posture in Anaesthetic Accidents ; 2, The The of
Sedatives in Heart Disease ; 3, The Efficacy of Ichthyol
011 Inflamed Tissues. — Dr. Hobart A. Hare, of Phila-
delphia, read a paper containing brief remarks upon
these three subjects. Under the title Posture in Anaes-
thetic Accidents, he spoke of the position of the head,
neck, and tongue, and their influence on opening or
closing the glottis. Artificial respiration was often ren-
dered nugatory by placing the head or tongue in a posi-
tion which closed the glottis and obstructed entrance of
air to the lungs. If the tongue were pulled out and over
the lower incisors by the tip it would not raise the epi-
glottis ; it must be pulled outward and upward toward
the upper incisors. Regarding control of the glottis by
Howard's method of extension of the head and depres-
sion of the neck, Dr. Hare showed by experiment on
the cadaver, and could give clinical evidence, that the
neck must not be depressed, but lifted, else the velum and
tongue would obstruct the passage of air through the
mouth, which would prove very serious if the nostrils
should also happen to be obstructed. Regarding the
comparative efficacy of Sylvester's and Marshall Hall's
methods of artificial respiration, he had made some
experiments which proved that Sylvester's was much
more efficacious in inflating the lungs. It was important
that the feet should be held while the movements were
being made with the arms — that the body should be
stretched.
Cause of Death in Chloroform Anaesthesia. — Dr.
Hare referred to his studies in connection with the
Hyderabad Commission, and said he was convinced that
the chief factor in causing death in chloroform anaes-
thesia was cessation ot respiration through paralysis of
the respiratory centre in the medulla, although he knew
also of the influence exerted on the vasomotor system,
and through it upon the heart, and did not doubt that
the heart might first give out in certain cases where this
organ was diseased, just as death might take place from
cardiac shock brought on by various causes provided the
heart was already unsound. The death from chloro-
form in such a case was due more to sudden vascular dis-
tention than to direct influence on the heart. He had
found that atropine allowed more chloroform to be used
without depression.
Cause of Death in Traumatic Shock. — The author
had observed in many cases of death supposed to be
due to circulatory failure in traumatic shock that respira-
tion was first to give out. He had, therefore, made use
of Sylvester's method of artificial respiration in similar
cases, and had seen the breathing and pulse improve
from the increased quantity of air made to enter the
chest.
Sedatives in Heart Disease. — The next part of the
paper dealt with the treatment of heart disease. Digi-
talis had been much abused. It was very useful in certain
cases, but was contra-indicated in others, while agents of
an opposite nature, sedatives, not stimulants, were called
for. These agents were aconite, atropine, gelsemium.
In practice he found that he prescribed the sedatives
oftenest. Digitalis was beneficial in those cases where
the heart was failing and unable to do its work. The
sedative agents did best where the heart was beating
with sufficient force or too much force, but spasmodi-
cally, irregularly, and ineffectually. In cases of compen-
satory hypertrophy among laborers or gymnasts the
heart was likely to cause trouble when they ceased their
usual degree of exertion. Digitalis, under such circum-
stances, would increase the palpitation and cardiac
symptoms, while aconite would act as a sedative and
give relief. Next to aconite in value as a cardiac seda-
tive came gelsemium, then veratrum viride. The form of
cardiac palpitation and oppression complained of by
medical students on climbing stairs at the commencement
of a term was usually best relieved by one of these
agents.
The Efficaoy of Ichthyol on Inflamed Tissues. — Dr.
Hare concluded his paper by citing some experiments
made on rabbits at his suggestion in the laboratory,
with a view to explain the influence of ichthyol over in-
flammatory action. Under certain precautions the skin
of the rabbits was bruised in a way to produce subcutane-
ous injection and inflammation. The rabbits were di-
vided into nine series : in one the affected area not re-
ceiving treatment; in another it was simply rubbed;
in a third, ichthyol was applied ; in a fourth, the ichthyol
was applied with rubbing;- in a fifth, it was applied
along with lanolin ; in a sixth, the latter was applied
alone, and so on, the object being to determine whether
the benefit was due to the rubbing, the ichthyol, the lan-
olin, or to any combination in die use of these agents.
Sections of the skin were examined microscopically.
The conclusions drawn from the experiments were, that
the inflammatory exudate disappeared more quickly
under rubbing than without ; that it disappeared most
quickly with the combined use of rubbing and ichthyol,
and that lanolin had no effect. The rubbing made the
oil-globules penetrate more deeply.
Dr. E. K. Dunham was requested to open the discus-
sion. He showed some cultures of micro- organism
which he had made with a view to determining whether
ichthyol had any antiseptic value. Its action on the
growth of disease germs was found to be only slightly
inhibitory.
Prolonged Lincoln's Life.— Dr. C. A. Leale said
that in drowning and anaesthetic accidents, he put the
finger far back in the mouth and drew the tongue for-
ward, thus accomplishing what Professor Hare did by
pulling the end of the tongue forward and upward. He
had been much indebted to Dr. Flint for knowledge
540
MEDICAL RECORD.
[October 27, 1894
acquired in his laboratory regarding artificial respiration
as it had led him, when he found President Lincoln sitting
in a chair after the shooting, the head dropped forward,
breathing stopped, pulse absent at the wrist, to imme-
diately lay him on his back upon the floor and to lift the
chin and thereby restore respiration. The coaguli were
then removed from the skull, relieving cerebral pressure,
whereupon he had the happiness to see restoration of
lung and heart action. Miss Keen, the actress, came in
while in stage costume, and seeing the President lying
upon the floor, sympathetically begged permission to
hold his head. Dr. Leale replied, " No, the head must
not be raised an inch, or else it may interfere with res-
piration and cause death."
. Dr. Leale also referred to a case of suicidal attempt
with two ounces of chloroform, which he had reported in
1873, aQd in which he practised artificial respiration and
irritated the great sympathetic ganglia by introducing
his hand a distance of sixteen inches up the colon.
Much of the further discussion was directed to the
comparative safety of ether and chloroform as anaesthet-
ics.
Dr. Manley felt that ordinarily to give chloroform
instead of ether was to needlessly imperil the patient's
life. He inquired the author's opinion of the new
French method of rhythmical traction on the tongue
where breathing had ceased ; also of Dr. Fell's method
of artificial respiration.
Dr. Rupp said Dr. A. C. Post had years ago taught
and practised pulling the jaw and tongue forward, the
finger being applied to the back of the tongue.
. Dr. J. Mount Bleyer said with reference to the
method of artificial respiration credited to Dr. Fell, that
he had himself first described it, in a paper read in 1886,
one tube being used for the introduction of air into the
lungs, the other for its escape. Further remarks were
made by Drs. Collyer, McKeeby, Brothers, and others.
.Chloroform had its advocates.
Dr. Hare in some concluding remarks said that a per-
son's susceptibility to chloroform or ether, like to some
other drugs, seemed to depend to some extent upon the
climate. In the South and in Europe chloroform Ap-
peared to be less dangerous than in this section of the
United States. Here, judging by immediate results,
ether was much safer, but it was a question whether as
much could be said of it if the after-accidents as nephri-
tis, bronchitis, etc., attributable to its use, were taken
into consideration. The observations of those who had
discussed the question this evening were in harmony
with those of all others who had made it a point of
special investigation that in chloroform accidents the
respiration ceased before the heart-beat, although a
contrary view had generally been held at first.
Chart Illustrating Mortality Tables TTsad by Life
Assurance Companies. — Dr. N. S. Westcott explained
such a chart. On it vertical lines were drawn to the
number of 100, every fifth one heavier than the oth-
ers; they were crossed by horizontal lines up to any
required number. The horizontal lines beginning at
the bottom of the left were numbered from 1 up, which
stood for thousands, the number living; the perpen-
dicular lines beginning at the left and bottom were
numbered from 1 to 100, the age; at 'the top the same
lines contained the number still living for the respective
years, the number decreasing from left to right until
zero was reached at the age of one hundred. A red
line was drawn from the left upper corner of the chart,
sloping gradually to the right lower corner, dropping as
it proceeded to each horizontal line representing the
number of living at any given year. There was a rapid
fall in this oblique line the first five years, another in-
creased declination after the fiftieth year, and a third,
corresponding in degree to the first, beginning at old
age. By this chart one could quickly estimate the prob-
ability of life at given ages. Without the age being
given, mortality rate per thousand in any community
was of little value.
OUR LONDON LETTER.
(From our Special Correspondent.)
THE WINTER SESSION — THE MEDICAL SOCIETIES — ^EPIDEM-
ICS— DIPHTHERIA — ANTITOXIN — EPIDEMIC SKIN DIS-
EASE— EPIDEMIC MUSCULAR RHEUMATISM — BERIBERI —
THE CHELSEA HOSPITAL SCANDAL — HONORARY MEDICAL
OFFICERS TO PAY WARDS.
London, October 6, 1S94.
We are already settling down to the work of the winter
session. The schools having opened on the traditional
October ist, and a number of them having celebrated
the occasion with a dinner, are now quietly engaged in
their usual work. The societies, too, are all awakening,
and next week we shall be in the full tide of their pro-
ceedings. The Obstetrical Society has already met ; on
Monday the Medical Society of London will begin its
session with an address by the President, Sir W. Dalby ;
on Wednesday the Hunterian Society will be addressed
by Mr. Bryant ; on Thursday the Gynecological Society
will meet ; on Friday, the Clinical Society.
I have not yet heard when the Epidemiological Society
will hold the first of its few meetings, but an early date
would seem to be appropriate, for much of our attention
has lately been demanded by epidemics, and we seem to
be threatened with an outbreak of epidemiological con-
versation and literature. I do not refer in this to chol-
era or the more distant Eastern plague, but to diseases
in our midst with a more or less epidemic character.
First of these is diphtheria, which has for some years been
present in London, but seems to have rather increased.
Last week there were sixty-seven deaths, and the numbers
admitted to the hospitals of the Asylums Board show
that the disease has been more prevalent in the last
quarter than in previous Michaelmas quarters. The
same may be said of the numbers of notifications. A
most interesting point in reference to diphtheria is the
success that has attended the treatment by antitoxin.
Stimulated by the success reported from the Continent,
quite a number of practitioners have been using the new
treatment, and successful cises are being rapidly accumu-
lated. Like all ether remedies, it must be employed in
the early stage if it is to be effectual, and there is some
evidence that it is even preventive. The Pasteur Insti-
tute prepares the remedy on a large scale, but not enough
for French demand. It is not easy to obtain a supply
here, but soon perhaps may be. It is to be hoped that
no spurious or imperfect preparations will come into the
market. A considerable time is required for preparing
the remedy, and no little skill. Now is the time for the
British Institute of Preventive Medicine to show its
capacity and establish its position. Some are calling out
for the State to provide a supply. That is not likely to
be done in a hurry, and the British Institute ought to be
able to meet the demand.
The second epidemic that forces itself on our notice is
exfoliative dermatitis. Your readers will remember my
report on this three years ago, when Dr. Savill first de-
scribed it as "a contagious malady in which the main
lesion is a dermatitis, sometimes attended by vesicles,
always resulting in desquamation of the cuticle, usually
accompanied by a certain amount of constitutional dis-
turbance, and running a more or less definite course of
seven or eight weeks." This disease was epidemic in
some of our workhouse infirmaries in 1891, and in them
studied by Dr. Savill. It has since recurred each sum-
mer and autumn, but this year to a much greater extent.
It chiefly afreets the old and feeble, and the temperature
is generally subnormal. The mortality in 1891 was
12.8 per cent.; this year, so far, it has been 11.6. A
diplococcus was discovered by Dr. Savill, but he has not
been able to find it in later cases. Milk and other arti-
cles of food have been suspected of conveying the con-
-tagium, but there is not much evidence on the point.
October 27, 1894]
MEDICAL RECORD.
54i
Another disease alleged to be epidemic in several lo-
calities, is muscular rheumatism. I am informed that
some of the so-called epidemics resembled influenza, but
in others this was not the case. At all events the out-
breaks were not very serious. The attacks lasted some
two or three days, and consisted in sudden pain in the
head or chest, with a rise in pulse and temperature.
Some observers mention pleurodynia and neuralgia as
being similar, others notice sweating of the odor com-
mon in acute rheumatism. No one that I know of has
met with cardiac complication.
Yet another epidemic is reported. In a lunatic asy-
lum in Dublin there has been an outbreak of beriberi.
The origin of the disease has not been traced, and it is
not a little singular that it should appear in our climate
as an epidemic limited to an institution in Dublin. Odd
cased have at times been brought to our ports, but as a
rule do not spread.
The Chelsea hospital is not yet " out of the wood.11
The Home Secretary has declined the request of the ves-
try to appoint an official inquiry, as he has full reliance
on the impartiality of the independent inquiry that has
been held. This he reads as a condemnation of the man-
agement and of the staff. You will remember that I
foresaw the medical staff would be made the scapegoat, as
usual in all hospital scandals. The cool assurance of the
managing committee in proceeding to elect a new staff
when the old resigned, is just what might be expected
from an ordinary hospital committee. But this one was
involved in the same condemnation — only, as an Irish-
man says, " more so" — as the staff. The ladies' com-
mittee seem to be able to show the others the proper
course of conduct, for most of these ladies have sent in
their resignations. The managers should do likewise,
and the governors would do well to make a clean sweep of
all the lay committeemen, and start afresh with new man-
agement by new men. If any of the staff are still to be
scapegoats, let them all go too into the wilderness of un-
recognized medical service. Then, if the profession were
worthy of its position, no one should succeed them as
unpaid officers. Let the public pay their doctors, and
they would then appreciate their value. Unpaid medical
service is the bane of the profession. A further develop-
ment of this has lately occurred. The Great Northern
Central Hospital is starting pay wards. Patients are to be
admitted at two guineas per week. The honorary staff is
to attend the pay wards on the same terms as the other
parts of the hospital. Delightful, is it not? A depart-
ment to be run at a profit, and the doctors to do
everything for nothing. This is the notion of managers
of our charitable institutions. Ah! " Charity, what
crimes are committed in thy name."
DANGER FROM INDISCRIMINATE HOT IN-
TRA-UTERINE IRRIGATIONS.
To thk Eoitok op tub Mkdical Rkookd.
Sir : In the Medical Record of October 6 th is an ex-
cellent article on the management of abortion. In the
closing paragraph, however, the recommendation is made
that " in septic cases large, hot, antiseptic intra-uterine
injections should follow the cleansing of the uterus.'1
The italics are mine. In justice to the author I would
say that I have repeatedly seen the same recommenda-
tion by good authorities, and have witnessed the pro-
cedure carried out by eminent men. Yet it is this very
recommendation and practice which I must enter a
vigorous protest against as illogical and dangerous.
Of the value of curetting or otherwise clearing the
uterine cavity, with, in suitable cases, gauze- packing and
intra-uterine irrigation, in cases of septic metritis follow-
ing abortion, miscarriage, or childbirth, there can be
no doubt. As to the value of antiseptic douches there
is no question. That hot intra-uterine irrigations are
invaluable in their proper place I am ready to concede.
But is this the place for a hot douche ?
I may state here that I have repeatedly observed cases
of acute septic metritis which were curetted, the curetting
being followed by the hot douche, and the douche al-
most as uniformly followed by a severe chill (often be-
fore the operator had left the room), the chill being in
turn followed by fever, sweating, and other evidences
of acute septicaemia. I have seen this occur repeatedly
in the same patient every time the procedure was gone
through with until the patient and her friends begged
the doctor not to interfere and "bring on those dread-
ful chills," while the doctor assured her that the douches
were essential to her recovery. I have seen this occur in
private practice under expert gynecologists ; I have
seen it occur in the routine of hospital work ; I have
seen it occur in the practice of the country doctor ; I
have seen it altogether too frequently.
Cases of septic trouble following abortion are com-
mon— much too common. A woman has a miscarriage,
perhaps a criminal "miscarriage, at the fourth month let
us say. The foetus is expelled. Shreds of placental tis-
sue and decidual membrane come away, but some re-
main. The patient has a temperature of ioo° or 1010
F. The pulse is good. There is mild septicaemia. The
lochia is dark, bloody, profuse, has a gangrenous odor.
If left to nature she will keep on in this state for some
time. Eventually pelvic peritonitis, cellulitis, or gen-
eral septicaemia will result, or more fortunately a gradual
separation of the decidua occurs and a protracted conva-
lescence follows, complicated perhaps by prolonged
metrorrhagia and chronic metritis or other sequelae.
But the doctor is called. He is fin de siicle. He is
acquainted with bacteria,
" And various animalculae
Of middle, high, and low degree.' '
He uses antiseptic vaginal washes. Good ! He ste-
rilizes his hands and instruments. Better 1 He clears
out the uterus thoroughly. Best yet ! Then he uses a
hot intrauterine irrigation. Error in judgment! He
kills a few more putrid or septic germs, but he checks
drainage.
Why?
What have we to deal with in the septic cases referred
to ? A uterus, the cavity of which has just been cleared
of decomposing dtbris ; but a uterus, the structure and
substance of which is infiltrated with septic germs ; a
uterus with its blood-vessels and lymphatics filled with
morbific products ; a uterus which under rational treat-
ment, now that the focus of infection is removed, will
pour out offensive discharges for days and drain itself of
the poisonous products as nature intended, by a free
lochial discharge. That is the object at which we all
aim— elimination.
Now use a hot injection into the uterine cavity. The
most constant and powerful action of a hot douche is to
check hemorrhage. It contracts the blcod vessels. It
contracts the uterus. It does it rapidly, thoroughly ;
watch the result. The blood-stained malodorous dis-
charge is checked ; drainage is thus interfered with ; the
distended vessels filled with poisonous products, cut off
from their natural sewerage into the uterine cavity, and
compressed by the sharp contraction of the uterus under
the stimulus of a hot injection, empty themselves into
the general circulation, and a chill, with general septi-
caemia takes the place of what had been prior to this time
a more localized septic process. This occurs more fre-
quently in the septic states following childbirth than in
those following early abortions, simply because the
uterus being larger contains more septic material to be
forced into the general circulation. As well apply an
Esmarch bandage from the hand up to the shoulder in a
cellulitis of the arm as a hot injection into the cavity of
a uterus swarming with bacteria and infiltrated with
septic poison.
This argues nothing against intrauterine irrigation
properly performed and used with good judgment. But
the use of hot injections immediately following the cuiet-
542
MEDICAL RECORD.
[October 27, 1894
ting of a septic uterus is far too common. That their
use is dangerous is reasonable and logical in theory, and
any careful observer will find that the theory is borne
out by clinical experience.
Why use a hot intra uterine irrigation, when a warm
one would be more comfortable to the patient, would be
far safer, and would fulfil every indication ?
W. N. MacArtnky.
^ftt&iaxl Stems.
Contagious Diseases— Weekly Statement— Report of
cases and deaths from contagious diseases reported to the
Sanitary Bureau, Health Department, for the week end-
ing October 20, 1894.
Tuberculosis
Typhoid fever
Scarlet fever
Cerebrospinal meningitis
Measles
Diphtheria
Small-pox
Deaths.
61
103
30
8
40
a
X
a
30
0
141
4«
a
0
Apomorphine and Hysterical Attacks. — Rosser recom-
mends one tenth of a grain of apomorphine, hypoder-
mically, to break up and prevent the recurrence of hys-
terical attacks.
Breakfast for Chlorotio Girls— Dr. Carl Von Noor-
den, in the International Medical Magazine, May, 1894,
speaking of the dietetic treatment of chlorosis says:
" Most chlorotic girls feel weakest and worn out during the
hours of the forenoon, and incapable of any proper kind
of work. This condition is uncomfortable, and directly
harmful from the educational point of view. The best
remedy is the English fashion of a good hearty meal at
the beginning of the day. Chlorotic girls are advised to
drink half a litre of milk of the best quality, while still
in bed, and to do it very slowly, taking fifteen minutes
to drink the quantity prescribed. Half an hour later
they should rise and be rubbed with a dry, rough, woollen
towel. Then comes the breakfast, consisting of a small
cup of tea, one or two slices of buttered toast, and plenty
of meat. Two hours and a half later some bread and
butter is to be eaten, together with two eggs, this to be
followed by a quarter of a litre of milk. A glass of
sherry is now permissible, if special reasons warrant it
This morning regulation of diet makes the forenoon
hours quite comfortable. Fixed rules for other meals are
0 f less importance. ' '
Deatl* rates and Race. — I will not weary you with
further details of figures, which those of you who are
specially interested in the subject will find in the reports
of the Vital Statistics of the Eleventh United States
Census, but will merely say that the corresponding data
from Boston, Philadelphia, Baltimore, Washington, and
from the New England States as a whole, taken with
those from New York State and New York City, and
with those derived from a special investigation of over
10,000 Jewish families, including over 50,000 persons,
lead to the following conclusions as being probable for
the United States: 1. The colored race is shorter lived
than the white, and has a very high infantile death rate ;
it is specially liable to tuberculosis and pneumonia, and
less liable than the white race to malaria, yellow fever,
and cancer. 2. The Irish race has a rather low death-
rate among its young children, but a very high one
among adults, due to a considerable extent to the effects
of tuberculosis, pneumonia, and alcoholism. 3. The
Germans appear to be particularly liable to disorders of
the digestive organs and to cancer. 4. The Jews have a
low death-rate and a more than average longevity ; they
are less affected than other races by consumption, pneu-
monia, and alcoholism, but are especially liable to
diabetes, locomotor ataxy, and certain other diseases ot
the nervous system. — Dr. J. S. Billings.
Morphinomania in the Medical Profession. — Dr.
Jules Rochard, in the Union Medicate, draws a gloomy
picture of the increase of the morphine habit in France
and elsewhere. The habit, he finds, becomes incurable
at the end of six months of indulgence. The fair sex
and the doctors are, in his opinion, the most deeply
addicted to morphine. He draws an unpleasant com-
parison between the behavior of each kind of delinquent.
Women, he says, delight in declaring how they indulge
in this vice, and show ornamental hypodermic syringes
to their friends. Dr. Notet states that a lady having
broken the needle of her syringe in a remote country
village, wounded her skin with scissors and thrust the
stump of the needle into the wound, injecting herself in
this manner till a new syringe arrived from Paris. Men,
Dr. Rochard declares, and especially medical men, the
bulk of male morphine injectors, take the greatest pains
to hide their vice. Hence the precise number cannot
be estimated. He believes, however, that doctors and
persons associated with them form nearly half the total
of men addicted to morphine.
Medical Sculpture. — Dr. Paul Richer, the director of
the Salpfctrfere laboratory, has been recently engaged in
enriching that renowned neurological school with a
series of heads and busts reproducing certain types of
pathological deformities. In the last number of the
Iconographie de la Salpitriire there appears the photo-
graph of one of these busts, representing a subject affected
with primary progressive myopathy. This patient was
frequently shown by the late regretted Professor Charcot
at his cliniques as a perfect example of the myopathic
physiognomy of the Landouzy-Dtjerine type.
Catharsis by Means of Hypodermatic Injections Im-
possible.— The editor of The Medical Age believes it to
be absolutely proved that catharsis cannot be induced by
the introduction beneath the skin of purgative elements.
He relates some of his own experiences. A number of
tablets of both sulphate of magnesium and sulphite of
soda were prepared, embodying the utmost quantity
available for hypodermatic use. These were employed
in some thirty instances, and a quantity distributed among
a half-dozen other physicians, who used them in from fit-
teen to fifty cases each. In no instance was any cathar-
tic effect observed, except now and again when a patient
was informed of a probable purgative action — here the
results were only such as would accrue to " suggestion."
In one instance the physician experimented upon him-
self, making use of two tablets of magnesium sulphate of
one and one half grain each, injecting into the upper
and external aspect of the thigh at 8 p.m. ; at 10 p.m.
he retired to stool, but felt no assistance had been given
to defecation — was rather constipated than otherwise.
Being very easily influenced by laxatives, and the hour
of defecation being that of daily habit, he is quite posi-
tive that no better test could have been given of the ut-
ter inefficiency of the drug. Further, says U he Age,
the evidence per se is conclusive that neither magnesium
sulphate nor soda sulphite can be employed hypoderma-
tically as a purgative, even were one sure of a cathartic
effect, since the dose available for the sub-cellular method
is entirely too small and the method itself, so far as pur-
gative drugs are concerned, too unsatisfactory for adop-
tion. The hypodermic holds the keys that bind, but not
those that loose.
Trichinosis. — At a recent meeting of the Pathological
Section of the Buffalo Academy of Medicine, Dr. Frank J.
Thornbury made a preliminary report on 500 cases of
trichinosis observed in his work as Inspector in the Bu-
reau of Animal Industry of the United States Department
of Agriculture, at Buffalo, N. Y. Special attention was
given to conditions in the pathology not previously
spoken of, comprising peculiarities of encapsulation of
October 27, 1894]
MEDICAL RECORD.
543
the trichinae, degenerations, calcifications, pigmentations,
etc A large number of photographs and drawings were
presented whichshowed these conditions, and an extensive
exhibit of rare and interesting slides under microscopes
was given. Reference was made to the relative fre-
quency of location in the hog and extent of infection of
the different parts examined according to the Govern-
ment system of inspection. The parts examined com-
prise the diaphragm, neck, and loin respectively. The
entire number of cases in which trichinae were found in
the diaphragm was 399, in the loin, 291, in the neck,
171. The average number of trichinae found in the
diaphragm in the entire number of cases was 8, in the
loin 5, and in the neck 3. In the 500 cases studied all
of the three parts were infected in 200 instances, two
parts were involved in 136, and one part only was infected
in 164 cases. The part of predilection for the trichinae
therefore appears to be the diaphragm. This is explained
by its close proximity to the digestive tract, from which
the trichinae primarily migrate. It would appear also
that the tenderloin is not to be preferred as an article of
diet. This comprises the psoas muscles. Where the
hogs are extensively affected the trichinae are also usu-
ally found in the hams, shoulders, sides, and, in fact, in
almost any part of the body. Dr. Thornbury has also
studied the subject of trichinosis in man with the follow-
ing results: O/21 subjects examined in the dissecting-
room of the University of Buffalo, trichinae were found
in the muscles in three cases. The muscles principally af-
fected were those of the extremities (one slide from the
biceps of the arm containing fifty of the parasites), the
diaphragm, intercostals, abdominal muscles, the psoas,
etc Many of the trichinae were old and calcified,
others were still alive. One of the cases of infection was
not very extensive, the trichinae being scattered in limited
numbers through the muscles of the thorax and abdomen.
This observer contends that many cases of chronic mus-
cular rheumatism are disguised under this head. This is
corroborated by the continued observation of cases of
trichinosis in the acute stage and seeing the patient suffer
from muscular pains which under ordinary circumstances
would be regarded as simply rheumatism.
Bicycling. — The Paris Academy of Medicine recently
discussed the question of bicycling, and came to the con-
clusion that this form of exercise might be attended with
great danger to the heart in those who suffered from any
affection of this organ. One speaker referred to the
recent death of three persons from heart disease while
riding bicycles, and asserted that not less than one thou-
sand wheelmen in Paris were suffering from cardiac af-
fections, and were in danger of the same fate.
Suicide. — The number of suicides in England has in-
creased so much in recent years, that the question has
been raised whether the elimination from insurance
policies of the clause dealing with that subject has not
tended to encourage self-destruction. One of the lead-
ing insurance journals has taken the matter up, and con-
cludes that the cause must be sought elsewhere ; and that
it is only very rarely that a man puts an end to his life
from a desire to benefit his family, although it is possible
that, having already made up his mind to kill himself, he
may take out extra insurance for the sake of his wife and
children. Such deliberate suicide is, however, among
the most seldom of occurrences. Some German statis-
tics recently published show that Saxony heads all the
other states of the empire in the matter of suicides, the
percentage being almost double that of Prussia. One
per cent, of the suicides are children under twelve.
Dr. Sacharjin, the Czar's regular medical attendant,
is a most eccentric person. When called to see a patient,
he insists upon the removal of all female attendants dur-
ing the time of his visit, and allows no one to utter a
word in his presence except in reply to his questions,
and in many other ways he is noted for his blunt frank-
ness-, often rudeness, toward his patients, including those
of the highest rank. When the Czar's illness became so
alarming that it was thought best to have his physician
constantly within call, Dr. Sacharjin could with difficulty
be persuaded to come, and when he did finally consent
to take up his residence temporarily in the palace, he
positively refused to occupy the suite on the third floor
which had been provided for him, because he was accus-
tomed to the ground floor, and he required apartments
to be provided for him there. When the Czarina asked
him to lunch at the imperial table he declined, on the
ground that he was not in the habit of taking his meals
with women. He was allowed to eat in his own rooms.
In spite of his eccentricity he is in great demand among
the aristocracy of Moscow and St. Petersburg. He is
reported to be worth 7,000,000 rubles, made in the prac-
tice of his profession.
Wouldn't Trade with Him.— The following story is
told by the Medical Herald, at the expense of Dr. F. C.
Hoy t, superintendent of the insane hospital at Clarinda,
Iowa. One of the chief attractions for him in the Mid-
way was Hagenbach's "trained animal" show. He is
noted for his sympathetic nature, and, after witnessing
the performance, sought an opportunity to converse with
the lion- tamer. After a few preliminary inquiries as to
the disposition of the animals, the doctor proceeded to
sympathize with the king of the den concerning his lot,
isolated as he was from civilization, and compelled to
associate entirely with the wild beasts. Doctor Hoyt
digressed eloquently upon the uncertainty of life, and
expressed his great satisfaction at not having to play
with the monster lion, who was nervously pacing his
cage and growling. The keeper listened attentively,
only remarking that he was "used to it." When the
doctor turned to depart, the "king " courteously asked
for his card. It read : " Iowa Hospital for the Insane."
" Great guns!" gasped the tamer, "I wouldn't trade
jobs with you for a million dollars."
Data on Keeleyism.— Rev. Dr. J. M. Buckley, editor
of the Christian Advocate, of New York (150 Fifth
Avenue, New York City), solicits specific data in refer-
ence to " Keeley Institutes." He asks only for infor-
mation from physicians and ministers, and desires to
make a thorough and impartial investigation of the
Keeley business. He will not, we think, be able to find
anything very new or instructive, unless he is able to col-
lect the facts regarding relapses. The Keeley cure is
atropine, strychnine, simple bitters, good resolutions, and
a certain amount of hypnotism. -
State Board of Medical Examiners. — An autumn ex-
amination will be held by the Pennsylvania Board. Its
influence is already clearly felt in the solicitude shown
by some of the medical schools concerning the fitness of
students to pursue the study of medicine. It was rare
in former years to hear the dean of a medical school ad-
vise a pupil not to enter or continue in the course unless
indeed the student had paid all the fees that the college
could exact. We hear now, however, occasionally of
students being advised that they are not sufficiently pre-
pared to enter upon the medical course. It is to be
hoped that the Pennsylvania Board will maintain the
position that was assumed in the first examination. —
Medical News.
Anatomical Material. — The Association of American
Anatomists has issued the following circular : " Dear Sir
— At the last meeting of the Association of American
Anatomists, the undersigned committee was appointed
to ' consider the question of the collection and preser-
vation of anatomical material, and to report, at the next
meeting, what in their opinion are the best means of ac-
complishing these objects.' In order to make the work
of the committee as comprehensive as possible, and to
obtain information which will be of service in arriving at
definite conclusions as to the best methods of accom-
plishing the purposes indicated in the resolution, the
committee has deemed it desirable to send to the teach-
544
MEDICAL RECORD.
[October 27, 1894
era of anatomy, not only in this country, but abroad,
this circular letter, with the questions appended, and re-
spectfully to request answers thereto, as fully as they can
be made.
" 1. Is anatomical material obtained in accordance
with a legal enactment, wholly or in part ?
"2. If there is an anatomical law in your country or
State, please send a copy of it to the chairman of this
committee, Dr. J. Ewing Mears, 1429 Walnut Street,
Philadelphia, Pa. Please state whether the law is satis-
factory, whether it is readily obeyed by those upon whom
duties are imposed by it, and mention any improvements
you would suggest, as to its requirements.
" 3. Is the material received in good condition ?
" 4. What disposal is ultimately made of the remains ?
" 5. Please state what means are employed to preserve
anatomic material for the purposes of dissection or oper-
ative surgery. If injections of preservative fluids are
used, state their composition and the methods of use, at
what point injections are made, whether at the heart or
in the large arteries, and their effect in accomplishing
the preservation, with any changes in the color or the
character of the tissues. What length of time can
material be used in dissection by the methods employed
by you ? If preservation by means of ' cold storage '
is employed, please state the cost of the machinery
which it was necessary to construct for this purpose, and
what means are taken to prevent decomposition after
the subject is placed upon the table for dissection.
" 6. Please state the cost, by the method employed by
you, for each subject : a, for receiving it ; b, for inject-
ing and preserving it.
"7. Do you obtain an adequate supply of material for
the purposes of anatomic instruction ? How many stu-
dents are assigned to each subject, and what is the
method of allotment ?
" 8. Please give any information which you may deem
of importance. As the report will be general in char-
acter the name of the informant or institution will not
be mentioned by the committee unless requested.
" Your compliance with the request of the committee,
at an early date, will be fully appreciated as render-
ing assistance to it in accomplishing its work, and it de-
sires to thank you for the same in advance.
J. Ewing Mears, M.D.,
Joseph D. Bryant, M.D.,
Thomas Dwight, M.D."
A Medical School for Women is to be established in
St. Petersburg through the initiative of Prince Wolkow-
ski, the educational representative of Russia at the
World's Fair in Chicago.
Medical Etiquette Among the Ancients. — In an old
Latin poem, the manuscript of which has been found in
the National Library at Paris, occur some interesting
pages in which the author, whose name is unknown, ex-
plains the proper conduct of a physician. (Boston Medi-
cal and Surgical Journal,)
"On approaching the patient, you should assume a
calm expression and avoid any gesture of greed or vanity ;
greet those who salute you with an humble voice and sit
down when they do. Then, turning to the sick person,
ask him how he is, and examine his pulse and his urine.
To the patient you promise cure, but immediately on
leaving the room you say to the relatives that the disease
is grave. The result will be that, if you cure him, your
merit is greater and you will receive the greater praise
and fee ; while, if he dies, they will say that you had no
hope from the first."
This counsel has been well followed by some physi-
cians to the present day. The directions for table man
ners are equally amusing :
"When those who preside over the house ask you to
the table, conduct yourself in a seemly manner. Each
time that a new dish is brought on, do not fail to ask for
the condition of the patient. This will give him great
confidence in you, as he sees that in the midst of the
variety of the repast you do not forget him. On leaving
the table, return to the patient, and tell him that you
have dined most excellently, and that everything was
served to perfection. The sick person who was anxious
about these points will rejoice at your words."
Professor Amoyama, of Tokio, who accompanied Dr.
Kitazato to Hong-Kong to study the plague, contracted
the disease and nearly lost his life. Happily, however,
he finally recovered, and has not returned to Tokio.
BOOKS RECEIVED.
Food and Feeding. By Sir Henry Thompson. 8vo, 22a
pages. Published by Frederick Warne & Co., London and New
York City. Price, $1.25.
The Horse. By George Armitage, M.R.C.V.S. 8vo, 271
pages. Illustrated. Published by Frederick Warne 8c Co., New
York and London. Price, $1.00.
Medical Register. Dr. John Shrady, Editor. Published
by G. P. Putnam's Sons, N. Y. Price, $2.50.
The Senile Heart. By George William Balfour, M.D. 8yo,
300 pages. Published by Macmiilan & Co. , London. Price, $1.50.
Transactions of the Medical Society of New York for
the Year, 1894. Published by the Society.
Directions for Laboratory Work in Bacteriology.
By Frederick G. Novy. 8vo, 200 pages. Illustrated. Published
by George Wahr, Ann Arbor, Mich. Price, $1.50.
Therapeutics— Its Principles and Practice. By H. C.
Wood, M.D. 8vo, 1007 pages. Published by J. B. Lippincott
Co.
Prescribing and Treatment for Infants and Children.
By Philip E. Muskett. i6mo, 334 pages. (Third Edition.) Pub-
lished by Young J. Pent land, Edinburgh and London.
Bread from Stones. A New and Rational System of Land
Fertilization and Physical Regeneration. i2mo, 135 pages. Pub-
lished by A. J. Tafel, Philadelphia, Pa. Price, 25 cents.
The Principles of Bacteriology. A Practical Manual for
Students and Physicians. By A. C. Abbott, M.D. Published by
Lea Brothers & Co., Philadelphia, Pa. 8vo, 470 pages.
Transactions of. the Ohio State Medical Society.
1894. 8vo, 488 pages. Published and Printed by the Society,
Toledo, O.
Laboratory Manual of Elementary Chemical Physiol-
ogy and Urine Analysis. By John H. Long. 8vo, 365 pages.
Illustrated. Published by E. H. Colegrove 8c Co., Chicago, I1L
Price, $2.50.
Diseases of the Chest, Throat, and Nasal Cavities. By
E. Fletcher Ingals, M.D. 8vo, 686 pages. Illustrated. Price,
$5.00. William Wood & Company.
Transactions of the American Surgical Association.
Edited by DeForest Willard, M.D. 8vo, 33a pages. Illustrated.
Published by William J. Dornan, Philadelphia, Pa. 1894.
Syllabus of Lectures on Embryology. By W. P. Man-
ton, M.D. 8vo, 125 pages. Illustrated. Published by the F.
Davis Co., Philadelphia, Pa. Price, $1.25.
When All the Woods are Green. By S. Weir Mitchell.
8vo, 417 pages. Published by The Century Co., New York City.
Price, $1.50,
Healthful Womanhood and Childhood. Plain Talks to
Non-professional Readers Relative to Healthy and Diseased Condi-
tions Peculiar to Women, and Concerning the Care of Young Chil-
dren. By Henry Bixby Hemenway, M.D. 8vo, 290 pages. Pub-
lished by V. T. Hemenway & Co., Evanston, I1L Price, $2.00.
Mugwumps. By One of Them. 8vo, 328 pages. Published by
Arena Publishing Co. , Boston, Mass.
Addresses, Papers, and Discussions in the Section on
Surgery and Anatomy. At the Fifty-fifth Annual Meeting of
the American Medical Association, held at San Francisco, Cal.,
June 5 to 8, 1894. Printed at the Office of the Journal of the
American Medical Association, Chicago, 11L
A Manual of Human Physiology. By Joseph H. Raymond,
M.D. 8vo, 382 pages, illustrated. Published by W. B. Saunders,
Philadelphia, Pa. Price, $1.25.
Essentials of Diseases of the Ear. By E. B. Gleason,
M.D. 8vo, 147 pages, illustrated. Published by W. B. Saunders,
Philadelphia, Pa. Price, $1.25.
Text-book on Anatomy and Physiology for Nurses.
Compiled by Diana Clifford Kimbler 8vo, 268 pages, illustrated.
Published by Macmiilan & Co., New York. Price, $2.50 net.
Medical Record
A IVeekly Journal of Medicine and Surgery
Vol. 46, No. 18.
Whole No, 125a.
New York, November 3, 1894.
$5.00 Per Annum,
Single Copies, ioc.
©rtgitral Articles.
TREATMENT OF DIPHTHERIA.1
By A. CAMPBELL WHITE, M.D.,
NBW YOBK.
RKSIDBNT PHTSICIAN OF THE WILLARD PAKKKR HOSPITAL.
The nasal cavities were irrigated every eight hours with
a warmed i to 4,000 solution, and the throat every three
hours with a 1 to 3,000 solution.
Besides this local treatment, nearly all the cases re-
ceived frequent doses by the mouth of the tincture of the
chloride of iron and of alcoholic stimulants.
Saltwater Total Num-
Irrigation. o[Q^
The cases of diphtheria included in this investigation Tv?J±ri?L°F ALL Case^ Showing the Duration from
were subjected * three different modes of treatment. SSSLtci ITb^" Pseudomkmbrane ™ ^appear-
In the first series, the nasal and throat cavities were
thoroughly irrigated, every one to three hours, with warm Number of Days From I
salt solution, until the pseudo* membrane had disappeared, Appearance ^ Mem- Salt water im-
then from one to three times daily until the entire disap- ^* 0? wSSSES- |pySon2 spray.
pearance of the bacilli. For irrigation, the fountain or fler baci,,i*
Davidson syringe was used.
In the second series, the cases besides receiving the treat- l'."] '.'.'.'.. [[[.'.[.'.
ment given in the first series, had their nares and throats J
thoroughly sprayed every three hours (except during 9"-' '.»"".»"'.
the night) with solutions of peroxide of hydrogen, which 1° ; ; " ;
varied from twenty-five per cent, to five per cent, in "••■•
strength. The special form of peroxide used was that \l. '.'..'.'.'.'.'.'.'.".'.v.
known under the name of pyrozone. js
The following tables show the results obtained by these '7 .' '. '. '.
comparative tests : l*"!!"".".';.'.'!.
Tabulation of all Cases, Tabulation of all Cases, n'.'.'.V.'.'.'.'." '.'.'.'.".
Showing the Day of the Showing Number of Days 22 ."."!!!!!.'.'!!.'!!. .'
Disease on Which the on Which Bacilli Persist- 2£
Pseudo- membrane Disap- ed After Disappearance 11
peared. of Pseudo-membrane. 30!!".!!!!!".;."!!".'
33
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84
Recapitulation.
8 ' fi
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r
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Salt water rriga- Years,
tion and pyro-
zone spray.... 13
Bichloride irri-,
gation 10.5
Salt water irri-
gation
Total.
3
1.6
2.4
2-3 I 5-8
6.6
6.3
4-5
J*
a
9.6
7.9
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* Before membrane. In these four cases bacilli disappeared one day
before membrane. In those cases treated with bichloride irrigation
only were cultures taken before disappearance of membrane, while in
some cases treated with the salt-water irrigation examinations for ba-
cilli were not made for two or three days after membrane had disap-
peared.
The third series of cases were subjected to the same
treatment as the first, except that solutions of bichloride
of mercury were substituted for the salt-water solution.
1 Being the substance of a report to the Health Department of the
city of New York, on a series of investigations relating to the duration
of the false membrane and persistence of Klebs-Loeffler bacilli in the
throats of patients subjected to systematic irrigation with antiseptic or
cleansing solutions.
In using the pyrozone three different strengths were
employed, twenty five, twelve and one- half, and five per
cent, solutions. With the twenty five per cent solution
the average time for disappearance of bacilli after disap-
pearance of membrane was 6.8 days, a somewhat better
result than with bichloride or salt solution, but it was
very noticeable that the pseudo-membrane treated with
the stronger solutions of pyrozone lasted much longer
than would be expected from the severity of the dis-
ease, and certainly much longer than in those cases
where the five per cent, solution of pyrozone or the salt
or bichloride solution was employed. Out of 16 cases
treated with the twenty- five and twelve and one-half per
cent, solutions of pyrozone ten had membrane from ten
to sixteen days, while in another quite bad case traces of
the pseudo membrane persisted for twenty- three days.
The average time from first appearance of diphtheritic
546
MEDICAL RECORD.
[November 3. 1894
membrane to the disappearance of bacilli in the twenty-
five per cent, cases was 1 7.75 days, this not being quite as
good a record as that made by the bichloride solution,
and about the same as that made by the water irrigation.
As all the pyrozone cases received, as mentioned before,
thorough washing of throat and nose before and after
treatment with the spray, the results as shown in the
tables would certainly indicate that the addition of
spraying strong solutions of peroxide to the treatment
with plain water irrigation had no good results. On the
contrary, it would seem from the long continuance of
tie diphtheritic membrane in those cases treated with the
twenty-five and twelve and one half per cent, solutions
that they acted as an irritant to the already inflamed
mucous membrane.
The five per cent, solution caused no noticeable irrita-
tion. The pseudo membrane disappeared in the usual
time, and it would certainly appear to be the best
strength (if any) to use for this purpose.
Among the twenty cases on the bichloride treatment,
one, a boy four years old, developed mercurial stomatitis
in quite a severe form, and another showed symptoms of
intestinal irritation ; both of them were undoubtedly
caused by swallowing bichloride solution during irriga-
tion, as they had not been given internally mercury in
aay form. Both soon recovered after the cessation of
the bichloride irrigation.
Laryngeal cases have not been included in this list,
as the treatment tried in these cases could have no
possible effect upon membrane or bacilli in the larynx.
In six cases in which these three tests were tried, it ap-
parently had no effect whatever, the bacilli being found
in the larynx from thirty to forty days after admission to
the hospital.
Since the tabulation of the cases in this report was
made, I have had two cases in which the Kleb*-
Loefflsr bacilli persisted for twenty-nine days and forty-
eight days respectively after disappearance of membrane.
These cases received the bichloride irrigation treatment
as described above, until all signs of the bacilli had dis-
appeared. This would make the average number of days
for the persistence of the bacilli after disappearance of
membrane and the entire duration of die disease about
the same in the bichloride cases as in those where no
antiseptic was used.
The results obtained in the special series of forty cases
treated with plain or salt-water irrigation are similar to
those obtained in over six hundred other cases treated in
a like manner ; while frequent and careful experiments
with nearly all the well established antiseptics have given
practically the same results accomplished by the pyro-
zone and bichloride of mercury in this series of experi-
ments.
The conclusions derived from this series of cases, to-
gether with investigation and observation on a much
larger number of cases, lead us to believe :
1. That frequent washing of the air-passages attacked
by diphtheria lessens the duration and amount of diph-
theritic membrane.
2. The addition of antiseptics, in sufficient strength to
be germicidal, to the irrigating fluid is irritating to the
micous membrane, thereby causing extension and per-
sistence of false membrane rather than the effect de-
sired.
3. The addition of antiseptics to the irrigating fluid is
liable to cause systemic poisoning and disagreeable com
plications from the swallowing and absorption of some
of the fluid used, e.g., the two bichloride cases cited
above.
4. Spraying the throat (also the pernicious treatment
of swabbing), whatever solution is used, can have no
good effect, as the parts reached by the spray must nec-
essuily be very limited, excepting possibly in the hands
of an expert. Furthermore, the spray cannot be used
with young children, as anyone can testify who has tried
it This is especially true of some solutions where it is
necessary to use a glass syringe.
5. Frequent cleansing of the throat and nasal cavities
with a bland solution, such as plain warm water or nor-
mal salt solution, is easier of application, is more agree-
able to the patient, and does all that any antiseptic solu
tion can accomplish, either upon duration of the mem-
brane or the period of isolation.
A CONTRIBUTION TO THE STUDY OF MOD-
ERN AMPUTATION.
By W. L. ESTES, A.M., M.D.,
DIRECTOR, PHYSICIAN, AND SURGBOK-IN-CHIFK OF ST. I UKB*S HOSPITAL, SCOTS
BBTHLBHBM, PA.
The writer had occasion to search for some recent statis-
tics of mortality-rates after major amputation, and he
was disappointed in finding very few available contribu-
tions from American surgeons to this formerly very prom
inent and important, but now somewhat neglected, branch
of surgery. Improved methods of conservatism have re-
duced very largely the necessity for amputating limbs,
but aseptic practice and bloodless methods have also so
reduced the mortality-rate after amputation, that statis-
tics of the older writers are obsolete and useless as stand-
ards of comparison, and misleading to students of sur-
gery.
This study, based upon the statistics of a single op-
erator, working in a modern hospital, and who has ec-
deavored to carry out as strictly as practicable aseptic,
and especially bloodless, methods, is offered as a contri-
bution to what must still remain a very important branch
of surgery, with the hope that it will stimulate other
surgeons to report their results in this line, and so re es-
tablish the prestige of American practice in acute sur-
gery.
This study is based upon 294 single major amputa-
tions, 38 complicated cases requiring two synchronous
operations, 7 triple, and 1 quadruple operation, making
altogether 340 major amputations.
Only 19 of these were amputations for pathological or
diseased conditions, so that there were 321 amputations
done for injuries to limbs, usually the result of great vio-
lence, as they were all cases from the railroad, mines, or
factories. In many of the cases there elapsed several
hours between the time of the injury and the reception
of the patient at the hospital, and commonly they had
to make pretty long journeys to reach the hospital.
In considering the conditions requiring amputation,
pathologic conditions will be left out entirely, and only
conditions resulting from violence will be considered.
Conditions Calling for Amputation. — Esmarch * very
pithily sums up the whole matter, in speaking of injuries
in war, by saying : " The removal of a limb is, as a rule,
only indicated when by so doing the prospect of saving
the life of the wounded is rendered essentially better
than by the conservative treatment." I believe one
would do well to follow this rule in civil practice also.
Aseptic practice has made conservative attempts much
safer than in former years, however, and conservatism
ought therefore to be given a much wider range than
formerly. Evulsion of a limb, of course, admits of no
question. Compound fractures, if the bones were badly
comminuted, formerly called for amputation. Now they
rarely do, unless too great a length of bone be implicated,
and unless the soft tissues have suffered severe laceration.
It is my rule to attempt to save a limb if not more than
two inches of the principal bone is comminuted. In at-
tempting to estimate whether or not the soft tissues have
undergone too great injury for any conservative attempt,
I think the muscular laceration should receive less con-
sideration than the degree of injury to the skin. I have
over and over again saved limbs having comminutions of
the bones, and bad lacerations of the muscles, but only
slight injury to the skin. I have very rarely succeeded
in saving a compound comminuted fractured Limb having
slight lacerations of the muscles, but extensive injury to
1 Surgical Handbuch, p. 277.
November 3, 1894]
MEDICAL RECORD.
547
the skin. I have found that one or two lacerations of
the skin are not particularly hurtful ; it is the complete
death of the skin through immense pressure, as the
weight produced by the pushing of a car- wheel, or heavy
beam, or stone. If all the muscles at a given level are
pulpified, amputation is of course indicated. As to
whether injury to a principal vessel or system of vessels
calls for amputation in a case of compound fracture in
every instance, I should say decidedly — no. Serious in-
jury to the femoral vessels or brachial vessels high up, by
a compound fracture, usually requires amputation, but
one system of vessels in the forearm or leg may be en-
tirely destroyed at a given level, and yet the limb be
saved. The following case will illustrate : A man about
thirty years of age, of stout build, while plastering a ceil-
ing of a public building, lost his balance and fell from his
scaffold to the floor, a distance of some ten feet ; he
came down on his feet in a standing position ; his right
leg gave way and he fell in a heap on the floor. *He was
picked up bleeding profusely, his right foot turned out-
ward so that the sole was in the position of extreme
talipes valgus. He was brought as soon as possible to
the hospital. On examination it was found that the
tibia was projecting through the skin and his drawers on
the antero internal aspect of the leg, at the level of junc-
tion of middle and lower thirds. This fragment of bone
was large, with sharp jagged spicules projecting. The
skin had been lacerated almost half the circumference of
the leg at this point, but by the sharp fragment, which
occasioned very little contusion ; the anterior tibial ves-
sels were torn and bleeding. The fibula was fractured
about the same level. Upon enlarging the wound and
investigating further, the tibia, for two inches, was found
comminuted. These fragments were removed, the an-
terior tibial vessels tied, and the ends of the principal
fragments squared off. By a lineal incision over the
fracture of the fibula this was exposed, two inches of the
fibula removed to correspond with the tibia, and then
both bones were wired* The shortening of limb threw
the soft tissues up in a transverse rounded ridge. The
man made a good recovery with a perfectly useful limb.
Compound dislocation of a large joint is stated by
Ashhurst, and indeed by most older writers, as an imper-
ative call for amputation. I have treated compound
dislocations of all the large joints of the limbs, except
the shoulder, conservatively, with excellent results. These
compound dislocations are usually accompanied, in the
cases I have seen, by fracture of at least one, or a part of
one. of the bony surfaces of the joint. It is necessary, as
a rule, to remove the small fragments of bone, but unless
the principal vessels are torn, or the greater part of the
circumference of the skin killed by pressure, I should
never amputate primarily.
Great contusion and laceration of muscles, without
fracture of a bone and little injury to the skin, I have
found very rarely require amputation. Certainly no
primary amputation should be done. The important
point is to relieve the immense tension of the skin on
account of the hypodermal effusion of blood and serum,
by immediate ^multiple punctures of the skin, in order
to drain away the effused fluid. No drainage-tubes
should be used, nor should even a strip of gauze be em-
ployed as drain — only canalization — as the least local
pressure will usually cause necrosis of the already badly
nourished skin, and from this point infection is apt to
occur.
Injury to the skin without serious injury to the deeper
tissues, I have never found call for amputation. Sponge
grafting and, if need be, skin grafting, after separation of
the necrosed skin, usually avails to bring about a useful
healing.
Whenever there is a question as to the advisability of
an amputation, or any reason to doubt that an amputa-
tion is actually necessary in a given case, there is very
little danger in postponing the operation, in the mean-
time keeping the extremity in an aseptic condition by
thorough surgical cleanliness and perfect drainage. Of
132 complicated fractures of the bones of the extremities
which I have treated in the last eleven years, most of
these compound comminuted fractures, associated com-
monly with other serious injuries, 113 were cured, 6 im-
proved, and 12 died ; 1 unimproved, as he refused to be
operated upon and left the hospital. Of the 12 deaths
one died of delirium tremens, one had also fracture of
three ribs and injury to the lungs, besides a fracture of
the humerus and extensive lacerations of the scalp. One
had also a fracture of the ilium and dislocation of the
sacrum ; one had head injury and cerebritis, of which he
died ; one died of apoplexy. So that only seven deaths
could be charged to the complicated fractures directly.
Two of these died of septicaemia. Both cases persist-
ently refused amputation until they were thoroughly auto-
infected. One hundred and four of these cases were
complicated fractures of the lower extremity ; of these
88 were cured, 5 improved, and 1 1 died ; 28 were com-
plicated fractures of the upper extremity ; 25 were cured,
1 died, 1 improved, 1 unimproved (left the hospital).
Thirty six of these cases were operated upon conserva-
tively, that is for the purpose of removing pieces of bone,
uniting fragments, etc. Thirty were cured, limbs re-
stored to full usefulness, 2 improved, 2 required amputa-
tion afterward. One of these died after the amputation,
of septicaemia. This man refused absolutely to have his
leg amputated at first. It was clearly a case for amputa-
tion, as all the soft tissues were badly comminuted as
well as the bones. The conservative operation was done
as a forlorn hope. The other case requiring amputation
was done on account of the coincident injury to the
axillary vessels resulting in a thrombus of the vessels.
One died of cerebritis following a head injury received
at the same time. So that, except in the one case of
septicaemia (which was the result of the obstinacy and
ignorance of the man, and ought not to be classed as a
case of conservative attempt), there was no death which
could be laid to the conservative attempts, and 30 posi-
tive cures.
Schede, in Pitha and Billroth's " Handbuch der allge-
meinen und speciellen Chirurgie," Zweiten Band, Zweiter
Abtheilung, p. 25, quotes Volkmann as saying he (Volk-
mann) had treated 75 complicated fractures of the large
bones of the extremities conservatively, without a single
death; and Schede himself (vid. ibid.) treated 37 cases
conservatively with only one death, due to delirium
tremens, and fat embolus of the lungs. Volkmann was
obliged to amputate in three of his cases, and Schede in
four of his, for beginning gangrene.
Having settled the fact that an amputation must be
done, the next point to determine is when shall the
operation be done ; that is shall it be done as soon as
practicable after the injury, or shall it be postponed for
several hours ? In my opinion this point should be de-
termined entirely by the condition of the patient when
seen by the surgeon. It seems to me the height of bad
judgment, in this day of aseptic methods, to amputate a
limb when the patient is almost moribund from loss of
blood, or nearly exhausted from a long rough journey,
or not yet recovered from psychical or primary shock.
In short, whenever a patient is almost exhausted for any
reason soon after injury, I have found that a major
amputation undertaken at once is usually followed by
death. I have convinced myself, at least, that the con-
dition ordinarily observed by the surgeon a few hours
after a major injury, and usually called shock, is really a
condition of acute anaemia.1 To operate while a patient
is in this condition, as a rule, is followed by the death
of the patient. If, however, the hemorrhage be thor-
oughly controlled by Esmarch's tourniquet, applied over
the crushed tissues if practicable, and if not practicable,
applied at a point just above them, and the comminuted
tissues and the uninjured parts of the limb thoroughly
cleaned and disinfected, and an antiseptic dressirg
applied over all, the amputation may be deferred for
twenty-four or thirty- six hours, or even longer; while by
1 See Lehigh Valley Medical Magazine, January, 1894.
548
MEDICAL RECORD.
[November 3, 1894
careful feeding and stimulation the patient may recover
some strength, and the blood-vessels shall again have
time to fill with fluid. Of the three cases of hip- joint
amputations I have done for injuries, each patient was
so nearly exsanguinated when the hospital was reached
that no radial pulse, or a bare flutter of a pulse now and
then, could be felt, and the patient seemed actually
moribund. By the treatment suggested above, the ampu-
tation was deferred in two cases for thirty hours, and in
the other case forty hours, and all of them recovered after
the amputation. The former classification of (1) pri-
mary, (2) intermediate, and (3) secondary amputations,
has lost much of its significance. Now intermediate
amputation refers rather to deferred (simply element of
time) operation. The former terrors, suppuration, sep-
ticaemia, and pyaemia, are rare ; so that in my experi-
ence a so-called intermediate amputation is no more
dangerous than a primary one.
If the patient is in good condition I believe the proper
time to operate is immediately, as nothing is usually
gained by waiting.
The next point is, Where shall the amputation be
done ? The former rule and dictum of the authorities, to
operate as far away from the trunk as practicable, has
met with some modification, since the almost universal
use of prothetical apparatus after amputations. It is
generally conceded that it is best to leave as much as
possible in amputating the upper extremity at any point.
With the lower extremity there are certain " points of
selection." In a painstaking and well-written paper
read before the National Association of Railway Sur-
geons in 1 89 1,1 Mr. Truax argues against all tarsal or
medio-tarsal amputations; he gives scant license to
Symes's amputation, and finally selects the junction of
the lower and middle thirds of the leg as the point of se-
lection when an amputation can be done so low down.
As this is the product of long observation and experience
as a manufacturer of prothetic apparatus, the opinion de-
serves some consideration. Mr. Truax argues, however,
from the premises that tarsal amputations are followed,
as a rule, by a condition of pes equinus, on account of
the contraction of the tendo Achillis unantagonized, or
atleast not " balanced/' by the extensors. Furthermore,
he states that the stumps of tarsal or medio-tarsal ampu-
tations are usually painful. Counting the double ampu-
tations, I have had 12 Chopart, and 7 Hay amputa-
tions ; all of these 19 stumps have been painless stumps,
and have generally preserved useful extension. I cannot
admit Mr. Truax's premises, and therefore think his ar-
gument worthless with reference to this point. If the
well-known fact with reference to the bearing of a false
leg be remembered, namely, that the weight does not
come on the end of the stump, but on the sides of the
extremity a little above the end (as an obtuse wedge fits
into a conical cavity), one will not go far astray in
fashioning his stump. If he remembers that the false
limb must owe all its motion to the stump, he will be
convinced that as long an extremity as is necessary for
good leverage should be left whenever practicable. I
quite agree with Mr. Truax that the upper part of the
lower third is the preferable point for amputations of the
leg, when it can be done ; 75 of my amputations of the
leg have been at or near this point. I feel convinced as
much of the thigh as possible ought to be left in ampu-
tating above the knee, but when at all practicable, the
knee-joint amputation, I think, should be employed if
an amputation must be done as high up as the upper
third of the leg. The mortality- rate of amputations at
the several points below the knee are so nearly the same,
that this factor has no practical weight in determining
the point of amputation.
Indeed, my experience corresponds with that of Volk-
mann's and Billroth's clinics, namely, that the danger of
an amputation is not so much the region (the locale of
the operation) as the size of the limb at the point of am-
putation. An amputation through the thigh of a small,
1 See Transactions National Association of Railway Surgeons, 1891.
weazened, dried-up man, whose thigh may be so small
that it can almost be spanned by the fingers of one
hand, is not nearly so much of an operation, nor nearly
so dangerous (the general condition of the patient being
good), as an amputation through the calf of a big, well-
muscled, and well- developed man. I believe, therefore,
that the increased danger of an amputation of an extrem-
ity near the trunk is due chiefly to the fact that the area
of the dissection, the bulk of the severed tissues, is so
much greater there than farther away. The reason of
this is, of course, the larger the limb the greater the
traumatism of the operation, more blood-vessels, more
nerves, and more muscles are cut. Also, the larger the
area of the wound the greater the danger of infection,
and the more difficult is it to make the operation thor-
oughly aseptic, and to make the tissues fit well together
and to drain perfectly.
Method or Technique of Amputation. — The first and
most important point is to establish an aseptic condition
of the limb at and about the point selected for the seat
of operation. This is sometimes an extremely difficult
thing to do, in many instances almost impracticable. In
cases of individuals who are habitually dirty, and who
have been mangled on the railroad, in a mill, or in a
mine, filth, grease, coal, and sometimes soiled clothing,
are fairly ground into the tissues. To make such a
wound surgically clean is impracticable. It is my custom,
in cases of injuries, to have all clothing removed as soon
as the patient is in a condition to bear this, after reach-
ing the hospital. The patient having been carried first
into a reception-room, near the operation-room, but
separated from it by a hall, the assistants begin at once
to cut off all his clothing, and to remove each article
separately in such a way as not to rub against nor into
the lacerated tissues if it can be avoided. The nude pa-
tient is then covered by a clean blanket, and the crushed
extremity, which has been temporarily dressed by the
ambulance surgeon before his arrival at the hospital, is
now inspected and is washed, first with the German
green soap and hot water, then carefully shaved, and
again washed with the soap and water, then rubbed of
with alcohol, and then thoroughly washed and rubbed
with 1 to 1,000 sublimate solution, and then gauze thor-
oughly wet with 1 to 1,000 sublimate solution is pat over
the laceration or wound of whatever kind, and the limb
at the point selected for the amputation also encom-
passed in this wet dressing. Then the patient is taken
on a clean stretcher, with only clean blankets over him,
to the operation-room, and put upon the operation-
table, and covered by a fresh relay of blankets used only
for the operation-room, and those brought in with him
are taken away. All instruments having been previously
arranged and sterilized, the patient is now anaesthetized,
and during this time the operator and assistants carefully
wash, brush, and sterilize their hands and nails. As
soon as the patient is anaesthetized an Esmarch's band is
applied as a tourniquet, the blood being driven back by
raising the extremity for a short time, rarely by the Es-
march band applied from below upward, as this bruises
already injured tissues. Haemostasia accomplished, the
limb is isolated and protected from the other limb and
other surroundings by pure gum tissue and sterilized
towels, and only the seat of operation left uncovered.
The temporary covering is now removed and another
thorough scrubbing of the limb at the seat of operation
is done with alcohol or turpentine, and then with a 1 to
1,000 solution of sublimate. If the patient has been
very dirty and there was a large accumulation of dead
epidermis on the extremity before it was shaved, I be-
lieve with Lister that carbolic acid penetrates the epider-
mis better than sublimate solution, so I commonly use a
five per cent, carbolic solution as well as the sublimate
for a final disinfection. During this last sterilization or
disinfection, the wound is kept sedulously covered and
bandaged by wet sublimate dressings, as it is regarded as
hopelessly infected in most cases, and except the wash-
ing and douching it gets in the reception-room, no for-
November 3, 1894]
MEDICAL RECORD.
549
ther attempt is made to clean it when an amputation is
to be done.
As to the operation itself, there are in my judgment
and practice two cardinal points only to be regarded :
first, the flaps must be long enough and wide enough to
cover the stump thoroughly without tension ; and second,
there must not be any hemorrhage. As a matter of fact,
like most operators, I have learned to have preferences
as to the kinds of flaps to be employed and the manner
of forming them. I cannot absolutely deduce from my
experience, however, that in the ordinary amputation
the methods I employ are better than those used by other
operators. For the upper extremity I almost invariably
use anteroposterior flaps for the forearm, and the cir-
cular or modified circular for the upper arm. For the
shoulder joint I also like anteroposterior flaps, with the
anterior flap about twice as long as the posterior. This
method enables one to tie the brachial vessels before
they are cut without any further inconvenience than a
little care in dissecting the inner edge of the anterior
flap until the vessels are isolated, ligated, and cut through.
It also furnishes good drainage. For the lower extrem-
ity, I have rarely used any osteoplastic method in the
foot For working-men I think these stumps require too
long a time for healing, and are of doubtful utility after-
ward. Hay's, Chopart's, and Symes's are my preferences
in foot amputations. In Chopart's, and in Hay's, indeed,
I have found it of great advantage to leave the extensor
tendons long, and to unite them with the anterior flap.
This results in preventing disagreeable contractions of
the tendo Achilfis, and gives freely movable stumps, in
extension as well as flexion. In the lower third of the
leg, both anteroposterior and lateral flaps have given me
great satisfaction. I believe that Teale's operation is
likely to give trouble by the fact of the long lateral
cicatrix it leaves, which is just in line and at the point for
pressure of a false limb. In later years I have never
used it. I have found the lateral flap method the best for
all the regions of the leg. It gives the best drainage,
least tension, and results in the most useful stumps. At
the knee, and in the lower part of the thigh, long ante-
rior and short posterior flaps I have found best, and nearly
always employ. For hip-joint amputations I would em-
ploy the Dieffenbach Volkmann method when long flaps
could be obtained, and should always tie the femoral
vessels before cutting them. When short flaps are to be
used I believe the method recommended recently by myself l
and called the gradual dissection method, the best. This
is a modification or amplification of Rose's method. It
consists essentially in first forcing the blood up by Es-
march's band, when this is practicable or expedient, else
by elevation ; second, deligation of the femoral vessels by
double ligatures at Poupart's ligament, and incising the
vessels between the ligatures ; third, gradual dissection
of an anterior and posterior flap successively, taking the
utmost care to ligate all known vessels before they are
cut, and always securing immediately all small muscular
branches as soon as they are cut. Exarticulation is per-
formed as in other methods, after hemorrhage is con-
trolled.
I always form my flaps from without inward. I never
transfix. The muscles are cut long enough to unite
over the sawed bone and at different levels — in order to
make a hollow cone — and a periosteal flap is almost in-
variably used when the amputation is through the shaft
of a long bone. The greatest care is used in securing
and ligating all vessels, veins as well as arteries. When-
ever a point persistently oozes after the tourniquet is re-
moved, and torsion, or torsion and pressure, for a short
time does not suffice, this is also ligated. When the
medullary cavity bleeds or oozes it is packed with a
bunch of sterilized catgut, which is covered in by the
periosteal flaps. Catgut is invariably used as ligatures.
Recently I have begun to put in provisional sutures of
silk, with permanent sutures introduced during the an-
1 See Lehigh Valley Medical Magazine, January, 1894, and the
Philadelphia Polyclinic, March 24, 1894.
aesthesia and tied in long loops, and then pack the
stumps with iodoformized gauze for twenty- four hours,
in cases of persistent oozing, as frequently happens after
an Esmarch tourniquet has been on for a long time.
The gauze is removed after twenty-four hours and the
flaps apposed by the sutures already introduced. In these
cases the muscles are always held by the silver-wire
quilled suture, which I almost always employ for this
purpose. Ordinarily, however, the apposition is accom-
plished at once, as follows : If there is good reason to
believe that the wound is aseptic when the operation is
done, no douche is used unless persistent oozing requires
it, then hot sterilized water is employed. The periosteal
flap is brought down and fitted over the end of the bone ;
no suture is necessary, as a rule. Then deep sutures of
silver wire are passed, beginning about five to six centi-
metres from the edge of the flap, through the skin and
muscles of one flap, into those of the other flap and out
through the skin at a point corresponding to its entrance ;
by means of two short quills, in the shape of a small
wooden peg 1.5 ctm. long by 2 or 3 mm. in diameter,
the flaps are brought together and the muscles firmly se-
cured, and their surfaces apposed.1 From two to four of
these quill sutures are necessary for the purpose. Then
interrupted sutures of silk, lastly a continuous catgut or
small silk suture to nicely appose the skin. A small cap-
illary drain of iodoformized gauze is used, for forty-eight
hours. Dressings — dry iodofotmized gauze and dry
sublimated or heat-sterilized gauze. Over all a pad of
absorbent cotton, and the dressing completed by a splint
to hold the extremity quiet and lessen muscular twitchings.
The table on the following page shows the operations
performed, the result, and percentage of mortality. In the
list of single major amputations I have not included ampu-
tations done for purely euthanastic purposes, in cases of
evulsion complicated with other serious injuries, when
the patients arrived at the hospital in moribund and
utterly hopeless conditions. In the list of double and
triple operations, all operations are noted. While in
nearly every case the condition of the patient was des-
perate, yet in none of the multiple operations did the
patient die on the table, and I have thought it but fair
to include all of them. In the double amputations it
has been my custom invariably, in the last few years, to
have my senior assistant amputate one limb while I was
operating on the other. Thus the double amputations
were strictly synchronous. This method saves time, and
markedly lessens the quantity of the anaesthetic necessary
to be given ; this in my judgment is a very important
point. It will be noticed that the multiple operations
are not always all of them amputations. Whenever it
was necessary to do an operation of a gravity equal to
another amputation, I have included it as multiplying
the amputations. The cases mentioned of lacerations
of the scalp, with comminuted limbs, were no ordinary
lacerations, but very extensive, and in themselves very
dangerous wounds, and the operations for their repair
were extensive and more difficult sometimes than the
amputation which accompanied it.
Of the deaths following the single amputations, two
were from septicaemia. One case had septicaemia when
he was admitted, an old-fashioned " intermediate ampu-
tation " was done ; the patient was in an extremely weak
condition when admitted, and he died about five days
after the operation, of exhaustion. The other case was
the one mentioned in speaking of complicated, com-
pound fractures — who persistently refused to have his
leg amputated until he was almost moribund from septi-
caemia.
A third death occurred from croupous pneumonia fif-
teen days after amputation at lower third of thigh, when
the amputation wound was practically well. Besides
these cases but one other case lived longer than two
days; it was an amputation of lower third of thigh,
complicated by crush of the muscles of the other leg ;
it died in nine days, of exhaustion. So that, barring
1 This is a modification of Lister's lead-plate suture.
55°
MEDICAL RECORD.
[November 3, 1894
these four cases, all the deaths occurred from exhaustion
within forty- eight hours after admission.
List of Amputations.
Sijvgle Major Amputations.
ill 1 1H
Amputations of arm 27
Amputations of forearm 37
Amputations of foot, Chopari's 7
Amputations of foot, Hay's a
Amputations of foot, PirogofPs I 1
Amputations of foot, Symes's 9
Amputations of leg, lower third 47
Amputations of leg, middle third 28
Amputations of leg, upper third aa
Amputations of thigh, lower third 1 44
Amputations of thigh, middle third 25
Amputations of thigh, upper third 8
Amputations at hip-joint 7
Amputations at knee-joint 17
Amputations at shoulder- joint 13
Total.
294
Synchronous Double Major Operations. j
Amputation at shoulder-joint, and the other arm, lower third x
Amputation at shoulder-joint, and the other arm, middle third a
Amputation at shoulder-joint, and the other forearm, middle,
third.. ,
Amputation at shoulder-joint, and a leg lower third 1
Amputation at shoulder-joint and operation for compound de-
pressed fracture of the cranium I x
Amputation of both arms x
Amputation oi arm, upper third, and leg, middle third I 1
Amputation of arm, lower third, and forearm, middle third . . ' 1
Amputation of both forearms x
Amputation of both feet, Chopart's 2
Amputation of both feet, Hay's j 3
Amputation of one foot, Chopart's, and other leg. lower third. 1
Amputation of one foot, Symes's, and other leg, lower third .. ] 3
Amputation of both legs 7
Amputation at knee-joint, and other leg, lower third x
Amputation at knee-joint, and other leg, middle third J 1
Amputation at knee-joint, and other thigh, lower third 1
Amputation of one leg, lower third, and exsection of the other)
ankle-joint I 1
Amputation of one leg, lower third, and other thigh, lower
third 3
Amputation of one leg, middle third, and other thigh, lower
third , 2
Amputation of one leg, upper third, and other thigh, lower.
third ' t
Amputation of both thighs, lower third I 3
Amputation of both thighs, middle third 1
Amputation of one thigh, middle third, and all the toes of,
other foot x
Amputation of one thigh, lower third, and > operation for re-|
moving fragments and apposing, and draining of compound
fracture of other leg | x
Total.
Synchronous Triple Operations.
Amputation of thigh, lower third, left arm, lower third, andj
half of right hand
Amputation of thigh, lower third, leg, middle third, arm,
upper third |
Amputation of thigh, lower ihirdj leg, lower third, and dosing
and draining extensive laceration of the scalp
Amputation of thigh, lower third, arm, middle third, and.
closing and draining extensive laceration of scalp
Amputation of thigh, middle third, right foot (Symes's), re-'
moval of fragments, apposition and drainage of compound '
comminuted fracture of right humerus
Amputation of both thighs, middle third, and closing and'
draining extensive laceration of scalp
Total.
Quadruple Operation. i
Amputation of thigh, lower third, leg, middle third, half of1
palm of the hand, and closing and draining extensive lacer-
ations of scalp and forearm I
Total ...
a. ia
o
434
xi. 36
8.00
12.50
14.28
5.88
7-99
4.76
4».8
100
SO
.1 38
I
»3-68
57. H
• Died of cerebritis, produced by the injury to head.
One of the deaths after amputation of both legs was
from delirium tremens, on the fifteenth day, when the
stumps were practically well.
Except one case, a man sixty-five years of age, who
had both legs amputated in the upper third, and who
died of exhaustion on the fifth day, all the fatal cases
were young individuals — all under forty- five years of age,
and three- fourths of them were under thirty years of age.
A search through the records of my cases shows amputa-
tions done on individuals from ten to eighty years of
age, and as stated above, only one of the fatal cases was
past forty-five years of age. Age seems to have played
very little part in contributing to the death-rate. It has
happened that none of my fatal cases belonged to the
feminine gender.
Only one death followed amputation for diseased con-
dition. That was a case of very large periosteal sarco-
ma of the upper part of the femur, which required ampu-
tation at the hip joint. The man refused to have ampu-
tation done until he was almost exhausted. He died on
the third day after the operation, from exhaustion. His
stomach refused to retain any food after the operation,
and in his extremely weak condition rectal alimentation
was not sufficient to support him.
It is shown by the foregoing statistics, that barring
two cases of septicaemia, one of pneumonia, one of cere-
britis, and one of delirium tremens — five altogether — all
the fatal cases resulted from exhaustion following hemor-
rhage, and coincident injuries. The most common
cause was hemorrhage. In order to make this apparent,
and to emphasize the point I wish to make, I must divide
my amputations into two series. These amputations
were done in twelve years. My observation and study
during the first part of this period convinced me that by
far the majority of cases of crushes which were brought
to the hospital were greatly reduced, in many cases mori-
bund, from acute anaemia (from excessive hemorrhage),
and I had been accustomed to operate before any suffi-
cient time was given for the patient to recuperate. I
reasoned, therefore, that if by any arrangement injured
persons could be saved from excessive bleeding, and, in
case of marked acute anaemia, if the operation be post-
poned for a period of hours in order to permit the pa-
tient to recuperate somewhat, results after amputatiors
ought to be better. By far the greater number of in-
jured persons brought to St. Luke's Hospital are trans-
ported over the Lehigh Valley Railroad. I had dis-
tributed along the railroad, at all the stations, on the
wreck-cars, and on ail the principal passenger trains,
cases containing some simple antiseptic dressings, and
especially two Esmarch elastic tourniquets. As surgeon-
in-chief of the railroad, I had issued orders that in every
case of serious injury, first aid, especially the stoppage of
hemorrhage, should be accomplished by means of this
apparatus. After this I also made it a rule to defer op-
erating until a patient had thoroughly " reacted," if he
was in a very weak condition when he arrived at the hos-
pital. Results began at once to be better. The follow-
ing statistics will show how much improvement there
was. The apparatus has been in use, and the deferred
operation method has been employed, during the last
six years. The term of twelve years then ought to be
divided into two periods of six years each. During the
first period of six years there were 114 single major am-
putations and 9 deaths, giving a mortality-rate of 7 89
per cent. There were 9 cases admitted in hopeless con-
ditions. In the last period of six years, during which
the regime has been in operation, there were 180 single
major amputations and 5 deaths — 2.77 per cent, mor-
tality. There were only four hopeless cases admitted.
In the last period there were a larger number of opera-
tions, and the mortality- rate reduced almost one-third.
Again, in the first series, having fewer cases, there were
9 hopeless cases ; in the last series there were only 4
hopeless cases, less than one half.
The double synchronous operations exhibit the differ-
ence in even a greater degree. There were altogether
38 double synchronous operations and 9 deaths, 23.68
per cent, mortality. In the first period there were 13
double operations and 6 deaths, 46.25 per cent, mor-
tality. In the last period there were 25 double opera-
tions and 3 deaths, only 12 per cent, mortality. In the
first period there were two triple synchronous operations,
and both patients died. In the last period there were
5 triple synchronous operations and 2 deaths.
These statistics show 50 per cent, less mortality after
amputations since the regime has been in operation.
The argument seems to me incontrovertible. I urge,
therefore, the saving of blood as the paramount necessity
for recovery after major amputations, and in a line with
this the immense importance of allowing an exsanguin-
ated patient time to recuperate before attempting to am-
putate.
November 3, 1894]
MEDICAL RECORD.
55i
After-treatment and Result with Reference to
Usefulness of Stump. — In forty eight hours, usually, the
stump is redressed for the first time, and the primary
drain or packing is removed. If there bas been oozing,
or serum retained, then the drainage is continued; if
not, all drains are removed and the flaps allowed to come
together. After this a dressing once a week suffices. In
a week the patient is usually out of bed. Of 100 cases
analyzed with reference to this point (all cases for two
and a half years taken), the average number of days in
the hospital after amputation was 22.6.
There was one case of secondary hemorrhage — a dys-
crasic individual ; oozed most extraordinarily in spite of
the greatest care, and finally a ligature gave way and the
stump had to be reopened, clots turned' out, and the ves-
sel, a muscular branch of the popliteal, retied. This
occurred after an amputation at the knee-joint. The
man made a good recovery.
It has been quite impossible to keep track of all cases
operated upon. So far, however, I know of only four
cases requiring re amputation. Three of these were in
young boys, two having amputations through upper part
of the femur and one through upper part of the humerus ;
developed conical stumps, and exsection of the end of
the bone was necessary afterward. The fourth was done
for necrosis developing in a compound fractured humerus
after an amputation had been done lower down. It was
necessary to re- amputate above the fracture. All the
cases, as far as I have been able to find out, were able to
wear false limbs comfortably, except one case of double
amputation. This man's stumps looked typically healthy
and well formed, but he said the constriction of false limbs
caused him so much discomfort that he preferred to go
about without the prothetic assistance. He was quite
comfortable when not wearing the false limbs.
Mortality rate after Amputations. — Aseptic prac-
tice and the saving of blood during operation, have rev-
olutionized the mortality statistics after amputations.
Schede quotes Billroth as having said, with aseptic prac-
tice and Esmarch tourniquet a surgeon should consider
himself at fault if he loses a case of uncomplicated ampu-
tation, if the patient dies after he recovers from the im-
mediate effect of the operation (writer's paraphrase).
In other words, nowadays no patient should die after an
amputation, unless he dies from the immediate traumatic
effect of the injury or operation. I would go further and
say, if a thoroughly bloodless method be pursued, and the
operation be not done during the non tolerant stage of
acute anaemia, statistics after major amputations ought
to be as good as those of abdominal sections, and I be-
lieve they will finally be so.
The following statistics are far from complete, and are
indeed meagre, but they will serve to indicate a compar-
ison of results which I wish to urge in favor of the meth-
ods I have advocated.
Schede l gives 321 uncomplicated cases of amputations
done after the Lister method of operation, and after-treat-
ment by Socin, Volkmann, and himself (Schede), with a
death-rate of 4 4 per cent. Of complicated cases, some
requiring double operations and others having multiple
injuries, there were 24, and n deaths — over forty-four
per cent, mortality.2
Messrp. C. F. Dent and W. C. Bull 3 give the statistics
of St. George's Hospital from October, 1874, to June,
1888, 400 major amputations, and an average mortality
of twenty-one per cent.
Mr. A. E. Barker * performed 50 major amputations at
University College Hospital, from 1876 to 1892 — 29 for
disease and 2 r for injury — with an average mortality-rate
of eight per cent.
Mr. Frederick Page 'gives 687 major amputations per-
formed at the Royal Infirmary, Newcastle* on-Tyne,
from April 1, 1878, to December 31, 1891, including 22
1 Pitha und Billroth : Handbuch der Allgemeinen und speciellen
Chirurgfe, Zweitcr Band, Zweite Abtheilung, p. 338.
* Vide ibid., pp. 240 and 242. a Lancet, June 14, 1890, p. 1303.
* Lancet. January 2, 1893, p. 22.
■ Ibid., March 5, 1892, p. 523.
hip-joint amputations, with general mortality of eight
per cent; 272 amputations for injury, with 12.9 per
cent, mortality; and 415 amputations for disease, with
4.8 percent, mortality.
Dr. A. G. Gerster l gives a collection of 43 cases of
his own, done mostly in hospitals, with a general mor-
tality-rate of 4.65 per cent.
Ashhurst, in the 1893 edition of his " System of Sur-
gery," gives the following statistics :
Major Amputations.
For Diseases. For Injuries.
Mortality, ' Mortality.
French hospitals 42.87 French hospitals 57-98
English hospitals 22.67 English hospitals 40.98
American hospitals. .... 18.60 \ American hospitals 3*-95
Wolfler8 collects 704 uncomplicated amputations done
by v. Bruns, Volkmann, Busch, Esmarch, Hunter, ard
Schede; the general mortality-rate was 15 6 percent.
He gives also v. Bruns's amputations from October, 1878,
. to October, 1880, 47 cases and no deaths. Also, Busch,
1873-1876, 57 cases, with 3.5 per cent, mortality. Bil3-
roth's Klinik, 1877-1880, 68 cases, 5.88 per cent, mo:-
tality.
Oberst ' gives R. Volkmann's amputations at his Klinik
in Halle, from 1874 to 1880. There were 73 uncompli-
cated amputations for injuries, and 10.5 per cent, mor-
tality; 188 amputations for disease, with 3.7 percent,
mortality — a general mortality-rate of 5.3 per cent.
Three hip-joint amputations done for injury, all died; 8
hip-joint amputations done for disease, twenty five per
cent, mortality. There were 8 double amputations ft r
injury, 3 deaths, and 5 double amputations for disease,
no death; 13 cases, and general mortality twenty-three
per cent.
My own statistics show, for the whole number of single
major amputations, 294, with only 19 of them done for
disease, and including seven hip-joint imputations, a
general mortality- rate of 4.76 per cent. This is but a
little higher than Schede's uncomplicated cases. Tak-
ing out the 19 done for disease with 1 death, there
were 275 amputations for injuries and 13 deaths, 4.73
per cent.; and in nearly every case there were multiple
injuries. Taking the last period, however, of six years,
when the cases were exactly of the same character as te-
fore, but when hemorrhage was prevented, and when the
operation was deferred until the condition of acute ar aemia
was somewhat relieved, there were during this period 180
single major amputations and only 5 deaths, or 2.77 per
cent, mortality ; these figures include six hip-joint amputa-
tions. This is the lowest mortality-rate I have ever
seen reported for a series of 180 major amputations.
The multiple operations and extremely complicated
injuries, in 26 cases, resulted in three deaths, 11.5 per
cent mortality. This is a small series of cases — these
last — but the mortality-rate is less than the single opera-
tions in Ashhurst's statistics.
In conclusion, I beg to say these statistics speak far
more impressively and eloquently than I could possibly
do for the saving of blood and the conservation of
strength.
Hospital Patients Poisoned. — An attempt was made
recently to poison the inmates of a hospital in California
by putting strychnine into the coffee. Twenty two
patients were poisoned and one man died. The wife of
the superintendent was taken sick, but her life was saved.
The coffee pot was examined and traces of the poison
were found in it. It is supposed that the work was done
by a Chinaman who had trouble with the steward ard
had been discharged. He had made threats, and it is
supposed that he took this means of venting his malice
on the inmates.
1 Aseptic and Antiseptic Surgery, p. 60.
9 Die Amputationen an Prof. Billroth's Klinik, 1877-1880. Dr. An-
ton WOlfler, 1882.
9 Die Amputationen unter dem Einfl '.sse der antiseptischen Be-
handlung, Dr. M. Oberst, 188a.
552
MEDICAL RECORD.
[November 3, 1894
TUBERCULOSIS OF THE ADRENAL BODIES
UNACCOMPANIED BY BRONZING.
By WARREN COLEMAN, M.D.,
MEW YORK.
INSTRUCTOR IN BACTERIOLOGY AT THE LOOM 18 LABORATORY, j
The value of this case depends upon the extent and
chronicity of the lesion, and upon the fact that adrenal
disease was not suspected during life.
The patient was a Danish sailor, thirty six years of
age. He entered Bellevue from the Chambers Street
Hospital as a case of constipation. Death took place
about three weeks later, without any assignable cause.
During his stay in the hospital, he attracted attention
only as a case of obstinate constipation with marked
inanition. The man spoke English imperfectly, and no
interpreter could be found. Consequently nothing is
known of his previous history, and the history of his last
illness is incomplete.
There was marked asthenia without any apparent rea-
son for it. On one occasion an attempt was made to
get the patient out of bed, but it had to be abandoned
because he complained so much of weakness. There is
no mention of any attendant syncope.
He ran a temperature, but the range was low; it not
rising at any time above ioi° F. The heart- action was
feeble, and the surface of the body generally gave evi-
dence of a poor circulation. The pulse-rate varied from
72 to 88.
The constipation continued, in spite of vigorous treat-
ment, up to the time of his death. There is no record
of an alternating diarrhoea. No vomiting or nausea was
present during his stay in the hospital.
He manifested certain derangements of the nervous
system. The reflexes were much exaggerated ; sensation
was delayed ; and during the last few days of life he be-
came delirious, attempting several times to get out of bed.
At the autopsy the body was found anaemic, but not
much emaciated. The heart weighs nine ounces, and its
walls are pale. The valves are normal. The right lung
is bound to the chest wall by a few old stringy adhesions.
The upper lobs contains several tubercular masses of
considerable size (1.5 ctm. in diameter), in a state of
caseation, while throughout the middle and lower lobes
a few small nodules are found. The pleura is adherent
to the chest-wall over the apex of the left lung, and there
is a large area of tubercular infiltration in the upper lobe
which has undergone caseation. The rest of the upper
lobs is studded with miliary tubercles. The lower lobe
contains a few tubercles in its substance and on the
pleura. The bronchial glands are enlarged and are
cheesy at the centre.
The left adrenal body weighs an ounce and a half.
Its original shape has been lost entirely, it being irregu-
larly oval and somewhat flattened antero-posteriorly.
On section it is found to bs caseous, and a greenish-
yellow pus exude3 from several points on the cut surface.
All trace of medulla or cortex has disappeared. The
cheesy matter has become calcareous at many points.
The capsule of the organ is much thickened. The right
adrenal weighs only one half ounce, and has contracted
down to about one-half the size of the normal gland.
It is similar in shape to the left, and contains one large
calcareous mass with numerous smaller ones scattered
through its substance. Both glands are somewhat
nodulated.
The process, as far as the adrenals are concerned,
began in the right gland.
The other details of the autopsy are unimportant as
regards the present report. Unfortunately, the semi-
lunar ganglia and abdominal sympathetic nerves were
not removed for examination.
Microscopic Examination — The left adrenal only
was submitted to examination, the right being too cal-
careous to permit the cutting of sections. The gland
tissue has been replaced by amorphous masses showing
only the remains of the nodules which originally charac-
terized the process. No trace of a medullary or cortical
cell can be found. In the outer portions of the gland,
immediately under the capsule and between the nodules,
a faint fibrillar structure may be seen with round cells,
many of them dead or abortive, filling the interspaces.
The appearance is distinctly different from a true in-
flammatory process. No giant cells are anywhere pres-
ent, a fact which has been noticed in many cases. The
capsule is much thickened and is the seat of inflamma-
tory foci. The inflammation has extended beyond the
capsule into the adjacent fat. Two moderately large
caseous masses lie in the capsule, and appear entirely dis-
tinct from the inflammatory process. The capsule con-
tains numerous small round cells and young connective-
tissue cells.
The glands were not examined for tubercle bacilli
while fresh, as it was intended to stain for them after-
ward in the sections. The difficulty, however, experi-
enced in cutting the sections thin forced me to resort to
another procedure. I thoroughly scraped the cut sur-
faces of the hardened gland, dissolved the scrapings in a
dilute solution of liquor potassse, fixed the sediment to
slides with the ordinary albumin fixative, and after sev-
eral attempts found the bacilli. Hence there can be no
doubt as to the nature of the process.
The integument and buccal mucous membrane were
carefully examined for evidences of discoloration without
finding any but the normal pigment deposits.
No sufficient cause for death, aside from the condition
of the adrenals, was found at the autopsy.
< It is impossible to fix upon the duration of the illness,
because the history is so incomplete. The Chambers
Street Hospital is merely a reception hospital for medi-
cal cases, so the patient was transferred to Bellevue after
a few days.
The most important conclusion to be drawn from this
case is, that tuberculosis of the adrenal bodies, per se9
though both glands be entirely destroyed, is not produc-
tive of skin discoloration.
According to Wilks,1 " we have no data by which to
determine the time necessary for the deterioration of
the capsules. It is probable that this is very lengthened,
and judging from the cretaceous deposit, it is fair to con-
jecture that the disease is extended over many years."
There can hardly be any question as to the seat of
primary infection in this case. The appearances pre-
sented by the adrenal bodies leave no doubt that they
became involved prior to the lungs or bronchial glands.
Whether the disease in the latter situations was secondary
to that in the adrenals, or whether the infection was pri-
mary from without, is an open question.
I have examined systematically the adrenal bodies in
all the autopsies I have performed at Bellevue Hospital
during the last two years, and this is the first instance in
which I have found them to be tuberculous, though
many of the cases have shown extensive tuberculosis in
other parts of the body.
In conclusion, I wish to express my thanks to Dr. E.
S. Farrington, formerly house physician on the fourth
medical division of Bellevue, and to Dr. F. F. Russell,
his junior, for the kindly interest they took in furnish-
ing me with such facts in the case as were at their dispo-
sal, and the notes of the autopsy.
5 West Thirtieth Street.
A State Medical Law in Idaho. — At the session of the
Idaho State Medical Society, held in September, the
question of a State Board of Examiners was discussed,
and a resolution passed urging the legislature to appoint
such a board during the coming winter. A committee
was appointed to draw up a bill for a medical practice
act, after the model of that in force in Washington. Drs.
Sweet, Watkins, Moore, Maxey, and Fairchild were
nominated to represent the Society upon this board when
created.
» Reynolds's System of Medicine, Article Addison's Disease.
November 3, 1894]
MEDICAL RECORD.
553
TUBERCULOSIS OF THE FRONTAL SINUS.
By J. FRANK, M.D.,
SUXGBON TO THB COOK COUNTY AND ST. ELIZABETH HOSPITALS*
AND
S. KUNZ, M.D.,
CHICAGO, ILL.
Diseases of the frontal sinuses are of interest on account
of their infrequent occurrence. In the past fifteen years
there have been ninety-five cases reported, the analysis
of which will follow.
Family history of the patient: The father, who is
sixty- eight years of age, was not expected to live when
thirty-three, physicians having diagnosed his case as pul-
monary tuberculosis. The mother is fifty-eight years of
age, and in good health. Two brothers ; one of them
mil, the other had, about five years ago, some lung
trouble; diagnosis of same not known. Two cousins
died of tuberculosis.
Patient's history : Twenty-eight years of age, married,
5 feet 8 inches tall, and weighs 160 pounds. Has al-
ways been in fairly good health up to a year ago, when
he began to lose in weight, had severe headaches, last-
ing for a day or two, recurring every week, the intervals
being entirely free from any ill feeling. He continued
in this way for three months, when he complained of the
pressure of his hat across the forehead ; he would fre-
quently tilt his hat back and thereby gain relief. Three
months later he consulted a physician for some growth
on the left side of the forehead, which lasted three
weeks. At about the same time the patient noticed a
swelling in the region of the right frontal sinus, which
caused him incessant pain. Hot fomentations, nasal
douches, and anodynes were given, with no apparent
relief. On the morning of June 16th, the patient no-
ticed that his right eye was partially closed, and the
upper lid was inflamed and painful. Dr. Frank was then
requested to see the patient, who found, in addition to
the above-mentioned facts, that the right eye was pushed
downward to a slight extent ; vision was not impaired.
On outer right side of nose there was a faint blush
creeping gradually toward the inner cantbus, and min-
gling there with the redness of upper lid. The patient
had a temperature of iooj^0 F.; pulse, 96. Kidneys
and heart, negative ; fingers are clubbed. About meatus
urinaris, a tubercular ulcer was found, which healed
promptly upon application of europhen. The lungs on
auscultation revealed vesiculo - bronchial breathing ;
rhinoscopic examination gave negative results. A mild
anodyne was given, and the patient was kept under ob-
servation. Four days later he was again examined, and
in palpating the upper lid a fluctuating mass was discov-
ered in the region of the lachrymal gland. Temperature
was ioo° F.; pulse, 96. Operation was advised, and on
June 26th was performed in the presence of Drs. Verity
and Edmunds, and assisted by Dr. S. Kunz. A curved
incision was made, starting about half an inch to the left
of the glabella, and extending to a point half an inch
posterior to the external angular process, the incision
being made down to the bone and one-fourth of an inch
above the eyebrow. The pericranium was found thick-
ened, the tissues having been pushed back, and the bone
over frontal sinus being roughened. The sinus was
opened with a hammer and chisel, and in the sinus there
was found a yellowish cheesy mass, which was removed
with a sharp spoon. On the posterior wall of the sinus
there was found a focus, which had almost gained access
to the vault. This focus was removed by the sharp
spoon, and a small portion of the dura was all but ex-
posed. At the right lower angle of the sinus, a small
channel was found, which, upon being followed out, led
the way to the fluctuating mass in the upper lid. The
tissues now being pushed over the supraorbital arch, the
fluctuating mass was reached, and was found to be about
one drachm of yellowish pus, coming from the frontal
sinus by means of a small channel on the inner surface
of the frontal bone already described. The supraorbital
arch was found diseased throughout its entire extent ;
four foci were found, which had undergone cheesy de-
generation. The entire arch was chiselled away, the
soft tissues being thoroughly scooped ; the right nasal
cavity was also scooped out through the frontal sinus by
means of a small spoon. The sinus was packed with
iodoform gauze, extending into the right nasal cavity,
and the wound sewed up with interrupted silk sutures.
The wound was entirely healed on the eighth day,
with the exception, of course, of the part immediately
above the sinus. The air sinus lasted to the eighteenth
day, when it also clc«ed up. The patient felt free from
pain from the day of the operation, and his temperature
was normal after the first day of operation.
Anatomy of the Frontal Sinuses. — The frontal bump,
as it is termed, does not exist in childhood, as the tables
of the frontal bone do not separate until after puberty.
Absence of the bump, even in middle age, does not nec-
essarily imply absence of the sinus, since it may be formed
by a retrocession of the inner wall of the skull. An
adult, especially an elderly person, may have a large
frontal sinus, without any external indication of it. . A
very prominent bump does not necessarily imply the ex-
istence of a large sinus, or even a small one. The bump
may be a mere heaping up of bone, a degradation, as is
often found in Australian skulls.
The cavities are larger in men than in women, the
left being commonly the larger. They are lined by mu-
cous membrane, and communicate with the nose by the
infundibulum and occasionally with each other by aper-
tures in their septum.
In the ninety- five cases reported, we find the follow-
ing etiological factors: Mucocele, 24 cases; abscess,
51, 3 of them being double ; fracture, 1 ; foreign body,
1 ; injury, 1 ; exostosis, 1 ; osteoma, 7 ; tumors, 3 ;
cholesteatoma, 1 ; polypi, 2 ; periostitis, 1 ; cyst, 2.
In the cases reported as mucoceles, is it not possible
that some of them at least were of tubercular origin ?
Had the contents of the sinuses been examined for bacilli,
tuberculosis of the frontal sinus would be more often
heard of.
Through the kindness of Dr. T. Gramm, the bone chips
from the arch were examined for bacilli, the cheesy
masses and foci having been accidentally lost ; although
no bacilli were found there seems to be no doubt about
the diagnosis, from the character of the cheesy masses
found in the sinus, from the cheesy foci in the bone,
from the yellowish pus found in the cellular tissue of up-
per eyelid, and from the history of patient.
The various methods of operation are about the same,
with the exception of the drainage, vulcanite rubber or
soft rubber being used oftenest, but where these were
used the air sinus remained for a long time, some even
necessitating a plastic operation for their closure, the
average length of time of duration of air sinus being
about eight weeks.
Literature. Index Mbdicus from 1879 to Date.
Ogston: Med. Chron., pp. 235-238. Manchester, 1884-85.
Kipp : Tr. Am. Ophth. Soc Boston.
Higgens : Lancet, p. 892. London.
Thompson : Northwestern Lancet, p. 286. St. Paul.
BuU : New York Medical Journal, p. 120.
Panas : Revue, de Chir. , v., p. 356. Paris.
Kroger : Wil«.( p. 2a
1886.
Armstrong : New York Medical Journal, p. 95.
Borthen : Arch. f. Ophth., 4th abth., pp. 244-250. Berlin.
Masse : a la Soctete de chirur , p. 113. Paris, 1885.
Bull : Tr. Am Ophth. Soc, xx., p. 243. Boston.
1887.
Middledorf : Aertzl. Zeitschrift, viii., pp. 260-274.
Lucas Champonniere : Soc. de Chir. Paris, 1886.
Magnus : Klin. Monatsblatt Stuttg., xxiv., p. 194.
Jurasz : Berl. Klin. Wochenschrift, pp. 24-36.
1888.
Berger : Schmidt and Klauning, p. 18. Kiel.
Wolff: p. 47. Bonn.
Martin : p. 40. Paris.
1889.
Pitiot : p. 88. Lyon.
Labit : Ann. de la polyclin. de Bordeaux, i., pp. 13-15*
554
MEDICAL RECORD.
[November 3, 1894
Padula : Riv. vineta di sc. mod., xM pp. 70-74. Veneria.
Pizzamiglio : Bull. d. Comit Med. Cremohese, viii., pp. 973-279*
Cremona.
Gross : Mem. Soc. de. Med. de Nancy.
Eliasson : Hygeia, li., p. 285. Stockholm.
Kikuzi: Klin. Chir. Tubing., p. 489.
Seiss : Medical News, pp. 10-ia. Philadelphia.
Herold : p. 30. Wflrrburg.
Weinlechner : Wein. Klin. Wochenschrift, p. 136.
1890.
Boyd : Lancet, p. 607.
Bessel : Hagen, Centralblatt, Leipsic.
Walker: Ophth. Hosp. Report, xii., pp. 351-355. London.
Esauloff : Laitop Khirrurg Obsh. v. Mosk., ix.
Ischunin: Chir. Vestnik, vi., pp. 1-1x3. St Petersburg.
Richards : Journal of the American Medical Association, ziv., 444-
447. Chicago.
Sapejka : Vestnik oftal mol., vi., p. 481. Kieff.
Panas : Mercredi Med. Par., I, p. aai.
Schauz : Cor. bl. d. allg. artel. Ver. v. Thuringen, xbc. Weimar.
189a,
Paris.
Alexias : Compt rend. Soc. de Biol., S. iii.( pp. 703-705.
Prochnow : Gyogyaszat, Budapesth.
Mei : Am. di ottal. xx., pp. 410-420. Pavia.
Lanphear : Times and Reg., xxiv., p. 459. New York and Philadel-
phia.
Nakel : Deutsche Zeitschrift f. Chir., xxxiii, pp. 308-314. Leipsic.
Mories : Nice. Med., xvi., pp. 103-105.
Cross : Ophth. Rev., xi.,pp. 331-431. London.
Schnidler : Arch, de Med. et Pharm. mil. xx., pp. 341-343. Paris.
1893.
Rankin : New York Medical Journal, pp. 575-577-
Bark : Medical Press, p. 636. London.
Browne : Medical Press and Circular, p. 64a London.
Collier : Medical Press and Circular, n.s., pp. 633-634. London.
Deguin : Ann. Soc de Med. de An vers, lxv., p. 184.
Hajek : Wien, vi., pp. 1985-3038.
Winckler : Munchner Med. Wochenschrift, xxxiv. , p. 835.
Valude: Arch. Internal de Larvngol., etc. Paris.
Lichtwitz : Ann. d. mal de l'oreille, etc. Paris.
Watson : London Lancet, L , p. 1061.
Grant : Tr. Brit. Laryn. and Kina. Assoc London and Philadelphia.
Scott : Tr. Brit Laryn. and Rina. Assoc. London and Philadelphia.
Hartmann: GeselL f. Chir., xxi Pt. 3, pp. 402-405. Berlin.
Hoppe : Clin. Monatsblatt f. Augenh. Stuttgart
Di Vincentiess : Med. Chir. di Napoli.
Freche : J. de Med. de Bordeaux.
Beccaria : Ann. di ottal., xxi., pp. 359-364. Pavia.
1894,
Engelmann: Wochenschrift.
Gregor : New York Medical Journal, p. 396.
Ramage : London Lancet, i., p. 599.
Collier: London Lancet, i., p. 304.
CHOLECYSTOTOMY AND CHOLECYSTECTO-
MY FOR STONE IMPACTED IN THE CYS-
TIC DUCT.
By MAURICE H. RICHARDSON, M.D.,
VISITING SURGEON TO THE MASSACHUSETTS GSNEJtAL HOSPITAL; ASSIST AWT
PROFBSSOB OF ANATOMY, HARVARD MEDICAL SCHOOL.
The two following cases seem of sufficient rarity and
interest to be placed on record, for in a somewhat ex-
tensive experience in the surgery of the gall-bladder the
writer has seen only those in which the symptoms de-
pended upon the impaction of a single large stone in
the cystic duct, and in which the diagnosis was so ob-
scure that movable kidney was supposed to be present by
several diagnosticians. In both cases the distended gall-
bladder, which could be felt through the abdominal wall,
was so tense and so movable as to suggest very strongly
a floating kidney. In one case the symptoms were caused
by a large stone, the removal of which, owing to its long
and firm impaction in the cystic duct, was accomplished
only by complete extirpation of the gall-bladder and
cystic duct. In the other the stone was detached, after
prolonged effoits, through the gall-bladder itself. In
both cases a very gratifying recovery followed.
Case I. — Tumor in the right side of the abdomen sug-
gesting movable kidney ; absence of pain and of other
symptoms of biliary obstruction ; tumor found to be di-
lated gall bladder, with large stone impacted in the cystic
duct; cholecystotomy ; cholecystectomy; recovery.
Mrs. W. C , aged thirty- two, was admitted to the
Massachusetts General Hospital on June 9, 1894. She
was brought to me on May 10, 1894, by Dr. Zatae Longs-
dorff-Straw, of Manchester, N. H., with the following his-
tory. Has had five children, the youngest aged three and
a half. She was well up to a year and a half ago, when
slight irregularities in menstruation began. With each
period there was pain and tenderness, suggesting a mild
localized peritonitis. During the past year there have
been three severe attacks of what seemed to be a local-
ized peritonitis with symptoms .referred at one time to
the right, at others to the left hypochondrium. In one
of these attacks there was general distention and tender-
ness. In December, 1883, Dr. Straw discovered a kid-
ney shaped tumor, somewhat movable, in the right side
of the abdomen at the level of the umbilicus. The tu-
mor was supposed to be a movable kidney. No surgical
interference seemed advisable. During the next few
months there was a rapid increase in the size of the tu-
mor ; it grew more tender and more movable, at one
time extending toward the right groin. The idea of a
tubal pregnancy was for a moment entertained. The
mobility was so great that the tumor could be pushed
well over to the left side of the abdomen. No constitu-
tional disturbance complicated the condition, though
there was marked local pain and soreness. There had
been some loss of weight.
I found a small oval, tender, non- fluctuating tumor in
the right side, under the liver, at the normal position of
the gall-bladder. At first it seemed very evidently a
movable kidney. Under prolonged and repeated exam-
inations the fundus of the tumor was found to move in
the arc of a circle about the attachments of the gall-blad-
der.
In this case the question of movable kidney was first
considered. With the patient in dorsal decubitus a
movable tumor could be felt in the right renal region.
It could be grasped between the hands on deep inspira-
tion, slipping upward apparently into the usual position
of the kidney on loosening the digital grasp. The slight
force necessary to retain the tumor between the fingers
caused some complaint of pain. In the erect posture
nothing could be felt. The urine was normal Re-
peated examinations showed that the tumor could be
moved in all directions about the normal position of the
gall-bladder. This kind of mobility, differing materially
from that of a movable kidney, suggested strongly a di-
lated gall-bladder, especially since the other physical
characteristics were not incompatible with the latter con-
dition. The absence of jaundice did not vitiate the diag-
nosis of obstruction to the cystic duct, nor did the nor-
mal urine preclude the possibility of movable kidney.
Perhaps the strongest sign in favor of the gall-bladder as
the seat of the disease was the direction in which the
tumor could be moved. In a slightly movable kidney
the only variation in position that can be detected is the
downward dislocation. If the kidney can be moved into
the epigastrium its downward displacement will be found
excessive. In gall-bladder dilatation, on the contrary,
the fundus will be found no farther from the centre of at-
tachment in one direction than in another. That the
kidney should wander farther in the downward direction
than in the upward is natural, considering the viscera
which hinder upward displacement. In the shape and
size of the tumor, too, there are points of difference,
though they may not be always present. An oval shape,
smooth and uniform walls, absence of hilum, etc., favors
the gall bladder. In spite of every precaution, however,
it will be found at times difficult to distinguish between
the two conditions, and preparations must be made to
meet both at operation.
The diagnosis was made of an obstruction in the cys-
tic duct On opening the abdomen in the right linea
semilunaris, over the tumor, a very large gall bladder,
distended almost to bursting, was found. The contents
were removed by aspiration until the lax and distended
walls of the gall-bladder were easily delivered through
the wound. The cause of the trouble was found to be a
large stone impacted in the cystic duct. The fluid in
the gall-bladder was perfectly colorless, the biliary pig-
ments having been absorbed, as is usual in cases of long-
continued obstruction at the cystic duct with dilatation
of the gall-bladder. With one finger of the right hand
November 3, 1894]
MEDICAL RECORD.
555
in the gall bladder, and with the fingers of the left out-
side the duct, prolonged efforts were made to dislodge
the stone. This proved impossible, however, although
the calculus could be plainly felt both inside and outside.
I was therefore finally obliged to lay open the duct and
to detach the stone through the wound. The roughened
surface of the calculus was so intimately connected with
the changed structures of the duct that it was even then
hard to lift the stone from its bed. It seemed best,
therefore, in view of the great laceration of the parts, to
remove the gall-bladder and duct entirely. This was
done by passing a ligature about the duct just below the
incision through which the stone had been removed. A
small gauze drain was placed next the ligature and the
external wound was closed, except for about an inch.
This patient made a rapid recovery, and was discharged
on July 21, 1894.
Case II. — Paroxysmal pain in the hepatic region, with-
out jaundice, for three years ; tumor ; cholecystotomy ;
removal of great numbers of stones from the gall-blad-
der, with one large stone impacted in the cystic duct ;
drainage; recovery.
Mrs. S. B. M , aged twenty-five, trained nurse for
Dr. Donnel Hughes, of Philadelphia, who was present
at the operation. Examined on July 13, 1894. First
suffered from cramps in the stomach three years ago.
They were transitory and seemed of little importance.
At first the attacks of pain returned at intervals of sev-
eral months, but within the last six they have occurred
frequently — often seven times in two weeks. When
suffering from the pain, which is always located in the
right side, the patient is doubled up; relief has been ob-
tained only by the use of morphine. After the cessation
of this distress or agony there is a transient soreness
which extends into the back. There has never been any
jaundice. The exact region of the gall-bladder was in-
dicated as the seat of pain.
On examination I found on the right side below the
margin of the ribs and opposite the cartilages of the
ninth and tenth, a tumor oval in shape, hard, tense,
unfluctuating, movable, and tender. From physical ex-
amination alone it would have been impossible to dis-
tinguish between a tumor of the gall-bladder and one of
the kidney if it had not been for the two following facts :
first, the presenting rounded extremity of the tumor
moved through the arc of a circle, the base of which was
somewhere near the usual attachments of the cystic duct ;
secondly, the urine was perfectly normal.
The pain, described as transitory and resembling colic,
was quite as suggestive of renal as of cholecystic disease.
The peculiar kind of mobility was not incompatible with
a floating kidney, although it seemed to me more like
die mobility of a dilated gall-bladder than like that of a
movable kidney.
The patient was advised to submit to operation, and
she entered St. Margaret's on July 29, 1894. Under
ether we obtained a much more satisfactory examination,
by which almost all doubts as to the nature of the dis-
ease were dispelled. It was very evident that the tumor
was a gall-bladder and not a kidney.
Assisted by Dr. Brewster, I began the operation by a
small incision at the cartilaginous border of the ninth
rib, along the outer border of the rectus abdominis.
The tumor immediately presented itself in the wound,
with the sharp edge of the great lobe of the liver, and it
proved to be the gall-bladder. Its walls were tense and
very much thickened. The presenting extremity was
sewed into the small abdominal wound, and the gall-
bladder was opened. A large number of gall-stones of
all sizes, with a clear, viscid fluid, were washed out.
The state of distention, with the altered character of the
fluid, made it very evident that there was an impediment
in the cystic duct, though no stone had been removed
large enough to cause so firm and so effective an obstruc-
tion. Nothing could be felt in the cystic duct, with the
finger in the gallbladder. The parts were carefully
dried by means of aseptic gauze, and the stitches by
which the gall-bladder had been attached to the abdom-
inal wound were removed. Explorations with the finger
'in the peritoneal cavity then revealed a large stone deep
down in the cystic, near the common duct. By biman-
ual palpation the stone was slowly and with difficulty
started from its bed and delivered through the gall blad-
der. Very soon after the removal of this stone the col-
ored bile from the gall-bladder showed that the cystic
duct was now patent. The gall- bladder was again
stitched to the wound and drained by means of rubber
tube and sterile gauze.
Though the prognosis seemed almost hopeless to some
of those who were present, the patient made a rapid re-
covery, without a single unfavorable symptom. She was
discharged well in three weeks, and on August 31, 1894,
she wrote as follows: "lam getting along very, very
nicely, and feel better than I have felt for years, and am
gaining every day. I haven't an ache or a pain, and my
side is entirely healed, and there is scarcely any soreness
inside.11
In these cases the diagnosis was interesting. The cor-
rectness depended more upon the situation and the kind
of mobility than upon anything else in the physical ex-
amination or in the history. An interesting point in
connection with these cases is the character of the fluid.
In the first and only previous case in which I had noted
this symptom * the gallbladder contained about a quart
of perfectly colorless, limpid fluid. Whether this fluid is
decolorized bile or simply the accumulation of secretions
from the mucous membrane I am unable to say. In view
of the fact that in most cases of obstruction with jaundice
the bile is thick and dark in color, it would seem that the
presence of such fluid indicates a complete and protracted
shutting off of the gall-bladder from the biliary passages.
At all events, the existence of this symptom is a very
clear indication that there is a complete obstruction in
the cystic duct. With an obstruction in the cystic duct,
however, it does not follow that there is not also an ob-
struction in the common duct. This combination was
illustrated in the case of C. C. R , above referred to,
in which the disease proved to be cancer of the head of
the pancreas extending into the region of the cystic duct,
obstructing the latter as well as the common duct.
In operating upon a distended gall-bladder the subse-
quent manipulations are very much facilitated by aspira-
tion. In both the cases reported it was very hard to feel
the stones or to examine the cystic duct when the tumor
first presented itself. On withdrawing a few ounces of
fluid, the collapsed gall bladder could be brought into
and out of the wound with the greatest facility. The
subsequent manipulations were, therefore, very easy and
simple, even to the ligation of the cystic duct.
These cases, which perhaps in some respects may be
deemed difficult, both as to diagnosis and as to surgical
treatment, recovered without any untoward symptoms.
Operations upon the gall- bladder undertaken when the
patient is in good health, before the obstruction has ex-
tended so as to check the escape of bile through the com-
mon duct, and before the patient's vitality has been im-
paired by prolonged illness, are followed by the most
brilliant and gratifying results. Undertaken for pro-
longed jaundice, however, especially when it is necessary
to remove from the common duct, a stone of the size,
roughness, and fixity of that in Case I., these operations
are inevitably attended by a very considerable mortality.3
As in the removal of the vermiform appendix when there
is neither local nor general peritoneal extravasation the
mortality is practically nothing, so in operations upon
the gall-bladder before the severity of the local condition
requires the more formidable surgical manipulations, and
before the long- continued impactions have resulted in the
presence of pathogenic bacteria and the infection of the
biliary passages, the results are gratifying in the extreme.
» Case I. C. C. R , Boston Medical and Surgical Journal of
April 28, 1893.
• Vide paper by J. W. Elliot in the Boston Medical and Surgical
Journalf
556
MEDICAL RECORD.
[November 3, 1894
The deplorable results in gall-bladder surgery which are
sometimes unjustly placed at the door of the surgeon arise
from our failure to heed the warning of the disease in its
incipiency — in our neglect to remove the source of future
disasters at a time when the procedure may be accom-
plished with very slight danger. Hence it seems to the
surgeon folly, in cases of repeated and persistent biliary
obstruction, to attempt the removal of gall stones by*
medicinal means. Sooner or later in most cases a stone
gets impacted in one place or another. It grows, be-
comes rough, and not easily detachable, and finally, if it
does not cause death by sudden rupture into the peri-
toneum, the grave symptoms to which it gives rise con-
vince even the most conservative of the necessity of an
operation — an operation which then must be done under
the most unfavorable conditions, and with a prognosis
infinitely graver than in the early days of the disease.
EPILEPSY— AT TIMES A BLADDER REFLEX.1
By HUGH K. AIKEN, M.D.,
LAUMpS, S. C»
If you consult any work upon the subject of the " Causes
of Epilepsy" the first statement you meet will be that
heredity plays the most important part as a predisposing
cause. Then follows the well-authenticated fact that
peripheral irritation of various kinds will inaugurate and
keep up the paroxysms. There is also a group of what
we may call central or systemic causes producing the
epilepsy that follows diphtheria, scarlet fever, malaria,
tertiary syphilis, strong mental impressions, as excessive
joy, grief, or anger. All these factors and others have by
trustworthy observers been reported as first producing
the disease. But most interesting of all the foregoing
is the study of those cases in which epilepsy stands out
clearly as a reflex, and while cases the result of reflex ir-
ritation from several organs have been recorded, the
writer has never seen attention called to this particular
reflex as a causative agent of any importance. The few
cases to be cited would at least seem to prove that some-
times, when otherwise unable to account for the seizures,
investigation in this locality might be successful and
thus some light be shed upon what would else remain
obscure.
There may be some who will regard as superfluous any
further contribution to the literature of a disease of whose
symptomatology we already know so much and whose
etiology is so varied. But our treatment remains pain-
fully deficient. The criticism of such readers reduced to
few words is always " If you have not some new remedy
to offer us, be silent'1 Such critics overlook the fact
that the mastery of etiology is the first step to satisfac-
tory therapy. Finding the cause and removing it is the
ideal of scientific practice.
Reading a journal article recently on "Suprapubic
Cystotomy," I was struck by the following, which I will
call
Case I.—" A. M. W , aged twenty, one. Ten
years ago this patient was suddenly attacked with an ur-
gent desire to urinate, which he could not explain. This
irritation has persisted ever since. Three years after the
onset of this attack he became subject to epileptic seiz-
ures, which would occur about once a month and in
some manner seemed to be associated with his vesical
trouble. . . . Since the latter has been relieved the
convulsions have ceased."
This extract reminded me of a personal experience
which constitutes
Case II. — Miss E. C , aged thirty-eight, had been
ill eighteen days with typhoid fever. I had, in a per-
functory manner, been examining the bladder daily and
never found it distended. In the middle of the night I
was hastily summoned, and informed that my patient
was having convulsions. She had two after I reached
her. Briefly described they were as follows : Coincident
1 Read before the Laurens County Medical Society, July 34; 1894.
with a momentary loss of consciousness a wave of mus-
cular spasm would pass over her, and then in an anxious
tone she would ask, " Doctor, what is the matter with
me ? " I was puzzled. Groping about to find a cause,
I felt over the bladder region and found the organ fulL
The catheter was used at once. She had no more con*
vulsions, nor has she had any since. No antispasmodics
were given.
What were these epileptic explosions if not the result
of irritation of the hypogastric or sacral plexus ?
Case III. — Muscroft reports a case of stone in the
bladder which gave rise to epilepsy and a cure followed
its removal.1
If phymosis causes infantile paralysis, may not irrita-
tion of the vesical nerves give rise to epileptic seizures?
I do not lay claim to any great discovery in connection
with the cause of epilepsy, and only record my limited
observations as a working hypothesis by means of which
something more valuable may perhaps be brought out.
The modesty and diffidence with which I would advance
this view will, I hope, save me from the rapacity 01J
those fierce critics who delight to prick each little bal-
loon labelled " Theory " just to see the gas escape.
If occasionally epilepsy be due to irritation about the
bladder, this fact should be borne in mind, and this is
all I wofild insist upon. I feel ashamed of our boasted
advances in therapeutics every time a case applies for
treatment. Every unrelieved sufferer from this disease is
a reproach to our profession, and if we are ever to cure
the morbid condition the energies wasted in the search
for some new compound that will act as a specific must
be diverted and applied to finding the cause at work in
each case as it comes to us. In long-standing cases the
best I have ever been able to do is to lessen the severity
and decrease the frequency of the attacks by the use of
sodium bromide, and while this is given in the smallest
dose that will accomplish the purpose, even then I am
deranging my patient's stomach and impoverishing his
blood by the forced ingestion of an excess of alkali.
Trephining has not achieved the results at first ex-
pected from it. The cicatricial mementos of youthful
exploits have been carefully excised and buttons of bone
removed. At first, he who was before " possessed of a
devil " went his way and perhaps sinned no more, but
after one or two years the insidious petit mal returned.
Some hold that an operation of any sort upon an
epileptic produces a temporary improvement in his
disease. Tincture of horse-nettle will do very well to
sell at three dollars per pint, as an enterprising (?) practi-
tioner in Indiana advises me he is willing to do, but I
have never seen any considerable number of cures to its
credit. The profession would, no doubt, appreciate any
further evidence in its favor from Dr. Napier, of Blen-
heim, S. C, who first called attention to this agent as a
remedy. We are all too prone to prescribe a palliative
and dismiss these unfortunates with the reflection that it is
a case of idiopathic epilepsy and beyond the reach of cura-
tive effort. If we would associate the ideas of irritation
and epilepsy, and search diligently for a cause in every
case, removing it, where possible, the number of idio-
pathic and inexplicable cases of epilepsy would be re-
duced. There is irritation somewhere and somehow-
brought about but not always connected with a scar.
Having seen the explosion, work back, following the fuse
until we reach its beginning. There sit and watch until
you see what it is that applies the spark, reasoning back-
ward from effect to cause.
Dr. Bathianadhan, the first and only native woman
novelist in India, died recently at the age of thirty-one.
Her parents were Marathi Brahmans ; she herself was a
Christian and the first woman to study medicine at the
University of Madras. Her first book was entitled
"Saguna," a picture of a high-caste girl's home life;
another, called "Kamala," has just been published.
1 Wood's Reference Handbook, vol. it, p. 706.
November 3, 1894]
MEDICAL RECORD.
557
THE MANAGEMENT OF VALVULAR HEART
DISEASE, WITH PARTICULAR REFERENCE
TO THE USE OF STRYCHNINE.
BV L. HARRISON METTLER, AM., M.D.,
CHICAGO, ILL.
Valvular diseases of the heart all require about the same
line of treatment. So long as compensation is complete
and the accompanying hypertrophy or dilatation does
not give rise to any very marked secondary symptoms,
medicines should be withheld entirely, and none but
general instructions given in regard to rest, diet, and
hygiene. I do not deem it wise, as some authors do, to
inform the patient, at this stage of his trouble, of the
seriousness of his condition. The effect is apt to be de-
pressing, and therefore deleterious, whereas no immediate
benefit is to be obtained. From the treatment and in-
structions given he will soon enough suspect the nature
of his malady, and the hope born of uncertainty will in-
duce him to follow directions more closely than the de-
spair awakened by a gloomy prognosis. I make it a
rule always to inform the family. If, at the solicitation
of the family and the patient himself, I am obliged to tell
him the real state of his condition, I do so most guard-
edly, making the prognosis as reasonably hopeful as
possible, but not belittling in one iota the nature of the
cardiac lesion. Only in this way is confidence estab-
lished, and in certain cases a foundation laid for the
proper observance of the treatment deemed necessary.
Of the first importance is rest. Nothing so recuper-
ates a tired heart as absolute rest. This does not mean
merely to lie down whenever the feeling of exhaustion is
experienced, but to keep regular hours in regard to ris-
ing and retiring; to regulate the daily exercise so that it
falls short of producing weariness; to adopt the proper
kind as well as amount of exercise; and to furnish
the mind with congenial entertainment. A man may
declare that he gets abundant exercise by walking in the
open air all day in connection with his business. There
is neither pleasure nor variety in that sort. An hour's
stroll over the rolling ground of a park in company with
a congenial friend, with mind free from business cares,
will do more than a day of the former kind of exercise.
Gymnasia are to be very cautiously recommended, for
they are frequently badly ventilated, and competition
with the other attendants is liable to lead to over-exer-
tion. Any form of out-door sport may be approved of
so long as no sudden or violent movements are required
by it. The stomach must never be overloaded, and the
nutrition must be kept at its maximum ; hence frequent
small meals rather than heavy dinners are to be com-
mended. Fats, sugars, and succulent vegetables are to
be indulged in very sparingly. The nitrogeneous, albu-
minous foods are the best. As a rule, I find that patients
do better when they take as little fluid into the system as
possible, and abstain entirely from all kinds of stimulat-
ing drinks. The following case illustrates the benefit
derived from the observance of general treatment alone :
Case I. Mitral Regurgitation — J. P , boy, twelve
and a half years of age. Family history excellent. Has
had none of the severe diseases to which all children are
liable. Three years before he first came to me, June 24,
1893, he had his first attack of acute inflammatory rheu-
matism. The ankles, wrists, and other joints were suc-
cessively swollen, painful, and immovable. The mother
says she treated the child herself, chiefly with external
applications. Every succeeding winter he seems to have
had similar attacks, in some ofwhich medical attendance
was engaged. Immediately after his first attack his
heart began to trouble him. At any time, most fre-
quently at night, so as to arouse him out of his sleep, he
will experience a sharp, intolerable, lancinating pain
about the region of the heart, but never down the left arm.
Sometimes this pain lasts half an hour, disappearing as sud-
denly as it comes. At the same time pains start up all
over the body, chiefly in the neighborhood of the joints.
These pains are of an aching character. The heart then
beats laboriously and violently, so that he feels as though
" it would beat out of his body entirely." He suffers
continuously from a slight headache. For the last three
years he has not been able to lie on his left side without
bringing on an attack of cardiac pain and shortness of
breath. There seems to be no dyspnoea under other cir-
cumstances. Respiration and digestion are as yet unaf-
fected. Appetite is ravenous and bowels move regularly.
Micturition is normal. Urine is pale yellow, feebly acid,
specific gravity 1. 028, with an excess of urates and earthy
phosphates, no albumin, no sugar. The pendent parts
of the body, such as the lower abdomen, are slightly ery-
thematous. Passing the finger-nail firmly over the skin
produces a white streak which slowly disappears before
the returning redness. The feet are at all times slightly
swollen and cyanosed. When the hands are allowed to
hang down for sometime they also become slightly swol-
len and congested. Hearing and eyesight are good, and
there is no congestion of the conjunctivae. He is very
regular in all his habits, but has been indulging in violent
exercise, such as base-ball, and drinking freely of tea and
coffee. By a former physician his family was told that
"something was growing over the heart.'1 Upon in-
spection I found the left side of the chest decidedly larger
than the right, and the intercostal spaces less distinctly
marked. The area of cardiac dulness was considerably
increased and the apex-beat of the heart remarkably pro-
nounced. One could see it thumping against the tho-
racic wall like a caged creature striving to get free.
Palpation revealed an irregularly acting, throbbing,
violently beating heart. The pulsations were jerky and
apparently performed with much effort. Upon careful
auscultation I could distinguish nothing abnormal in the
action of the tricuspid and semilunar valves, but the
sound of the mitral valve, heard most distinctly near the
apex of the heart, consisted of a coarse, grating, troubled
murmur. It resembled a churning noise occurring syn-
chronously with each systole. The second sound of the
heart was sufficiently accentuated. The radial, femoral,
and temporal pulse were all feeble and irregular. It
would have been an unnecessary cruelty to have told this
young lad the real state of his condition and its probable
termination, though the parents were fully advised of
the same. He was a sensible boy, and having won his
confidence I had no difficulty in getting him to follow
my instructions. As soon as he began to moderate his
exercise, to study and lead a more sedentary life, to
avoid all stimulants absolutely, and to live upon a plain,
nutritious, dry diet, the cardiac pain diminished and left
him almost entirely, the heart's action became steadier,
and he lost his former expression of distress and anxiety.
No medicines whatever were given, and up to the last
time I saw him he was still doing well.
When, as a result of beginning failure of the compen-
satory hypertrophy of the heart with over-dilatation, at-
tacks of dyspnoea and vertigo become troublesome, and
other secondary symptoms begin to make their appear-
ance, I find that strychnine in small and frequent doses
steadies the heart's action in the happiest manner. The
appropriate general tonic treatment with iron, arsenic,
and vegetable bitters must not be neglected, but used in
conjunction with the strychnine. Sometimes I have
seen the strychnine assisted most materially by the so-
called heart tonics, such as digitalis, strophanthus, and
convallaria. The following case, kindly referred to me
by Dr. Henry M. Lyman, illustrates what has just been
said:
Case II. Mitral Regurgitation. — Mrs. S. D ,
aged about fifty- seven; mother of several living chil-
dren. Family history good. Prior to marriage and in
early life health was excellent. Never had any pro-
longed severe illness, but has suffered a number of at-
tacks of acute and subacute rheumatism. At present
there is general weakness, precordial distress, nervous
irritability, and some emaciation. Patient suspects
heart trouble, but has never been told (fortunately, I be-
lieve) the seriousness of her condition. There is a
558
MEDICAL RECORD.
[November 3, 1894
slight cough with occasional attacks of dyspnoea. Di-
gestion is troublesome ; tongue clean and red ; bowels
irregular. There is a constant tendency to diarrhoea.
Constipation sometimes causes much distress. Vertigo
with slight headache is not uncommon. The liver is
enlarged and jaundice occasionally makes its appearance.
The action of the kidneys is as yet but little affected.
The hypostatic condition of the lungs produces shortness
of breath and favors attacks of capillary bronchitis. Of
these attacks she has now had several. The last while
under my care, and from which she is now convalescing,
was the severest she ever experienced. The cough was
incessant, hard, and racking. Fever was high; pulse
small and rapid. There was pain in the chest, extreme
shortness of breath, and loud rales heard both anterior-
ly and posteriorly. Complete heart failure seemed im-
• minent a number of times, a disaster which was only
averted by the free use of hot poulticing and stimulation,
together with the administration of such cardiac tonics
as ammonia, digitalis, strophanthus, and convallaria.
For the happy outcome of this attack not a little credit
is due a good, careful nurse. The patient suffers occa-
sionally from hysterical melancholia, for which the vale-
rianate of ammonia is given. When convalescence be-
gan, the patient having been several weeks in bed with
the present attack, I began using the tincture of nux
vomica, but soon changed to strychnine and general
ferruginous tonics. Almost immediately the improve-
ment became pronounced and rapid. The cough dimin-
ished, the pulse grew stronger, the heart beat more
steadily, the nervous excitement and distress were great-
ly allayed, and the appetite and digestion increased.
Only small doses of the strychnine were employed, such
43 -gV to *V grain three or four times a day. Soon I dis-
pensed entirely with the digitalis, strophanthus, and con-
vallaria, and depended upon the strychnine alone.
When the patient began to go about the house she was
advised to take maltine, with strychnine, quinine, and
iron, which has continued to act as a most efficient tonic.
She is now able to attend to her household duties, and is
as well as could be expected with her heart trouble.
Having tried many remedies and travelled both in Eu-
rope and California in search of health, she is naturally
overjoyed at having found something that gives her
greater comfort than she had yet experienced. She has
gained somewhat in weight, is less nervous, and, as her
friends tell her, looks better. I attribute the result
chiefly to the strychnine, as I have seen it act similarly in
other cases. Of course all these heart cases sooner or
later fail to respond to any medicine or plan of treat-
ment ; the end is then close at hand.
In the text-books and general literature I find very
little reference made to the use of nux vomica and its
alkaloid in valvular disease of the heart. In view of my
own experience with it, acquired during the last three
years, I am not a little surprised at this. Digitalis is
still the remedy par excellence, when the heart flags so as
to produce alarming dyspnoea and beginning dropsy;
but all authorities agree that this remedy should be
withdrawn as soon as its beneficial effects have been se-
cured. Even strophanthus must be discontinued after
a time, though its administration may be continued
longer than that of digitalis. It is singular that author-
ities do not recommend the use of nux vomica and its
alkaloid at this stage of the treatment, when the heart,
having regained its tone under the influence of the digi-
talis or strophanthus, is so liable to relapse unless sup-
ported by a steady and gentle stimulant. Flint says
that " nux vomica or strychnia appears, either directly or
indirectly, to have a tonic influence upon the heart/'
and there he dismisses the subject.
Loomis, writing upon mitral reflux in Pepper's " Sys-
tem of Medicine," asserts that "small doses of quinine
and strychnine, alternating with the administration of
iron, are often of service." Bartholow suggests the use
of nux vomica merely for its stomachic effect. Fagge, as
well as many other authors, does not even mention it as a
heart tonic. As most of these patients are anaemic and
debilitated, every remedy that will strengthen the gen-
eral system and improve the nutrition will have a most
beneficial effect upon the heart. There is universal
agreement, therefore, that chalybeates and stomachics
are always useful. As digitalis disturbs the stomach and
interferes with digestion, it is evident that it should be
avoided as much as possible. A steady, continuous sup-
port afforded the heart and its nutrition, is far more de-
sirable than the use of "digitalis and active hydragogue
purgation repeated from time to time.1' In regard to
this all clinicians are of one mind ; but there seems to be
a lack of opinion in regard to strychnine as a direct
heart tonic and stimulant favorable in these cases.
Other things being equal, the nutrition of the heart is
better conserved by a steady, continuous, gentle stimula-
tion, such as is afforded by small doses of strychnine, than
by an occasional powerful propulsion produced by digi-
talis and its congeners. The former better favors the
nutrition of the heart muscle, while the latter, prolonging
the diastole, only occasionally gives the heart-muscle a
rest. There can scarcely be any doubt about nux vom-
ica and its alkaloid being a heart tonic. In the words
of Bartholow, " increased action of the heart has been
experimentally demonstrated to be caused by strych-
nine. " It has been proved that in large doses strych-
nine prolongs the diastolic pause and augments the force
of the systole, and that these results are due to an action
on the cardiac ganglia and on the pneumogastric The
blood-pressure and rapidity of the blood- current are in-
creased by contraction of the arterioles. In overdose
the heart is arrested in tetanic rigidity. These effects
are all similar to those produced by digitalis. The latter,
however, is not a general tonic, but rather the reverse,
whereas nux vomica in small doses may be administered
a long time with the happiest results to both the heart
and general nutrition.
Though far advanced toward a fatal issue, the com.
pensation having long been ruptured, the following case
illustrated up to the very moment of death the benefit
derived from the use of nux vomica.
Case III. Mitral Regurgitation.— H. G. T , aged
sixty-six, married, two children living, and one dead of
pulmonary tuberculosis. Family history neurotic and
tuberculous. Patient was much exposed to hardship
during service in the Mexican War. Denied specific
disease. Up to the time he entered the army his health
was excellent. Twice during campaigns he suffered se-
vere attacks of rheumatism, chiefly in the arms. On ac-
count of exposure and the intense heat, he .was several
times returned to the hospital with severe diarrhoea.
His bowels have been weak ever since. Later on he was
unsuccessfully operated on for external bleeding piles. He
is now troubled with costiveness. When he first consulted
me, January, 1893, he was suffering from a great deal of
headache and vertigo. When he arose in the morning
his sight was blurred. He had frequent attacks of nau-
sea with a desire to vomit. Digestion has always been
bad. Has never used tobacco or stimulants of any sort.
There was a constant hard cough and much difficulty
with breathing. There was no pain, but a good deal of
precordial distress. He said he felt as though his lungs
were "filled up; " had no appetite whatever, and felt
exceedingly weak. He was obliged to sit up most of the
night to feel at all comfortable. Micturition was diffi-
cult, but not so bad as six or seven years ago, when he
had to catheterize himself. The patient was pale and
emaciated. There was no swelling of the arms and legs,
though the abdomen was slightly enlarged. Dropsy had
not shown itself yet to any very marked extent. The liver
was enlarged, the lungs congested, the conjunctivae
red. Eyesight and hearing were good. The scrotum
was slightly enlarged with hydrocele. Upon inspection
and palpation the apex-beat of the heart was violent and
lower than usual, while the area of cardiac dulness much
increased. With the ear over the cardiac apex, could
be heard a loud, rough, grating sound. At none of the
November 3, 1894]
MEDICAL RECORD.
559
valves except the mitral, could I distinguish a murmur.
The mitral murmur, however, was pronounced and asso-
ciated with systole. The second sound of the heart was
feebly audible, though not sharp. The pulsations were
irregular, tumultuous, and labored. The radial pulse
was the same in both arms, though markedly irregular,
like that of the heart. Examination of the urine revealed
nothing abnormal, but a trace of albumin. The pres-
ent attack began two weeks prior to my first visit, and
had come on very gradually. About ten years ago the
patient fell suddenly to the floor in an unconscious state,
and was thereafter confined to his bed for a month. A
year later he had a severe attack of vertigo without un-
consciousness, which also caused him to fall. On account
of his heart trouble he was unable to attend to his busi-
ness for the last few years. He was thoroughly ac-
quainted with the seriousness of his condition, so that, in
spite of a certain degree of obstinacy and nervous irrita-
bility which gave rise to more or less impatience, I
succeeded very well in getting him to follow instructions.
Absolute rest and a light dry diet were enjoined, while
hydragogue cathartics, digitalis, and chalybeate tonics
were administered pro re nata. In a couple of weeks he
was relieved of many of his symptoms ; could lie down
and sleep through the entire night ; and was able to go
out and take a little exercise each day. As soon as I
withdrew the digitalis, I replaced it with the tincture of
nux vomica or strychnine, to the well- expressed comfort
and satisfaction of the patient. Thus he was treated for
more than a year, coming every now and then to my
office for advice, and doing as well as could be expected.
He declared that he believed it was the nux vomica
that helped him more than anything else. '
Several weeks ago I was hurriedly sent for, and found
the patient in bed with a return of all the old distressing
symptoms. I had not seen him for a few weeks prior to
this attack, and was* therefore surprised to note the dis-
tressing cough, marked weakness, anasarca of the lower
extremities, and the presence of small ulcers in the
mouth. The state of the patient was indeed serious, and
I so informed the family. The usual treatment with
cathartics, digitalis, strophanthus, and convallaria was
instituted, but with only slight and temporary benefit.
It was clear that the man had taken to his bed now for
the last time. In spite of every effort he soon became
water-logged, and died quietly in a semi conscious con-
dition on the morning of April 26, 1894. Up to the
moment of his death he begged for, and was given, fre-
quent small doses of tincture of nux vomica, as that gave
him the most comfort. The widow afterward informed
me that, in spite of all entreaties on the part of his family
and friends, he had gone to one of the advertising dis-
pensaries of this city, where they promise cures for
monthly payments ; almost immediately he began to foil,
so that he had to take to his bed and send for me a
couple of weeks before his death. Death is liable to
occur at any time in valvular disease of the heart, but I
believe this man's life might have been prolonged a while
longer if he had not suddenly broken off, for a much-
promising advertised treatment, one which was helping
him but not doing it as rapidly as his impatience could
endure. While under my care the patient had to resort
less frequently to digitalis than he otherwise would
had he not taken the continuous small doses of nux
vomica which had been ordered him.
My notes record a number of other cases in private
practice in which nux vomica and its alkaloid in small
doses gave great satisfaction. As a stomachic tonic, a
respiratory stimulant, and heart tonic, it fulfils three of
the most important requirements in the treatment of
valvular heart disease. Under the head of treatment
of senile heart, Balfour lauds strychnine as a " most
valuable remedy, especially when venous congestion and
a tendency to catarrh exist, as is so constantly the case
when the circulation is feeble. In a great many cases,
even of well-marked senile irregularity, the continuous
use of strychnine is sufficient of itself to promote a cure,
while it is a powerful adjuvant to digitalis; and the
combination of these two drugs often enables the most
admirable results to be obtained, quite unattainable by
either separately. ' '
What Balfour finds true of the use of strychnine in
senile heart, I have found almost equally true in cardiac
valvular disease. The prolonged use of digitalis and
strophanthus has its disadvantages. The former is sup-
posed to have a cumulative action and certainly disar-
ranges the digestion ; the latter is not always effective in
relieving the dyspnoea, and is powerless in preventing or
removing oedema. Nothnagel says that in a few cases
convallaria and adonis vernalis do very well, but that
as a rule the so called substitutes for digitalis are of
little use. Caffeine is more of a diuretic than a car-
diac tonic, and therefore cannot be relied upon alone.
Coronilla is slow in its action and is not always
certain. One feature of the Oertel treatment I have
found of inestimable value in this class of cases, and that
is the rigid adoption of a dry diet. In two or three
cases a withdrawal of fluid from the diet, as much as could
be borne, produced in a short time a noticeable improve-
ment in the dyspnoea and pain. I have allowed milk in
small amounts as the only beverage, varying it with
kumyss, matzoon, and buttermilk. Remembering the
overburdened condition of the circulation, with the at-
tendant dropsy and defective renal function, the use of
a dry diet seems to me eminently rational.
In conclusion, my best results in the management of
cases of valvular heart disease have been obtained by the
following outlined treatment: Physical rest, associated
with light, regular, pleasurable exercise ; absence of all
worry, mental anxiety, and sudden emotion ; plain abun-
dant, nutritious diet, dry as possible ; absolute avoidance
of all stimulants; the use of general tonics and hydro-
pathic measures conducive to the building up of the gen-
eral constitution. For the heart, the continuous use of
small doses of nux vomica or its alkaloid, reserving the
more powerful heart stimulants like digitalis for threat-
ened dropsy. In two of my cases I obtained better re-
sults from the combination of digitalis, strophanthus,
and convallaria than from either alone. In others I
have found that either of these special heart tonics alone
produced the greatest comfort when assisted by minute
doses of strychnine. I believe it is bad treatment to
use larger doses of any drug than is absolutely necessary,
and ofttimes three to five drops of digitalis with yfo or
■fa grain of strychnine will act better than the larger
doses of either alone. The use of strychnine alone is, in
the majority of these cases, the best for prolonged treat-
ment. I have said but little of the management of such
special symptoms as dropsy, dyspepsia, etc. ; for these,
of course, will require special treatment as they arise.
They will present themselves less frequently, however,
the more the general health is built up and the action
of the heart strengthened and steadied.
Columbus Memorial Building.
The Price of a Physician. — Under the Roman Empire
the prices paid for slaves were ruled, as prices always are,
by the relations of supply and demand, the capture of a
province being followed by a glut in the market, and a
consequent fall in value. The value of an ordinary slave
without special accomplishments, fluctuated between five
and eighty dollars, but that of a physician remained nearly
constant, for a long period, at the very respectable figure
of $ 10,000.
Tuberculosis in Domestic Pets.— Dr. Foehner, of
Berlin, has examined some seventy thousand sick domes-
tic animals in the past seven years, and of this number
only two hundred and eighty- one suffered from tubercu-
losis. The parrots were relatively the most frequently
affected, twenty- five per cent, of those coming under his
care being tuberculous. Of the cats, only one per cent,
showed symptoms of the disease.
5<5o
MEDICAL RECORD.
[November 3, 1894
Medical Record:
A Weekly Journal of Medicine and Surgery.
GEORGE F. SHRADY, A.M., M.D., Editor.
Publishers
WM. WOOD & CO., 43, 45, & 47 East Tenth Street.
New York, November 3, 1894.
ANAESTHESIA BY ETHYL BROMIDE AND
CHLOROFORM.
Dr. W. S. Magill, of Chicago, describes a new and rapid
method of anaesthesia by bromide of ethyl and chloro-
form {International Medical Magazine). The procedure
is as follows :
" Everything being in readiness for the operation — in-
struments in order, the surgeon and aids prepared for im-
mediate action (for the patient will be ready in about one
minute if anaesthesia is performed on the operating-table)
— draw out all pillows from under the patient's head.
Note pulse and respiration, and the time exactly. Open-
ing the bottle of ethyl-bromide, pour a few drops upon
the folded towel and pass it oyer the nose of the patient to
accustom him to the odor. Immediately, upon the upper
side of the towel, pour out about three grammes of the re-
agent, and, rapidly reversing the towel, apply it closely to
the nose and mouth, so that every inhalation may be
taken through its meshes. For a moment the patient
holds the breath, perhaps making a slight effort to pull
away the towel, at the same time swallowing in rapid
succession the saliva which is secreted abundantly. In
an instant a long inhalation is made, followed by others,
especially if so commanded in a decisive voice by the an-
aesthetizer, the face becomes red, sometimes violently con-
gested, the eyes fixed, the eyelids frequently difficult to
raise with the ringer, the lines of the face are drawn, the
under jaw firmly set, and a general muscular contrac-
tion of short duration may be manifested. After three
or four long inhalations the patient has lost all sense of
pain or touch, but is still conscious. This is the moment
for operation, if ethyl-bromide alone is used. A few
grammes again poured on the towel and inhaled result
in complete unconsciousness, if not already obtained,
with the first dose. Time, one-half to one minute and a
half; pulse, rapid and strong ; respiration, deep, and of
about normal rapidity.
" At this moment pour out upon another folded towel
about ten drops of chloroform, throw aside the ethyl-
bromide, and immediately apply the chloroform towel in
the same way. Watch carefully the pulse and respiration.
At this time the operation should commence if the patient
be already on the operating-table.
" The iris should be carefully watched. At the com-
mencement of the ethyl-bromide administration, from
normal contraction the iris dilates the pupil by its relaxa-
tion. The dilatation is rapid, and at the moment of
analgesia reaches the maximum, and alone indicates the
instant to change the reagent. The dose of chloroform
indicated above is the first and only strong one ; the an-
aesthesia must be maintained by pouring frequently one,
two, or three drops of chloroform upon the towel, which
is immediately reversed and applied over the nose and
mouth, taking care that the patient has no chance of in-
halation during the change."
Dr. Magill finds records of sixteen alleged cases of death
from the administration of bromide of ethyl. Six of
these he finds were really caused by bromide of ethylene,
and of the other ten he finds that only one can be fairly
attributable to the ethyl. He adds :
" The practical advantages of successive anaesthesia—
the rapidity, the elimination of the disagreeable phases of
chloroform or ether which precede or retard recovery
from anaesthesia with these reagents, the diminished
quantity of the toxic agent required — all these elements
of superiority combine to invite the notice and experi-
mentation of surgeons. Its advantages have, on two oc-
casions, been discussed recently at the Soci6t6 de Chirur-
gie of Paris — on May 2 and 9, 1894 — where Dr. Segond
relates its introduction into his wards by Dr. Malherbe,
coming directly from Professor Terrier's service. With
Segond the method was immediately preferred to all
others, and at the meeting of the Society his official
statistics of one year's use of successive anaesthesia are
given — four hundred and forty- three cases without an ac-
cident of any kind. Dr. Bazy related his first acquaintance
with the method in the wards of Dr. Bran, and its imme-
diate adoption by him. Dr. Monod spoke in much the
same way. Dr. Richelot was already on record as en-
dorsing the method to the extent of preferring it in all
cases of heart or pulmonary troubles which might he
contra- indications of chloroform or ether.
DANGERS OF PRACTICAL BACTERIOLOGY.
A practical but unfortunate illustration of the truth of
the old adage that " Familiarity breeds contempt " is
shown by the death from cholera recently, in the Ham-
burg Hygienic Institute, of Dr. Oergel, one of the assist-
ants in that Institution. The facts of the case are
stated in great detail, by Dr. Reincke, in the current
number of the Deutsche Medical Wocherischrift, and would
seem to prove that the ill-fated young physician inad-
vertently swallowed some suspected water which had
been sent to the laboratory for examination. And al-
though subsequent bacteriological examination could
not prove the presence of the cholera bacillus, it was
not at all improbable that the water had become con-
taminated from cholera cultures with which he had
been working.
Knowledge is too often the result of dearly bought
experience, and the fact of one such case as this should
go far to counteract the opinion, which has been grow-
ing apace since the last cholera epidemic, that the
comma bacillus is a much-maligned organism, and is
really not nearly so dangerous as was its repute. Al-
though Von Pettenkofer and others may believe that
cholera organisms may be swallowed with impunity, and
Dr. Ernest Hart may avowedly prefer the shelter of a
well-directed cholera hospital to any other during the
prevalency of this disease, it is a fact notwithstanding
that a too intimate association with the vibrios of this dis-
November 3, 1894]
MEDICAL RECORD.
56i
• is liable to be followed by disastrous and lamentable
consequences.
The opinion that no pathogenic germ can act other
than in a favorable soil is continually gaining ground ;
bat the fact that a person is apparently in a healthy state
is no safeguard. A slight local departure from the
norm in some part of the body may give the germ a hos-
pitable point of entrance, and then sinister manifesta-
tions rapidly follow.
In the case of Dr. Oergel, general health and resisti-
bility may have been impaired by confining and exact-
ing laboratory work, and chances that were taken with a
greater exemption from consequences when in a vigorous
condition proved fatal when taken after a period of
confining labor.
As Dr. Reincke remarks, it is to be hoped that this sad
event may not be without warning to those who would
treat the cholera organism with too great familiarity.
ST. LOUIS AS A MEDICAL CENTRE.
St. Louis is just now the centre of a very considerable
depression of spirits and harrowing self analyses. The
trouble began when Professor Chaplin, Chancellor of
Washington University, said publicly some unkind words
about the disproportion between the quantity and the
quality of the St. Louis medical colleges. Then an es-
teemed practitioner of St. Louis, Dr. Thomas O'Reilly,
a little later is said to have addressed to the Health Com-
missioner an eloquent protest against the reckless surgery
and the excessive cceliotomic zeal of the much professored
city. The editor of The Medical Mirror has been de-
• voting his most alluring alliterations and his elegant and
eulogic eloquence to the purpose of refuting all charges
and restoring the self-esteem of his justly celebrated towns-
men.
" St. Louis," he says, " has been charged with posses-
sing eleven medical colleges, but there are really only six
regular schools. And why are there so many as that?
Simply because the two oldest medical colleges (both
being over fifty years old) were not possessed of a gen-
erous spirit in the direction of encouraging and utilizing
the ambition of the younger brood of medical men im-
bued with a taste for teaching. In other words, in pro-
portion to population St. Louis has no more medical
teachers than any other city/1 That is to say, we pre-
sume, if one counts only six of the eleven schools.
As to the second charge, a writer in the Times and
Register says :
" Missouri has sown the wind, and now she is reaping
the whirlwind. She is the hotbed of medical anarchy.
Her once honored influential State Medical Society, we
are informed, has gone to pieces. She has only fifteen
medical colleges, and at the annual meeting this year but
seventeen members answered to the roll-call. A practi-
tioner in that country, it seems, must be a professor or
nothing, and surgery has run mad there."
We do not know on what ground Missouri in general
or St. Louis in particular should be characterized as a
"hotbed of medical anarchy." And we are quite in
agreement with the Medical Mirror in denying that the
charge of "surgery run mad" has any special truth as
applied to that locality. There has been some reckless
surgery no doubt ever since surgery began, and especially
since anaesthesia was introduced. There always will be
foolhardy people in every class of society, but probably
fewer among surgeons proportionately. There has been
a wave of zeal for laparotomy which has swept over oiearly
all parts of the country. It certainly rose very high in
New York at one time, as we have often remarked. We
doubt if the high-water mark has ever reached an equal
point in St. Louis.
We trust that the remonstrances of the Mirror will
clear the atmosphere and perhaps be successful in con*
densing the colleges, improving their status, and making
of St. Louis what it ought to be, a great medical centre.
WHO IS PROFESSOR ZAKHARIN?
A great many curious stories have been published about
the eccentricities of Professor Zakharin, the Czar's phy-
sician. His name is not familiar outside of Russia, al-
though Russian medical literature so far as it is valuable
is quickly turned into German, English, or French. The
conclusion of many of the profession has doubtless been
that Zakharin was an errant and eccentric man who had
gained position and notoriety rather through his bizarre
character than any solid scientific merits. A St.
Petersburg correspondent of the British Medical Jour-
nal says, however, that, though eccentric, the Professor
is distinguished by something more than eccentricity.
He has the most extensive and lucrative consulting prac-
tice in Moscow, he fills with distinction the Chair of
Medicine in the University of Moscow, he is the author
of " Clinical Lectures," which is a classic in this coun-
try ; and he has done more, I am assured on the best
authority, to raise the status of the medical profession in
Russia than any other man living.
We are glad to learn that the Professor is really the
leader of medicine in Russia. Still it is remarkable that
his fame has heretofore been so local.
fftettrs txt tfee WBLtsk.
Disappearance of Cholera.— Latest advices announce
such a decrease of Asiatic cholera in Europe as to de-
prive the disease of any further interest .this season to
public health authorities. For the week ending October
10th, Surgeon Fairfax Irwin, U. S. M. H. S., reports a
decline of nearly fifty per cent, in the number of cases
in Austro-Hungary, which has been the principal seat of
the disease in Europe outside of Russia. In this latter
country, also, the decrease has been marked, and the be-
lief is expressed that the advent of cold weather will put
an early end to the epidemic. The port of Marseilles
has been declared free from the disease, and inspection
of vessels has been discontinued ; " sporadic " cases con-
tinue to occur elsewhere in France, and in Holland and
Belgium, but these excite no alarm, and the cholera epi-
demic of 1894 in Europe is practically at an end.
Dr. George M. Sternberg, Surgeon-General of the
Army, received the degree of LL.D. from the Univer-
sity of Michigan at its last Commencement.
The* Hew York State Association of Railway Sur-
geons will hold its fourth annual meeting at the New
York Academy of Medicine, on Thursday, November
562
MEDICAL RECORD.
[November 3, 1894
15 th, at 9.30 in the morning. At eight o'clock in the
evening of the same day, there will be a joint meeting of
the Section on Medico-Legal Surgery and of the Medi-
co-Legal Society.
The American Academy of Bailway Surgeons will
hold its first meeting in the Grand Pacific Hotel, Chi-
cago, on November 9 and 10, 1894. The Academy has
adopted a motto, which is : " The higher the order of
railway surgery, the greater the protection to the em-
ployee, the passenger, and the company."
The Mississippi Valley Medical Association will
hold its next annual meeting at Hot Springs, Ark., on
November 20, 21, 22, and 23, 1894.
The French Public and the Serum Treatment for
Diphtheria.— A correspondent of The Lancet writes that
public interest in the new treatment for diphtheria has
taken a very practical form at Paris. The subscriptions
now being received for the foundation of an antitoxin
department at the Institut Pasteur, whose business it will
be to supply the vaccine to the practitioners of France,
have reached the total of £51,100. The Budget Com-
mission has, on the proposition of M. Rouvier, voted
100,000 fir. as a subvention to the Assistance Publique
for the same purpose. It remains for the Chamber to
confirm this vote. The Municipal Council has instructed
its special commission to arrange with Dr. Roux for the
distribution, at the Council's expense, of serum to differ-
ent depdts to be created in Paris. The Comit6 Consul-
tatif d' Hygiene Publique de France, at its meeting yes-
terday at the Ministry of the Interior, resolved to address
a congratulatory letter to Dr. Roux and his illustrious
master, M. Pasteur, and also to ask of the Government
an annual credit to facilitate the diffusion of the anti-
toxin. The enthusiasm shown in favor of the movement
is extraordinary. For example, a livery- stable keeper
offers a horse to the Pasteur Institute to serve for the
preparation of the serum. A vote of 10,000 fr. will be
proposed at the next meeting of the Conseil G6n6ral de
la Seine. Numerous prefects of departments having ad-
dressed inquiries to the President of the Council, who is
also Minister of the Interior, on the value of an ti diph-
theric seropathy, the Minister referred the question to
the Academy of Medicine, which body named a com-
mission to study the matter. The commission, com-
posed of MM. Bergeron, Proust, Cadet de Gassicourt,
and Strauss (reporter), to-day delivered its conclusions,
which I transcribe verbatim : " Votre commission vous
propose done d'6mettre un avis favorable sur l'emploi du
s6rum antidipth&ique, et de formuler, en outre, les voeux
que rinstitut Pasteur soit mis en mesure de faire face aux
demandes qui pourront lui etre faites, soit par les m6de-
cins, soit par les pouvoirs publics."
Monument to Charcot. — The pupils and former asso-
ciates of Charcot, in Paris and throughout France, are
engaged in raising a fund for the erection of a bronze
statue of him in the Salpetriere. This movement is now
receiving cordial and material support in Germany, in
England, and in Italy.
It has therefore seemed desirable to the New York
Neurological Society that the profession in America join
in this testimonial.
For this purpose the society has appointed a commit-
tee consisting of Drs. Edward D. Fisher, E. C. Seguin,
M. Allen Starr, Charles L. Dana, and C. A. Hcrter, to
bring the matter to the attention of the profession and
to receive contributions, which will be duly acknowledged
and forwarded to the central committee in Paris.
Death of Dr. George W. Moody.— Dr. George W.
Moody, of Huron, N. Dak, died of cerebral hemorrhage
October 13th, aged forty-two years. He was educated
in Chicago, graduating from the Chicago Medical Col-
lege in 1878. He moved to Huron, Dak., in 1880, and
became surgeon of the Central Dakota Division of the
Northwestern Railroad. A widow and one son survive
him.
Professor Carl Fraenkel, of Marburg, has been elected
to the Chair of Hygiene in the University of Halle, ren-
dered vacant by the transfer of Professor Renk to Dres-
den. Professor Fraenkel will not assume the duties of
his new position until some time next year, his place in
the interim being occupied by Professor Behring, of the
Institute for Infectious Diseases in Berlin.
Hospital Beds for Cases of Appendicitis. — At the last
meeting of the Board of Managers of the University
Hospital, the Director was authorized to set aside certain
beds to be used by Professors William Pepper and J.
William White for cases of appendicitis, those gentlemen
being engaged in a special investigation of the symp-
toms, treatment, and pathology of that disease.
Perhaps we will next have special hospitals for appen-
dicitis.
The Practice of Medicine by Women in 1578.— In an
address before the Yorkshire Branch of the British Medi-
cal Association this summer, Mr. W. H. Jalland stated
that York seems to have been ahead of most places in
countenancing the practice of medicine by women. In
closing his address {Quarterly Medical Journal) he says :
" I find on reference to the Corporation Minutes dated
1572, Elizabeth XIV., the following entry: 'And for as
much as it appeareth that Isabel Warrick hath skill in the
science of surgery and hath done good therein, it is there-
fore agreed by these presents that she upon her good be-
haviour shall use the same science within this city without
let of any of the surgeons of the same.' "
The Scaroity of Patients. — There may be some com-
fort to the many physicians who have felt the long-con-
tinued " dulness " in their practice, in learning that it is
not a local stagnation, but that the same conditions are
being felt in other parts of the world. English medical
journals speak of the " marvellous health of the country ; * '
and the large number of physicians who have attended
the many congresses without being missed, so few are the
patients. An Edinburgh correspondent of the Medical
Press writes recently, " that in that city it was a vacant *W
vacation with a vengeance ; there was absolutely nothing ,
stirring, and he knew of one practitioner acting as locum A
tenens for seven others on their holiday, who, notwith- C
standing this weight of responsibility, jet found ample
time to play golf every day."
The Four Tears' Course at the College of Physicians.
— In the College of Physicians the new four years' course
commences with the present season, but notwithstanding
this fact the registration indicates that a larger class will
enter this year than last year, when the highest number
yet recorded was reached. In the session of 1893-4 the
November 3, 1894]
MEDICAL RECORD.
563
total enrolment of students numbered 766, a gain of 112
over the previous year. To the development of the four-
year curriculum much attention has been devoted by the
Faculty. Each student will be examined, each year,
upon the work of that year, and each student of the four-
year will be required to elect from a list of elective courses
either one course or more, as may be hereafter deter-
mined.
Mission Hospital in China. — President Seth Low,
of Columbia College, and his brother, have just built for
and presented to the mission station of the Protestant
Episcopal Church in Wuchang, China, a well-appointed
hospital for the use of the mission and the people of the
town.
The Hew House of Belief of the Society of the
Hew York Hospital, at the corner of Hudson and Jay
Streets, was opened for inspection on Tuesday, the 30th
ult It is to take the place of the emergency branch of
the New York Hospital, commonly known as the Cham-
bers Street Hospital.
Bellevue Hospital. — It is announced that Dr. Lucius
C. Adamson has been appointed to succeed the late Dr.
Stuart Douglas in the charge of the insane patients.
The Haw York Cancer Hospital.— Dr. Charles N.
Dowd has been appointed a surgeon to the hospital.
St. Luke's Hospital to be Moved Hezt July.— At
a meeting of the Board of Managers of St. Luke's Hos-
pital, held October 29th, it was stated that an agreement
had been made with the purchaser of the hospital prop-
erty on Fifty-fourth Street and Fifth Avenue, by which
the delivery of this property is deferred until July 5,
1895. The work of the hospital will, therefore, be con-
tinued without interruption during the coming winter at
the present site. The new hospital buildings in 113th
Street and Morningside Avenue are being pressed rapidly
forward, so that the work of the hospital may be trans-
ferred there next July.
"Doctorein." — Wanted, a handy and convenient name
for the " lady doctor. " A discussion having for its aim
the discovery of an appropriate title to take the place of
the awkward terms "lady doctor," "woman doctor,"
"female practitioner," etc., has been started in the
Glasgow Daily Herald. " Doctor " indicates the male
practitioner; "doctoress" is felt to be inadmissible.
"Doctorein," plainly of quasi-German parentage, is
suggested. " Doctorein Mary Walker " would be dis-
tinctive enough, but slightly clumsy and un-English.
The irreverent correspondent thinks it reminiscent of
margarine — an objection which may weigh with the
ts of the Glasgow Queen Margaret College. —
^Lancet.
The Physiological Effects of Cycling.— The physio-
logical effects of cycling have recently been studied by
Dr. Blazhevitch, of St. Petersburg, who publishes his re-
sults in his "Graduation Dissertation." He tabulates
270 observations on 104 individuals of both sexes and
various ages, distinguishing between ordinary riders and
those who train themselves for, and ride in, races or at-
tempt to cover long distances. He finds that the play
of the chest is diminished immediately after riding, es-
pecially in the cases of women and children, and of men
racing or commencing cycling, the diminution amount-
ing in these cases to from 1 to 1.5 centimetres. In men
accustomed to the exercise the effect was scarcely percep-
tible. The general effect of the summer's riding upon
the male votaries of the sport was, according to Dr.
Blazhevitch, practically nil. In women and children the
effect was slightly to increase the vital capacity. The
arm power was found to have increased more than the
leg power in young persons and in beginners, but in the
case of men of mature age who had previously been ac-
customed to cycling this was not so evident. Speaking
generally, the effects of cycling on the system were found
to be very similar to the phenomena noticed by Tsym-
kovski in soldiers who had been running, and by Gruz-
deff and Passover as resulting from rowing.
Fin de Siecle Treatment of Gonorrhoea. — Among the
numerous suggestions on the treatment of gonorrhoea
with which the medical press abounds, none has ap-
peared which is so entirely unique as that presented by
Dr. Burnside Foster in a recent issue of the Journal of
Cutaneous and Genitourinary Diseases. The method
proposed is described as follows by the author : "As
soon as may be after we have established the diagnosis
of a first gonorrhoea, the patient should be etherized and
properly prepared ; a buttonhole opening made in the
perineum, and drainage of the bladder established.
Through a properly contrived apparatus the anterior
urethra could then be thoroughly flushed with any anti-
septic or cleansing fluid and treated on surgical princi-
ples. The details of the local treatment would vary
with the fancy of the operator. The feasibility of pack-
ing and distending the anterior urethra with iodoform
gauze suggests itself to me ; but any one of a great num-
ber of methods would, doubtless, be efficacious."
Longevity and Drink. — The British Medical Associa-
tion has been investigating the question of longevity in
connection with the use of alcoholic beverages. Deaths
to the number of 4,234, taken at random, show the
average age of temperate drinkers to be sixty-three
years ; careless drinkers, fifty-nine years ; free drinkers,
fifty-seven years ; intemperate drinkers, fifty-three years;
total abstainers, fifty-one years. The analysis in the
case of those who reached the age of over eighty shows
that fifteen per cent, were total abstainers, ten per cent,
heavy drinkers, and seventy-four per cent, moderate
drinkers. Of those who lived more than ninety years,
fifteen per cent, were total abstainers, nine per cent,
were hard, and seventy-five per cent, moderate, drinkers.
These figures must be applied with some caution. A
certain large proportion of total abstainers are so, be-
cause of some form of ill-health or natural weakness.
The Correction of Urinous Odor. — It is well known
that the essence of turpentine gives, when taken inter-
nally, an odor of violets to the urine. This fact has been
put to good account by a learned professor, who has for
some time been in the habit of giving the essence in ten-
drop doses three times daily to persons afflicted with in-
continence of urine. In a short time the disagreeable
odor of the secretion is replaced by the characteristic
odor of the violet, to the great satisfaction of those about
the patient. The treatment can be continued without
inconvenience for several weeks, and is only counter-
indicated in gastric catarrh and nephritis.
564
MEDICAL RECORD.
[November 3, 1894
©liuical gepartmeut
DOSES OF MORPHINE HABITUES.
By L. S. OPPENHEIMER, M.D.,
BAKTOW, FLA.
In a recent number of the Medical Record Dr. Groom,
of Iowa, contributes a note on the case of a lady who was
supposed to be taking an extraordinary daily quantity of
morphia — thirty grains. My experience is, of course,
limited in these cases, but I may safely say that in a gen-
eral practice of twenty years I have seen not less than
twenty persons who were taking a full drachm of morphia
every twenty-four hours. The reason that the physician
so rarely knows the actual quantity of morphia taken by
his patients and friends is because the latter usually try
to conceal the fact from everybody, and the druggist
who furnishes the article is the only person who can ap-
proximate the quantity consumed in the majority of these
A man of my acquaintance, Mr. B. C. T , has
authorized me to use his name in reporting the fact that
he to day began his thirty-second drachm of morphia in
thirty days, all purchased from one store. He attends
to his daily business about as well as the average business
man. This is not a rare case, but is mentioned because
of its illustrating the above.
PILOCARPINE IN URTICARIA.
By L. B. McBRAYER, M.D.,
ASKBTUXft, K. C
On Monday, September 1 7th, I read your valuable journal
of September 15 th, and found therein an article by R.
Abrahams, M.D., on " Pilocarpine in the Treatment of
Acute and Chronic Urticaria."
My little boy, aged two years and nine months, happened
to be suffering very badly from this very unpleasant malady
just at this time. The wheals would cover his face at
times and seemed to have a special liking for his nose,
which they would distort terribly. At one time the
wheals coalesced until they covered nearly the whole of
the posterior surface of the thigh. He had slept very lit-
tle the previous night, although I had given him two grains
Dover's powder. In fact it was the worst case of the
kind I have seen. The itching was very annoying. I
had cleared the bowels out well, and he had eaten almost
nothing for the past twenty- four hours. He had been
bathed in solution of soda bicarbonate and several
other things, yet he continued to grow worse. After
reading the article I gave him on Monday night, at bed
hour, X grain of pilocarpine muriate. He slept very
much better, and on Tuesday morning there was no evi-
dence whatever of the urticaria.
~. Last night (Tuesday) he slept as well as he ever did
in his life, and is perfectly well, and all this with only
one dose ^ grain of pilocarpine. I have written this
hoping to emphasize the article referred to, and hope
that the profession may profit by it.
A CASE OF ORBITAL CELLULITIS ABORTED.
By GUY C. M. GODFREY, M.D.,
r»ST LIEUTENANT AHD ASSISTANT SURGEON, U. 8. A«, POST SURGEON FOST
WASHAKIE, WYO.
Private S , Hospital Corps, U. S. A., aged twenty-
two, a large man, dark-complexioned, and of a good
family history, had a boil near the outer corner of his
right orbit. He had opened the abscess before he came
to me, but was alarmed at the condition of his eye. The
skin over the orbit was red and the subcutaneous tissue
much infiltrated. The lids were swollen and the con-
junctiva injected. There was considerable chemosis, and
the cornea was beginning to be cloudy. He also had a
slight fever. In short all the symptoms of incipient or-
bital cellulitis. I immediately ordered the boil to be
dressed antiseptically and had a wad of cotton placed in
the orbit, and over that a snug roller bandage. The pa-
tient was then put to bed. In about an hour I had the
dressings removed. I then made a free incision down-
ward and outward in the line of a wrinkle, so as to provide
for drainage and leave no disfiguring scar. I afterward
painted the skin over the entire orbit with a five per
cent, solution of nitrate of silver. The abscess was then
dressed with powdered boric acid, a compress of cotton
was placed in the orbit, and over all a tight roller ban-
dage. The patient was then put on strong tonic treat-
ment. At the end of three hours I removed the compress
and found that, though there was still some redness in
the skin, the swelling had mostly disappeared and that
the chemosis was going down. I again painted the skin
over the orbit with the solution of nitrate of silver and
had a new compress put on.
The next morning all the signs of inflammation had
disappeared. The skin was normal in color except where
it was darkened by the solution. There was no chemosis ;
the cornea was clear and the patient felt much better.
The abscess was washed with a solution of bichloride of
mercury (i to 1,000) and dressed with boric add. The
compress was not reapplied, but the tonics were kept up.
The patient had an uninterrupted recovery, and has had
absolutely no trouble with his eye since then.
This method is easy of application and most potent in
results, if the disease is taken early. When the danger of
the inflammation travelling along the ophthalmic vein to
the meninges is so great, it would seem that the method
used in this case would be much better than that of caus-
ing pus to form, and then draining through the conjunc-
tiva or through the lower lid.
SYMPTOMS OF POISONING FROM A PROB-
ABLE OVERDOSE OF PHENACETINE.
By FRANCIS E. KNOWLES, M.D.,
SOUTH ORANGE, M. J.
MISS B , aged about thirty, rather stout, and very
healthy, had a severe attack of migraine. She was recom-
mended by her friends to take one of Dr. C 's magic
headache powders, which she did, but obtained no relief,
and in about an hour and a half repeated the dose ; this
also did not produce the desired effect She was then
advised to try phenacetine ; she drove down to the drug
store, and took ten grains, drinking with it a glass of
carbonic water. She drove directly home, about a mile
distant from the village, and in a few minutes was taken
with a well marked chill. Her friends foreboding evil, I
was sent for immediately. On arriving, and before be-
ing able to ask any questions, I was told the history of
the case as related above. I found the patient prostrated
from what seemed to be muscular weakness; there was
great cardiac depression ; pulse forty per minute, scarcely
perceptible at the wrist; respiration was labored and
slightly quickened ; there was general cyanosis, which
was particularly marked at the extremities ; cold perspi-
ration ; feet and hands were nearly cold ; she had an
anxious expression, and was trembling from nervous ex-
citement. She said her whole body felt numb. Heat
was applied, and the limbs rubbed vigorously, and five-
minim doses each of tincture of digitalis and nux vomica
in a teaspoonful of brandy were administered every
fifteen minutes, to stimulate the heart and respiration.
Her condition commenced to improve immediately, and
in three hours she felt well again.
I examined one of Dr. C 's magic headache pow-
ders, which of course is a patent medicine, and was
satisfied that it contained phenacetine or some other
coal-tar derivative. The patient had been used to the
homoeopathic treatment all her life, and the doses which
her allopathic friends prescribed for her proved entirely
too large. It has been my experience with people
who have had homoeopathic treatment for a number of
November 3, 1894]
MEDICAL RECORD.
565
years that smaller doses will produce their physiological
effect than with those whose systems have become accus-
tomed to larger potions.
SIXTY GRAINS OF MORPHINE AT A DOSE.
By,M. J. SWEENEY, M.D.,
KANE, PA.
I noticed in the columns of your excellent paper of Sep-
tember 15th, under heading "A Large Dose of Morphine,"
an account of a case using thirty grains a day. The final
sentence in that article was " One ounce of P. & W.'s
morphia every sixteen days beats the record of any case
I ever heard of." Allow me the privilege of establishing
a new record. I have under my notice now a case of
morphinism, cured by Mattison's method of treatment,
who took sixty grains each day, not hypodermatically
but by the mouth. When he came to me for relief from
his habit, with the story of sixty grains per day, I could
not believe it and told him so. I, however, gave him
four 15-grain powders, with instructions to take one every
four hours, intending to watch the effects of the first dose
and be guided accordingly. He deliberately took the four
powders, emptied them into the palm of his hand, and ate
the morphine like so much flour. To say I was horrified
is putting it mildly. I instantly loaded up my hypo-
dermic with a tenth of apomorphme to emetize torn, and
when he objected I felt like sending for the undertaker at
once. His perfect sang-froid and smiling assurances
allayed my fears a little, so I sat down and decided to
watch him, interfering forcibly, if necessary. I was more
than surprised, after eight hours' observation, to witness
no untoward symptoms whatever. He is entirely off the
drug now, in good condition, and I see him every day.
A CASE OF ANOPHTHALMIA DEFECTUS OCU-
LORUM.
By LEONARD LANPES, M.D.,
new \orac.
I desire to put the following case on record on account
of its great rarity.
About July 1st I was called to see a Mrs. G , a
healthy woman, thirty years of age, who had just given
birth to a female child. I found her in no worse condi-
tion than ordinarily is the case after a very hard labor,
as in this case. She asked me to examine the child, say-
ing it could not open its eyes. I found a perfectly de-
veloped child, weight about six pounds. There were
eyelids, eyebrows, and ocular cavities, but when I suc-
ceeded in opening the lids I found no eyeballs. It was
evident that the child was born without eyes. The
woman's family history was good, and she had previously
given birth to two children ; both of them died a few days
after birth. Her husband is a healthy-looking man of
about thirty-two years of age, but I found, later on, that
he had been an inmate of an asylum, having been afflicted
with melancholia. He is now perfectly well, and his
family history is also good. I took the case to Dr. F. F.
Reyling, who kindly examined it for me, and he also
concluded that the child was born without eyeballs.
Another peculiarity of this child is that it has six fingers
on each hand and six toes on each foot. Dr. Reyling
tells me that he never saw or heard of such a case before.
Since I have had this case in hand my attention has
been called to some other cases of a like character.
There is now in the Missouri School for the Blind, at St.
Louis, a girl, aged eleven, the daughter of a clergyman,
who was born without eyeballs, but with eyelids and
sockets well developed. This case corresponds in every
respect with the one above recited, except as to the su-
pernumerary fingers and toes. This St. Louis case was
examined by Dr. Green, of St. Louis, the celebrated
oculist. The report of the school superintendent shows
that this child is bright in intellect, she having a very
high percentage in all studies.
Dr. V. Condory, of Hot Springs, Ark., has called to
my attention a similar case that came to his notice when
he was on board the steamship Fatherland, in 1871.
Among the third-class passengers, five hundred in num-
ber, was a young woman, eighteen years of age, an Israel-
ite, who gave birth to a female child without eyes.
Dr. Edward Frankel, of this city, refers me to what is
said on this subject by Dr. Karl Assmund Rudolphi, Pro-
fessor of Anatomy in the University of Berlin, 1816 to
1840: "Anophthalmia defectus oculorum is found in
various degrees ; occasionally both eyes, with all the ad-
junctive parts, are absent, as in cases where the heads of
one monstrosity are so joined together that only the
occiputs are visible laterally ; while on the other hand I
have on one occasion seen a well- developed, mature
foetus, which died after birth — case published in the Re-
ports of the Berlin Academy, 1840 to 1850 — where the
right eye was totally absent, so that there were neither
ocular cavities, eyeball, eyelids, nor optic nerve, and
the skin was smooth from the forehead to the cheeks ; in
the brain the thalamus opticus was rudimentary, etc. I
have also observed the absence of both eyes in an other-
wise well-developed child, in whom the eyebrows, eyelids,
and all relative parts, were completely developed."
I have also noticed in Bruneau's " Old French Natural
History" a case of this kind in a male child. The child
died a few weeks ago. I tried very hard to get an au-
topsy but did not succeed.
A CASE OF HYDRAMNION, WITH ATRESIA
ANI IN THE CHILD.
By FREDERIC H. PLUMMER, M.D.,
ILYMPTON, MASS.
I was called at 4 p.m., on September 20, 1894, to Mrs.
S ,in labor with her fifth child. On reaching her I
found that she had been in labor for three days prior to
my being summoned, the pains having been rather weak
but wearing. The abdominal examination revealed an
enormously distended uterus, and extreme suprapubic
oedema. Palpation failed to elicit any definite informa-
tion as to the position of child, and the foetal heart-
sounds were inaudible. Vaginal examination showed an
unruptured amniotic sac protruding through a fully
dilated cervix, with breech presenting, but not engaging ;
after a moment of exploration the presenting part disap-
peared and its place was taken very quickly by the head.
Rectum and bladder were empty, and passages well lubri-
cated and dilatable. Concluding that the case was one
of hydramnion, I waited until the head again came
within reach, and after the pain subsided ruptured the
membranes. I had a Marcy pad under my patient,
which quickly filled, but from the hollowing of the bed
only a small part of the fluid passed through the outlet,
the major part overflowing, soaking a quilt folded under
her, and also the feather-bed through to the under mat-
tress. The head engaged L.O.A. after rupture of the
membranes and the labor was rapidly completed, the
child weighing five pounds. He was extremely cyanotic,
and the cord being so short as to prevent my getting
his face from between his mother's thighs, I thought
best to sever it immediately. Then after I had cleared
out the mouth and fauces, and given a few mouth-to-
mouth insufflations, the child commenced to cry and
breathe. A few drops of urine were voided during his
toilet. The mother had rather a free hemorrhage, and
the uterus was slow in retracting. Firm manipulation
controlled both hemorrhage and relaxation, the placenta
being expelled by Credo's method twenty minutes after
delivery of the child. On account of possible danger
from hemorrhage, the uterus was carefully manipulated
for an hour, and then, as contraction seemed good, a
binder was applied and the patient's toilet made.
These being the incidents, let me call attention to the
abnormal quantity of the amniotic fluid and stricture of
the child's intestine. The receptacle beside the bed
566
MEDICAL RECORD.
[November 3, 1894
contained two quarts of fluid, the folded quilt weighed
12^1 pounds as taken from the bed, its dry weight as
afterward ascertained being ij£ pound, and there was
an indefinite amount of fluid in the feather-bed, probably
half as much as was in the quilt. From the quantity
collected and the weight of the absorbing materials, we
will find that the amount of fluid was approximately
twenty pints, which seemed to me to be an unusual
amount.
The next morning I found that the nurse (one of the
traditional old women who know it all), no meconium
having been passed, had administered a dose of castor-
oil before my arrival. The next day, the oil being in-
operative, I injected half a drachm of glycerine, which
brought away a mass about two inches long and three-
eighths of an inch in diameter, of a light brownish color,
and appearing like a small earthworm folded upon it-
self enough times to make up the bulk of the mass. This
was followed by several small pellets, about the size of
split peas, and slightly darker in color than the larger
mass. During the day vomiting set in, which soon be-
came dark in color, apparently from containing meco-
nium, and this continued, with increase in number of
ejections and darkness of color, till death, on the sixth
day.
During this time he lay in a comatose condition, and
after third day refused to take any nourishment per
orem. Gavage was tried but proved unsuccessful, all
ingested matter being vomited almost immediately. The
bowels never moved spontaneously, and injections only
brought away a few of the small pellets of the same
character and color as the first evacuated.
An autopsy was denied, so that I was unable to verify
my diagnosis of a stricture of the gut about two inches
above the internal sphincter, but think the occurrence
of these abnormalities of mother and child make the
case of sufficient interest to warrant my reporting it.
I suggested an operation for the making of an artificial
anus, but it was refused by the mother, the reputed father
having died of phthisis pulmonalis in the early part of
January.
A NEW TREATMENT FOR ERYSIPELAS.
By W. V. GAGE, M.D.
m'cook, neb.
At the risk of being assailed, after the publication of this
article, with numerous letters disputing my claim to orig-
inality in the method of handling the above-named dis-
ease, I beg leave to call your attention to the treatment
of erysipelas with the wet carbolic-acid dressing. The
treatment, as far as I know, is original ; but I am more
than willing that you should demonstrate to me that it
is in no way new. Every physician has often expe-
rienced a conflict with erysipelas, and has probably
many times arrived at the conclusion that his local ap-
plications did harm, not much good, or were absolutely
inert. Strumpel says, " The chief indications for treat-
ment will be to check the unceasing advance of the dis-
ease; but, unfortunately, the means recommended for
this purpose too often fail."
Iodine painted over the healthy skin at the border of
the inflammation seldom arrests the progress of the local
manifestation ; and the old-fashioned method with the
nitrate- of silver pencil is certainly as barren of results.
In regard to internal medication, iron has, no doubt,
been exhibited more than any other one medicine.
Probably no one, however, can state that he has noted
any marked diminution in the severity of the disease un-
der the influence of its administration. The same may
be said of camphor, benzoate of soda, and salicylic acid.
In the treatment of erysipelas with the wet dressing I
have practically discarded internal medication, treating
the disease as a local manifestation, which it certainly is ;
and only in cases where the patient has been treated in a
previous attack by the use of both local application and
internal medication, have I given some placebo " for the
blood." I might add, however, that I have employed
sulfonal for sleeplessness and delirum, in some cases,
with marked results. For the cure of the disease I rely
wholly, however, upon the local use of the wet five-per-
cent carbolized dressing. I make my own dressing from
the bleached cheese cloth, and the method employed for
the preparation of this gauze is so familiar as to need no
repetition here. I use a dressing of my own preparation,
as the manufactured article which we get in the shops is
too dry for the purpose, while that which I keep in my
office is put up in a large earthen crock and covered with
a five-percent solution of carbolic acid. The treatment
can of course be applied to any case of erysipelas, bat we
will take for example a case of the facial manifestation 01
the disease. If the area of inflammation has encroached
upon the line of the beard, the face should be shaven, as
should the head if the region of the hair be involved. I
have found it best, even though the eyes are not yet af-
fected by the disease, to close them and place over each
one a fluffed pledget of the wet gauze. If the ears are in-
volved a small portion of the dressing should be placed
back of each one, so that they shall not be pressed against
the head by the bandage which is to be applied. Now
apply the main dressing, which should envelop the head
and face, including all parts which have a tendency to
show the blush of the extending disease, being careful to
let the dressing extend over the area of redness in all
directions. Over the dressing a sheet of rubber tissue or
oiled silk should be placed, the edge of the protective
lapping well over the edge of the gauze. A bandage is
now applied to hold the dressing in place. Care should,
of course, be taken to so fix the dressing that the mouth
and nasal cavities shall be free, although the eyes are to
be covered. You have now converted your patient's head
into an object somewhat resembling an Armour ham, but
he feels better at once, as the gauze has, by mere contact,
removed a considerable amount of heat from the diseased
area. This dressing should be allowed to remain on for
twenty-four hours, when it is to be removed and replaced
by a similar one. I think, if you have never employed a
like treatment, that you will be surprised at the marked
diminution in the heat and redness over the area covered
by the dressing, even after the first twenty-four-hour
period. The dressing is to be reapplied as long as the
least suspicion of redness of the skin remains.
Compare the last case treated by you with the first
one treated by the above method, and notice the differ-
ence. Mark the shortening in the course of the disease,
and the diminution of all disagreeable symptoms. It is
absolutely essential that all signs of inflammation should
disappear before the dressing is removed for good, as
you will otherwise often be disappointed to notice a re-
turn of the disease which you had supposed cured. Bet-
ter a day too long in a bandage than a repetition of the
trouble. In order to satisfy myself as to the efficacy ot
the treatment, I have, after applying the dressing for
twenty- four hours, removed it and left the case without
treatment for a short period, on the return call finding,
instead of the soft, pale, moist surface, the hot, tense,
dusky skin of well-developed erysipelas. I have, up to
date, handled eleven cases of the disease after the man-
ner set forth above, and have yet to be disappointed in
a single instance. The cases have included, besides the
facial type of the disease, three cases of traumatic ery-
sipelas, and I am inclined to think that, if anything, the
success of the treatment was more fully demonstrated in
the last-named cases than in the so-called idiopathic
variety. I would like to receive a report of cases in
which there has been a failure to effect a prompt cure
after pursuing the wet-dressing treatment.
Preventable Deaths. — A statistician of Moscow has es-
timated, from a study of the death returns of the States
of Europe, that at least forty per cent, of the inhabitants
of that portion of the world die of preventable infectious
diseases.
November 3, 1894]
MEDICAL RECORD.
567
MALARIAL INFECTION.
By A. SCHIRMAN, M.D.,
NEW YORK.
During a residence near the Rosso-Persian b6undary be-
yond the Caucasus it fell to my lot to see a great deal
of intermittent fever. Malarial diseases in that region
are very similar in their symptoms and course to those
endemic in many parts of the American continent. My
experience there and elsewhere has led me to regard the
presence of potted plants in living apartments as pro-
ductive of much malarial fever. It has been abundantly
shown that this disease prevails often in places which
are free from swamps or any bodies of standing water.
All that is necessary to the propagation of the malarial
poison is a small quantity of moisture in the soil and a
vegetable growth in somewhat high temperature. The
development of the poison is arrested when the air does
not penetrate the soil and when the average temperature
is not high. Both excessive dryness and excessive moist*
ore seem to be inimical to the propagation of malaria.
The cities of Vladi in the Caucasus, of Susal, where is
the grave of Haman, and of Erinan, near Mt. Ararat,
and their environs are noted for excessive heat and
moisture and a great variety of vegetable growth. Dur-
ing my practice in these cities I often had occasion to
observe that malarial fevers were more prevalent on
days following a warm rain, and especially among those
living in unsanitary dwellings where there were many
plants and much decaying animal and vegetable matter.
The relation between house plants and malaria was well
shown in a case seen by me in Moscow. A woman from
the Caucasus, who had always enjoyed the best of health,
was taken ill with intermittent fever. She was treated
for the fever and soon recovered, but another paroxysm
occurred soon after she began to go about the house.
After a succession of these attacks I made an investiga-
tion. I found that she had a large number of plants in
a sitting-room which was well heated but not ventilated.
She was very fond of her plants and passed the greater
part of her time in this room, but during the attacks of
illness remained in her bedroom, which was large and
well ventilated. I insisted upon the removal of the
plants from the house, and from that time the attacks
ceased.
PERMANGANATE OF POTASSIUM AS AN AN-
TIDOTE FOR RATTLESNAKE BITES, A RE-
CENT CASE.
By F. W. MALONEY, M.D.,
ROCHESTER, N. Y.
About three months ago, a Mr. P. G was bitten on
the right middle finger by a fair- sized ^rattlesnake which
he was handling at the time.
He immediately put the snake back in the cage, and
applied suction with his mouth to the wound, this was
continued for about fifteen minutes, when he used a strong
solution of ammonia. At the end of half an hour the
finger began to swell. He tied a string on the finger
above the bite, but the swelling continued, in two hours
it had reached the wrist ; he then removed the string and
made an incision through the wound with his pen-knife.
After partaking of a large drink of whiskey he set out to
obtain medical aid. Not finding the person he desired
he went to the City Hospital, where the house surgeon
made several free incisions on the finger, hand, and fore-
arm, as by that time the swelling had extended as far as
the elbow-joint. The wounds were then dressed with
iodoform gauze, and bandaged.
The free bleeding relieved the pain and some swelling.
The after treatment was dressings, changed every day for
four weeks ; when all the wounds were healed he had no
constitutional symptoms, as the swelling did not go be-
yond the elbow- joint.
I read Dr. Moor's article in the Medical Record
stating the antidotal properties of permanganate of po-
tassium in morphine poisoning, and a short time after-
ward another article on a case of snake poisoning treated
by permanganate hypodermatically. I suggested the idea
to Mr. G and he said he would get it, and be pre-
pared in case he was bitten again. He secured a hypo-
dermic syringe and some permanganate of potash ; taking
a two-ounce bottle he made a dark purplish solution of
the permanganate. He also has a rubber bandage he
keeps in the same box with the syringe and solution.
These are near the case which contains the rattlers.
An opportunity presented itself on Friday afternoon
September 28th, by which he clearly demonstrated the
value of permanganate of potash as an antidote to rat-
tlesnake poisoning.
Mr. G- very often exhibits the fangs of a rattle-
snake to the visitors of his place. This he does by
catching the snake just behind the head with one hand,
and by a sort of tongue depressor opens the mouth of the
snake with the other. This day the snake might have
been a little hungry, and while handling it Mr. G
felt a sharp sting in the joint of the left index finger ; he
dropped his pet back in the cage, and reached for his
syringe and solution ; an assistant filled the syringe while
Mr. G tied a string round the finger above the
wound. He then injected the solution into the finger
near the bite. In a few minutes the finger began to
swell, and when the pain became severe he used the rub-
ber bandage at the wrist and loosened the string, and
again injected another syringeful of the solution. There
was no further swelling and very little pain. In two
days there was no sign of the bite ; he used the finger as
usual. He stated that he was more at home now than
ever with the rattlers.
PREGNANCY; CONTRACTED PELVIS; DOUBLE
DERMOID CYST; PORRO'S OPERATION.
RECOVERY OF MOTHER AND CHILD.1
By NEIL MacPHATTER, M.B.C.M., L.R.C.P. Edin.,
DENVER, COL.
PROFESSOR OF CLINICAL GYNECOLOGY IN GROSS MEDICAL COLLEGE J GYNECOL-
OGIST TO ST. ANTHONY'S HOSPITAL ; FELLOW OF THE BRITISH GYNECOLOGI-
CAL SOCIETY.
I believe the part assigned to me for discussion this
afternoon is a consideration of the unusual methods or
extraordinary measures that may be legitimately resorted
to in difficult parturition, when the difficulties assume
such proportions that the woman cannot be delivered by
any of the ordinary means. My sphere is limited to a
still narrower margin than this, for I have been requested
by the gentleman who so kindly invited me to partici-
pate in this discussion to endeavor to confine my remarks
more particularly to that part of the obstetric art which
calls for the use of cutting instruments, i.e., when there
exists such a disproportion between the natural passages
and the size of the foetus as to render it absolutely impos-
sible for the child to be delivered in the ordinary manner.
Here we come upon a peculiarly interesting and tremen-
dously responsible situation, for it is one in which the
lives of mother and child are placed in imminent jeopardy,
and one that calls for the most evenly balanced judgment
on the part of the attending physician. In the remarks
to which I give expression I trust I shall approach the
subject free from the thralldom of preconceived ideas
and unbiassed in the advocacy of any one method of pro-
cedure only in so far as the merit of such a method de-
mands.
Fortunately for mankind, more particularly for those
who are obliged to bear the burdens and dangers of par-
turition, nature in her own inimitable ways and by or-
dinances that far surpass in beauty and perfection of
design the imagination of man, is usually quite compe-
tent to fulfil this trying ordeal. Occasionally, however,
the pelvis of the mother or unnatural development on
the part of the foetus may render it absolutely impossible
1 Read before the Colorado State Medical Society, June 19, 1894*
568
MEDICAL RECORD.
[November 3, 1894
for the woman to be delivered normally, and it is here
that the cunning hand of the surgeon may be of the ut-
most importance to life. It is highly commendatory to
the standing of the profession at the present time that
the principles we advocate have been so beneficial to
mankind. The method in vogue not many years ago of
resorting to the operation of craniotomy, with the appal-
ling disasters that followed in its wake, forms one of the
darkest pages in the history of obstetrics. When one
contemplates the frequency with which this operation
was resorted to in preference to others much less danger-
ous, it would seem that the spirit of scientific midwifery
was long lulled to sleep and that nature had become
emasculated. The operation of eviscerating the yet warm
and quivering body of an innocent babe from its mother's
womb should be reserved for very rare and exceptional
cases, such as hydrocephalus, or where the child is already
dead. Much more satisfactory and humane methods are
the Caesarean section and Porro's method of operating.
Porro's operation, unlike the majority of recent tri-
umphs in surgery, is not one which has been resuscitated
after having been performed and discarded many years
before, but is of comparatively recent origin. The first
successful case on record was performed in the year 1876
by Porro, of Batavia. It has since been performed a
great number of times with comparatively good results.
Heretofore, and even at the present time, this operation
and the Caesarean section had been indiscriminately ad-
vocated when the condition present called for one or the
other method. I believe this to be a mistake. Whether
the Caesarean section can have any advantages over its
recent rival rests wholly upon a question of morals.
Certain it is that there are well-defined conditions and
complications in pregnancy when Porro's method is the
only scientific course to pursue.
Each method may possess well-defined advantages over
the other, and in estimating the relative values of Porro
and Caesarean sections a number of important conditions
should be remembered. In all cases where pregnancy is
complicated by tumors, such as fibroid of the uterus,
ovarian, or dermoids, as was the condition in this case,
hysterectomy is the preferable operation. Where labor
has proceeded for a long time and the uterus becomes pu-
trid, Porro's operation ought to be the one selected. In
certain operations begun as Caesarean sections, but which
become complicated by difficulties in the detachment of
the placenta, uncontrollable hemorrhage, or complete
atresia of the vagina, Porro's is the operation indicated.
These are some of the advantages that this operation pos-
sesses over the classical one. In straight, uncomplicated
cases I doubt very much if the Caesarean method is* su-
perior to the Porro. The advocates of the Caesarean
section maintain that because Porro's operation forever
renders the woman sterile, the Caesarean method has the
advantage. This question again is one altogether of
morals ; but given a woman with a deformed pelvis and a
contraction of its diameters so that one or the other op-
eration was absolutely demanded, and believe the fact
that one would save her life equally as certain as the
other, the one that would place her in such a condition
that pregnancy could not again occur would be the pref-
erable one. I look upon this point alone as a decided
advantage of Porro over its rival. Such a proceeding
would leave the life of the mother absolutely free, so far
as any future chances were concerned. I am well aware
that this is at variance with the opinions of many able
minds, but nevertheless it is one that I have long main-
tained, and is at least one of honesty.
There can exist no reason why this operation, if
properly planned and carried out with as much care and
precaution as other abdominal sections, should not be
almost entirely free from risk, as far as the lives of mother
and child are concerned. It is to be regretted that in a
great majority of instances the idea of the operation does
not enter into the head of the physician until the patient
becomes almost entirely exhausted from the reiterated
efforts of the uterus to expel the foetus. An operation of
this character above all others should be done opportunely
and not left until the rough manipulations have exhausted
the woman and materially reduced her chances. It can
readily be understood why the mortality of this opera-
tion has remained so high in view of the fact that it is
usually done as a forlorn hope.
An operation that has recently sprung into promi-
nence, and one that is receiving considerable attention, is
that of symphyseotomy. This method of delivery is not
of recent origin, but is one that was described and ad-
vocated by a French medical student as far back as the
year 1768. At first his method was received with in-
credulity and doubt, but subsequently having performed
the operation successfully upon a woman who had pre-
viously given birth to four dead children, his method
was at once admitted and he became the recipient of
much adulation and marks of esteem. He was looked
upon as the benefactor of mankind, and the neglected
student became in the eyes of the nation an illustrious
personage. From that period the operation seems to
have lapsed into neglect until recently revived.
The conditions calling for this method of operation
are necessarily limited. It is only in slightly contracted
pelves that any benefit can be looked for, and the neces-
sity for Porro's method or the classical Caesarean section
will begin where the operation of symphyseotomy ends.
In well-marked contracted pelves this operation gives
way to the suprapubic methods, and finds its advan-
tages in such cases where the question of premature labor
may be meditated.
Whether this operation will ultimately supplant the
necessity for inducing premature birth, will rest with
the future. At present, according to the most recent
arguments, it is frequently beset with disastrous results,
sufficient to raise a doubt of its surviving. The most
frequent risks seemingly are septicaemia, hemorrhage,
ossification of the symphysis, laceration of the bladder,
with fistulae, and prolapse of the vagina.
On August .16th I was called in consultation by Dr.
E. J. Rothweli to see a patient who was eight months
and a half pregnant. The history given was that she
was thirty-two years of age, had always enjoyed good
health, and had been delivered of twins a few years pre-
viously by Dr. E. J. Rothweli, weighing three and a
half pounds each. Dr. Rothweli at that time noticed
the condition of the pelvis. She afterward became
pregnant, and after the repeated effort of days Dr. Roth-
weli removed the child by craniotomy. She was con-
fined to her bed for three months afterward. Upon ex-
amination the cervix was so high that I could not detect
it with my finger ; I could, however, make out that the
foetus was alive and that it was in the fourth position. It
was of large size, and we felt certain it was physically
impossible to deliver the patient by the normal channel.
This we explained to her and her husband, and ad-
vised the removal of the child by abdominal section as
the method attended by the least risk. The following
were the pelvic measurements : Between anterior-supe-
rior spines, 9f inches ; between crests of ilia, 10 inches ;
conjugate vera, 3^ inches.
A few days subsequently she was removed to my
private hospital on Vine Street and was prepared for the
operation. We decided to operate several days before
the expected time of labor.
Thursday morning, August 23d, she was put under the
influence of an anaesthetic by Dr. Leavitt. The abdom-
inal incision was made in the median line and was con-
tinued above the umbilicus. Any bleeding points were
caught up by pressure-forceps and secured. The trans-
versalis fascia was cut through to the full extent of the
abdominal wound. The subperitoneal fat was caught
between two pairs of forceps and gently cut, layer after
layer, changing the forceps for a deeper layer as each
one was cut. This process was continued until the
peritoneum was opened and the uterus bulged forward
into the wound. Whether to apply the temporary liga-
ture before raising the uterus from its position, as is re-
November 3, 1894]
MEDICAL RECORD.
569
commended by the majority of operators, or doing so
afterward, as advocated by Miiller and others, is yet
under discussion. In this case I decided upon the latter
alternative, for the reason that it can be more properly
adjusted and the risk of including a loop of intestine or
a piece of omentum under the rubber is obviated. The
increase in abdominal incision is more than compen-
sated by the advantages gained.
Before the incision into the uterus was begun, several
warm, flat sponges were placed between the uterus and
intestines, for the double purpose of keeping them from
cooling and preventing fluid from escaping into the ab-
domen. The incision was vertical, beginning near the
fundus, cutting toward the cervix about four inches. I
went carefully through the whole extent of the incision,
layer after layer, until I came to the membrane, which
was intact. The uterine walls retracted, exposing the
foetus as through tissue paper. I ruptured the membrane
and the uterus contracted, the child entered the world
head first, crying lustily, and was turned over to one of
the attending nurses. Here I was confronted by the
unexpected complication of two dermoid tumors of the
ovaries, and decided to remove them also, together with
the uterus. As in hysterectomy for fibroid tumors of
the uterus, experience has taught us that the extra-peri-
toneal method of fixation of the pedicle is the one fol-
lowed by the most favorable results. The simple method
of converting the temporary elastic ligature into a per-
manent one is as good as any, and saves time. The
pedicle was now fixed in the lower part of the wound after
all clots were removed from Douglas's cul de sac. In order
to prevent the pedicle from retracting, a staple was
passed through it, immediately above the constrictor.
The peritoneum was then sutured separately. The deep
sutures to close the abdominal wound were inserted
subsequently. Stitches were inserted as in other ab-
dominal sections and the wound dressed. The patient
made a very satisfactory recovery. Her temperature re-
mained normal for nearly two weeks. She and her baby,
as you may see, are enjoying the best of health.
405 California Building, Seventeenth Street.
PERMANGANATE OF POTASSIUM IN MOR-
PHINE POISONING.
By HILBERT B. TINGLEY, M.D.,
KCCKAWAY BEACH, M. Y.
On July 30th I was hastily summoned to see baby
C , eighteen months of age, who had taken two mor-
phine pills, one-quarter grain each. On arriving at the
house I found the child still conscious with pupils con-
tracted almost to pin point and as it was about 8.30 p.m.
I decided that I had an excellent case for the trial of
permanganate of potassium. I sent across the street for
the bottle of permanganate in the drug store immedi-
ately opposite, and gave about one grain at once, and as
I wished to give this drug a thorough trial, gave no
other medicine, not even an emetic. About n p.m. I
allowed them to put the child to bed, as it was then two
hours later than its bedtime, but before they did so, I
gave about one grain more of the permanganate. Dur-
ing the night the child had some delirium of a wild nat-
ure and had little sleep, but next day appeared none the
worse for its overdose of morphine. The result has
given me great faith in this drug in these cases.
To Elevate Woman.— A writer in an ethical journal
has a new idea for the benefit of women. It is that men
and women should deliberate together and establish a
rule that the woman's child bearing years should be very
much reduced in number, also that they should agree to
allow a longer period between the birth of children. The
lady does not go into particulars, so we are unable to
give the details by means of which these reforms are to
be made effectual.
NEW YORK ACADEMY OF MEDICINE.
Stated Meeting, October iS, 1894.
D. B. St. John Roosa, M.D., President, in the Chair.
Reports. — Dr. A. B. Judson, statistical secretary, and
Dr. M. Allen Starr, corresponding secretary, presented
reports. The recording secretary read a written report
from the Committee to the State Constitutional Conven-
tion, presented by its secretary, Dr. W. R. Pryor, a
synopsis of which has been published. Allusion was
made to the necessity for a committee on legislation,
and the President said he would at some other time
gladly entertain a motion to appoint such a committee,
as he felt there was great need of one in order to prevent
the passage of bad laws relating to medicine, as well as
to urge the passage of good ones. It was desirable,
however, in case there were any who might oppose such
a motion, to first give notice of its introduction, in or-
der that all might have a chance to vote on it as their
consciences dictated. But the fact could not be repeated
too often that the profession must make its wants known
if it would have them granted.
Defective Vision, in its Relation to Crime. — Dr.
Frank Van Fleet read a paper bearing this title. He
believed the human race had not altered since the be-
ginning ; that, at any rate, there had been no change
since the earliest time known to history. At one time
man roamed over the globe in herds, there being no
family ties, no laws, consequently no criminals. As
people multiplied, it became more convenient to settle,
to live in towns, and in families ; to have laws ; and
these being violated, crime came into existence. There
was a change of environment, not a change of man.
Heredity was a misnomer. Everything was due to en-
vironment. One who could control the education and
environments of a child could make of it what he
pleased. An English child put in Germany, and taught
only German, would grow up with no English character-
istics, and differ in no way from German children. If
one were to expect criminals to beget criminals, he
should also expect intellectual persons to transmit to
their offspring greater intelligence than those not intel-
lectual. The author asserted, however, that the only
influence which good parentage could have was to give
better training and set a better example during the de-
veloping period ; the sole influence of criminal parentage
was the bad example set during growth.
Man received his education through the senses. Any
of these might be defective, and warp his view of things,
or interfere with the race of life. But it was with de-
fective vision that the author was concerned. His
idea of the way in which this produced criminals
seemed to be chiefly, at least, that it detracted from the
individual's power to compete with his more fortunate
fellows. Mention was made of the fact, however, that
defective vision might cause one to take a warped view
of things. Examination of the eyes of a part of the
juvenile delinquents on Randall's Island, led him to
think there was defective vision in a larger percentage
of these persons than the average. Ocular defects
should be corrected as far as possible, and those which
were acquired, such as ophthalmia neonatorum, should
be prevented or arrested a.t once. A certificate of ocular
examination and proper treatment was more important
than one of vaccination among school children.
The discussion was opened by Dr. H. D. Chapin, and
continued by Drs. Joseph Collins, Frederick Peterson,
John E Weeks, the President, and the author. As far
as the gentlemen expressed their views, all disagreed with
the author, except with regard to the importance of at-
tention to defective vision wherever it existed.
Drs. Collins and Peterson especially criticised the
stand taken with regard to the overwhelming influence
57o
MEDICAL RECORD.
[November 3, 1894
of environment as compared with heredity, and failure
to refer to any other authority than an article by a po-
lice superintendent, when so many scientists had studied
and written upon the subject. Dr. Peterson had ob-
served that eye troubles were very common among the
Egyptians and Arabs, while crime was extremely rare.
Dr. Weeks thought the author had adopted a very
superficial way of examining the eyes at Randall's Island
institution, considering the point which he was trying to
prove. The fact that more than half of those examined
had been found to have defective vision was not aston-
ishing, when it was remembered that astigmatism was
present in about two thirds of all persons, while perfect
vision was very rare. In his opinion defect of vision
was not more productive of crime than defect of any
other sense.
Dr. Chapin spoke feelingly of the want of accommo-
dations in the eye hospitals and other institutions in the
city, for children suffering with inflammatory eye troubles,
especially those of a contagious nature.
Dr. Weeks and the President said this was not the
fault of the existing ophthalmic institutions, but of the
city officials, in failing to provide hospital accommoda-
tions for these patients. Dr. Weeks had found it possi*
ble to cure nearly all of the cases at the out-door depart-
ment, where the mother followed instructions and brought
the patient back for treatment daily.
SECTION ON GENERAL MEDICINE.
Stated Meeting, October 16, 1894.
William H. Porter, M.D., Chairman.
Case of Sporadic Cretinism. — Dr. Morris Manges
presented a case of sporadic cretinism which had once
been on exhibition in a dime museum and had once been
demonstrated before a medical meeting by Dr. Leszynsky.
The subject was a male, twenty- five years of age, forty-
nine inches in height, weight sixty eight pounds. He
was born of healthy parents in Posen ; the father was six
feet in height, the mother of ordinary size. Other chil-
dren in the family were healthy and normal. When
carrying the child the mother had haemoptysis. She de-
scribed.him as a little old man when born. He was always
dull and stupid The eyes were small, the forehead small,
the bones prominent, the folds on the forehead deep, the
scalp loose, the gait waddling, the hair dry and wiry,
thyroid gland apparently absent. Before treatment with
thyroid extract there was some infiltration of skin, par-
ticularly of eyelids. When irritated, the boy used
vigorous language. Since beginning treatment with
thyroid extract over two months ago there had been
loss of nine pounds in weight, the eyelids had lost their
oedematous appearance, the voice had become less stridu-
lus, the patient gave more attention to his surroundings,
the daily excretion of urea had increased from o 8 to
1.2 per cent. It was very doubtful, however, whether at
this late date the thyroid extract could manifest curative
properties or do more than somewhat ameliorate the pa-
tient's condition.
The speaker expressed surprise that so few cases of
sporadic cretinism had been reported in this country, the
whole number since Osier's first paper a few years ago
amounting only to sixteen, whereas it was pretty certain
that a good many cases were in existence.
Among the preparations of the thyroid gland which
had been tried on this patient were those of Parke, Davis
& Co., of Armour, and of Burroughs, Welcome & Co.
The latter had given the best results with the least dis-
agreeable effects. Twenty-five grains were now being
taken a day.
Dr. George W. Crary, to whose case Dr. Manges
had referred, said that since the publication of his case
he had received letters regarding sporadic cretinism from
all over the United States, which showed that the condi-
tion was not rare, notwithstanding the paucity of the re-
ported cases. By the use of the thyroid preparations we
could easily get rid of the glandular growths, could ren-
der the skin moist, and produce certain general improve-
ments in the patient's condition within a short time, but
it had not been at all decided that we could cause these
diminutive persons to go on and develop into complete
human beings. He had been disappointed in the slow-
ness of the improvement in his case. It was quite differ-
ent, however, with myxoedema, in which condition the
agent possessed wonderful curative properties. Like Dr.
Manges, his experience with other preparations of the
thyroid gland, including that which he had himself for a
time made, had been less favorable than with the tab-
loids of Burroughs, Welcome & Co. Unlike the former,
the tabloids did not cause rise of temperature and disa-
greeable effects upon the gastro intestinal tract, and the
dose with these was determined by the frequency of the
pulse instead of by the temperature.
One of the staff at the Vanderbilt Clinic said they had
been treating a child there a few months with thyroid
extract, and it had shown marked improvement.
Dr. Caill£ had seen some cases treated by thyroid
preparation, but could not say that there had been spe-
cial improvement.
Barly Local Treatment of Diphtheria and other Af-
fections of the Throat. — Dr. Francis H. Williams, of
Boston, read the paper. It was based on studies in diph-
theria in the hospital at Boston ; also in private practice.
It was assumed that at the beginning diphtheria was a
local disease. These studies had shown the value of
bacteriological examinations of the juices in the throat
in making an early diagnosis, especially in apparently
healthy members of a household in which there was one
known case of diphtheria ; of determining whether the
patient had become fully convalescent ; of the efficiency
of treatment by its destruction oi the bacilli. All pa-
tients, however, should be warned of tte possibility of
communicating diphtheria even after bacteriological ex-
aminations had ceased to show bacilli or diphtheria.
A few years ago the author had become convinced that
many local treatments were useless or injurious, and to
determine what was best turned to the laboratory.
Many germicides, while capable of killing the germs,
did so only in poisonous doses to the patient or by in-
juring the local parts. He found peroxide of hydrogen
a weak germicide in ordinary strength. He then found
that the efficiency of this agent was increased by the
presence of an acid. The two mixed acted more strongly
as a germicide than either did separately. The prepara-
tions in the market were not reliable either as to the
strength of the peroxide or of the amount of acid which
they contained. He made careful study and found that
where the membrane was thick and the case severe a fifty-
volume solution of the peroxide was not too strong if
one would disintegrate the membrane and reach all the
germs. For the hydrogen dioxide acted not only as a
germicide, but was specially valuable as a disintegrator of
the false membrane. The paper contained a series of
cases, showing that the fifty- volume solution was more ef-
ficient than the ten, and that where the former was used
the throat was free of germs of diphtheria and other
germs by about the fourteenth day, as against the twenty-
seventh day where the weaker solutions were used. Of
course the persistence of the germs varied with the se-
verity of the case. The strength of the solutions which
he now used varied from twenty five to fifty volumes, ac-
cording to the severity of the case. In a few days the
bacilli were found much diminished in number, and he
was strongly inclined to believe that where the Klebs-
Loe filer bacillus was present after the tenth day under
this treatment it was due to its being concealed in some
crypt?, or other hiding-place, and should be sought out
carefully. In some cases membrane remained after the
Klebs-Loeffler bacillus had disappeared, and was due
probably to the presence of the staphylococcus, which
was not so easily killed, and required the use of some
other germicide, as chlorinated soda.
Dr. Williams had used the stronger solutions of hydro-
November 3, 1894]
MEDICAL RECORD.
57i
gen dioxide in one hundred cases of diphtheria, of vary-
ing severity, in all the jliagnosis having been confirmed
by bacteriological examination. It did not injure the
mucous membrane. It could be used along with other
compatible germicides, or alternately. It should be
used early and until the germs disappeared. Applications
every hour or two. The operator should always see the
parts when making the applications. Use a spray, not
more than six pounds pressure. An ingenious apparatus
was exhibited for spraying the liquid. All gentleness
should be observed, and then harm would not be done,
and the patient would call for the treatment, since it
cleansed out the throat and nose and made breathing
easier.
Dr. George L. Peabody being called upon, made a
few remarks, but said he did not see enough cases of
diphtheria to speak with authority on local treatment.
The author had properly emphasized the importance of
early diagnosis and treatment, whatever the treatment
might be, if it were only beneficial.
Peroxide of Hydrogen Found Injurious.— Dr. A
Catlls mentioned the following facts: diphtheria is
endemic here; some years it is more plentiful than
others; it may be a mixed infection, and may kill by
the presence of either the streptococcus or the diphtheria
bacillus ; every local abrasion favors the development of
the germs, which may be present even in seemingly
healthy throats; prophylaxis by attention to the teeth
and mild germicides and cleansing of the throat and
mouth should be observed. Regarding peroxide of hy-
drogen, Dr. Williams's experience had not been in har-
mony with that of New York physicians. Beginning
with the meeting of the American Pediatric Association
in Boston a few years ago, the profession had given ex-
pression to its experience that peroxide of hydrogen ap-
plied to the throat in diphtheria caused irritation, gave
rise to new patches of membrane, and made the case
more formidable than it had been before. It seemed
impossible to apply chemical antiseptics to the mouth
and nasopharynx without doing injury, and he had
come to content himself with gentle mechanical removal
and cleansing by mild solutions of salt, boracic acid, or
pure water, through the nose.
Impossible to Disinfect the Air - passages. — Dr.
W. H. Park said he would only give his personal ex-
perience, and remarked that it was seldom that any two'
persons agreed in all respects. At Willard Parker's they
had tried whether it was possible to completely disinfect
the air passages, using even strong solutions of bichloride
and other agents for twenty-four to forty-eight hours, in
some persons who had no membrane in the throat, in
others in whom a membrane was present, but in no case
could they make the throat perfectly aseptic. In a cer-
tain number the Klebs-Loeffler bacillus did disappear,
but in others they were as numerous as if nothing had
been done. Even if the membrane quite disappeared
from view, germs would still remain and cause its devel-
opment elsewhere. He hoped to hear from Dr. White,
who had carried out treatment at Willard Parker's to
test the comparative value of bichloride, of peroxide,
and of simple salt solution. Bichloride, 1 to 2,500 in the
throat, 1 to 4,000 in the nostrils was used in one class,
peroxide of hydrogen up to twenty-five per cent, in an-
other, salt solution in a third. In all, the bacilli per-
sisted about the same length of time, or even longest
where the strong solutions were used. As to results, Dr.
White had noticed little difference.
It was very difficult to apply %swab without injuring
the member. They now tried simply to use a cleansing
solution, and to avoid irritation. He had been told by
Dr. White that very rarely did an adult or a person over
ten years old die of diphtheria.
Dr. Joseph £. Winters also thought that Dr. Will-
iams's experience with peroxide of hydrogen was entirely
different from that of physicians in New York. In fact
the frequent use of the agent increased rather than di-
minished the symptoms. He regarded it as impractical to
use any spray or atomizer in diphtheria in a child ; as to
adults, they almost always recovered, as Dr. Park had
stated. It seemed to him that he could not resort to any
form of local treatment in the mouth of a young child
suffering from diphtheria without running contrary to
the first indication in the management of these cases,
namely, not to exhaust the patient.
Experience at Willard Parker Hospital.— Dp. White,
resident physician at the Willard Parker Hospital, said
that his experience with peroxide of hydrogen in diphthe-
ria at that institution had been very unfavorable. All the
cases showed some signs of irritation from the peroxide.
His remarks confirmed those of Dr. Park with regard to
the danger of irritation in local treatment of the mouth
in children and with regard to the rarity of death in
adults with diphtheria. Cleansing with plain water or
normal salt solution was best.
Dr. A. Jacobi dwelt upon the clanger of making local
wounds in diphtheria of any size or nature, as they ab-
sorbed diphtheritic poison very rapidly and formed new
centres of infection. For twenty or thirty years he had
impressed the danger of wounds in the throat in times of
diphtheria. Bacilli were ubiquitous. The discussion at
the American Pediatric Association referred to by Dr.
Cailll, regarding the dangers incident to irritation
caused by peroxide of hydrogen, was based on a paper
presented by Dr. Jacobi. A striking example in which
the continued use of this agent had prevented perfect
convalescence and caused renewed attacks of diphtheria,
was that of a child which the speaker had been requested
to see in consultation with Dr. Cailll. He advised dis-
continuance of the peroxide, whereupon the child got
well.
Dr. Jacobi used only physiological salt solution, or
possibly mild boracic- acid solution, or lime-water, intro-
duced gently through the nose. It was criminal to bore
into the mouth of a child and try to pry open its jaws
while it was struggling and becoming exhausted. Besides
the affected parts could not be reached in that way, while
they could through the nose.
Dr. Williams, in some concluding remarks, reiterated
the points in his paper, that the peroxide must be strong,
it must be acid, and the treatment must be carried out
with gentleness. Only the remarks of Drs. Park and
White had a real bearing upon his paper, for they alone
had used a strong solution of peroxide, but that was neu-
tral, and therefore not efficient.
An Ectromelic Monster. — Dr. A. Schirman, of this
city, writes concerning a monstrosity "which he saw
about two years ago in Baltimore. He was called to
attend a woman in confinement. The child, a female,
was born dead. The frontal bone was undeveloped, the
parietal was flattened, the occipital was horizontal in
position, the temporal bones were very prominent.
There was a cleft palate, and the narrowed cranial cav-
ity contained no hemispheres. The mother was about
thirty years of age, and had given birth to several healthy
children and to two with cleft palate and hare-lip. No
dissection of the monster was allowed.
The Way of the Health Officer is Hard.— In Brook-
lyn there has been much dissatisfaction expressed in some
quarters with the health officer, and a petition for his
removal was circulated, and obtained a number of sig-
natures of those who thought he was too strict in enforc-
ing quarantine and vaccination during the prevalence of
small-pox. In Detroit the health officer has been de-
posed because it was said that he was too lax in enforc-
ing quarantine and vaccination during the prevalence of
small-pox. In Milwaukee, also, impeachment proceed-
ings have been begun in the common council against the
health commissioner, for the manner in which he handled
the small- pox epidemic in that city last winter. It is not
said whether he is accused of being too severe or too
lenient The sanitary via media is a very narrow path,
apparently.
572
MEDICAL RECORD
[November 3, 1894
fkncKtevon&euce.
OUR LONDON LETTER.
(From our Special Correspondent)
OLIVER WENDELL HOLMES— OBSTETRICAL SOCIETY — AB-
SCESS OF OVARY — MEDICAL SOCIETY OF LONDON — THE
PLEASURES OF MEDICINE AND SURGERY — BERIBERI —
CHELSEA HOSPITAL SCANDAL — MEDICAL DEFENCE UNION
— SMALL POX — DIPHTHERIA — DEATH OF MR. BUNCH —
SIR JAMES PAGET AT THE ABERNETHLAN SOCIETY — THE
CLINICAL SOCIETY'S FIRST MEETING — SMALL-POX — DIPH-
THERIA.
London, October 13, 1894.
My first word this week must be to express the sense of
loss we feel here in the decease of Dr. Oliver Wendell
Holmes. England, as well as America and all English-
speaking countries, were delighted by his genius, and
medicine may well be as proud of him as literature.
Since his last one hundred days in Europe he has been,
if possible, more one of us than ever, and his death is
the one talked-of topic of the week among medical and
literary men.
The Obstetrical Society was the first to meet this year,
and set to work with a full programme on October 3d.
Specimens were exhibited of tubal abortion and of preg-
nancy in a rudimentary uterine horn, by Dr. Remfry ;
of myoma removed by abdominal hysterectomy, by Dr.
Cullingworth ; of fibrocystic tumor, by Dr. Lewers ;
and the following by Dr. Duncan : dermoid of left ovary
with pedicle twisted from left to right, cystic sarcoma
of omentum, sarcoma of ovaries, and malignant disease
of omentum. There were some interesting remarks on
these specimens by Mr. Bland Sutton and others. Dr.
Cullingworth read the paper, which embodied three cases
of pelvic inflammation attended with abscess of the
ovary and some clinical remarks on the terminations of
such abscesses, the illusory character of temporary sub-
sidence of the symptoms in some cases of severe pelvic
inflammation. He said that an analysis of eighty three
cases, in which he had performed abdominal section for
non-cellulitic pelvic suppuration, showed that in a large
percentage there was ovarian abscess which was, next to
salpingitis, the most frequent form of non-cellulitic sup-
puration. Dr. Galabin supported the view held by the
author, that the suppurative inflammation was communi-
cated from the tube to the ovary, but this was contro-
verted by Dr. Hayes, and Dr. Griffith believed that the
ovarian suppuration was usually the result of septic in-
flammation of the broad ligament. Dr. Lewers recalled
a case in which he found the inflammatory process be-
tween the layers of the broad ligament in the stage of
phlegmon, but in the adjoining ovary a small abscess
containing about a drachm of pus. The president (Dr.
Herman) mentioned two cases differing somewhat from
Dr. Cullingworth's, one of which showed the chronicity
of the process, and proved that with our present knowl-
edge the patient might have been saved twenty years of
suffering.
The Medical Society began work on Monday last,
when the president (Sir William Dalby) delivered an
address on the " Pleasures of Medicine and Surgery," in
which he proposed to show that our pursuits may so oc-
cupy us as to raise them to an art in its highest sense,
and will then give us all the delights which art gives to
its votaries. He limited the pleasures to mental proc-
esses, excluding those of sensation and, therefore, those
which appeal to the eye and the ear. The exercise of
the imagination, he said, was one of the greatest pleas-
ures, and he saw in some the enthusiasm of the explorer,
and gave illustrations from both medicine and surgery.
The activity of the imagination is the mark of genius in
poets and artists. If the mental processes are the same
in one who establishes a great advance in medicine,
should he be denied the attribute of genius ? He wished
to place our art side by side with literature and the arts,
and held that it is worth cultivating not only for its
utility but for the pleasure of those engaged in it. Poe-
try and literature give pleasure of two kinds, emotional
and intellectual, and although in some instances they
are both operative, there are forms of literature of which
the enjoyment is purely intellectual, the emotions re-
maining untouched. So he claimed for medicine a
family relationship with the arts and literature, and a
share in the intellectual pleasures they give.
The outbreak of beriberi in the Richmond Asylum,
Dublin, continues. There have been 149 cases, of
which 1 7 have died. Possibly some other cases have oc-
curred, for in some of these it came on so insidiously
that it would have, perhaps, been overlooked but for at-
tention being directed to the epidemic. Some army
surgeons who have seen beriberi in the East have visited
the asylum and they observed differences in the clinical
manifestations of the Dublin cases, but these they seem
to think may be accounted for by the difference of cli-
mate. If the disease is really beriberi it has for the first
time obtained a footing in these countries. Some cases
have, indeed, been brought in ships, but it has never
spread. Yet this outbreak at Dublin, whatever it may
be, has spread very rapidly. This is attributed to over-
crowding, always an important point in this disease, and
temporary hospitals are being erected to relieve this.
On Wednesday last (October 10th) there was a gen-
eral meeting of the Governors of the Chelsea Hospital
for Women, when the committee gave a report and of-
fered their defence and resignation. Some sarcastic
criticisms were offered on the conduct of a Board which
had been publicly condemned proceeding to elect a new
staff and offer suggestions for improved management
This Board actually asked for power to suspend or dis-
miss any medical officer who had acted in a manner det-
rimental to the interests of the hospital. What this
means is obvious from the declaration of the Chairman
that some of the staff who had not been reelected had
injured the hospital by circulating a statement of their
own defence. And yet men are to be found ready to
accept this ignominious position with the glaring fact of
the injustice to their predecessors confronting them.
And we call ourselves a united profession and prate
about ethical conduct !
The Board also announced their intention of appoint-
ing consulting physicians of eminence from those who
held office at the general hospitals. Now Sir Spen-
cer Wells, Dr. R. Barnes, and Mr. Hutchinson were
the consulting officers. They have resigned and evi-
dently in disgust. It is well known that they disclaim
any part in the election of the new staff, and condemn
the conduct of the Board in proceeding to the election.
If this condemned Board can find obstetricians attached
to general hospitals ready to succeed these celebrated
consultants, such fresh consultants ought to be ostracized
by the rest of the profession.
Notwithstanding the conduct of the Board a resolution
was carried not to accept their resignation — so the hos-
pital is left tp the same management which has been
condemned in two special reports as well as by the
Home Secretary — a strange comment on our methods
of management and an agreeable prospect for the physi-
cians who are willing to accept appointments terminat-
ing yearly as the humble servants of such a Board.
Meetings of members of the Medical Defence Union
have been held in London, Manchester, Birmingham,
and Bristol to discuss the steps taken by the council in
the litigation respecting Drs. Bloxam and Collie. At
these meetings suggestions were offered as to the avoid-
ance of such litigation in future, and at each meeting
confidence was expressed in the council. So we may
hope that controversy is closed. It is a pity that all
concerned in medical defence do not unite their forces.
Small-pox has abated lately, but diphtheria has in-
creased. This last disease has carried off another prom-
ising young member of the profession, Mr. F. V. Bunch,
F.R C.S., Surgical Registrar of University College Hos-
November 3, 1894]
MEDICAL RECORD.
573
pital, who contracted diphtheria from a patient in the
wards and died on the 5th inst.
London, October 19, 1894.
Sir James Paget opened the one hundredth session of the
Abernethian Society on the nth inst. with one of his fe-
licitous addresses. He said he was not aware that it was
the centenary of the Society or he might have prepared
some account of its history. It was quite as well that he
did not, though he would, I doubt not, have been able to
make the dry bones of such a history live. He said it
was sixty years since he joined the Society. It is rather
rare certainly for anyone to address a society after sixty
years' membership, though I believe outside the profes-
sion this from time to time occurs. Sir James repudiat-
ed the notion that a man could not be a scientist and
general practitioner at the same time, and urged his au-
dience to add well-observed facts to the general store,
illustrating the necessity of this by myxoedema, first ob-
served twenty years ago when little was known about
the thyroid gland, but the result of that observation was
now a larger knowledge of the thyroid than of many
other organs. The questions as to relations of mixed
diseases were brought forward and tuberculosis and can-
cer named as to which facts were needed. Then the fal-
lacies of diagnosis were spoken of, and as they might lead
to unexpected actions of drugs, a natural transition was
offered to the subject of therapeutics. Then Sir James
urged that all the sciences must work together not as
enemies or rivals perhaps, but the practitioner must
avail himself of the knowledge afforded by all without
allowing himself to be unduly influenced by any one of
them.
But I need not give any further account of the ad-
dress. Suffice it to say that Sir James received on the
occasion one of those enthusiastic ovations to which he
has long been accustomed, and that the crowded audi-
ence seemed more than usually delighted.
The Clinical Society of London opened the session
Friday last with distinctly practical work. Dr. J. M.
Bradford related a case of aneurism of the basilar artery.
On admission, at 7 p.m., the patient was partially uncon-
scious, axillary temperature, 980 F. ; pulse, 70, irregular
and intermittent. No paralysis. Respiration, irregular.
Abdomen not retracted. Pupils equal and medium
sized. Deep reflexes increased. Patient rather restless.
At 9 p.m. he became comatose, and the respiration be-
came infrequent, ceasing at 10 p.m. Artificial respira-
tion was kept up for four hours, but the pulse then failed,
and he died at 2. 10 a.m. Temperature at midnight 970
F. No convulsions occurred. Autopsy showed numerous
gummata in the liver and a fusiform aneurism of the
basilar artery, which had ruptured, the extravasation
forming a blood-clot one- fourth of an inch thick on the
under surface of the pons and medulla, and extending
round the sides of the medulla into the fourth ventricle.
Dr. W. Hale White described two cases of intra- cra-
nial aneurism. The first was that of a woman, aged thirty-
four. There was a large amount of clot on the under
surface of the brain, it extended to the fourth ventricle
and was one-eighth inch thick all down the spinal canal
in the subarachnoid space. The second case was that
of a man who suddenly fell down insensible and was
brought to the hospital. On admission he was uncon-
scious, the pupils were fixed and dilated, the eyeballs
were prominent. The breathing became difficult and
he died seven and one half hours after admission. Blood
clot was found in both the subdural and subarachnoid
cavities nearly all over the surface of the brain ; and it
had extended along the sheath of the optic nerve, ulti-
mately getting under the retina. The hemorrhage came
from a small aneurism springing from the right internal
carotid just at its termination. The whole of the rest of
the body was absolutely healthy.
Dr. J. £. Paul read the notes of a case of acute pan-
creatitis in a man of forty-three years of age, who died
eight hours after admission. Temperature rose to 1040
F. just before death. The peritoneum covering the
pancreas was found to be glued with recent lymph to the
posterior surfaces of the stomach. The pancreas itself was
much swollen, and hemorrhages were to be seen, most
numerous in the tail. Stomach and duodenum healthy.
The rest of the organs healthy, except cloudy swelling
of kidneys. No fat necrosis. Microscopic examination
showed considerable disintegration, with total destruction
in parts of the structure of the pancreas. Numerous
hemorrhages were to be seen, and clumps of crystals of
hsematoidin.
Dr. Soltau Fenwick described two cases of fatal form
of tetany associated with chronic dilatation of the stom-
ach. One was that of a carpenter, aged thirty- four, who
stated that for six months he had suffered pain in the
stomach after meals, and attacks of vomiting. The other
had had symptoms of ulceration for four years, was sud~.
denly seized with tonic spasms of the extremities after an
unusually severe attack of vomiting. The condition
closely resembled true tetany, and the seizures were re-
peated several times.
This complication of chronic dilatation of the stomach
was first recorded by Kussmaul in 1869, and twenty-six.
cases have been published since. In the majority the
gastric symptoms had been present for years, and in
ninety-two per cent, of the cases which came to a ne-
cropsy a chronic ulcer in the vicinity of the pylorus was
found to be the cause of dilatation of the stomach. In
every case the tetany followed severe vomiting, the at-
tacks lasting from one hour to several days. In seven
cases the condition was further complicated by seizures
of a tetanic nature, in which trismus and opisthotonos
were usually marked symptoms, while in three others
epileptic convulsions supervened. The disease is ex-
tremely fatal, out of the twenty-six instances eighteen*
terminated in death. The rational treatment which has
met with some success is the regular employment of
lavage, either warm water or a weak solution of resorcin.
being used.
Dr. Holman said that Dr. Ogle, of Reigate, had de-
scribed to him a case of a patient who was admitted to-
the Cottage Hospital for severe vomiting. The stomach
was found to be much dilated. The patient had two-
attacks of tetany and died in the second. At the au-
topsy no sign of ulceration was found, but the stomach-
reached far below the umbilicus.
Mr. Eve then read the notes of a case of tuberculosis-
lymphangitis of the arm following a sore on the finger.
The patient was in good health three years later but was
afterward lost sight of. It appeared probable that an
ordinary whitlow had been inoculated, perhaps in wash-
ing a handkerchief soiled with tuberculous sputum. For
the purpose of establishing the diagnosis, guinea pigs
were inoculated with pus from the abscesses, with posi-
tive results. The case was illustrated by colored draw-
ings and photographs.
A similar case, described by Turner, was quoted, in
which the patient succumbed to general tuberculosis^
and this or phthisis is the usual termination of such
cases. Tuberculosis- lymphangitis almost invariably fol-
lows superficial lesions and usually the cutaneous inocu-
lation of tubercle. In one case it was an anatomical-
tubercle, in another a warty tubercle on the back of the
hand, and in three other cases the patients were women
who developed nodules on the fingers while nursing
their phthisical husbands. Stress was kid on the neces-
sity of an early diagnosis so that the disease might be
extirpated as soon as possible by erasion of the abscesses
and removal of the nearest chain of lymphatic glands.
The President, Mr. Hulke, referred to the account of
tuberculosis following inoculation in a surgeon, who
accidentally inoculated his own hand, which ultimately
ended unfortunately.
Small-pox has declined in London. No deaths from
it were registered last week and only nine fresh cases
were notified. The cases remaining under treatment for
the last four weeks have been respectively 100, 98, 84,.
and 63.
574
MEDICAL RECORD.
[November 3, 1894
Diphtheria has also declined. The deaths for the last
three weeks have been 67, 66, and 54* This number is
19 more than the corrected average for the week. The
disease is widely distributed over the different districts.
CAR SANITATION.
To the Editor op ths Medical Record.
Sir : The short reference to Dr. Cann's paper on " Car
Sanitation/1 prompts me to write you of some of the
observations made by myself recently regarding this
matter.
What the Doctor says of the all prevailing amount
of carbonic-acid gas in the cars is beyond question the
rule in all cars save the drawing-room variety, especially
in winter time.
Sufficiently noticeable, however, is this great amount
of poisonous gas for those of us who took a train each
day from early spring during all the summer months to
note the fact, and seek an unoccupied car put on a sta-
tion above where we boarded the train. Of course be-
fore our car had gone far it was as bad as the rest, but
the system so quickly adapts itself to circumstances that
we did not particularly notice the (act — but did, of
course, have the headaches that go with the inhalation
of this vitiated air.
Bad as all this is, it is by far the least objectionable of
a lot of other unhealthful things to be noticed upon the
trains. Not long since I noticed a filthy looking spot
on the plush-covered back of a seat in front of me, and
it took only a glance to see that some " filthy hog," as
the lady with me observed, had been riding there before
us, and had expectorated very disagreeable looking pus
or muco-pus on this seat back.
If one's mind reverts to the fact that the germs of any
one of several diseases may have been lurking in that
dried sputum he feels uneasy and wants to change his
seat, which, if the car is full he cannot do, and if he can
accomplish it how shall he know that the next seat is bet-
ter than the one vacated, since not all disease germs re-
qiire a visible medium of transportation.
The unfortunate custom of covering that portion of
the back of the seat which presents itself in front of each
seat with plush or some other dirt-absorbing substance
is a thing easily remedied, for there is no reason why
thin hard wood should not be used instead.
As to the disposal of germs in the cars there is a very
simple and not very expensive way of doing this. If a
compartment into which each car could be run and re-
main for two hours after each trip should be so con-
structed that a temperature of, say 2400, could be main-
tained, all animal life would thus be destroyed.
There are many other things tending to convey dis-
ease and death. Take the matter of the handling of the
ice for the ice-water tanks. You shall see men with
dirty, ill kept hands, handling the ice in those filthy
hands and putting it at once into the tank, wiping their
hands on already very-much soiled trousers, and then
repeat the operation with the tank in another car.
Then too there is the question of where the water itself
is obtained. On one of our leading railroad through
trains for the West, the water is supplied from the Jersey
City water, which is taken from the lower Passaic River,
a notably unhealthy stream because of sewage from fur-
ther up, as note the cases of typhoid fever in Jersey City
and Newark until recently.
All this is easily avoided, and the State should see to
it that the water be taken from pure sources and the ice
also, besides seeing to it that the companies provide suit-
able means of carrying ice without the men handling it.
Minor matters, like the ridiculous custom of the one
sitting next a window being the sole arbiter of whether
the window shall or shall not be open ; if open it may
chance to let in very objectionable draughts on every one,
as very many suffer bronchitis, etc , from it, or possibly
smoke, cinders, and dust may cloud the car, and all suffer
because of the carelessness or stupidity of the one pas-
senger who claims the right to control this particular
window.
It is quite true that all these matters would entail some
care, possibly some expense on the companies if they are
to be corrected, but certain it is that these matters all
require attention and none of them are at all trifling, but
of grave moment to the lives and health of the travelling
public. W. Washburn, M.D.
THE DANGERS OF -NIGHT CALLS.
To the Editor op thb Medical Record.
Sir : In the daily papers of Thursday and Friday of last
week appeared sensational reports of my appearance in
the Jefferson Market Police Court as complainant against
a man whom I believed had robbed me. The injustice
which this publication has done me is of so grave a nat-
ure that I beg you to print the actual facts of the case,
which are as follows :
At about 3 a.m. Thursday morning I left my house
to visit a patient, in answer to a messenger call to West
Forty-second Street. I went directly there, arriving
about 3.30. I left there at about 5 AM. Arriving in
Seventh Avenue on my way home I stopped at a public
house and ordered a sandwich. While paying my check
at the cashier's desk I was jostled by three men, and a
roll of bills which I had returned to my pocket was taken
by one of them. The man ran out upon the street and
I quickly followed. I called a policeman, and, together
we started in pursuit of the fugitive, who sought refuge
in a public place one or two blocks above. I identified
the man, and caused his arrest. I went to the station
house with the policeman and his prisoner, and made
my charges against him. A little after eight o'clock I
appeared against the prisoner in Jefferson Market Court,
before Justice Hogan. I was asked by the Justice if I
was drunk at the time of the robbery. I indignantly
and truthfully answered "No." The policeman was
then ordered to make the charge against the prisoner.
In his written statement, I found the following : " De-
fendant was arrested on the complaint of Dr. Phelps,
who had the appearance of being drunk, and was under
the influence of liquor." I quietly asked the policeman
to charge me with being drunk, and to sign his name to
it When he declined to do so, I tore up the statement,
not knowing that it had been signed by the Justice — if
it had been. The Justice then held me in {200 bail for
contempt of court. By permission I went for bail to
the house of Dr. George Evans, 49 West Thirty-ninth
Street, and soon returned. The Justice imposed a fine
of 1 5 and discharged me.
In support of the above I can furnish statements — 1.
From my patient, showing that I had not been drinking
and was not intoxicated when I left the house soon after
5 a.m. 2. From Dr. W. O. Plimton, 19 West Eighty-
fourth Street, my medical associate, snowing that I was
not intoxicated immediately before I went to the police
court; and 3. From Dr. Evans, showing that I was not
intoxicated thirty minutes after the trouble in court —
however excited I may naturally have been at that time.
I would deem such explanations entirely unnecessary
for those who know me, but in view of the widely pub-
lished statements in the public press I deem it incum-
bent upon me to put in a general denial.
With this brief presentation of the case, showing that
I was assaulted and robbed while in the performance of
professional work, such as calls a physician to any part
of the city, I will say nothing more, but will leave the
whole matter to the judgment of the reader.
A. M. Phelps, M.D.
[It is obviously unnecessary to dilate on the facts of
the case. To anyone who knows Dr. Phelps the charge
of drunkenness is ridiculously absurd. Indeed it would
scarcely be worthy of notice save to offset a widely pub-
lished scandal, in which insult was added to injury, and
proper redress was apparently out of the question. —Ed.]
November 3, 1894]
MEDICAL RECORD.
575
Hero Snstroraeuts.
A NEW NASAL FORCEPS.
By SAMUEL GOLDSTEIN, M.D.,
NBW YORK.
SINIOR ASSISTANT SURGEON, NBW YORK THROAT AND NOSE HOSPITAL ; ASSIST-
ANT SURGBON, OUTDOOR DSPAKTMBNT, MOUNT SINAI HOSPITAL.
How frequently, in the examination of the no6e, the sur-
geon finds hypertrophy or exostosis of the inferior turbi-
nated bone, of such a nature that only removal of this
obstruction will afford the radical relief the anxious pa-
tient seeks.
The patient comes to you and enumerates his symp-
toms : of having cold upon cold in the nose ; the nos-
tails being alternately obstructed ; obstructed very often
to such an extent that he does not breathe through one
nostril, and barely with the other. He seeks radical relief.
In a large majority of cases we are told that all forms
of treatment have been tried, including cauterization
with chemical caustics, and the actual cautery. These
msthods of treatment have given him temporary relief,
as the mucous membrane, which was only part of the
trouble, was reduced in size ; the main cause of the trou-
ble being still in situ. He further tells us that he does
not wish to be continually under treatment, but wants
such operative measures enacted as will rid him of his na-
sal obstruction.
The question naturally arises, can we place such a pa-
tient in a condition that when we discharge him we
can truly say that his nasal obstruction has been re-
moved ; that he may still contract a slight nasal inflam-
mation, not as readily as before, and of such a nature
that very simple treatment will be effectual ? How are
we to accomplish this end, should the cause of the trou-
ble be due to hypertrophied inferior turbinated bone?
The answer to this query, from the results experienced
at the New York Throat and Nose Hospital, and my
own, is in the removal by saw and forceps of a sufficient
amount of the hypertrophied inferior turbinated bone.
The objections that are usually made to the operation are,
I fully believe, of little weight. I will enumerate such
as I usually hear, and endeavor to meet them in detail.
We are told that this bone has a function, and should
not be removed, even in part ; that the operation is at-
tended with too much shock; that the hemorrhage is
excessive, often uncontrollable, and is so great that the
patient becomes exsanguinated; that the operation, as
done under cocaine anaesthesia, is too painful for the or-
dinary patient ; finally, that the results do not justify the
means.
I fully concur with the statement that the inferior tur-
binated bone, in its normal state, has a function, and ap-
preciate that thoroughly. May I, however, ask, what
surgeon would hesitate to remove an extensive exostosis
in any other region of the body ? It is only when the
inferior turbinated bone is so hypertrophied as to cause
obstruction, that this part is to be removed.
In all of the operations that I have witnessed, and in
those that I have performed, there has been so little
shock, that the patient, in a comparatively short space
of time, was able to retire, and in some cases, resume
his usual vocation. Hemorrhage, there, necessarily is,
greater or less, depending upon the condition of the
nose ; but never so great as not to be within the control
of the operator ; in the main so slight as only to ooze
for a short time after the operation, and perhaps for
twenty-four hours later. That there is some pain at-
tending the operation is most true ; but it can be min-
imized by the skilful surgeon, who performs the opera-
tion in a comparatively short space of time ; and fur-
thermore, much more quickly by the aid of a forceps
that will grasp the detached segment of bone firmly, and
permit immediate withdrawal of the same.
I hardly believe that it is necessary for me to state
that the operation is done in a worthy cause, that the
end amply justifies the means. Anyone who has seen
the mouth breather, whose nostrils were obstructed with
hypertrophied inferior turbinated bone, and who has re-
moved such obstruction, knows the gratitude felt by his
patient for the immediate relief afforded.
For the purpose of making the time consumed in
operating as short as possible, to minimize the pain, pos-
sible shock, and hemorrhage, I have planned and had
this forceps made. The nasal forceps now in use have
their inner flanges serrated, or partly serrated and tun-
nelled.
There is always a flow of blood resulting from sawing
through the bone ; after the bone has been sawn, and
the segment hangs pendent, attached only to mucous
membrane and perhaps some cartilage, the forceps is
applied to grasp the segment for removal. Here con-
siderable difficulty is met. The blood fills in the serra-
tions, making the surfaces of the flanges of the forceps
slippery ; upon their withdrawal we are surprised not to
find the segment in its grasp. We tell the patient to
blow his nose to clear the field, and read j 1st the forceps,
and repeatedly meet with similar disappointment upon
their withdrawal. This is disappointing and discourag-
ing to the average operator. By this time the segment
may be entirely detached, and slipped to the floor of the
nasal fossa toward the posterior nares. The forceps is
applied and re applied often fruitlessly. This having
consumed much time, much, if not all, of the cocaine
anaesthesia has worn off, and further manipulation
of the parts becomes painful to the patient, who
has also been made nervous through delay.
To prevent this delay, unnecessary manipula-
tion, and contusion of the parts and subsequent
pain, I place this forceps before you, hoping that
it will prove as satisfactory and efficient with you
as it has been to me in my work. The forceps
consists of two blades with scissors handles. The
flanges at the end of the blades are about the
size of the hypertrophied portion of bone usu-
ally removed. The inner surfaces of the flanges have
five pointed uprights, and between the uprights are per-
forations through which the uprights pass when the
forceps is clamped. The inner surfaces of the flanges
are also serrated to make the clamping more secure The
blades are bent and strong, the joint connecting them
especially so. At the handle is a spring catch that can
be used at will, to insure a more thorough grip after the
forceps has been clamped.
The working mechanism is simple : After the hyper-
trophied segment of bone has been sawn through and
hangs pendent, the forceps is clamped over it, and when
once placed properly, the pointed uprights piercing the
bone, the forceps is closed, the catch sprung tightly, and
then there is no possible chance for slipping to take
place. Then the segment can be twisted off and re-
moved from the nostril ; or if not sufficiently sawn, the
forceps is twisted toward the septum, the saw re -intro-
duced at the side of the forceps, the remnant detached, and
the segment removed. This, when properly done, rend-
ers the operation expeditious and successful. This part
of the operation, usually occasioning so much delay, with
the aid of this forceps consumes the least amount of time.
All parts of the forceps can be detached for cleaning.
I am indebted to Messrs. George Tiemann & Co. for
the skilful execution of the plans.
x66 East NiNKTif-THiPD Street.
576
MEDICAL RECORD.
[November 3, 1894
IJfcedical Stems.
Placarding Contagious Diseases in Tenements. — The
following official document has just been issued by the
Health Department of New York :
" Charles F. Roberts, M.D., Sanitary Superintendent.
" Sir : We desire to direct the attention of the Board
of Health to the necessity for the adoption of some
more adequate means to prevent the extension of conta-
gious disease in tenement- houses and apartment-houses,
and particularly for the enforcement of isolation of per-
sons sick with these diseases. The methods which have
been long employed in the Health Department, i.e.,
frequent visitation and instruction by Department inspec-
tors, have been found to be only partially effective. It
has been the custom for years in cases of contagious dis-
ease for the inspectors of the Department to visit the
families of the sick persons, inform them as to measures
of disinfection and methods of isolation, and at the
same time to notify other families in the house of the
existence of a case of contagious disease in a given
apartment. This method of giving publicity to the case
and of warning other occupants of the house is ineffective
in the accomplishment of the desired end; i.e., the
complete isolation of the patient and the prevention of
further infection. Notifying all the inmates of a large
tenement is a very difficult matter, and, if notified, ex-
perience has shown that they soon forget the existence
of illness in the house. Repeated inquiries have demon-
strated the fact that frequently many of the inmates
of a house where there is a case of contagious disease do
not know of the existence of any sickness. Further than
this, this method fails entirely to protect strangers or
visitors who may go to the house or apartment. Ladies in
search of servants have been repeatedly found in houses
or in apartments where cases of contagious disease were
present, and servants who have been living with families
where there are cases of contagious disease, on obtaining
situations frequently go to their employer's house carry-
ing infection with them ; or, when relieved from duty
for an afternoon or evening, visit families where there are
cases of contagious disease, and not infrequently carry
infection back to the houses in which they are employed.
Very commonly washing or various kinds of sewing is
secretly done by other members of the family in apart-
ments where such cases are ill, and the garments thus in-
fected on the premises are later returned to the owners.
In small shops business is sometimes carried on, and in
one of several instances recently a number of cases of diph-
theria were directly traced to an infected candy-store.
" Notifying inmates of the house is ineffectual, further,
because it has been found that, as a rule, intercourse of
families in tenement-houses is not with others in the
same house, but with families which live in other houses,
and the latter are entirely unprotected by the methods at
present followed. It has seemed to us, after careful con-
sideration of this subject, that the desired object would
be best obtained by the placarding of apartments in
tenement-houses where cases of contagious disease exist,
and we therefore have the honor to recommend that
hereafter the Chief Inspector of Contagious Diseases be
authorized, in his discretion, to placard apartments in
tenement houses where there are cases of contagious dis-
ease. The following considerations may render still
more apparent the necessity for this action: 1. Under
the present conditions it is impossible to prevent strang-
ers and visitors from entering apartments where there
are cases of contagious disease, and they or their clothing
thus frequently become infected and either they contract
the disease themselves or they transmit it to others.
These strangers or visitors are usually not aware of the
existence of disease in the house or apartment, and un-
wittingly expose themselves and act as media for the
dissemination of the disease. If the apartments were
placarded, this means of dissemination would be pre-
vented. 2. In diphtheria, as has been repeatedly and
abundantly shown by the investigations of this Depart-
ment, patients are often apparently well long before they
are free from the infectious agents, and in spite of re-
peated warning from Department inspectors these pa-
tients, especially when children, mingle with other chil-
dren and thus transmit the disease to them. This is one
of the most common and important means for the dis-
semination of diphtheria, and it is of no less importance
in scarlet fever and measles, as in the latter diseases
desquamation frequently continues many days after the
patient has apparently quite recovered. 3. There are at
present no means by which other inmates in tenement-
houses can know when convalescent cases of contagious
disease have ceased to be dangerous. They can only be
governed by appearances, which, as we have seen, are
deceptive. If apartments where cases of contagious dis-
ease existed were placarded, isolation would be enforced
by the other occupants of the house until the department
inspectors allowed the placard to be removed. 4. The
moral influence of such placards, both upon the inmates
of the apartments, the inmates of the house, and strangers
or visitors to the house, would be of as great service in
enforcing isolation and preventing extension of disease
as the visits and instruction of our inspectors. It has
been found impossible, even where daily visits were made
by medical inspectors, assisted by the sanitary police, to
enforce the isolation of children convalescing from diph-
theria and scarlet fever after the serious symptoms have
disappeared. It is undesirable at such times, unless ab-
solutely required, to remove such patients to the hospital,
and yet in the eruptive fevers this is the period of the dis-
ease when there is greatest danger of transmission to
others.
" During the last year we have had a serious epidemic
of diphtheria to deal with. The number of cases re-
ported weekly during the last months, however, has
steadily decreased. The schools have just now opened,
Mid it seems to us that the most strenuous efforts should
be made to prevent a new outbreak of the disease or its
reintroduction to the schools. This measure would be
of undoubted service in accomplishing the desired object.
We would recommend, therefore, that placards should
be nailed to the outside doors of the apartments in which
cases of contagious disease are present, when in the judg-
ment of the Chief Inspector of Contagious Diseases this
course seems to be desirable, and that the placards should
bear the following inscription, differing as to the name
of the disease in question and as to color. The color
for diphtheria should be white ; for scarlet fever, red ;
for measles, blue.
Diphtheria.
All persons not occupants of this apartment are noti-
fied of the presence of diphtheria in it, and are warned
to avoid entering it until this notice is removed. The
persons sick with diphtheria must not leave the apart-
ment as long as this notice remains here.
The removal or defacement of this notice is forbidden.
By order of the Board of Health,
President.
Secretary.
" For some months in certain classes of tuberculosis
the system of placarding apartments has been authorized
and employed by the Health Department, and has proven
very satisfactory in the attainment of the object desired.
The only objection apparently to be urged against this
measure is that the inmates of the apartment may object
to the publicity thus entailed. This, however, is exactly
the object which the measure is justly and properly de-
signed to subserve, and is, in our opinion, the strongest
argument in favor of its adoption.
1 ' (Signed) Respectfully submitted ,
" Hermann M. Biggs.
" Pathologist, and Director of the Bacteriological Laboratory.
"A. H. Doty,
" Chief Inspector of Contagious Diseases."
Medical Record
A Weekly yournal of Medicine and Surgery
Vol. 46, No. 19.
Whole No. 1253.
New York, November 10, 1894.
$5.00 Per Annum.
Single Copies, ioc.
Original %rXit\t&.
ON SYMPHYSEOTOMY, WITH THE REPORT
OF A NEW CASE.1
By HENRY J. GARRIGUES, A.M., M.D.,
COMSULTIKG OBSTETRIC SURG BON TO THE NSW YORK MATERNITY HOSFIT7 L ;
GYNECOLOGIST TO ST. MARK'* HOSPITAL OP NEW YORK CITY, ETC.
When I had the honor of reading my last paper on sym-
physeotomy before the Obstetric Section of the Pan Amer-
ican Medical Congress, in the month of September, 1893,
I said that taking the/w and the cons into due con-
sideration, I thought that the next time I bad the op-
portunity of performing the operation I should try the
Italian method first, and so I did in the following case,
that presents several points of interest in regard to the
indication, the operation, the course, and the result.
Pelvic Tumor; Large Child; Italian Method; Wad-
dling Gait. — Mrs. G. V. D , aged twenty-nine, Ger-
man, married, was admitted to St. Mark's Hospital on
June 27, 1894. She had had one child, eight years ago,
which died at the age of eleven weeks. She had been
suffering from dysmenorrhea for yearst and menstruation
had been very irregular of late. She last menstruated in
August or September. For three months she had been
suffering from lumbar pain, and for two from anasarca.
Labor pains began at four o'clock in the morning. She
had been examined by a midwife, who said she was preg-
nant, and by a doctor, who said she had an ovarian cyst,
and abstracted some fluid with a hypodermic syringe
through the abdominal wall. She had considerable
anasarca all over, especially the face, hands, abdomen,
and legs, and on boiling about one-sixth of the urine
coagulated. She was in labor. The os was situated far
forward over the symphysis and measured two inches in
diameter. Bag unbroken. Vertex presentation. Foetal
heart very distinct, one inch to the left of and above the
umbilicus.
At 4.30 PM, the os was fully dilated, but the head made
no progress, being pressed forward over the symphysis
pubis by a soft, non fluctuating mass in the rectovaginal
septum, extending nearly up to the cervix. The heart-
sounds had become so weak that they were heard with
difficulty. I proposed to perform symphyseotomy, in
which my colleague, Dr. Boldt, who happened to come to
the hospital, and whom I requested to examine the pa-
tient, concurred. After thorough disinfection and the
patient being in the dorsal decubitus with bent knees and
raised feet, I made an incision in the median line two
inches long and ending one- half inch above the symphysis.
Small transverse incisions were made right and left, just
above the pubic bones, and just long enough to admit the
left index finger, which was easily inserted down to the
lower end of the symphysis. A few small blood-vessels
were clamped. Next, Galbiati's falcetta was introduced
along the finger. The bones were in close contact and
the notch at the lower end of the symphysis could not be
felt. There was slight difficulty in finding the symphysis,
but once found it was easily cut from below upward, and
from behind forward, using the left index finger as a guide
in the vagina, and having the urethra held by an assistant
over to the right side with a metal catheter. By reintro-
ducing the finger into the wound I felt that the ends of
■ Read before the New York County Medical Society, October as,
1804.
the bones were only separated ore inch, especially at the
upper end of the symphysis, and less at the lower, where
they were bound together with a sinewy tissue (part of the
subpubic ligament) which was easily ruptured. The head
descended immediately and was easily extracted with for-
ceps without any tear of the vagina or the perineum. The
child, a female, weighing ten and three-quarter pounds,
was dark blue, the heart- beat very slow, no respiration,
and the meconium pouring out from the anus. Seeing
the great danger of the child, I removed it to another
room and concentrated my whole attention on its re-
vival, leaving the care of the mother to Dr. Boldt, who
saw a large artery spurting in the cervix, which he tied
with catgut carried round it with a curved needle. The
placenta was expressed by Credo's method, and two hypo-
dermic injections of twenty-five minims of fluid extract
of ergot given.
The child having been revived I returned to the
mother and found by actual measurement a distance
of five inches (12.5 ctm.) between the pubic bones,
merely due to the weight of the thighs, which were be-
ing kept bent, but without pressure on the trochanters.
Then two assistants were directed to bring the ends of
the bones together by pressing on the trochanters, while
I held back the bladder and vagina. There was slight
venous bleeding from the bottom of the wound. Four
silk sutures were inserted through the edges of the wound
in the soft parts; nothing was done to the ends of the
bones ; the wound was packed with iodoform gauze, the
end of which was led out at the lower end of the wound
while the three upper sutures were tied. The vagina
was likewise tamponed with iodoform gauze. While the
pelvic bones were kept together, and the legs were kept
extended, three straps of rubber adhesive plaster, two
inches wide, were drawn round the pelvis and the tro-
chanters, and crossed in front above the wound. The
vulva was covered with my pad.
The next morning the gauze was removed and the last
suture tied. The child was large and in excellent con-
dition.
Centimetres. Inches.
Occipitomental diameter 14 54
Occipitofrontal diameter 12.5 5
Biparietal diameter 10 4
Bitemporal diameter 8 3$
Circumference of head 38 15
Length of body 56 22
Circumference of chest at arm- pit 38 15
Bisacromial diameter 13.5 5±
On the third day after the operation the mother de-
veloped incontinence of urine, which lasted a few days.
The urine contained many cells from the kidney epi-
thelium and numerous casts from the circumvoluted,
straight, and narrow tubules ; but these, as well as the
anasarca and albuminuria, disappeared soon.
July 3d (Sixth day). — She had a rise in temperature
reaching 1030 F., probably due to mastitis, bard, ten-
der nodules forming in both breasts, but disappearing in
four days under the use of ice-bagp. But the fever may
also have been partly due to suppuration at the wound.
July 4th. — There appeared slight suppuration round
the stitches, which were removed. The edges were
united by first intention, but the following day half an
ounce of pus was pressed out from an opening at the
upper end of the wound, and a thin drainage tube, three
inches long, was inserted.
July 7th. — The patient, who was rather self willed,
578
MEDICAL RECORD,
[November 10, 1894
lifted herself on the bed -pan by arching herself on her
shoulders and heels, without any pain.
July 10th (Thirteenth day). — She took a few steps,
supported under her shoulders, and felt solid. On the
12 th the upper two thirds of the symphysis were felt in
perfect apposition, while at the lower end there was just
room for the tip of the finger. The plaster straps being
loose were renewed.
July 1 8th. — The distance between the bones was only
one-eighth to one-sixth inch. The tumor in the pelvis
had entirely disappeared, and must, therefore, probably
have been due to serous infiltration, like that forming
the anasarca. Only the left ovary was felt swollen way
up in front of the left iliac synchondrosis.
July 20th. — She walked alone by holding on to the
furniture ; on the 26 di she walked without support and
amused herself by carrying food to other patients.
July 31st (Thirty-fourth day after the operation). —
She left the hospital by her own request.
O a October 9th I saw her and her child. The latter
was in excellent condition, and the mother could lift it,
but she had a waddling gait, some cystocele, and off and
on pain in all the three j )ints of the pelvis ; but she
said she was improving. By vaginal examination I
found the greater part of the ends of the pubic bones in
apposition, but at the lower end the diastasis had in-
creased to half an inch.
The subject of symphyseotomy has attracted so much
attention during the last two years that I may suppose
every member of this Society is familiar with the chief
features of it, and I have twice treated it at some length.1
I shall, therefore, to night, limit myself to the discussion
of some particular points upon which opinions differ
much among the different authors engaged in the dis-
cussion of this operation, basing my opinions not only on
the limited experience I have had with it myself, but on a
somewhat extended study of the cases reported by others.
First, however, I shall briefly call attention to some
features of the case I have just reported. The distance
of five inches between the ends of the pubic bones is
q lite unusual. As a rule it is only one and one-quarter
to one and one-half inches when you hold the legs
flexed without pulling. How much it was before and
during extraction of the large child I could not tell. The
child being in the greatest danger of dying, there was
no time for such investigations. What I can state for sure
is that I did not meet with any resistance in extracting,
and that no cracking sound was heard, such as is reported
invariably to be distinctly audible when the sacro iliac
joints are overstretched and ruptured. Perhaps the
great serous infiltration which produced the anasarca of
the whole body and the swelling in the pelvis for which
the operation was performed may have caused an unusual
laxity of the sacro iliac joints.
Secondly, I would notice the miserable condition of
the patient's kidneys, the microscopical examination
showing that all parts of the same were affected, and the
circumstance that the patient had been examined by one
midwife a ad three doctors without antiseptic precautions.
Either of these circumstances would have excluded
recourse to the Cesarean section, and if Porro's opera-
tion had been performed, she would undoubtedly have
died. Forceps and version being out of the question, on
account of the disproportion between the size of the
child and the space left in the pelvis by the tumor, the
only alternative would have been to kill this splendid
child, weighing nearly eleven pounds, while symphyseot-
omy allowed us to save both mother and child.
It is true the mother has a somewhat unsatisfactory
gait, but it is better to waddle through life than to be
put at rest under ground.
Passing to the consideration of the operation in gen-
eral, I shall limit myself to remarks on its prognosis, its
indications, its methods, and the question by whom and
where it ought to be performed ?
» American Journal of the Medical Sciences, March and April,
1893, and American Journ il of Obstetrics, November, 1893.
Mortality. — A chief point to be taken into considera-
tion in ventilating the advisability of performing a certain
operation is, of course, the prospects it. offers as to life
and health. In his large work on symphyseotomy Neuge-
bauer 1 has collected 213 cases of modern operations per-
formed between the beginning of 1887 and the middle
of 1893. ®f ^e mothers 183 recovered, 27 died, and
in 3 cases the result was unknown ; that is, a maternal
mortality of 12.85 VeT cent- As to the children the re-
sults were unknown in 8 cases. Of the remaining 205
children, 7 were dead before the operation ; 9 died dur-
ing parturition ; 189 were born alive; but of these 31
died soon, leaving 158 as permanently saved. The di-
rect infantile mortality was, therefore, only 4 54 per
cent., but counting those who died within a few days as
lost the mortality among the children was 20.2 per cent.
In connection with these general statistics it must
however, not be overlooked that the operations were
performed by a very large number of operators, e.g.,
the first twenty-eight American operations by twenty-three
different operators, and often in private houses, so that very
few men have acquired a large personal familiarity with the
operation, and that it often has been performed with defi-
cient antiseptic precautions. At the hands of men ac-
customed to obstetrical and gynecological operations
there has hardly been any maternal mortality. Thus we
find Pinard operating 18 times and Zweifel 23 times
without losing a single mother, and the Italians have,
since January 1, 1886, had 55 operations with a loss of
only two women.2 We are therefore warranted in saying
that performed under the most favorable conditions there
is practically no maternal mortality inherent in the opera-
tion.
For the child the outlook is not so good, but still bet-
ter than in most other methods of delivery, not to speak
of craniotomy, with which symphyseotomy especially
competes, and by which the child is deliberately killed,
and here again the skill of the operator has diminished
the mortality considerably. Thus in the above-men-
tioned 55 Italian operations only 8 children were lost,
i.e., 14 55 per cent.
Injuries. — Several operators, especially German,
have reported cases in which the soft parts of the mother
sustained considerable injuries — the urethra, the bladder,
and the vagina being togi during extraction. On ac-
count of the greater firmnes3 of the tissues this is more
likely to happen in primipare. The bladder and the
vagina may also be caught in bringing the pubic bones
together. The sacro-iliac joints have been ruptured and
separated. Such accidents may, however, to a great ex-
tent, be avoided by extracting the child slowly and in
the proper direction; by avoiding pressure in front;
if necessary, by performing episiotomy ; by keeping the
protruding vagina and bladder back during approxima-
tion of the bones ; and by not passing the proper limits
of the indications. Most of these injuries were success-
fully repaired either by immediate suture or by a consec-
utive fistula operation.
On the other hand, it cannot be denied that a certain
number of women develop a waddling gait. That this
is not so very rare will appear from the fact that I have
had one such case in two operations, Grandin one in
four operations, Zweifel three in twenty- three operations,
and Fritsch even four in four operations.8 But if this
waddling gait does not look well, it need not interfere with
perfect health and strength, even allowing the woman to
do the hardest field-work and carry her eleven months'
old baby many miles, as in a case reported by Fritsch.
Indications and Comparison with Other Methods. —
Since only a few years have elapsed from the time of the
new impetus given to this old operation in 1892, it is
quite natural that opinions in regard to its proper field
should vary much among leading obstetricians, and one
1 Neugebauer : Ueber die Rehabilitation der Schamfugentrennung
oder Symphyseotomie, Leipzig, 1893, pp. 272 and 276.
• Harris : Gynecological Transactions, 1894, vol. xix., p. 254.
* Centralblatt fur Gynakologie, 1893, p. 1097 ; ibidem, 1894, pp. 347.
46a
November 10, 1894]
MEDICAL RECORD.
579
has even the impression that national tendencies to preju-
dice in favor of or against it have not been without in-
fluence on the bias of the different authors. Thus, while
Leopold rejects the operation altogether in primiparae,
and wants it limited in regard to the flat pelvis to cases
of 6 to 7# ctm. (= 2^ to 3 inches) true conjugate, with
both mother and child perfectly healthy ; 1 Pinard thinks
it must replace introduction of premature labor and every
operation which exposes the head of the child to a pel-
vic resistance that cannot be overcome by uterine con-
tractions.2
Personally I think symphyseotomy ought to have a
rather wide range in lying-in hospitals and under circum-
stances that favor a good result, especially sufficient as-
sistance and the possibility of having a reasonable de-
gree of asepsis. In the flat pelvis I think we may expect
an easy delivery when the conjugate measures at least
three inches, and that it may yet be performed when the
conjugate measures only two and three fourths inches.
To go b:low this is hazardous, unless the child is abnor-
mally small.
The great gain obtained in the lateral directions make
symphyseotomy particularly valuable for us on account
of the preponderance of generally contracted pelves in
New York and Boston, and perhaps other parts of the
United States. As to the upper limit for symphyseotomy,
it ought, in my opinion, to be placed in a flat pelvis at
a true conjugate of three and one-half inches, and in a
generally contracted even at four inches.
Symphyseotomy may render good service under other
circumstances than a narrow pelvis, such as pelvic tumor,
occipitoposterior position, impacted mentoposterior face
presentations, ear presentations, in eclampsia, etc.
In studying foreign authors on the indications for
symphyseotomy in narrow pelves, it should be borne in
mind that the average weight of new-born children is
considerably greater in America than in Europe. Lusk
found the average of two hundred cases in Bellevue Hos-
pital to be 7^3 pounds, while 'Tarnier gives it as 3,174
grammes = 7 pounds, Spiegelberg as 3,174 grammes =
6 fa pounds, and Playfair at only 6l/2 pounds. We can,
therefore, not descend so low as European accoucheurs do,
and must place the upper limit for symphyseotomy higher.
Craniotomy on the living child is a repulsive opera-
tion that has met with just condemnation from many
sides. As long as the alternative was only Csesarean
section, I did not hesitate to sacrifice the child in order
to save the mother, but since in symphyseotomy we have
got an operation almost without danger to the mother
and with moderate danger to the child, I do not think
any man should feel compelled to, or justified in, delib-
erately murdering the child, provided the necessary con-
ditions for a successful symphyseotomy can be brought
about.
Induction of premature labor entails only a maternal
mortality of five per cent, against nearly thirteen in
symphyseotomy. In skilful hands there is hardly any
mortality for the mother in either of these operations,
but then the infantile mortality is very high,' and many
premature children die.4 In cases in which the mother's
life is to be preferred, which is the rule, and we see the
patient in time, recourse may, therefore, be had to in-
duction of premature labor; but in cases in which the
mother is particularly anxious to have a child, symphyse-
otomy at term should be preferred.
In Csesarean section the infantile mortality is only six,
against twenty in symphyseotomy, but then the mater-
nal mortality is twice as large in Csesarean section,
twenty-five against twelve and one- half per cent., and if
we only take the most skilful operators, the mortality of
symphyseotomy is practically none, against eight per
cent, in Csesarean -section. One must, therefore, be a
1 Centralblatt far Gynftkologie, 1894, p. 448.
•Ibid., p. 348.
• Forty-three per cent according to Wyder, Arch, t Gynilk., 1888,
voL xxxii, p. 60.
* According to Winckel two-thirds, Gynecological Transactions,
1894, vol. xix.,p. 255.
fanatic worshipper of the latter operation in order to
think ot performing it when the former is practicable.
Besides, Caesarean section is only indicated in aseptic
cases.
Symphyseotomy competes even with Porro's operation,
since it has been successfully performed after the patient
had been in labor for days, and bad been examined with-
out antiseptic precautions. But Porro's operation has a
maternal mortality of 37.78 per cent., and an infantile
mortality of 22.40 per cent.1 If the condition of the
patient is not too bad, and there is no absolute indica-
tion for Caesarean section, symphyseotomy should, there-
fore, be preferred.
Even difficult forceps and version operations ought to
be replaced by symphyseotomy. If the true conjugate
is three inches or more it may be well to try the forceps
before performing symphyseotomy as recommended by
Morisani,* but below that we only jeopardize the child's
life, and perhaps the mother's too, by using the forceps.
I have a painful recollection of cases in Maternity
Hospital of generally contracted pelves with the male
type, in which with all my strength I extracted a dead
child, its mother dying within a few days, so that I even
resolved in similar ones to perfoim Caesarean section, but
now would substitute symphyseotomy. Furthermore,
all those cases we read about of three strong men pulling
at once or in succession on a pair of forceps ought to be
relegated to the history of barbarian times.
As to version, we well know how difficult it is to get a
living child through the pelvis, if there is any apprecia-
ble narrowness. If the conjugate is less than three and
a quarter inches, both veision and the high forceps opera-
tion entail much greater danger for the life of both
mother and child, to which must yet he added the dan-
ger of the child becoming idiotic or epileptic. If the
child is unusually large, 'symphyseotomy comes in as a
life saving operation for both mother and child, even
when the pelvis is normal.
This paper has already become so long that there is
no time left for me to enter at length into the question
of the modus operandi. I shall only recommend the
Italian method as much the simpler one, which also has
given better results than the French.
Instead of the chain-saw needed in rare cases, which
is expensive and difficult to render aseptic, Gigli recom-
mends rough steel wire.8 It is not necessary to unite the
ends of the pubic bones with silver wire (Schauta), or,
to hammer steel pegs into them and draw them together
with silver wire (Regnier),4 or to have special apparatus
to press on the trochanters, as proposed by Pinard, Kof-
fer, Bidder, and Krassowski.* Rubber adhesive plas-
ter carried round the pelvis, while the legs are kept
straight, is sufficient for a good union. I think it is bet-
ter to leave a rubber drainage-tube behind the symphysis
for a few days. The extraction ought to be made while
the knees are kept bent, and not, as advised by Leopold,6
in the suspension position (Hangelage), which brings the
ends of the pubic bones together. Four assistants are
needed, and at least one of them ought to be an expert,
as the child often is asphyctic, and there may be maternal
hemorrhage demanding immediate attention.
Who shall Perform Symphyseotomy ?— In laying
down rules for the indications of symphyseotomy I have
only treated the question from a purely scientific stand-
point, as it ought to be, without taking into consideration
what every practitioner may be capable of doing. When
a man has a cataract, it ought to be taken out : whether
a particular physician is competent to do so or not, that
is a question between him and his patient. But just as
everybody is not a fit person for extracting a cataract,
thus a man may be an excellent physician and still not
be the right man to have a symphyseotomy performed
» Playfair : Sixth American edition, 1893, by Robert P. Harris.
*Morisani : Centralbl. f Gynak., 1894, vol. xviii., p. 346.
8 Gigli : Centralbl. f. Gynak. , 1894, p. 12a
4 Centralbl. f. Gynak., 1893, vol. xvii., p..75a-
6 Ibid., 1893, pp. 75a and 937.
• Leopold : Centralbl. f. Gynftk., 1894, vol. xviii., p. 45<>-
58o
MEDICAL RECORD.
[November 10, 1894
by. Nobody should undertake this operation who is not
an operative gynecologist or a general surgeon with ob-
stetrical experience. In some cases very serious hemor-
rhage has to be dealt with, in others severe injuries of
delicate and important organs demand immediate re-
pair, and in most the child has to be artificially revived.
This is, therefore, an operation which most general prac-
titioners had better place in the hands of a fellow- prac-
titioner with experience in that kind of work, just as he
would send a patient afflicted with a cataract to an ocu-
list
Where should Symphyseotomy be Performed ? — As it
is next to impossible to perform an aseptic operation in
most private dwellings, especially of the poor, who are
much more likely to require symphyseotomy than the
rich ; as many and skilled assistants are needed ; and as
the after-treatment often is quite complicated; the
chances for a good result with this, as with all major
operations, are much better in a hospital than in private
houses. Wherever it is possible, patients requiring
symphyseotomy should be removed to a hospital, be it a
lying-in hospital or another institution where abdominal
operations are usually performed. Such a place in this
city is St Mark's Hospital, and I shall be happy to treat
any case there you will place under my care. It is, in
my opinion, no excuse for killing a child that the ac-
coucheur is not prepared to perform symphyseotomy, as
long as there is somebody else within reach whose ser-
vices can be obtained, and who is able to substitute a
life-saving for a destructive operation.
SURGERY OF THE STOMACH.
By W. J. MAYO, M.D./
ROCHESTER, MINN.
SUKGBON TO ST. MARY'3 HOSPITAL, ROCHESTER, MINN. J IX- PRESIDENT OP
THE MINNESOTA STATE MEDICAL SOCIETY \ MEMBER OP THE STATE BOARD OP
HEALTH.
Mr. President and Members of the Southern Min-
nesota Medical Society : The stomach is now amena-
ble to surgical relief from a large number of conditions,
which until recently have been supposed to be purely
medical ir* character, and in many respects it offers un-
expected opportunity for operative interference. In the
first place, it is an organ more or less fixed within a cer-
tain definite part of the upper abdomen. In the second
place, in a large majority of instances it can be irrigated
and rendered fairly clean before operation. In the
third place, by rectal alimentation it can be given rest
afterward ; and lastly, its thick muscular walls afford a
good hold for suture, while its blood supply is of such
nature as to give union after extensive resections, herein
differing materially from the thin -walled, mesentery-
nourished intestine with more or less constant vermicu-
lar action. I will not take up your time with the anat-
omy of the stomach, more than to mention that its
cardiac extremity is the only fixed point, and that it is sus-
pended, so to speak, in such a way as to vary its position
whether contracted or dilated. In the former case,
lying deep under the liver against the crura of the dia-
phragm, and in the latter occupying a prominent posi-
tion in the hypogastrium. The lesser omentum, as con-
taining the main blood-vessels, is of much surgical
importance, as are also the relations of the mesocolon
and other delicate structures in the neighborhood of the
pylorus. As pointed out by Tillaux, the cartilage of the
ninth rib forms an important, guide to the lower border
of the stomach. The diagnosis of gastric disease, as a
rule, is not difficult. The stomach can be distended by
ether, as recommended by Felitzet, or by the use of bicar-
bonate of soda and an acid, as practised by Jacobi.
Usually, the introduction of a definite quantity of water
will sufficiently mark its outline, and by forcing air into
the colon per rectum, as practised by Senn, the relation
of the stomach to the transverse colon can be mapped
out. By such means, I was able to diagnose a pancreat-
ic cyst definitely, the tumor being shown to be retro-
peritoneal and lying behind the gastrocolic omentum,
the operation proving the diagnosis. (Case 13499 St
Mary's Hospital Records.)
The value of the examination of test meals and the
amount of acid as affecting the diagnosis of cancer, is
thoroughly laid down by Von Jaksch in his " Clinical
Diagnosis," the presence of free hydrochloric acid being
a factor in the diagnosis as against cancer and in favor
of ulcer. The effect of the weight of tumors in displac-
ing the stomach is ably shown by Osier in a series of
papers, beginning in the New York Medical Journal of
February 3, 1894. As preliminary to operation upon
the stomach, irrigation is of great value where it can be
practised, and, as pointed out by Kussmaul, much
benefit may be derived from lavage where obstruction
exists below, thus relieving the stomach of irritating
material, removing the distention and interference with
breathing, and putting the patient into better condition
for operation. Shall the stomach be distended previous
to operation, to facilitate finding it? I have personal
reason to know, in at least two operations, that where the
stomach is contracted from stricture of the oesophagus
and the colon greatly dilated through rectal alimenta-
tion, the difficulty of finding the stomach may be great.
In these cases the stomach was found by the sense of
touch, for after a little expeiience the feel of its thick
walls will not be forgotten. Previous distention may
assist in finding the stomach, but it complicates the
further manipulation and introduces an element of dan-
ger of wound contamination from escape of its dilating
contents. I believe it had best be empty. The after-
treatment of gastric operations is changing toward the
earlier administration of food by the stomach, especially
in exhausted patients, although rectal feeding is the rule
during the first few days.
Before closing these general considerations, I wish to
call attention to gastric distress produced by traction of
adherent omentum. Billroth has written well upon this
subject, especially in reference to the small buttons of
omentum protruding through little gaps in the upper
abdominal wall. Koenig reports some twenty cases
operated upon. I have seen several cases of this de-
scription (863 and 1059, St. Mary's Hospital Surgical
Record). The first, a boy of fifteen, with a small hernia
of adherent omentum protruding through a little defect
in the median line above the umbilicus. The second, a
lady of fifty, with adherent omentum in a femoral hernia,
both cases having no local symptoms at the site of pro-
trusion, and both relieved by operation. I have also
seen some cases of this form of omental adhesion with
corresponding symptoms in connection with post opera-
tive ventral hernise. Wounds and injuries of the stomach
are to be treated on surgical principles, and where evi-
dences of perforative wounds are found operative re-
pair is imperative. Rose speaks of persistent vomiting
of blood as a reliable sign of gastric injury. In case
there be injury to the head at the same time, however,
the possibility of there having been blood swallowed
from the upper passages should be borne in mind. For-
eign bodies in the stomach are a not infrequent cause of
danger and suffering, and gastrotomy for the purpose of
removal has been greatly perfected. Richardson, of
Boston, gives a careful analysis of reported cases, and
makes many valuable modifications in the technique, when
the foreign body lies in the lower oesophagus. Bull also
reports excellent work in this direction. The value of a .
potato diet in the non- operative treatment of foreign
bodies of the alimentary canal, should not be forgotten.
Fistulae are, as a rule, the result of operative work, and
rarely come from accidental or pathological causes.
They vary much in the difficulty of repair on account of
location, those adjacent to the bony framework being
much more difficult of operation than those more remote.
The great value of the provisional suture to prevent es-
cape of stomach- contents during manipulation, is at once
apparent. Chronic dilatation of the stomach, when not
due to organic lesion, may be caused by chronic gastric
November 10, 1894]
MEDICAL RECORD.
581
catarrh with sagging of the fundus, rendering it difficult
for the stomach to empty itself. Taylor, of Birming-
ham, has studied this condition carefully, and believes
that it produces a kinking at the pylorus with prominence
of the mucous fold, causing a bar-like obstruction to the
emptying of the stomach. He practises operative dila-
tation of the pylorus with success. Bircher, followed by
Weir, mechanically raises the fundus, and reduces its
size by putting a longitudinal plait along its walls, turn-
ing a fold into its cavity. This operation is indicated
in those cases where lavage for a length of time has failed
to relieve the symptoms.
Ulcer. — In the diagnosis of ulcer, the age of the pa-
tient, the quantity of the vomit, the lack of emaciation,
which in ulcer is more often a profound anaemia without
great loss of flesh, the presence of free acid, and slow
course of the disease, are all valuable symptoms of ulcera-
tion as against carcinoma. Operation may be demanded
for acute perforation, provided it can be diagnosed in
time. As can readily be perceived, the location of the
perforation, whether on the anterior or posterior wall,
will greatly influence the ease of repair. Ulcer of the
stomach being most frequent on the posterior wall, occa-
sionally a perforation may take place and the escaping
material, on account of its mechanical surroundings, be-
come encapsulated as a sub diaphragmatic abscess. Weir
points out the frequency of left pneumothorax due to the
secondary results of perforative ulcer. A case of sub-
diaphragmatic abscess came under my care. (No. 1,537,
St. Mary's Hospital Surgical Record.) A Scandina-
vian, fifty years of age, with history of chronic stomach
trouble, became suddenly ill, developed pain, and later,
cough and hiccough. A deep swelling became manifest
in the sixth interspace just to the right of the sternum,
for relief of which he entered the hospital. A deep
incision was made and pus evacuated ; but as a sinus
formed and failed to heal, the cartilages of the sixth and
seventh ribs and a large portion of the lower end of the
sternum were resected. The sinus was followed through
the diaphragm to the neighborhood of the lesser omen-
tum, where a small cavity existed; this was packed with
gauze and slow healing followed. The secondary results
of ulcer, in producing contraction at the pylorus, may call
for operation for obstruction, either the digital divulsion
of Loreta, or better the Heineke-Mikulicz pyloroplasty.
Weir reports a case of this character in which gastro-
enterostomy was performed, and in selected cases advo-
cates its expediency.
Cancer of the Stomaoh. — The age of the patient, lack
of free acid in the vomit, the emaciation, and the possible
presence of peptones and albumin in the urine, aid in the
diagnosis of cancer. Gussenbauer and Winiwarter
give sixty per cent, as the proportion of pyloric cancer
to the whole number. Bull, with statistics of thirteen
hundred cases of Stomach cancer, gives the proportion as
above fifty per cent, in the pylorus. Butlin, in his classi-
cal work, says of these cases, that a very large number of
cases of pyloric cancer die from obstruction before
glandular infection or extensive adhesion takes place.
Billroth, the great exponent of operative surgery of the
stomach, says that cancer of the pylorus produces great
muscular hypertrophy and death from obstruction in one-
half of the cases, before adhesions or glandular infection
supervene. It is probable, therefore, in the light of this
knowledge, that pylorectomy and partial gastrectomy
have a larger field than has been supposed, although
Butlin, in a careful analysis of reported cases subjected to
operation, takes a very gloomy view of the situation.
For cancer involving the cardiac orifice, gastrostomy is
advocated by Von Hacker for the purpose of feeding.
Lauenstein has been impressed by certain unfortunate
sequelae of gastrostomy in these cases, such as constant
leakage, involvement of the fistula, etc. With either the
Witzel or Frank operation of gastrostomy this objection
would not hold good, however. For cancer of the fundus,
Bernays, of St. Louis, practises gastrotomy and curet-
ting of the mass from within the stomach. He shows
that in the majority of cases the growth of the cancer is
toward its free cavity: The danger and difficulty of the
operation exceed the benefit to be derived from it, in my
opinion. In this connection an allusion to the remark-
able disappearance or temporary checking of the growth
of tumors after simple exploratory incision, would not be
out of place. Tait first called attention to this phenome-
non. J. W. White has gone extensively into this sub-
ject in regard to the curative value of operations of
themselves, independent of their intention. The total
disappearance of a cancer after simple abdominal incision
must be very rare, but I have twice seen temporary check-
ing of its progress after laparotomy. (Cases 368 and 571,
St. Mary's Hospital Surgical Record.) In cancer of the
stomach a varicose condition of the peritoneal veins
overlying the growth is frequently observed on laparo-
tomy, and is due to obstructed internal circulation leading
to adhesions. In one hundred and twenty-four opera-
tions on the stomach and intestines, Billroth gives a
mortality of fifty per cent.
Operations on the Stomaoh. — In stomach operations,
the abdominal incision for most purposes will be the
classical one of Fenger, parallel with the left costal car-
tilages, and, unless otherwise specified, is the one used,
excepting for fistula and other conditions where there is
no choice of locality. Gastrorraphy, due to the genius
of Billroth, may be performed for wounds and injuries,
the simple Lembert or a Czerny-Lembert suture being
applied. For fistulse, some special means of preventing
escape of the stomach contents during operation must
be used. The older method was to introduce a sponge
with attached string, and hold this firmly against the
opening. The provisional suture of the margins of the
fistula is a much better practice, and in many cases, by
trimming away the attached tissues afterward, can be left
as a Czerny suture and the Lembert applied to roll it in ;
or the stomach being brought well out, the whole of the
fistula may be cut out and the Czerny-Lembert suture
applied. In 1891 Bircher invented his operation for
simple dilatation of the stomach, by suturing a fold which
projects into its lumen with a Lembert suture. Weir
has practised this with marked relief.
Gastrotomy for Foreign Bodies. — Richardson, in
1886, recommended a large gastric incision and the in-
troduction of the whole hand, if necessary, to remove
bodies from the lower oesophagus. Much of our knowl-
edge of foreign bodies is due to his labors. Bull recom-
mends a small gastric incision, and with fingers intro-
duced, invaginates the wall into the stomach cavity. In
either case, several holding- sutures to manipulate the
stomach with are better than the fingers, which may slip,
or forceps, which may injure the vitality of the wound
margins. Gastrotomy for the purpose of curetting can-
cerous growths has been performed by Bernays, but
cannot be commended.
Gastrotomy for Dilatation.— In 1892 Loreta practised
gastrotomy for the purpose of digital divulsion of the
pylorus for obstruction. It can be performed for steno-
sis of either orifice of the stomach. J. W. Taylor has
made gastrotomy several times for the purpose of digital
dilatation of the pylorus, in cases of twisting at the neck
of the stomach due to chronic dilatation, and reports
successful cases. Heineke and Mikulicz, nearly simul-
taneously, performed pyloroplasty for cicatricial stenosis
of the pylorus. As ordinarily performed, a gastrotomy
is first made and a grooved director introduced through
the stricture from the stomach, the contracted tissues are
then divided by a longitudinal cut, and this incision is
now united in a transverse direction by suture. This
admirable operation has been performed by Senn and
many other surgeons, with the best of results.
Gastrostomy for the purpose of feeding is indicated by
any obstruction between the mouth and the stomach, if
it cannot be relieved by less dangerous and more expedi-
ent methods. First performed by Sedillot in 1849, it
has had a perilous existence, until in recent years the
method known as Fenger' s has usually been employed ;
582
MEDICAL RECORD
[November io, 1894
but its high mortality, the leakage, with its attendant
loss of nutrition and irritation of the surrounding skin,
made it but rarely resorted to. In preventing this leak-
age, Ferrier made the important suggestion that the gas-
tric opening be made high up near the lesser curvature.
Most operations up to this time were done in two sit-
tings, the stomach being first sutured to the abdominal
incision and the site of the future fistula marked by
ligatures, to guide the opening after adhesion takes place.
In a case oi impermeable cicatricial oesophageal stricture,
I was compelled to make a gastrostomy after this method
for the purpose of feeding, and for retrograde dilatation
and division after Abbe's string method. While the
eventual recovery was good, the annoyance of the con-
stant leakage was great. (Case 1,278, St. Mary's Hos-
pital Surgical Record.)
Hahn modified the operation by making the opening
in the stomach high up, and putting the fistula between
the ribs for better mechanical closure. This is done by
making an abdominal incision and locating the stomach,
then a special short incision in the eighth intercostal
space is made, and by passing forceps through this but-
ton-hole they can be applied to the proper place on the
stomach wall by the fingers in the large incision, and the
stomach fixed in the small opening, the abdominal inci-
sion being then closed. For retrograde dilatation of the
oesophagus Von Hacker's method should be preferred,
as, while it affords only a moderate degree of retention,
it permits of excellent intra-gastric manipulation. The
method consists of a perpendicular incision through the
body of the rectus muscle, which gives somewhat of a
sphincter action. Witzel's method is the best for tem-
porary fistula, as it gives perfect closure against leakage.
I have performed this operation once with the most per-
fect satisfaction. (Case 1,679, St. Mary's Hospital Sur-
gical Record.) After the usual incision the stomach
is drawn well out and a small cut made in its wall,
through which a rubber tube the size of a lead-pencil is
introduced one inch toward the fundus. With a Lem-
bert suture the free walls of the stomach are drawn to-
gether over the tube, beginning one inch to the left and
continuing to the right one and a half inch, forming a
channel lined with peritoneum. The stomach is dropped
back and sutured to the incision. The great advantages
of this operation are that feeding can be commenced at
once without any danger of leakage, and, on withdrawal
of the tube, the peritoneal granulation lining the chan-
nel will heal permanently. This is of obvious advantage
if the condition giving rise to the operation can be re-
moved. I can heartily commend this operation from
personal experience. Andrews, of Chicago, has modi-
fied this by free incision of the stomach and formation
of a channel from the mucous membrane. This is done
to avoid the use of a permanent tube, but has greater
danger of infection and is difficult of performance. For
permanent gastric fistula the method advocated by Frank
is undoubtedly the best. In this operation a fold of the
stomach one and a half inch long is drawn out and
sutured to the parietal peritoneum at its base. The
skin above the upper margin of the abdominal incision
is undermined along the seventh rib to a point over the
' sixth rib, where an incision three- fourths of an inch in
length is made. The stomach cone is now carried under
the skin flap and the apex sutured to this button hole ;
the abdominal incision is then closed, giving a spout-
like opening. This operation is a model one for the
purpose of a permanent fistula. Great credit is due to
Willy Meyer for the popularization of the Witzel and
Frank operations in this country.
Resections of the Stomach. — With these operations the
names of Billroth, Wolfler, and Czerny are inseparably
connected, and it was their courageous work in the face
of an appalling mortality which has made resection of
the stomach a legitimate operation. Pean, in 1 879, made
the first pylorectomy, though unsuccessfully. The mor-
tality of Billroth, the great exponent of pylorectomy, has
been nearly fifty per cent., deaths being due largely to
collapse, and a number to gangrene of the colon from in-
jury to the meso-colon while separating the pylorus.
This surgeon employs the transverse abdominal incision,
resects the stomach in a V shape, using a close Czerny-
Lembert suture in closing the gastric incision, and sutur-
ing the end of the duodenum into the lower angle of the
stomach wound. The separation of the pylorus is very
carefully done, and just sufficient of the greater and lesser
omentum tied off to permit of operation. The greatest
care of the meso colon must be taken. The tendency of
American and English surgeons, led by Bull, of New
York, McCormick, Treves, and Greig Smith, of Great
Britain, is to make the usual median abdominal incision,
and after the pylorus is separated, to at once completely
suture the stomach with the Czerny- Lembert suture. The
pylorus is now cut away from the duodenum and the end
of the latter sutured, gastro enterostomy* being then per-
formed. This carries the opening away from the danger-
ous suture line. Partial gastrectomy, as a rule, is a simpler
operation, Maydl having once removed nearly one-half
of the organ. Complete gastrectomy has been several
times attempted, notably by Conner, of Cincinnati, but
must fail on account of total destruction of the meso-
colon. Ohage, of St. Paul, in the midst of a partial
gastrectomy, was confronted by unsuspected difficulties
which rendered removal impossible. The stomach was
freely opened above, the malignant mass turned into its
cavity, and the upper cut edge sutured to the wall below
the growth. The patient not only lived, but for a space
of two years has been practically well up to the present
time. Gastro enterostomy is indicated by obstruction of
the pylorus, especially if this be malignant and not suited
for pylorectomy. It was first performed by Wtflfler in
1 88 1 , by suture, and up to the time of Senn's great innova-
tion in the use of bone plates for anastomosis, the mor-
tality was great — about fifty per cent. At the present
time, performed by the aid of bone plates or the me-
chanical device of Murphy, it is a rapid and safe procedure.
Postnikow has attempted to improve the suture operation
by freely incising the structures of the stomach and gut
to the mucous coat, which is ligated, and then suturing the
corresponding parts together, in the expectation that ad-
hesions will take place before sloughing of the mucous
coat completes the fistula. In all of these operations, if
the duodenum cannot be easily drawn to the stomach, a
loop of the jejunum may be used and drawn around the
omentum, which is pushed to the left rather than through
its folds. The latter practice has in several instances
caused death, from kinking of the intestine and obstruc-
tion.
Education and Cleanliness. — The Chicago school
board has been discussing the question of cleanliness, and
as a result, another innovation, the bath-tub, will be in-
troduced into the curriculum of certain schools in that
city. In several districts many scholars possess errone-
ous ideas regarding the proper degree of cleanliness, and
henceforth those presenting an unhygienic appearance
will receive a scrubbing. The boys will be immersed by
the janitor, and the girls will take their ducking under
the supervision of women who are employed as assistant
janitors. The board deemed it essential that a child
should know the value of soap and water, as well as the
double rule of three or the theory of the tides. The
plan to supply the schools with bath-tubs originated with
Mrs. J. M. Flower, who recently retired from a three
years1 service as member of the board of education, and
who is now a candidate for trustee of the State university.
This procedure marks another step toward clinical teach-
ing in the schools. Theoretical physiology has been
taught children for years, but it has not kept them clean.
Under the new rSgime pupils will be instructed in the
practical application of this science by demonstrations in
bathing, and proof of the superiority of this method of
teaching the phenomena of the human body will be
manifest on the surface. — The Physician and Surgeon.
November io, 1894]
MEDICAL RECORD.
583
A CONTRIBUTION TO THE STUDY OF THE
CAUSE OF STRICTURE IN THE MALE
URETHRA.
By CHARLES GETZ, M.D.K
BALTIMORE, MD.
The cause of stricture in the male urethra is a subject
which, it seems to me, has not received the amount of
attention its importance deserves in the majority of sur-
gical textbooks. Even in the special works upon the
subject of stricture, while exhaustive descriptions of
symptoms, diagnosis, and treatment are given, with clini-
cal illustrations ad infinitum, still, when the authors come
to consider the cause, they, with the single exception of
Sir Henry Thompson, have passed briefly over this im-
portant field. From those authors who have devoted a
few short paragraphs to the cause of stricture there have
originated ideas and theories so contradictory, in some
respects, that instead of throwing light upon the subject
they rather confuse the same.
By some writers inflammation, especially gonorrhoeal
inflammation, is given credit for causing most cases of
stricture. Others, again, differ, and in their efforts to
reach a correct conclusion concerning this disputed
point overstep the proper bounds by denying gonorrhoea
a place as an etiological factor altogether. Thus John
Hunter, one of the most profound surgical pathologists
of his time, in describing the relation of gonorrhoea to
the cause of stricture, says, " I doubt very much if it
commonly or even ever arises from this cause." 1 Against
this opinion we may array the words of Sir Astley Cooper,
who says, "If asked what was the cause of stricture, I
should say in ninety- nine cases out of every hundred it
was the result of gonorrhoea." 2 The writings of Hunter
show that he believed almost exclusively in a congenital or
anatomical cause for stricture, while the words of Cooper
prove that he considered the condition an acquired one
in nearly every instance. Both of these famous old sur-
geons were right, to a certain extent, in their convic-
tions, but as is the case with most vexed questions, the
truth lies between the two extremes ; and in the course
of my remarks I will endeavor to prove that in the ma-
jority of cases both a congenital defect and an acquired
pathological condition are essential to the formation of
close organic stricture.
Sir Henry Thompson, in his book on stricture, third
edition, page 120, give a table of cases, 220 in number,
in which the antecedent or supposed causes were as fol-
lows : Gonorrhoeal inflammation in 164 cases; injury to
perineum in 28 cases ; cicatrization of chancre in 3
cases; cicatrization following phagedena in 1 case;
congenital, including cases in which the urethra may
have been small from malformation, and those in which
marked irritability of the urinary organs existed from
childhood, accompanied by an unusually small stream,
6 cases ; poisoning by nitrate of potash, lithotrity, mas-
turbation, of each 1 case; inflammatory stricture, includ-
ing temporary stricture and retention from a sudden
acute inflammation, usually caused by some excess, and
disappearing by resolution, 8 cases ; spasmodic stricture
caused by irritation about the rectum, 2 cases ; spasmodic
stricture, no cause assignable, 2 cases ; spasmodic strict-
ure caused by undue acidity or alkalinity of the urine,
3 cases.
This table has been extensively quoted by other mod-
ern writers upon genito-urinary surgery and about repre-
sents the prevailing belief, as regards cause and effect
and the proportionate percentage of each, up to the
present time, with possibly two exceptions, namely, the
congenital variety and those attributable to masturba-
tion.
The former (congenital stricture), thanks to our mod-
ern exact methods of urethral exploration, are more aid
more frequently recognized. The latter (masturbators'
stricture)9 which from one case in two hundred and
1 Ricord and Hunter on Veneral Disease, page 151.
9 Surgical Lectures, reported in the Lancet, vol. iii.-iv., page 222.
twenty as quoted from Thompson's table has increased
(though I cannot accept the fact) proportionately to thir-
teen out of every one hundred cases, according to Dr.
Samuel W. Gross.1
Before entering fully upon the discourse cf the subject
I will preface my remarks with the admission that I ac-
cept every one of the causes of organic urethral stricture
quoted from Thompson's table as having an important
part to play in their formation, but with the exception of
the traumatic variety and those following the cicatriza-
tion of venereal ulcers, I claim that all the other stated
causes act secondary to pre-existing anatomical defects.
The chief source of error, so it appears to me, is that
most writers, in describing the lesion, seem to regard
the urethra as a tract anatomically perfect in structure
and physiologically normal in function until its owner is
unfortunate enough to acquire some form of urethritis,
then, after a variable period of time, the urethra, having
fretted under a lingering gleet, is examined, and if found
contracted at one or more points a diagnosis is recorded
of stricture — due to the variety of urethritis frcm which
the patient has suffered.
How many physicians, when confronted by a case of
stricture which seemingly may have originated as de-
scribed in the preceding paragraph, will pause to consider
how much the urethritis has had to do with the cause of
the stricture ? How can gonorrhoea, for example, make
such serious inroads upon the integrity of die parts?
The explanation, based upon anatomical grounds, is
simple. It is because all urethrse are not perfect in
structure. An overwhelming proportion have extensile
congenital defects of such a nature as to favor the perpet-
uation of inflammation and its sequelae once it has been
established. The urethra is not an exception to other
parts, but is as often the seat of irregular development
and malformation as is the nasal septum, the hard or
soft palate, the upper lip, and other structures in the
mesial line of the body which are formed by fusion of
opposite surfaces.
From the researches of the embryologist we know
that during the early period of foetal development the
genital furrow exists as an open tract, and that between
the third and fourth months the free edges of this tract
coalesce or fuse together, leaving a crevice which consti-
tutes the spongy portion of the urethra. Now it is co-
incident with this period and process of foetal develop-
ment that the first departure from perfect anatomy occurs.
The edges of the genital furrow may unite irregularly, the
normal limits may be exceeded at one or more points,
so that instead of a free tract capable of expanding
into an even open canal when required, we have bands
and narrowings more or less abrupt along this tract
which interfere with this free action. These congenital
bands, if not prominent enough in early life to cause
trouble, still are capable, even from natural laws, of ac-
quiring greater prominence, while if seconded by patho-
logical conditions they become formidable obstruction?.
These congenital bands, or, as we may very properly call
them, embryonic strictures, may be divided into two
classes according to the character of the tissue of which
they are chiefly formed.
The first and most common variety consists of folds
or puckerings of the urethral mucous membrane, but, un-
like the natural folds, they reduce the limits of expansion
at those parts of the urethra where they are situated.
They are permanent and cannot be obliterated by any
method of dilatation or condition of the penis. I say
condition of the penis, because Otis,2 in describing the
folds so frequently met with at the peno scrotal angle,
refers to a case where the folds disappeared during an
erection of the organ. Folds of that conditional charac-
ter are not included in this class. The true mucous fold
is a permanent structure, and no matter whether the
penis be flaccid or erect can always be demonstrated by
the bulbous bougie. This variety of congenital narrow-
1 Gross on Disorders of the Male Sexual Organs, 1st ed., p. 25.
* Otis, on Stricture of the Male Urethra, 2d ed. , p 212.
584
MEDICAL RECORD.
[November 10, 1894
ing is described by some writers as an adhesion of the
mucous surfaces. Englisch1 found forty six such exam-
ples in the urethral canals of new-born infants.
The second class of congenital narrowings differs from
the first in having, in addition to the mucous fold, a
toagh, fibrous connective-tissue base, over which the
mucous membrane is sometimes freely movable, though
it may be adherent. This variety varies much in width
and thickness, and sometimes the fibrous tissue is as
tough as tendon. This class is described by some
writers as cicatricial. Englisch also mentions having
found thirty nine examples of this variety in the urethral
canals of new-born infants. These congenital urethral
binds are very frequently met with in the adult, but be-
cause they are so constant in their occurrence we are not
justified in considering them physiologicaljn the full
sense of the word.
The rule first proposed by Dr. F. N. Otis, in regard to
a fixed relative proportion between the circumference of
the flaccid penis and the internal urethral calibre, is a
most reliable working guide, and though, as previously
stated, most urethral canals have slight departures from
this high normal standard, not sufficient in many in-
stances to interfere materially with the function of the
parts, still their frequent existence does not remove them
from the domain of congenital imperfections. I am
satisfied, from a large number of personal observations,
that the nearer the urethra approaches the relative pro-
portions as described by Otis, the more perfect are its
functions performed; while if pathological conditions are
acquired, the symptoms are milder and more promptly
recovered from. It is an easy matter to demonstrate the
existence of these congenital defects, but having done
so, a more difficult problem arises, namely, when to
clas3 them in the category of true strictures. This was,
and still ii, a much-mooted question among the leading
genito urinary surgeons, and has given rise to some of
the most heated discussions of any topic within the realm
of surgery.
Oris,* for example, is responsible for the following as-
sertion : 'If into a urethra, the normal calibre of which
is equal to a circumference of 30 mm. of the French
scale, only a 29 F. bulbous bougie will pass without de-
tecting obstruction, then the urethra is not ' about right.'
It is strictured to the extent of one millimetre in circum-
ference, and never can be a healthy urethra while that
stricture remains.1'
Keys,8 on the other hand, takes a very different, con-
servative view concerning these congenital narrowings,
and because they are not of pathological origin de-
preciates their importance almost as much as Otis
magnifies the same. He says : " I have raised my voice
for what it may be worth, in protest against the views of
the new school in urethral pathology, which seems to
claim that every natural undulation in the tissues of the
pendulous urethra is a stricture fit for cutting; and that
all the ills of the geni to-urinary passages may be ac-
counted for by the existence of these undulations, and,
usually, made to disappear when the latter are cut."
Finally, Berkeley Hill,4 in a few masterly lines, seems
to strike the happy medium, and is very conclusive upon
the question at issue.
He says : " If the balance between the natural expul-
sive force of the bladder and the friction along the ure-
thra is disturbed, the bladder is irritated, the kidneys are
affected, and the beginning of the long chain of events
which terminates not infrequently in death is made."
The vesicourethral balance to which Hill refers is a
far more important factor in normal micturition than is
generally supposed. That nature often fails to make a
perfect urethra does not admit of a doubt, nor is there
any doubt but that nature, as often, develops an unusu-
ally powerful detrusor muscle, therefore, the expulsive
1 Quoted from Belfield's work on Diseases of the Urinary and Male
Sexual Organs.
* Stricture of the Male Urethra, 2d ed., pp. 94, 95.
• Keys on Venereal Diseases, 5th and 6th pages of Preface.
4 Lectures reported in the Lancet, April 8, 1876.
force of the bladder may be so great as to irritate moder-
ate congenital narrowings in one case, where, in another,
with even greater urethral defects, but less powerful de-
trusor, there may be no discomfort whatever. If this
were not the case more persons having these congenital
narrowings would be complaining of serious symptoms
than we find in actual practice. Thus we have to con-
sider/hand in hand together, both the anatomical defects
and the symptoms of disturbed vesico-urethral balance in
order to decide when a congenital narrowing is to be
classed as a true stricture. A narrowing is always a
stricture, anatomically speaking, but not so clinically, un-
less it be attended by symptoms.
Congenital stricture, in proportion to its extent, often
gives rise to troublesome symptoms in early life. Vesi-
cal irritability, nocturnal incontinence, dribbling of
urine, priapism, and precocious sexual habits, are in many
instances due to this cause. Similar symptoms to the
above have been noticed time and time again by some of
the leading genito urinary surgeons, but, strange to say,
none have ventured an explanation.
Sir Henry Thompson, in his book on stricture (3d
edition, page 127), says: "There appears to be a ten-
dency, strongly marked in some individuals, to irritability
of the urinary organs, displayed first in early life, of
which no precise explanation can be given, but which
has sometimes been observed to precede the formation of
stricture in adult age. The subjects of it suffer as chil-
dren from obstinate incontinence of urine, particularly
during sleep. ' ' Again he remarks : " If such individuals
acquire a gonorrhoea, the attendant symptoms are more
than usually severe and distressing, and permanent strict-
ure is likely to follow. This state may be spoken of as
one of congenital irritability of the urinary organs, but I
have no solution of it at present to offer."
To my mind I do not think it possible for a more
graphic picture to be drawn of the symptoms and effects
of congenital stricture than is embraced 'in Thompson's
account of what he terms, " congenital irritability." It
is the key to the whole situation. If there exists this ir-
ritability there must be a cause for it, and, as the learn-
ed author very truly remarks, it (the irritability) " has
sometimes been observed to precede the formation of
stricture in adult age," what more convincing proof do
we want than that congenital stricture existed in these
cases from the beginning, and that the irritability is but
an effect of their presence ?
If in a case presenting such symptoms the prepuce is
non-adherent, and the bladder is free from calculus or
disease, depend upon it the clew to the trouble will be
found in the urethra.
In my experience with the treatment of urethral troub-
les I have many times had related to me histories simi-
lar to the above-quoted description from Thompson, by
patients whose memory and veracity were perfectly
trustworthy. The following case will serve to illustrate :
Mr. C , aged twenty-five, consulted me, in March
1 881, on account of a most distressing irritability of his
bladder. The symptoms had been especially marked
since his nineteenth year. He stated that nocturnal in-
continence had been a source of annoyance to him when
a child, and that priapism was very persistent, at the
same period of his existence, without excitation or known
cause. About the period of puberty he began to experi-
ence severe cutting pain every time he passed his water.
The pain was felt immediately within the meatus and
only as the first rush of urine impinged upon that point
— after commencing the act the balance of urine could
be voided without trouble. This symptom persisted for
many months, then gradually became less acute, but he
was ever afterward bothered by disagreeable sensations
within the urethra and other parts of his genitals. A
feeling of fulness would persist in the urethra after uri-
nating, followed by dribbling some minutes later. Severe
neuralgic pains were for a long time felt in the gluteal
region and over the hypogastrium. His urine was nor-
mal in character, but no system of medicine had ever
November 10, 1894]
MEDICAL RECORD.
585
given him relief or blunted his ever-pressing desire to
urinate. Thinking that his trouble might be due to
some urethral abnormality, I examined the parts with bul-
bous bougies and an expanding meatoscope. The result
of which examination was the discovery of a simple mu-
cous fold, one third of an inch from the meatus, reducing
the calibre of the canal at this point to 23 F. Lower
down, at the peno scrotal angle, were three distinct
bands reducing the calibre of the canal at this point to
27 F. His normal calibre at all other points was 30
F. I cut the anterior contraction up to 32 F., and di-
lated daily with full-sized sounds until healing was com-
plete. The result was immediate and surprising.
Before the cutting this patient was incessantly teased
by an ardent desire to urinate. Thirty-six hours after,
he retained his water ten consecutive hours without the
slightest inconvenience, and then only urinated out of
curiosity to know (as he expressed it) if his kidneys were
fulfilling their function. Years have now elapsed and be
remains perfectly comfortable. There never has been
the slightest return of his old symptoms.
From the history of this case it will be seen that un-
usual irritability of the urinary organs existed from child-
hood, as in the description given by Thompson, also
that all the symptoms were aggravated in adult life. -An
examination, however, according to the method of Otis,
proved the existence of congenital stricture in my case
(the patient never having had gonorrhoea), and though
the narrowing only reduced the extent of urethral ex-
pansion 6 mm., still, this congenital narrowing was the
sole cause of the existence and persistence of the symp-
toms, as was proved by a radical cure of the trouble upon
restoration of the canal to its full calibre.
When these congenital narrowings are not prominent
enough in early life to cause trouble, and the periods of
infancy and childhood are passed in comfort, still, the
maturing youth may fall heir to many distressing symp-
toms as he merges into puberty. This peculiarity can be
accounted for, I think, as follows: When the genitals
are undergoing rapid development in early adult life,
those congenital defects which were in existence, but not
of sufficient prominence to cause trouble, at this time
acquire greater prominence through failure of the defec-
tive areas to enlarge in proportion with the normal parts,
so that a canal which before puberty may have been suf-
ficient for the requirements of nature now becomes too
defective to perform its functions without disturbing the
vesico- urethral balance.
As was stated at the beginning of this paper, John
Hunter1 recognized a congenital cause as the starting-
point of stricture. He says : " Strictures are common
to most passages of the human body," " They sometimes
happen in the urethra where no venereal disease has ever
been."
This opinion of Hunter, it is needless to say, has been
severely criticised. To use the words of Sir Henry
Thompson, " the great pathologist . . • stands almost
alone in this opinion." If so, let it be to his credit.
For Hunter more than a century ago, without the assist-
ance of ball probes, bulbous bougies, or the urethrometer,
but guided by his wonderful perceptive genius alone, ar-
rived at about the same general conclusion which some
at the present day consider new. His opinion has out-
lived him and affords us the most satisfactory clew to the
cause of stricture. Bryant, in his " Practice of Surgery,"
page 518, says, in summing up his statistics of strict-
ure cases, that out of 646 cases in only 273 was the le-
sion preceded by venereal disease, 43 were of the trau-
matic variety, leaving 330 in which no definite cause
could be assigned. He concludes as follows : " That al-
though gonorrhoea often precedes a stricture, that at
least half the cases are found in subjects who have not
suffered from such a disease."
Having occupied the attention of my readers long
enough with the foregoing observations upon the relative
frequency of congenital stricture, let us next proceed to
1 Ricord and Hunter on Venereal Disease, p. 151.
study how these congenital defects are influenced by
pathological processes, and how they form the nuclei, so
to speak, of those close organic strictures which have
hitherto been generally considered as entirely of acquired
pathological origin.
In speaking of the relation of gonorrhoea to stricture
Otis * says : "I recognize the fact that it is most often
brought to our notice through the occurrence of and per-
sistence of this disease, and that all pre- existing strict-
ures, or thickenings, or irritations of the urethral mucous
membrane are increased and intensified by it."
With this opinion I perfectly agree. It has occurred
in my experience, and I think the same is universal, that
cases of gonorrhoea will not always yield to any form ot
constitutional or local treatment. In spite of all care it
may linger on indefinitely, nay, symptoms of stricture
manifest themselves during the early period of the dis-
ease. Now with the knowledge we possess in regard to
the formation and nature of cicatricial tissue is it at all
likely that we should have such prompt effects resulting
from an attack of gonorrhoea in a canal previously free
from congenital defect ? Furthermore, from a system of
treatment, once the most popular (I refer to gradual
dilatation), we derive most positive proof that congenital
strictures do exist before and are the nuclei of those
which are supposed to have resulted entirely from gonor-
rhoea. Any surgeon who has had much experience in
the management of urethral cases has certainly come
across strictures which respond finely to the method of
gradual dilatation until a certain limit is reached, but
beyond which it is impossible to progress without the
strictured parts becoming irritable under the method of
treatment. This class of strictures are mentioned by
Van Buren and Keys in their work on " Genito-urinary
Diseases," page 157, but no explanation is given for
their exceptional peculiarity.
From the convictions that I have arrived at, after a
careful study of the congenital urethral narrowing when
intensified by inflammation, the cause of this irritability
seems apparent, and I will venture an explanation for what
it may be worth. When a stricture is treated by the
method of gradual dilatation, the mechanical action of
pressure, together with the stimulus given to the circula-
tion in the affected parts, promotes the absorption of the
acquired inflammatory tissue, which will go on under the
gentle use of the sound until the original or congenital
narrowing is reached, but the tissue of the congenital
contraction, unlike the acquired inflammatory tissue, be-
ing unyielding and incapable of absorption, resents the
attempts of art to enlarge by dilatation structures which
nature had in the first instance failed to make of greater
calibre.
Sometimes the gleety discharge and other troublesome
symptoms disappear when the urethra has been dilated
up to its point of limitation, but you cannot depend
upon it, for when a congenital stricture has once been
infiltrated by gonorrhceal inflammation it becomes a
treacherous spot, prone at any time to light up trouble
from the slightest provocation.
As a rule these congenital narrowings are sensitive to
a degree far exceeding the other portions of the urethra.
They easily fret and become irritable, even from contact
with an exploring instrument. This irritability is quickly
called into play by inflammation affecting the urethral
mucous membrane, and as it happens that gonorrhoea is
the most common form of acquired inflammation the
urethra is subjected to, it necessarily becomes the chief
intensifying cause of congenital stricture. Under the
irritating influence of the gonorrhceal inflammation these
congenital strictures are thrown into a spasmodic state
of contraction and retain a certain amount of the acrid
discharge within the canal instead of permitting an easy
escape of the same — simulating small pus pockets at one
or more points along the urethra.
The more abrupt the congenital contraction the more
acute, generally, will be the symptoms, and from an in-
1 Stricture of the Male Urethra, 2d edition, p. 171.
586
MEDICAL RECORD.
[November 10, 1894
flammation which was at first confined to the mucous
membrane we have the morbid process, at these defective
points, extending into the deeper structures and not in-
frequently involving the erectile meshes of the corpus
spongiosum. Therefore, as a result of gonorrhoea! in-
flammation, the tissues composing these congenital nar-
rowings, and the parts immediately behind them, are
more unfavorably acted upon than the other portions of
the urethral tract. Bathed in pus and scalded by urine,
the healthy epithelium is destroyed at these points and
its place supplied by patches of granulation tissue ; con-
nective tissue corpuscles infiltrate the parts, and as the
latter proliferate and condense, the calibre of the urethra
is lessened, and we have formed those dense inodular
strictures, the bugbear of urethral surgery.
If the urethra is well developed from end to end —
free from prominent congenital narrowings, approaching
the highest normal type, as described by Otis, I believe
we can safely say that if such a urethra should become
affected by gonorrhoea the attack would prove mild and
in due time leave the parts unscathed by the ordeal
through which they have passed.
Next in importance to gonorrhoea, if not equally as
important as a cause for aggravating these congenital
strictures, is pathological urine.
The urethra in repose is a collapsed tube which only
becomes a canal in reality during the physiological acts
of micturition and emission of semen.
When these acts are completed by a normal urethra
the combined action of its muscles, together with the
wave of blood which passes along the meshes of the cor-
pus spongiosum should extrude every drop of fluid and
leave the urethra free from all traces of moisture except
its normal secretion. If, however, there should exist
congenital narrowings anywhere between the bulbo-
membranous junction and the meatus of sufficient prom-
inence to cause undue friction during the acts of mictu-
rition this perfect functioning of the parts cannot occur.
The narrow points will be rendered unduly irritable by
the forcible impact of the column of urine, and through
the resulting contraction of the urethral muscular fibres
interfere very materially with the extrusion of the last
drops of urine. A few drops of urine will be retained
back of the irritable urethral narrowing, where, acting in
the way of a foreign body, it causes any amount of un-
easiness until it is expelled. Nothing is more common
than to hear persons, in whom this condition exists,
complain of a sense of fulness in the urethra after uri-
nating. They are apt to imagine the act was incom-
pletely performed, and most likely will make another at-
tempt shortly after in order to ease themselves ; but if so,
they only displace the retained drops in the urethra by a
little more urine from the bladder, which leaves them in
the same uncomfortable plight as before. Sometimes the
drops of urine are retained quite a while before they
dribble away, or, as is frequently the case, the patient, in
making a quick muscular movement, as in rising from a
chair or stooping to pick some object from the floor,
forces the retained urine from his urethra, with immediate
relief.
When effects like these are noted from the action of
healthy urine upon the narrow defective points in the
urethra, it is easy to understand how much more trouble
is likely to ensue from a pathological secretion, such,
for instance, as the urine of a gouty or rheumatic subject,
that of the habitual dyspeptic, or urine containing in-
flammatory products, the result of disease in the upper
urinary tracks.
These abnormal secretions are very damaging to a
urethra previously crippled in conformation, and are just
as sure to lead to the formation of close organic stricture
as is a gleet resulting from gonorrhoea.
The irritation resulting from pathological urine is a
slow-acting cause, and, therefore, all the more dangerous,
for from the insidious nature of the symptoms neither pa-
tient nor physician is apt to have his attention directed
to the forming stricture until it has assumed formidable
proportions. On account of the slow development of this
form of stricture we are most likely to encounter them in
persons of middle age and advanced life; and I am of
the opinion that if a careful investigation is given to that
vast percentage of stricture cases which occur in men who
never have had venereal disease, a satisfactory clew to this
cause will be found under this heading.
Last in order, as a cause for intensifying congenital
stricture, is masturbation. While it is a fact that this
unnatural habit is entitled to a place among the recognized
causes •£ urethral stricture, still, from the histories of mat
of the recorded cases, I am far from convinced that it is
as potent a cause as some writers seem to think. It is
easy to understand that by the persistent practice of mas-
turbation a congested state of the prostatic sinus is in-
duced which finally develops into a catarrhal inflamma-
tion— a condition of affairs attended by a muco- purulent
discharge, a prostatic gleet in fact, which, like the gleet
following gonorrhoea, is irritating and capable of intensi-
fying pre-existing congenital defects. But without in-
flammation and a discharge first being excited, I fail to
see how the habit of masturbation can cause stricture.
Yet how many cases of stricture due to this cause have
of late years been reported ! Many that are said to be
due to this habit must, from the appended histories of the
cases, have preceded the practised vice. In fact nearly
all are nothing more or less than prominent congenital
strictures. Because these strictures happen to exist in the
urethral tracts of patients from whom a confession of the
habit of masturbation has been forced, they have wrong-
fully been attributed to this cause entirely.
From among the tabulated cases of urethral stricture by
Otis,1 1 find that out of a list of 234 patients, in 24 casts
the cause is attributed to masturbation. I have not in-
cluded any among the number who have a record of both
gonorrhoea and masturbation. Now in 22 of these caies
there is no history of an existing or pre existing discharge.
Also in 22 cases the contracted areas were situated in
the anterior and middle portions of the urethra— not
beyond three and one- half inches, just where we most
frequently encounter the greatest number of cogenital
narrowings. In the remaining two cases the contracted
areas were situated at a depth of four inches and beyond.
All were typical examples of stricture of large calibre,
but from the histories of at least twenty- two of these
cases I am forced to believe that the same contracted
areas would have been found even if the patients had rot
been addicted to masturbation.
In not a few instances I have had patients who were
suffering from the effects of congenital stricture, and who
were not given to masturbation, describe their symp-
toms as follows : They would complain of an itching or
tingling sensation within the urethra, and especially
about that part enclosed within the glans penis; some-
times sensations not unlike an impending orgasm would
be experienced, but without being attended by erection
or erotic fancy. The strictures in these cases were sit-
uated a short distance from the meatus, and with their
removal the irritations vanished.
Had these patients been addicted to masturbation how
natural it would have been, backed by modern theory,
to have ascribed both the stricture and reflex irritation
to that habit?
Of course it must be admitted that like symptoms can
be produced in some patients by the reflex irritations
proceeding from a congested prostatic sinus induced by
masturbation or excessive venery ; but to attribute all
these congenital narrowings in people who do mastur-
bate to a habit which in most cases has had nothing to
do with their existence, is as ridiculous as it is unfound-
ed. Again, reasoning from a hypothetical stand-point,
if sensations of the above nature were to be experienced
by persons of little self-control, is it not more than
likely that they might yield to these morbid feelings and
acquire the habit of masturbation ? No one will dis-
pute the fact that patients who suffer from vesical calcu-
1 Stricture of the Male Urethra, 2d ed., pp. 136 and 324-350.
November 10, 1894]
MEDICAL RECORD.
587
lus or adherent prepuce may acquire this habit from the
irritability of the genitals, superinduced by their infirm-
ities. Why not, then, from the reflex irritations due to
congenital stricture ?
From all the information that I have been able to col-
lect upon this topic, it seems to me that stricture of the
urethra is more to be blamed for causing masturbation
than masturbation is to be blamed for causing stricture.
If, then, we take these congenital urethral narrowings
as the proper basis from which most cases of stricture
arise, and consider them in association with inflamma-
tion, we will find that, with the exception of the trau-
matic variety and those rather uncommon cases resulting
from the cicatrization of venereal ulcers, nearly every case
may be classified under one or the other of the four fol-
lowing divisions:
1. Congenital stricture (simple), including all ana-
tomical narrowings which are prominent enough to inter-
fere with the normal vesicourethral balance.
2. Congenital stricture, aggravated by gonorrhoea.
3. Congenital stricture, aggravated by pathological
urine.
4. Congenital stricture, aggravated by masturbation.
In concluding my remarks I am fully aware that I
have not presented much that is strictly original, more
able observers having grasped the leading features long
before, but I have tried to reduce the subject to some-
thing like a system in the order of cause and effect, and
if my words have any weight in this respect, I shall not
have labored in vain.
^3i»,North,Carby}Strj«t.
A PLEA FOR MORE RATIONAL MEDICA-
TION.1
Bv W. P. OVERHOLSER, M.D.,
UAK&1SONYIIXH, MO.
A retrospective glance at the practice of medicine of
the nineteenth century presents to our view marked
changes in many of the theories of our science, and great
revolutions in the practices of our art. Our advancement
has been particularly marked by steps of progression
and retrogression, by a construction and reconstruction
of views, by a continual building up and tearing down of
medical beliefs and opinions. In fact this tendency has
been so evident, that the intellectual effort of the medical
world of the past and present seems to have been, and
continues to be, characterized by a propensity to frame
hypotheses and manufacture theories to meet and explain
the manifold phenomena of animal life in health and dis-
ease.
From the beginning of the history of medicine, when
in the Grecian temple of Esculapius medical information
was first recorded, and the first steps taken to reduce the
art to a science, by registering on durable tablets of
marble disease and its supposed cures, down through the
hoary ages of the past on through the latest centuries, and
even to the very threshold of the present time, empiri-
cism has largely characterized our work, and experimen-
tation in disease continues even with increased ardor,
with but few positive remedial results.
The recent laboratory and microscopical researches in
disease, and experimental work in normal and abnormal
processes of the body, have contributed volume after vol-
ume to the literature of medicine ; but notwithstanding
the light these researches have given us, as to the origin,
diagnosis, and course of many diseases, science has as
yet failed, except in but a few instances, to prescribe for
us rules, laws, and remedies which, when applied in cer-
tain conditions, will give us positive, satisfactory results.
Correct theories or doctrines of any science must coin-
cide with philosophical truth, and be confirmed by ex-
periment and observation.
A system of practice of medicine rational in its basis,
1 Read before the Hodgen Medical Society at Harrison ville, Mo.'
October 4, 1894.
scientific in its measures, and eminently successful in its
results, would be a system different indeed from the one
we so much boast of to day. Absolute facts in medicine
are comparatively few compared with its unstable hypo-
thetical teachings. It is true that many of our generaliza-
tions have stood the test of future experience and have
therefore been retained, serving as they do to give some-
thing more than empirical direction to intellectual ef-
fort ; but sometimes, and alas ! this is too frequently the
case in medicine, the airy castle of theory is found too
b'ght to withstand the onset of progressive experience,
and the structure of but yesterday is the ruin of to-
day.1
Is it not true that the conscientious physician of the
present who endeavors to gather from every resource at
his command more light and knowledge of the mysteri-
ous phenomena of disease, is often confused by the vari-
ous theories as to its origin, multitudinous remedies for
its treatment, and ofttimes contradictory clinical experi-
ence as to its progress and termination ? We speak not
disparagingly of our science, nor do we seek to condemn
the work of those of our profession whose untiring efforts
and profound research have scattered light and knowl-
edge in many directions. We are proud that we live in
a period of the history of medicine when every means of
research is used to fathom deeply into the mysterious
workings of nature ; yet in this age of advancement, as we
look back over our field of work and find scattered all
along the line of action the ruined remains of what *e
once thought to be scientific truth, but which have since
proven to be fallacies and inconsistencies, we feel more
forcibly impressed with the importance of testing in the
crucible of truth the great mass and bulk of medical ex-
perience and medical teachings that are heaped upon us
to-day, and accepting only the atom of gold that may be
found among the dross.
It is a fact to be deplored that we find in medicine
beliefs, theories, and practices that wear the guise of
learning, that ap{>ear scholastic in their teachings and
scientific in their measures, that are of no practical bene-
fit whatever to us as practitioners. Let me ask what
has become of many of the measures and remedies that
not a few of our profession, but a short time ago hailed
with wild enthusiasm and accepted with the utmost con-
fidence in their efficacy. They need but a mention :
Koch's tuberculin, Kleb's tuberculocidin, Brown-S6-
quard's elixir of life, and others of no better nature ;
what are they to day ? Are they not simply humiliating
memorials of the credulity and infatuation of the physi-
cians who commended and prescribed them ? Who can
tell that many of the boasted remedies of to-day will not,
like their predecessors, fall into disrepute, and in their
turn serve only as monuments in the history of medicine
to mark our mistakes and ever expose our faulty concep-
tions of proper medication.
We have no lack to day of medical literature, no lack
of medical theories as to the proper treatment of diseases,
no lack of medical remedies suggested. The very shelves
of our bookcases groan with the weight of medical lore,
and our text-books on therapeutics prescribe for us an
untold number of remedies for the various ailments of
the human body. In fact, our science is becoming so un-
wieldy, and contains so much that is unnecessary and im-
practicable, that the medical student of the present is
compelled to wade through the misty labyrinths of this
accumulated mass of existing doctrines to find a little
practical truth.
We do not wish to unjustly criticise the teachings of
honorable men of our profession whose superior talent,
moral worth, and dignified bearing have immortalized
their names in the history of medicine. We will ever
bow in humble submission to, and hold in high venera-
tion, the devotees of our science who seek to give us sub-
stantial truth, sound inductive philosophy, that will
stand the test of practical expeiience and ever be re.
* Dr. J. Leonard Corning, Medical Register, Philadelphia, Pa., vol.
iii.
588
MEDICAL RECORD.
[November 10, 1894
tained as immutable principles of eternal truth ; but in
the present status of our medical science we do not feel
like offering an apology for entering a plea for a more
rational system of medication.
Scientific medication must harmonize with physiologi-
cal laws, and thus facilitate nature to throw off disease.
Wherever a diseased process is going on, nature is striv-
ing to overcome it. Wherever there is a deformity or
impaired use of any part or organ of the body, nature
tries to compensate for it. The contraction of the mus-
cles with flexed thigh in hip-joint troubles is not the dis-
ease, but nature's effort to protect the joint by fixation.
The hypertrophied and throbbing heart is nature's
method of compensating for an imperfect valve. An
abnormal elevated temperature of the body is one of the
chemical results of her method of eradicating a poison
from her tissues. The adhesions surrounding a Fallopian
tube, or the vermicular appendix, is her inflammatory bar-
rier to prevent the escape of septic matter into the
peritoneal cavity ; and so on, through the whole category
of diseases, we will find that if we view their symptomatic
phenomena from a proper standpoint, they are conserva-
tive processes and nature's best methods toward effecting
a cure.
To study closely her own efforts in restoring abnormal
conditions of the body to health, will ofttimes give us
more light and guidance as to the proper management
of disease than that given us by the ineffectual specula-
tions of scientists, many of whom simply write books
for a reputation, and by their plausible theories and
logical deductions so well disguised in the garb of learn-
ing, receive the applause of the medical world for the so-
called latest and most rational methods of scientific the-
rapeutics. Dr. Aulde, of Philadelphia, Pa., says : " There
are a considerable number of the medical profession who
now claim to practise what is termed rational medicine
as contradistinguished from empirical medicine; but
when the question is asked as to the precise influence
which remedial agents have upon nerve-cells and proto-
plasm, no one can be found competent to answer."
Of recent years so much attention has been turned to
the study of bacteriology, so elaborate has been the
work in this direction, that there now seems to be a gen-
eral consensus of belief in .the bacterial origin of all in-
fectious diseases.
Bacteriologists tell us that all communicable maladies,
such as can be imparted from plant to plant, from ani-
mal to animal, from animal to human being, from one
man to another, are due to micro-organisms. The in-
finite variety and multitude of micro- organisms — the part
they play in the phenomena of fermentation and putre-
faction, and in the general break-up of organic life — the
incessant struggles of the living organisms against the
microbes, has furnished a large field for investigation by
our bacteriologists, and the measures which antago-
nize their action and destroy them in living tissue, seem
now to be the greatest problem of the present age. This
has given origin to what is called bacteriological thera-
peutics— a science that is to give us measures, medicinal
and hygienic, that will prevent the multiplication of these
infective agents in the human body and thus eradicate
disease by antagonizing their action and preventing the
baneful effects of their secretions and excretions (pto-
maines, toxines, and toxalbumins) upon the normal cel-
lular action of living tissue.
If the origin and course of all infectious diseases be
found to be due to the presence of some form of bacteria,
and bacteriological therapeutics can furnish us with
germicides that are available and safe, a system of para-
siticide medication that will successfully prevent the de-
velopment and multiplication of the microbe in the body,
then indeed might we boast at least of one branch of
scientific therapeutics. But let me ask how many here
to-day can testify, by practical experience, to the value of
any medicinal agent that has thus far been given us, that
will destrov in the body the Eberth bacillus of typhoid
fever, the Klebs Loeffler bacillus of diphtheria, the strep-
tococcus of erysipelas, the diplococcus of pneumonia, or
even Koch's bacillus of tuberculosis.
Is it not a fact that bacteriological therapeutics has
thus far proven to be much more beautiful in theory than
useful in practice? The modern idea of scientific medi-
cation we believe is slowly drifting away from so much
speculative investigation with bactericide agents, and
that " the rational treatment of disease will be based
more upon a knowledge of the effects which medicinal
substances produce upon the function of the cell." 1
A study of nature's own efforts in coping with disease
ought to lead us to observe, and in a measure under-
stand, the methods she adopts in effecting her own cures.
The term vis medicatrix natura is familiar to us all, and
frequently spoken of as the power by which nature cures
disease ; but the factors concerned in this process, and the
true secret of her success along this line, are yet imper-
fectly understood. We believe, however, there is now
somewhat of a lull in the enthusiastic labors of the bac-
teriological therapeutists, and that we find ourselves
gradually drifting back to investigate more carefully the
function of the cell in maintaining its integrity, resisting
disease, and restoring normal cellular life in an un-
healthy condition of her tissues.
A fundamental principle about whkh pathology and
physiology are not any more at variance, is that man, as
well as any other animal, and also vegetative organisms,
is a reiteration of structure ; however complete in its or-
ganization be the construction of a body, every single
part and all of it can be traced to a radical, an ultimate
element of living tissue — an entity — a cell — a little mass
of protoplasm which eats, grows, accomplishes work, and
then dies. The radical entity of which man is composed
shows a repetition of the phases of his accomplished be-
ing. It is in continuous motion, its life being kept up
by processes analogous to those of the complete organ-
ism. In this physiological radical of man, and in all
other organisms, is exhibited the function of disintegra-
tion and reintegration of tissue — a continuous change of
matter constructive and destructive, a ceaseless meta-
morphosis of cellular structures with accumulation and
liberation of life-forces. It is physiological cell-function,
with laws governing its action just as laws preside over
the existence and health of the developed organism.
All curing action, whether by nature herself or artificially
by the medical practitioner, is bound to be within the
limits of histolysis or histogenesis of the cellular elements
of the body. A point we wish to notice in the practice
of our work, is that our medicinal agents are adminis-
tered to the developed organism for their effect upon a
particular organ of the body, or for their effect ob-
served upon the organism as a whole, without a knowledge
of their effect upon the organized units — the indivi-
dual cellular structures of which it is composed — which
are the only ultimate living factors in the production of
lesions of disease, the only ultimate living agents in era-
dication of the same, and the only living factors of the
animal economy that can restore abnormal conditions to
health. All forms of disease come from some modifica-
tion of normal cell- function. All diseases that are cured
by nature or medicine must be accomplished through the
function of the cell.
Disease due to microbic infection is simply a perver-
sion of the physiological cell-function, an effort of nature
to destroy and eliminate the foreign elements from her
structures. It is a conflict between the subject who is
smitten and the particular micro organism which multi-
plies at his expense, appropriating his air, water, and
pabulum, disintegrating his tissues, poisoning him by
its secretions or by the decomposition which accom-
panies its development. Exacerbations of disease and
crises are occasioned by particular efforts of nature to
overcome the obstacles which she meets on her war- path.
It is a phagocytic reaction of the organism to an irritant
(Metschnikoff ). Ceils are phagocytes, hungry to devour
any toxine or microbe that may find entrance into the
* Dr. Aulde.
November 10, 1894]
MEDICAL RECORD.
589
blood. The physiological, chemical action of the cell,
by these irritant poisons is changed to a pathological,
chemical one. Nature seeks to cope with her intruders
by instituting measures that are incompatible with their
existence. If she fails, her failure is due to a lack of
power to resume in normal proportion her work of dis-
integration and reintegration of tissue with the normal
evolution of life- forces. Here I believe is the starting-
point of scientific therapeutics. The morphological re-
sults of cell-function in health and disease, I believe,
are the basis upon which must be founded all medical
means of treating disease by rational and scientific
methods.
When our science gives us a pathological chemistry of
the cell, with the physio-pathological effect of medicine
within the sphere of tissue metabolism — a cellular ther-
apy, we may then hope for a substantial basis upon
which to found our teachings of a system of rational
medicine; and until then, as Bigelow has said, " Thera-
peutics will continue to be a sad mixture of stale antiq-
uity with spurious enthusiasms, in new-fashioned crazes
— the theories of but yesterday becoming the super-
stitions of to-morrow, and the practices based upon
such theories the shuttle-cock of each doctor's battle-
dore."
" Students of other sciences are not content with sim-
ple ideas, or even facts, but are intent upon discovering
law. With unwearying energy they systemize their
facts, generalize, and rearrange, and whenever a law is
discovered it is hailed as a precious boon to many a glo-
rious messenger of light. In the domain of medicine
the energies of our students seem differently employed.
The field is swarming with adventurers who seek only
the discovery of new material, and here and there, as one
sees a fact which in the light of his fancy appears to
glitter, he seizes upon it with avidity and preserves it as a
precious gem for a short time, when his fickle fancy casts
it away to search for something new. And so they go
on increasing the disarray and adding to the heap of
rubbish that is fast accumulating on the field of medi-
cine, ever seeking, never finding, searching for specifics
and panaceas, deluded by mirages, but unwilling to profit
by experience.
" Have we not enough of speculative medicine,
enough of empirical practice, enough of ineffectual
efforts to combat microbic diseases, by internal parasiti-
cide medication ? Let us halt for a time and rearrange
our material, discard what is worthless, put in order
what is valuable and reduce it to a rule. Our palates
have been tickled long enough with the endless variety,
but our stomachs are worrying for something substan-
tial." 1
As earnest and conscientious practitioners, let us ever
hold fast to that which is good, and. until our science
can give us something better, let us not forget to ever
turn and listen to the voice of nature and seek to heed
more closely her admonitions in disease ; for many of her
symptomatic phenomena are but indexes pointing out to
us her mysterious ways of cure. Let us be content to be
her humble assistants and not aspire to be her chief, for
nature's skill is higher than our own, and to understand
fully her methods of dealing with human maladies would
be true knowledge indeed. When rational medicine is
the practice, we believe there will be more cautionary
guidance and less active interference in the measures
nature institutes for the cure of her ailments.
In conclusion, to get at the basic truths underlying a
rational practice ; to invigorate the field of medicine
with a new life ; to discover law for facts ; to lay a foun-
dation broad and strong upon which to build the super-
structure of our science ; we beg leave to enter a plea for
a more thorough investigation into the pathological
chemistry of the protoplasmic entities of man, ever bear-
ing in mind, as physicians, that practical medicine to be
really in fact, as well as in name, scientific medicine, must
be based upon therapeutics of the celL
1 Dr. Rendell : Medical Register of Philadelphia, vol. iii.
• THE NON-OPERATIVE TREATMENT OF UTER-
INE DISEASES.— EXPLANATORY.
By P. J. McCOURT, M.D.,
NSW YORK.
In a previous paper upon this subject (Medical Record
of May 13, 1893) I endeavored to describe so clearly
the various procedures of the method of treatment, that
the attentive reader might follow me without serious er-
ror ; but that endeavor has failed of its object. Subse-
quent to the publication of the article, applicants for
further information were very numerous ; yet the queries
propounded were usually brief, and were all answered by
letter. Now that many have, in a measure, prepared
themselves to apply the treatment and have met with
obstacles, the extent of the answers called for renders
* reply by letter impossible. Anxious to see the method
intelligently tested, and, if found worthy, generally
adopted, I wish to give such details to the profession as
will enable them to apply the treatment as successfully
as I have done.
z. The preparation of the sponge should present no
difficulty. A fine " Reef " sponge is best for use, and
the exact proportion of hydrochloric acid to water is not
constant. It should vary with the amount of calcareous
matter in the sponge ; but about one-half pound to the
gallon will usually suffice. Of the potassium permanga-
nate, cold water will dissolve the amount required in a
few minutes. The bleaching fluid may consist of such
solution of sodium hyposulphite (the sulphite has recent-
ly been found preferable) as cold water will make in
about thirty minutes, i litre, and HC1 200 c.c. (200 to
1,000).
2. Cotton, wool, linteum, etc., cannot be substituted
for the sponge-dressing ; nor can the sponge be employed
as an excipient for glycerin, since the latter will render
the sponge nearly as hard and rough as sand-paper.
3. The sponge-dressing cannot be accurately adjusted
to the parts through the speculum. The vaginal walls
are best separated by the first and second fingers of the
left hand, while the dressing is carried to its position
and adjusted by the index-finger of the right hand.
4. When not corroded by the secretions, the sponge
may be reapplied several times to the same patient, after
being cleansed each time in the bleaching fluid.
5. Neither septicaemia, nor any appreciable approach
to it (except in the breaking down of myomata), nor any
serious inconvenience to the patient, has ever yet result-
ed from the application of these dressings, when proper-
ly placed and medicated.
6. At the beginning of a course of treatment the dos-
age should be very light, and the patient may be treated
three times each week, rarely more frequently, for a
month, or until such time as improvement is apparent ;
then twice, and finally once a week. There is danger,
or at least waste of time, in overdoing the applications
advocated in this treatment. If the patient be treated
once or twice a day, as has been advised by one of my
former students in this journal, peritonitis may result.
7. In treating cases of hypertrophied uteri, as the size
of the organ diminishes the size of the sponge should be
relatively increased, otherwise progress may cease, or
the conditions may even take a retrograde course.
8. None of the materials used in this treatment can be
supplied by me.
9. It is imperative, for the reasons assigned in my for-
mer paper, that the tinctures be made saturated, and
from the fresh root or plant. The employment of other
preparations for this purpose will be certain to defeat
our object, and may injure the patient. The pharmacist
should be able to make these tinctures in season, and to
have them prepared where the plants grow.
10. The metric system employed has proven an obsta-
cle to many of my readers. It is only necessary to re-
member that the litre contains the weight of 1,000
grammes, or the measure of 1,000 cubic centimetres.
Hence, 3 grammes to 1 litre means simply three parts
59°
MEDICAL RECORD.
[November 10, 1894
to 1,000; 6 5 grammes to z litre means 6)4 parts to
1,000 ; and so on throughout.
11. I am asked to specify the conditions in which va-
riation of local temperature has been observed ; and it is
evident that this observation has been received with
some doubt. Disproportionate elevation of intra uterine
temperature has been found chiefly in connection with
local hyperemia; and the temperature has been found
subnormal in some cases of induration, malnutrition,
hydremia, and other forms of defective haematosis.
Surely these observations are not less credible than others
of unequal axillary temperature, editorially noted in this
journal, February 27, 1892, p. 240.
12. To vary the dosage on the sponge dressing "by
the fixed rules for individual cases," I meant that we
may give a larger dose to a woman of strong, coarse, rigid
fibre, than could be borne by one of fine, delicate struct-
ure— one whD, in modern nomenclature, is a "senai."
tif," or what we so lately and erroneously called a " ner-
vous temperament."
13. A careless reader — so familiar to all writers — tells
me, while asking what others do in substance, " You con-
demn the use of iron, yet call it a valuable agent, and
acknowledge that you prescribe it yourself. What are
your indications for it ? " I condemned no practice or
practitioner, and merely took exception to the prevail-
ing massive dosage of the metal, which repeated crucial
tests with unvarying results had taught me to be both
unnecessary and toxic. If the ears are pale and waxy,
especially when viewed by transmitted light, iron is in-
dicated. A person whose ears are red will rarely need
iron. The drug may also give brilliant results in many
cases when there is a deep, circumscribed redness of the
face during pain or excitement, although in repose the
face may be pale or yellow.
14. Evidence is curtly demanded as to " how the
chemistry of the body can change ingested iron into the
tannate ? " I did not so represent the change, but the
law of chemical affinity is not suspended within the
body. Several articles of food — notably tea, coffee, etc.
— contain tannin. This tannic acid will unite with iron
on meeting it in the stomach, intestine, or elsewhere, to
form the insoluble tannate of iron. The tannate thus
formed will unite with animal tissues, living or dead,
and remain permanently fixed in the body. It is unfort-
unate for many that none of these facts are given in our
text books on chemistry. A number of the drugs
named in the paper will, when indicated, dissolve this
tannate of iron and eliminate it from the body.
15. A ready solvent of the viscid secretion of chronic
cervical endometritis is not yet satisfactorily determined.
A few drugs of undoubted value in this condition are
now being tested. The best of these appears to be ja-
caranda gualandi, of Brazil; but I cannot yet commit
myself to assert of any drug that it is a true remedy. It
is still deemed best to remove the tenacious secretion by
the mechanical means recommended in the paper, or by
the curette, when the indicated remedies named will
complete the cure.
16. In the treatment of uterine fibroids I have as yet
nothing definite to add. When such tumors can be
readily removed by operative means, this course is rec-
ommended. Where obstacles prevent, or danger threat-
ens from operation, the sponge dressing may be resorted
to with a fair degree of confidence. In twenty-six cases
thus far completed I have met with only two failures.
17. In treating erosions of the os uteri, etc., when the
sponge-dressing adheres to the eroded surface, and its
removal is followed by the discharge of arterial blood, it
is evidence that a wrong drug has been used, and a re-
examination of the patient will reveal the remedy to be
employed. A very weak solution of silver nitrate, ap-
plied by the hair-pencil before the proper dressing, af-
fords marked relief in such cases.
18. When stenosis of the os or cervix uteri presents,
the first indication is to soften the cervical tissues, which
are almost constantly indurated in such conditions, and
then to open the cervical canal. Until the latter object
is accomplished, further treatment may only waste time
and irritate the organs involved. But once the cervix is
dilated, and so maintained, the remedy is immediately
distributed, not merely to the endometrium, but to the
entire system, and free drainage will soon be established.
It has been frequently observed, however, especially in
young women, that stenosis and flexions yield spontane-
ously to the treatment without instrumental aid.
19. Pain or inflammation has rarely followed dilata-
tion of the cervical canal, even when the patient had not
been fully prepared for the operation, or when she had
had a history of peritonitis. The dressing, charged with
the sanguinaria co., combined when necessary with any
other suitable remedy, will usually subdue pain and ten-
derness in a few minutes, after which the patient may
ride or walk home with safety and comfort.
20. It is gratifying that so many of my correspondents
seek adequate means for correcting excessive and defi-
cient menstruation. The great majority of women who
suffer from uterine diseases, lose by far too much blood
each month ; and but few other conditions can so rap-
idly make them prematurely old. I regard the normal
menstrual period (some few cases of general plethora ex-
cepted) as being three, or at most four, days each lunar
month; and that limit is usually established by a judi-
cious course of the sponge treatment, whatever the men-
strual history of the patient may have been. Abnormal
menstrual flow may usually be corrected by a careful se-
lection of the remedies named in my previous paper,
guided by a study and appreciation of the characteristic
secretions. If these fail — if we must treat the symptom
instead of the patient — a valuable general remedy for
menorrhagia may be found in savine, 1 to 12 of water.
In scanty menstruation conium and Pulsatilla are of
equal efficacy.
22. The badinage lavished upon me for my " extrava-
gant faith in medicine," would fill a small volume.
This shower of spice maybe gracefully accepted, since it
disproves nothing, while I have proven my positions.
But it is wise to bear in mind that our patients possess
and adhere to a living faith in medicine, whether we do
or not. They also have faith in us ; and it is our duty
to make that faith as well founded and abiding as possi-
ble. With this as well as higher objects in view, I have
delved in many mines — have sought far and near for
drugs of alleged value, and have studied in all systems
worthy of the name. In nearly all I have been able to
cull gems from the mass of detritus. The results of my
search have been given without reserve to the profession,
who can best judge of their value. I ask that those who
have tested or who may test my method in practice, will
report results in the columns of the Medical Record.
To many members of the profession, in this and other
countries, my grateful acknowledgments are due, alike
for their welcome criticism and for their generous words
of approval and encouragement. A reprint copy of the
original paper will be sent on request to those who have
not seen it.
■33 West Twenty-third Street.
Oliver Wendell Holmes as a Mieroseopiit — Forty-one
years ago, Dr. Holmes, who was eighty-five years old on
August 29, 1894, taught Dr. £. Cutter how to use the
microscope with direct illumination. He had an ar-
rangement of his own — a six-inch black disk fastened to
the tube and graduated so that turning the disk would act
as a fine adjustment. Dr. Cutter says that Dr. Holmes
worked a good deal with the microscope in those days,
and that the intellectual drill derived therefrom may have
been used in literature. Is not the technical use of the
microscope in college as good a discipline as the study of
Greek? Surely the cyclops of the Odyssey would be
better understood by one who has studied a living cyclops
taken from a hydrant and shown under the microscope. —
The American Monthly Microscopical Journal.
November 10, 1894]
MEDICAL RECORD.
59i
QK08V&66 of f9ftjedical gtimtt.
Pylorectomy with Gastro Duodenostomy Posterior. —
Professor Kocher gives his method of excising the pylorus.
(University Medical Magazine.) The incision is made
in the median line, and is 10 to 15 ctm. long.
The umbilicus is excised and all bleeding stopped. The
tumor having been withdrawn as much as possible, small
openings are made through the greater and lesser omen-
tums, through these clamps are adjusted. The attach-
ments of the omentum are then loosened from the growth
and the latter enveloped in gauze. All bleeding is care-
fully stopped. A clamp, resembling an ordinary hemo-
static forcep, is placed on the duodenum and an incision
made between it and one applied on the stomach. He
does not fear sloughing from pressure. The mucous coat
which protrudes from the cut section is carefully cleansed
with bichloride, 1 to 1,000. The stomach is then com-
pressed by the fingers of an assistant, and clamps placed
next the growth, an incision being made between them
the growth is removed and the cut stomach cleansed and
sutured shut with a continuous suture. This is then in-
vaginated and another continuous Lembert suture placed
above. The posterior wall of the duodenum is then ap-
proximated to the posterior wall of the stomach one-half
or three-quarters of a centimetre behind the closed end,
and the two are sewed together with a continuous sero-
serous suture. The forceps being removed from the
duodenum, all bleeding is stopped and its interior care-
fully cleansed. An incision is then to be made into the
posterior wall of the stomach and the free edge of the
duodenum sewed to it by a suture, either embracing all
the coats or else two layers applied — one musculo-serous
and the other mucous. The sero-serous layer of suture
first applied is then continued all around. The cut end
of the duodenum is thus fixed directly into an incision in
the posterior wall of the stomach. Of six cases so ope-
rated on, one only died, and it on the twentieth day.
Asepsis is insisted on, the lines of sutures being touched
with gauze wet with sublimate solution. No washing of
the abdominal cavity is to be employed. The continuous
suture only is to be used. It is unnecessary to guard the
forceps used to clamp the cut ends with rubber, because
the pressure does no harm.
The Mechanical Treatment of Chronic Constipation.
— Dr. F. Le Marinel believes that the mechanical treat-
ment should be the treatment of choice in a large num-
ber of forms of chronic constipation. The manoeuvres of
massage comprise three forms — frictions, pressures, and
percussions. In addition, various active and passive
movements are undergone — flexion, extension, abduction,
adduction, pronation, supination, rotation, and circum-
duction. The effects of medical gymnastics are studied
as regards the circulation, respiration, animal heat,
chemical phenomena, the muscles, bones and articula-
tions, and the local results. The effect of massage upon
the absorption, muscular system, nervous system, circula-
tion, and local temperature are fully recorded. {The
American Journal of the Medical Sciences.') The tech-
nique of various authors is fully described and illustrated.
The various forms of constipation which are likely to be
benefited are— (1) from anaesthesia of mucous membrane ;
(2) from muscular paralysis ; (3) from induration of the
stools, and (4) from mechanical obstacle. The contra-
indications are — (1) acute inflammation of intestines,
peritoneum, peri- intestinal cellular tissue, or of intra-ab-
dominal veins; (2) ulcerations (round, tuberculous)
of stomach or intestines ; (3) tumors of the alimentary
canal (sarcomata, carcinomata, polypi); (4) volumi-
nous faecal masses of stony hardness. An interesting
comparison is given of the value of diet, habit, purgatives,
hydrotherapy, injections, electricity, various medicinal
methods, with that described by the author, the general
conclusion being that of all these methods only one can
be compared to the mechanical, and that one is elec-
tricity. But when one considers the question from the
standpoint of success, massage shows figures which are
not surpassed by electricity. So far as facility of applica-
tion, massage is superior in that it does not require any
apparatus, and can be applied equally well at the house
of the patient as of the physician. Further, massage is
better borne than electricity, and particularly by chil-
dren. A series of 147 cases is reported, the treatment
being that advocated in the paper. The care shown in
the report, the apparent accuracy of diagnosis, the fulness
of detail, give an especial value to the clinical histories.
In the cases cited, those of the synoptical table, and
eleven in detail, 158 in all, radical cure was obtained in
about ninety per cent. The final conclusions are : 1.
Mechanical treatment takes rank among those therapeu-
tic agents whose action is most energetic upon the circu-
lation, the respiration, and general nutrition. 2. It can
modify the abdominal circulation, and cause certain for-
eign congestions, notably those which are met wish in
abdominal plethora, to disappear. 3. Under its action
the muscles acquire an increase in volume and strength.
4. It is the best curative agent in constipation dependent
upon muscular paresis or paralysis, if it is not of central
nervous origin. 5. It is the best curative agent for con-
stipation dependent upon diminished sensitiveness, or
anaesthesia of the mucous membrane when it is due to
local causes. 6. Finally, it is formally contra indicated
when constipation is due to acute inflammatory lesions
or to tumors.
The Treatment of the Fever of Phthisis.— Dr. Savigny
distinguishes three forms in this disease: 1, The initial
or continued; 2, the hectic or concomitant; 3, the sep-
tic. In the last form the purely symptomatic treatment
is powerless. The administration of the new antipyretics
is not favorable, for all of them diminish the energy of
the heart, only influencing the fever as a symptom, if in-
deed they have any notable effect, and they are only used
in rapid tuberculosis, and when humanity demands only
that the patient shall be made more comfortable. Hoch-
halt, after much research, has come back again to ane-
nic, but with the exception of recent initial apical ca-
tarrhs it has no influence upon the course of the disease.
Hectic fever is manifestly influenced by this remedy, but
it has no action upon the initial fever and upon the rapid
forms of phthisis. Fowler's solution is recommended, in
commencing doses of one to two drops, and increasing,
day by day, to five or six ; rarely more, for ten drops is
quite likely to produce symptoms of poisoning. Other
beneficial effects besides the lowering of temperature are
the suppression of night sweats and an increase of appe-
tite and body weight. The continued fever offers con-
siderable resistance to the treatment by arsenic, for this
fever is a manifestation of caseation, and is an expression
of the clinical form of phthisis florida. By building up
the system one can best combat the tendency to casea-
tion. In these cases the condition of the heart and cir-
culation is important; Brehmer and Dettweiler recom-
mend the prolonged application of ice-bags ; others use
alcohol. Kiihle and Liebermeister advise digitalis, which
however, should be used with caution ; but more advan-
tageously the ten per cent, tincture of coronilla, in ten
to twenty-drop doses, can be employed. In cases of in-
itial fever without grave lesion of tissue, in association
with fifteen grains of quinine, Hochhalt has seen this
fever transformed into the intermittent type, where ar-
senical treatment is useful. In apyretic phthisis creosote
is used ; if at the outset it is not well borne by the stom-
ach, it can be administered in cocoa-butter suppositories
— with steady increase of all doses ; in commencing with
large doses there is danger of exciting the fever. In gen-
eral the antipyretic treatment consists less in reliance
upon the antifebrile remedies, properly so called, which
have only a slight and transitory effect, as in the use of
remedies which act directly upon diseased pulmonary tis-
use, than upon arsenic, the cardiac tonics, and nutrition
by every means which can stimulate it. — American Jour-
nal of the Medical Sciences.
592
MEDICAL RECORD.
[November 10, 1894
Medical Record:
A Weekly Journal of Medicine and Surgery.
GEORGE F. SHRADY, A.M., M.D., Editor.
Publishers
WM. WOOD & CO., 43, 45, & 47 East Tenth Street.
New York, November 10, 1894.
THE NEW TREATMENT FOR DIPHTHERIA.
Whenever a new remedy is suggested for a prevalent
and formidable disease it is quite necessary to exer-
cise a becoming conservatism regarding facts which
bear on the possibility of a brilliant discovery. The
history of all similar cures proves that the initiative
reports are not always borne out by subsequent results,
and that nothing more is gained by a discussion of rela-
tive merits of other remedies than the ventilation of a
new theory and the final mortification of its ultimate
rejection.
On the other hand it must not be argued that students
of therapeutics should be backward in seizing upon every
plausible means to an end, or should neglect opportuni-
ties for the careful study of such data as may be pre-
sented with a proper spirit for deliberate judgment.
Even in view of these apparent drawbacks we cannot
resist the temptation of looking upon the antitoxin
treatment of diphtheria as promising better than any
that has heretofore been presented to the profession.
Making due allowance for the remarkable percentage of
cures, even in malignant cases, we can safely assume that
if one-half of what is said of the antidotal power of the
serum is true, we have made a most wonderful advance
in the therapeutics of a most formidable and fatal mal-
ady. There is, indeed, enough encouragement in the
astonishing results abroad to warrant an extended trial
in this country.
The articles by Professor Baginsky, of Berlin, and Dr.
Louis Fischer, of New York, in a recent issue of the
Medical Record, were calculated to arouse a new inter-
est in the subject by calling attention to some remarka-
ble results. The mortality of diphtheria in Berlin during
the three years preceding the trial of antitoxin ranged
from 32.5 percent, to 41.7 per cent. Baginsky broke
this record in one hundred and ninety-two cases by re-
ducing the death- rate to fourteen per cent., while in
eighty-two additional cases, making in all two hundred
and seventy-four, the average mortality was 15.3 per
cent. More recent statistics give in sixty-three cases a
fatality of 5.5 per cent. In France, Professor Roux low-
ered the death-rate from 51.71 per cent, to 24 33 per
cent. Viewed as plain facts the showing is certainly very
remarkable.
The theory of the action of the antitoxin serum from
a bacteriological standpoint at least is quite tenable,
while clinically there are no obvious objections to its
plausibility. It is in brief the transference of acquired
immunity in an animal to a similar condition in the hu-
man subject. The natural resistance to the disease, the
vital energies which are aroused to overcome the enemy,
are sufficiently reinforced by the immune serum to turn
the balance in favor of a cure. In a like manner the
antitoxin is claimed to act in a protective way for such as
may be exposed to the disease by a preliminary injection of
immunizing serum, thus anticipating the evil effects of the
disease by neutralizing its septic tendencies. So far the en-
couraging reports coming from Berlin and Paris are quite
convincing, and, unless contradicted by more extended ex-
perience, warrant the brightest hopes for the future. There
is certainly a singular agreement regarding the reduction
of mortality as observed by different experimenters,
which gives a truer scientific complexion to the facts
than could be gained from partial sources or through
biased channels. There is, then, every plausible reason
why the antitoxin treatment should be thoroughly
tested in this country. The great trouble at the start
will be the scarcity of the remedy and the difficulty of
obtaining it. This difficulty should be overcome as
speedily as possible by extending its manufacture and in
establishing necessary laboratories in different parts of the
country. Thus far the only antitoxin that has been
used in this country has come from abroad, and is now
in such limited quantity as to be practically useless for
purposes of extended experimentation. It is to be
hoped, however, that ultimately the supply will meet the
demand, and that opportunities may be afforded for such
tests of the efficacy of this new remedy as seem to be
warranted under existing circumstances.
LAUS GAMBRINO.
It is rare that one finds a physician nowadays who gives
that unqualified praise of beer, as compared with other
alcoholic liquors, which was heard a few years ago. The
tendency is rather to teach that " total " abstinence is
best, and that beer is not much better than other forms of
intoxicating drinks. The view once hopefully enter-
tained, that beer was the best and safest beverage/ and
that its introduction into America would lead to an
abandonment of spirits and to less drunkenness and alco-
holism, is not now generally held. We read with some
interest, therefore, an article in praise of beer by Dr.
Lambert Ott, in The Medical News. The article is
based on fifteen years1 observation among beer drinkers.
The class that Dr. Ott has studied is composed mostly of
laborers and employees in breweries, the men being
mostly Germans, but with a sprinkling of Irish and
Americans. Some of these had drank from one to two
gallons of beer daily for fifteen years without any obvi-
ous disturbance of the bodily functions.
Dr. Ott seems to think that beer-drinking has a dis-
tinct ethical value, for he says : " The German brewer
is by nature an honest, industrious, and good-natured
individual, fond of his home and family, and in every
way a congenial person ; even the Irish and American
brewer partakes of those kind and congenial elements so
common to the German brewer, leading one to believe
that the constant association and use of beer as a bever-
age begets a distinctive type of humanity, possessing
natures kind and pleasing. Often have I observed young
men, of slight build, with no inherited predisposition to
November 10, 1894]
MEDICAL RECORD.
593
obesity, after a year or two in a brewery acquire a sunny
disposition and an accumulation of fat, the attenuated
and introspective dyspeptic being transformed into the
happy and fat brewer."
The blood of beer drinkers shows an increased pro-
portion of red blood-cells and a diminution of white
corpuscles. Excessive beer drinking leads to a condi-
tion of mental torpor, which soon disappears, however,
when the cause is removed.
According to Dr. Ott, beer does not retard, but assists,
digestion. However, in the summer time, when large
amounts are poured into the stomach, a subacute gas-
tritis may develop. Diseases of the heart and lungs seem
uninfluenced by large potations of beer. Cirrhotic kid-
ney and hob-nailed liver are never, he says, found in the
beer drinker; neither does beer alone ever produce de-
lirium tremens.
Altogether the beer habit, when not accompanied with
other bad habits or the use of whiskey, is a healthful one.
Here, however, is the weak point in Dr. Ott's argu-
ment. The beer drinker is very liable to take other
drinks after a while, and then bad results follow. The
observations made upon a class of men who indulge in
hard manual labor, cannot be applied to the community
in general. It is the experience of most physicians that
in this country, beer drinking, except in great modera-
tion, leads to gastric troubles, and to gouty, rheumatic,
and renal disorders.
DOCTORS WHO GIVE AND RECEIVE "COM-
MISSIONS."
What shall be done with that peculiarly contemptible
species of huckster, which, protected by medical diplomas,
sends gullible people only to those "consultants" and
" specialists " who pay them an underhanded commis-
sion for their favors? That the thing is done admits of
no doubt. Bnt how to bring about exposure, and brand
the medical trader and commission pedler as he deserves
to be branded is a problem still requiring solution.
The Philadelphia Polyclinic is much exercised over
this state of affairs, but has no practical reform sug-
gestions to offer. According to this journal: "The
Tri- State Medical Journal published a letter from a
physician to a prominent consulting surgeon, asking
what percentage he would pay for cases referred to
him in consultation. Ophthalmic surgeons have all
had experience with such offers from opticians, and Or-
thopedic surgeons from truss and brace makers. More
than one hundred years ago it was declared reprehensi-
ble for a physician to enter into collusion with druggists
and receive a percentage on the price of prescriptions
compounded, and the declaration would hardly have
been made if the practice had not existed. That it con-
tinues, and from time to time assumes new forms, we
must also reluctantly admit. We will not here occupy
space in arguing against the practice of the physician ac-
cepting a fee from a patient with the understanding that
he is to give the best advice which his knowledge and ex-
perience enables him to offer, and then accepting a per-
centage or fee from somebody else in consideration of
giving that advice a special direction. To any one who
really has the slightest doubt as to the immoral and un-
ethical nature of such a transaction, we would suggest this
simple test. Would he be willing to do it openly and
with the knowledge of the patient? Let the doctor who
is captivated by the offer in question state frankly to his
patient, 'I think you had better go to Sanita-
rium, the company pay me jioo for giving you this ad-
vice ; ' or, * You must go to Mr. So and So to get your
glasses, who will give me 33 J per cent, of the price you
pay him for them, for sending you there ; ' or, ' You
must consult Dr. Medicus, who gives me $5 for every
patient I send to him.' The doctor who makes such an
explanation to his patients, we believe has a perfect
right to accept the stock or the percentage or the share
of the fee. The doctor who accepts such compensation
in secrecy, without any explanation to the patient of the
nature of the influences under which the advice is given,
belongs in the same class with the bunco steerer and the
man that cheats at cards. The grocer who puts sand in
his sugar, or the jockey that files his horse's teeth, are
honorable in comparison.1'
Our Philadelphia contemporary calls upon the profes-
sion to put a stop to bribery within the ranks of a noble
calling. Perhaps its pathetic outcry will be heeded.
And then, again, perhaps it will not. The hardened sin-
ner is generally too pachydermatous to be affected by
"press notices." His moral sense resides in his pocket-
book. To make him suffer, his emoluments must be re-
duced to the vanishing point. If all physicians would
resolutely refuse association of any and every kind with
the "commission doctors," the genus would soon be-
come extinct. If Philadelphia will only lead, New York
will gladly follow.
CIRCUMCISION.
Dr. Alexander L. Hodgdon, in the Medico-Surgical
Bulletin, lays down some reasons why, in his opinion, all
male infants should be circumcised. Aside from the
stock arguments on this subject, we find nothing to sup-
port Dr. Hodgdon's position, except the statement that
there are in the community two estimable classes among
which the operation is done, viz., the Jews and the
" physician class." Quoting Dr. Remondino, he says :
" In the United States, France, and England, there is a
class which also observe circumcision as a hygienic pre-
caution, where from my personal observation I have
found that circumcision is thoroughly practised in every
male member of many of the families of the class — this
being the physician class. In general conversation with
physicians on this subject it has really been surprising to
see the large number who have had themselves circum-
cised either through the advice of some college professor
while attending lectures, or as a result of their own sub-
sequent convictions when engaged in actual practice."
It will no doubt be somewhat of a surprise to our
readers to learn that they belong to a circumcised, if not
a chosen, class. We doubt if the facts at all support the
assertions of the writers we have just quoted. In most
cases the foreskin adjusts itself to conditions of perfect
cleanliness at the time of puberty, if not before. Physi-
cians are not so senseless as to unnecessarily mutilate
themselves and their families. Circumcision is a relic
of barbarous and semicivilized times, before soap and
water and sanitation had been preached. It no doubt
served a useful purpose among the nomadic tribes of
594
MEDICAL RECORD.
[November 10, 1894
tropical countries. Bat in these days physicians should
cease to preach or impose upon their patients an unnec-
essary and irrational mutilation.
The rite which in these modern times might be sub-
stituted for the early religious ceremony of circumcision
would, according to some, be resection of the spermatic
cord of the vicious and defective classes, so that they
should cease to propagate their kind. Spermatorectomy
will probably triumph over and replace circumcision, if
anything does.
THE PREVENTION AND CURE OF SNAKE-
BITES.
The early exploitation of a medical discovery in a popu-
lar magazine does not afford the best evidence that it is
new and valuable. If, however, the discoveries of Dr.
Calmette are not yet proven to the satisfaction of the
scientific world, the confidence of the doctor in what he
will be able to do is genuine and beyond the need of
demonstration.
Dr. Calmette believes that by the help of his thera-
peutic serum the most venomous serpents will be ren-
dered as harmless as doves. This substance will, he
thinks, be kept in all the drug stores of India, Africa,
and America, and will be carried in the pockets of all
travellers and sportsmen who are exposed to the bites of
serpents. The new antidote has been prepared and Dr.
Calmette's investigations carried out at the Pasteur In_
stitute. And the method employed is much the same as
that used in obtaining the immunizing serum of diph-
theria.
It is known that venomous serpents are not suscepti-
ble to the bites of their fellows, but that non- venomous
serpents have not this immunity.
This furnishes some evidence that there is such a thing
as being protected against snake poison. In order to
induce the condition artificially, rabbits and guinea-pigs
are chloroformed and then bitten by the cobra or viper,
or are inoculated directly with the venom. The blood
of the animals is then taken and its serum used as a pro-
tective against bites or inoculations of other animals. It
is asserted that whereas the cobra. bite usually kills the
rabbit in one or two hours, if properly protected the
animal skips around in as lively a manner as ever, no
matter how severe the bite.
Dr. Calmette finds that besides his therapeutic serum
there are two other substances which protect against ser-
pent poison, viz., the chloride of gold and the chloride
of lime, the last being much the better. He has not had
an opportunity to try the chloride treatment on man, but
his directions for such trial are these : " The chloride of
lime should be free from absorbed water, and, when used,
should in all cases be freshly taken from a hermetically
sealed bottle. One part of it by weight should be dis-
solved in eleven parts of boiling water, and the solution
should never be made until it is about to be used, as I
have found that the therapeutic power diminishes by
keeping. This should be injected subcutaneously with a
trephine [sic] all about the wound, and also under the
skin. From twenty to thirty cubic centimetres of the solu-
tion will suffice to save the life of a man bitten, it being
administered in doses of five cubic centimetres each."
As to the immunizing serum, he finds that, generally
speaking, about five cubic centimetres are necessary to
make the animal proof against one milligramme of pure
venom. He also finds that he can use three distinct spe-
cifics in vaccinating a rabbit, and by all analogy, a man,
against the bite of the most poisonous snake, or as an
antidote after they have been bitten. These are, first, the
serum from an envenomed animal by itself; secondly, this
serum mixed with chloride of gold or the hypochlorite of
sodium or of lime; and, thirdly, either of these chemi-
cals, or, preferably, chloride of lime, used by itself with-
out serum.
Dr. Calmette has not experimented with rattlesnake
poison, but he finds that the same antidote is good for all
the other venoms he has tried, and he feels confident that
it will answer for the rattler.
fgtexos tit ttxe ffitoelu
Honor to a Haw York Surgeon.— Dr. Arpad G. Ger-
ster has received from the Emperor of Austria and King
of Hungary the high distinction of the Knight's Cross of
the Order of Francis Joseph in grateful recognition of
his valuable philanthropic labors in founding the Hun-
garian Emigrant Aid Association of this city. This is
the first instance in which an American citizen has re-
ceived this honor who has not held office under the Aus-
trian government. It is eminently fitting also that a
member of our profession should be thus closely associ-
ated with such noble work, and that he should be so
worthily rewarded.
The Southern Surgical and Gynecological Associa-
tion.— The seventh annual meeting will be held in the
Artillery Hall, Charleston, S. C, on November 13, 14,
and 15, 1894. Members of the medical profession are
cordially invited to attend.
Chicago Gynecological Society. — At the sixteenth
annual meeting of the Chicago Gynecological Society,
held October 19, 1894, the following officers were elected
to serve the ensuing year : President, Dr. Franklin H.
Martin; First Vice-President, Dr. A. J. Foster; Second
Vice-President, Dr. J. C. Hoag ; Secretary, Dr. H. P.
Newman ; and Editor, Dr. T. J. Watkins. The retiring
president, Dr. Fernand Henrotin, delivered an interest-
ing annual address, after which the society adjourned to
the annual banquet. Dr. John B. Hamilton, J. B.
Murphy, Health Commissioner Arthur Reynolds, Alex-
ander H. Ferguson and others were guests of the Society.
Dr. Pliny Earla's Bequest to Leicester, Mass. — The
town of Leicester, Mass., has received $6,000 under the
will of the late Dr. Pliny Earle, for the erection of a
building for the public library of the town.
An Accident to Doctor Wiglesworth.— Dr. J. Wigles-
worth, superintendent of the Rainhill Asylum, Prescott,
Lancashire, England, was stabbed in the neck by a pa^
tient, who had obtained a sharpened staple ; the internal
carotid was severed, necessitating ligation of the common
carotid artery.
Want no Physiology. — The Christian Scientists ol
Burlington, la., have petitioned the school board to ex-
cuse their children from attendance when physiology is
taught. The petitioners declare that there is no material
November 10, 1894]
MEDICAL RECORD.
595
body, and object to having their children taught to
believe that there is anything so much in evidence as a
stomach or a liver. — Times and Register.
> Outbreaks of Smallpox.— A considerable outbreak 01
small-pox has occurred in Manchester, Mich., and neigh-
boring towns, and is causing some alarm. Several cases
of small-pox have occurred in Washington, D. C, re-
cently. They have been traced to a case occurring in
the family of an employee of the pension department.
Dr. Boux Decorated.— Dr. Roux has received from
President Casimir-Perier the congratulations of the Gov-
ernment and the Cross of Commander of the Legion of
Honor, in recognition of his work upon the serum treat-
ment of diphtheria.
Foot ball Casualties.— The Lancet of October 20th
chronicles three deaths and four fractures as the result
of the previous week's sport.
A Physician to be Trustee of the Boston Public Li-
brary.— Dr. Henry P. Bowditch has been appointed by
the Mayor to be a trustee of the Boston Public Library,
The Antitoxin Treatment of Diphtheria in Vienna. —
At the meeting of German naturalists and physicians
held in Vienna last month, one of the most attractive
subjects discussed was that of the papers of Professor
Behring and Ehrlich on " Serum Therapeutics/' and on
the " Use of Behring's Antitoxin in the Treatment of
Diphtheria." But neither paper brought any new facts
before the meeting, and the most interesting communi-
cation concerning this question was made by Dr. Was-
sermann, of Berlin. He was endeavoring to obtain in-
formation on the question of idiosyncrasy as regards
proclivity to or immunity from an infectious disease.
For this purpose he withdrew a quantity of blood from
persons who remained healthy though surrounded by
persons suffering from diphtheria, and studied the effect
of this blood on the diphtheria bacillus and its toxins.
He found that the blood of such healthy persons de-
stroyed the toxin of diphtheria, and neutralized tenfold
its bulk of the toxin. In eight persons aged over forty
years, he found in seven the same antitoxic property of
the blood, while the percentage of younger persons pos-
sessing such antitoxic blood was lower, and reached only
fifty per cent, of the children examined between four and
fifteen years of age. — Lancet.
Professor Ludwig Mauthner, of Vienna, died sud-
denly of heart failure. He had just been appointed Pro-
fessor of Ophthalmology in the Vienna University.
We Wonder if it be True.— The Medical News of
Philadelphia remarks that the first statue ever raised to a
medical man was erected in Brooklyn on October 20th,
to commemorate the memory of Dr. J. Marion Sims.
This bit of information will probably surprise Brooklyn
physicians, as none of them seem to have heard of it.
Dudley Sharpe Beynolds, Jr., M.D., son of Dr. Dud-
ley S. Reynolds, of Louisville ; born at Louisville, Feb-
ruary 20, 1873, died from the accidental discharge of a
pistol, at ColHnsville, 111., October 22, 1894.
Alvarenga Prize of the College of Physicians of
Philadelphia.— The College of Physicians of Philadel-
phia announces that the next award of the Alvarenga
Prize, being the income for one year of the bequest of
the late Sefior Alvarenga, and amounting to about one
hundred and eighty dollars, will be made on July 14,
1895, provided that an essay deemed by the Committee
of Award to be worthy of the prize shall have been
offered. Essays intended for competition may be upon
any subject in medicine, but cannot have been published,
and must be received by the Secretary of the College on
or before May 1, 1895. Each essay must be sent with-
out signature, but must be plainly marked with a motto
and be accompanied by a sealed envelope having on its
outside the motto of the paper and within it the name
and address of the author. It is a condition of competi-
tion that the successful essay or a copy of it shall remain
in possession of the College ; other essays will be returned
upon application within three months after the award.
The Alvarenga Prize for 1894 has been awarded to Dr.
G. E. de Schweinitz, of Philadelphia, for his essay
entitled "Toxic Amblyopias." Charles W. Dulles,
Secretary.
Another Post-Graduate School. — It will doubtless be
news to many New Yorkers to learn that there is a third
post-graduate school in this city. It is called the Met-
ropolitan Post-Graduate School, and is homoeopathic. i
WILLIAM GOODELL, M.D., LL.D.,
PHILADELPHIA, PA.
Dr. William Goodell, the eminent gynecologist, who
had been in failing health for the last two years, died at
his residence in Philadelphia, on October 27th, aged
sixty-five years. Dr. Goodell was the son of the Rev.
William Goodell, D.D., of Holden, Mass., and was born
on the island of Malta, while his parents were journeying
to Turkey, where his father was engaged in missionary
work.
In 1849 he entered Williams College, Massachusetts.
Graduating three years later, he came to Philadelphia
and continued his studies at the Jefferson Medical Col-
lege, and received his diploma in 1854. The same year
Dr. Goodell rejoined his father in Constantinople, and
there entered upon the practice of his profession. In
1857 he married, at Smyrna, Asia Minor, Caroline,
daughter of the late Judge Thomas S. Bell, of West
Chester, Pa., who survives him. In 1861 he returned to
America on account of the unsettled condition of politi-
cal affairs in Turkey, and locating in West Chester,
there commenced practising medicine in this country.
In 1865, on his appointment as Physician-in-Charge
of the Preston Retreat, at Twentieth and Hamilton
Streets, he came to reside permanently in Philadelphia,
and continued to hold this appointment until his health
began to fail.
Soon after coming to Philadelphia he restricted his
practice to obstetrics and diseases of women, on the sub-
ject of which he was a prolific contributor to this and
other medical journals, and was also the author of " Les-
sons in Gynecology."
In 1870 he was appointed Lecturer on Obstetrics and
Diseases of Women at the University of Pennsylvania,
and in 1874 Clinical Professor of the University in the
Diseases of Women and Children. He was also Hono-
rary Professor of Gynecology of the University, a mem-
ber of the American Medical Association, and the Gyne-
cological Society ; also of the State and county medical
associations. He was a Fellow of the College of Physi-
cians, and a member for many years of the American
Philosophical and American Pathological Societies, and
a correspondent of the Boston Gynecological Society, of
the London Obstetrical Society, and of the Imperial
Medical Society^of- Constantinople.
596
MEDICAL RECORD.
[November 10, 1894
%snizms atufl Notices of gaofes.
A Practical Treatise on Orthopedic Surgery. By
James K. Young, M.D. Philadelphia : Lea Brothers
& Co. 1894.
In his preface, the author states that he has endeavored
to provide students and practitioners with a guide to
Orthopedic Surgery in accordance with the most approved
knowledge of the present day. A noticeable feature of
the work is the absence of long descriptions of operative
measures for the relief of deformities congenital or ac-
quired, or the result of inflammatory joint or spinal dis-
ease. The author wisely emphasizes the mechanical
treatment of the various conditions, leaving an extensive
description of operative measures to works on general
surgery, in whose province they rightly belong. He de-
votes considerable space to the pathology of the different
affections considered, and has brought this part of the
work up to the most recent views. Want of space ren-
ders a detailed criticism impossible, but the author has
given a fair and complete r&um6 of the different ideas in
vogue at present regarding the etiology, pathology, symp-
toms, and treatment of the different conditions now as-
signed to the specialist in orthopedic surgery.
The work is a beautiful example of typographical art,
and is abundantly illustrated. Dr. Young's work gives
evidence of careful and conscientious research, and is a
valuable addition to the literature of orthopedic surgery.
La Lepre. Observations et Experiences Personnelles.
Par le Docteur Jules Goldshmidt. Paris: Soci6t6
d'feditions Scientifiques. 1894.
What makes this little brochure so attractive that one is
not apt to lay it down until the fifty pages have been
carefully read, and the ten full-page phototype illustra-
tions studied, is the impression left upon every para-
graph, we might almost say, that the author is giving not
only his personal experience, but a personal experience
which is worth giving.
Leprosy has prevailed in the island of Madeira almost
since its discovery, or for some four centuries. During
the past twenty-six years of this time the author has lived
there, and has made the most of his time and advantages
for studying the disease in its many bearings, if we can
judge by the result before us.
Clinical Medicine. A Manual for the Use of Students
and Junior Practitioners. By Judson S. Bury, M.D.
Lond., F.R.C.P. London: Charles Griffin & Com-
pany, Limited. Philadelphia: J. B. Lippincott Com-
pany. 1894.
This book comprises twelve chapters, covering all the
more recent methods of diagnosis. It is quite novel to
find the vast changes in books of this kind within the
last few years. The skin, cutaneous eruptions, diseases
of the nails, are certainly interesting. The examination
of the blood is certainly as useful to-day as an aid to
diagnosis as any other special symptom. The chapters
on the chemical and microscopical examination of the
urine have been most carefully prepared ; so, for example,
Eshach's method of estimating albumin shows it to be up
to date. This book reminds us very much of that most
admirable book by Seifert Miller, published in Germany.
The illustrations are excellent, and the book is not only
admirably adapted for the position of manual, but may
even claim to be "exactly what every physician should
know to-day. It contains 468 pages, and is neatly
printed.
Diseases of the Nose and Throat. By F. De Havil-
land Hall, M.D., F.R.C.P. Lond. With 2 Colored
Plates and 59 Illustrations. Philadelphia: P. Bla-
kiston, Son & Co. 1894.
This book is divided into three parts. Part I. treats of
diseases of the nose, accessory sinuses, and naso-pharynx.
Part II. treats of diseases of the pharynx. Part IIL
treats of diseases of the larynx. It has been written
from a medical rather than a complete surgical stand-
point. It fulfils its purpose, for it is written plainly and
gives all that the ordinary practitioner requires for imme-
diate reference. The book is profusely illustrated, and is
well worth reading.
Some chapters, especially those on the specific infectious
diseases affecting the throat, e.g., scarlatina and diphthe-
ria, although very carefully written, still show that all mod-
ern therapeutics has not been included. So, for example,
antitoxine is not even mentioned as a therapeutic measure
in 1894, although it has been extolled since 1891. How-
ever, the book merits the confidence of the profession.
The Senile Heart. Its Symptoms, Sequelae, and
Treatment. By George William Balfour, M.D.
St. Andrews, LL.D. Edin., F.R.C.P.Eng., F.R.S. Eng.
Consulting Physician to the Royal Infirmary, to the
Royal Hospital for Sick Children, and to the Royal
Public Dispensary, Edinburgh ; Consulting Physician
to Leith Hospital; formerly Physician to Chalmers
Hospital, Edinburgh, etc. ; Member of the University
Court of St Andrews. New York and London : Mac-
millan & Co. 1894.
This is a very clearly expressed and readable treatise
upon a subject of great interest and importance, which has
perhaps hitherto not received the careful study it de-
serves. We are gradually learning that old age is not
the hopeless and helpless condition that some used to re-
gard it, but that it is just as deserving of study as is any
other period of man's life, and the rewards of its study
are as great or greater. We cannot cure old age any
more than we can cure infancy, but we can often, by our
art, change what would otherwise be a period of torment
and suffering into one of peaceful content. To this end
is the teaching of Dr. Balfour's book, and no one can
arise from a perusal of it without feeling that he is in
better position than before to assuage the distressing ills
to which some of our dear aged ones may be subject.
We can heartily commend the work as a valuable contri-
bution to the literature of old age.
The Students' Dictionary of Medicine and the Al-
lied Sciences. Comprising the Pronunciation, Der-
ivation, and Full Explanation of Medical Terms, to-
gether with Much Collateral Descriptive Matter,
Numerous Tables, etc. By Alexander Duane,
M.D., Assistant Surgeon to the New York Ophthalmic
and Aural Institute; Reviser of Medical Terms for
Webster's International Dictionary. Philadelphia:
Lea Brothers & Co. 1893.
The rapid growth of medical terminology, especially in
the departments of bacteriology, pharmacology, and
therapeutics, makes the possession of a reliable technical
dictionary an absolute necessity for student and practi-
tioner alike. Dr. Alexander Duane, who is well known
as a medical writer of wide experience, and who has had
special training as the reviser of medical terms for Web-
ster's International Dictionary, has issued such a work,
which proves to be a model of conciseness, convenience,
and thoroughness. Obsolete words have been discarded,
and the book is brought accurately to date by ex-
tended research among current medical journals and re-
cent monographs. The definitions of diseases include
a brief synopsis of their etiology, symptoms, and treat-
ment ; the anatomical and physiological terms are accom-
panied by outlines of the essential features of structure
and function, and each drug is described, with its reputed
action, therapeutic uses, and pharmacopceial prepara-
tions.
Although contained within the limits of a handy vol-
ume of 650 pages, many of the definitions possess ency-
clopaedic value. Useful anatomical and other data are
tabulated with originality and precision. Under the
word Artery, for example, is found a table covering eight
pages, presenting the origin, lateral and terminal branches,
November 10, 1894]
MEDICAL RECORD.
597
and their distribution, of each vessel. Twenty tabular
pages are allotted to the origin, direction, and insertion
of the muscles, with their action and nerve* supply ; while
thirty-two more are given to the " Table of Bacteria and
Fungi," with their origin, morphological characters,
proper temperature for culture, properties, etc., as well
as a complete list of all bacteriological diseases. The lat-
ter is the most comprehensive and serviceable table of
the kind yet issued. The system of pronunciation is
simple, and the spelling is in accordance with the best
usage rather than analogy. Derivations from foreign
tongues are given, those from the Greek being in English
text for the benefit of readers unfamiliar with the original.
The typography and arrangement of the book are highly
commendable.
The author is to be congratulated upon the production
of a work combining such practical utility with a fund of
most extensive research.
1. Directions for Laboratory Work in Bacteriology,
etc. By Frederick S. Novy, Sc.D., M.D. ; Junior
Professor of Hygiene and Physiological Chemistry.
Pp. 309. Ann Arbor, Mich. : George Wahr.
2. Laboratory Manual of Elementary Physiology and
Urine Analysis. By John H. Long, M.D., Sc.D.,
Professor of Chemistry, etc., Northwestern University.
With numerous illustrations. Pp. 366. Chicago : E.
H. Colegrove & Co.
If there be " no royal road to learning," the seeker after
medical knowledge to-day at least may choose a princely
road. The books, whose title-pages are given above, il-
lustrate that the American medical teacher is rapidly ap-
proaching perfection in method and style. Both books
present the subject-matter in a clear, comprehensible
manner, guiding the student gradually and pleasantly
through the intricacies of the primary work, which are
usually so discouraging. Neither work claims originality,
the authors in both instances frankly stating that they
have drawn from the best sources, and arranged the mat-
ter for their purposes. The paper and type are good ;
those of the first book excellent.
1. Professor Novy's work opens with clear directions
for preparation of nutrient gelatin, potato culture, de-
scribing the microscope and method of examination of
bacteria, hanging drops, staining of bacteria, exam-
ination of colonies. A description of various bacteria
follows, giving their origin, form, motility, sporulation,
growth, oxygen requirements, temperature, behavior to
gelatin, aerogenesis, and pathogenesis.
The bacteriological examination of water, soil, and
air is briefly described. Pathogenic bacteria, methods
of infection, post-mortem examinations, sputum exam-
inations, and agar plate cultures, are followed by a full
and mostly clear exposition of the technique of direct
microscopical examination of streak preparations made
from organs and tissues of infected animals. Methods
of testing disinfectants occupy the closing pages of the
book. The plan of interleaving the latter with blank
pages for drawings which the student is expected to
make, is to be commended.
2. Professor Long's little book is an outgrowth of the
course given to the second-year students. He claims
that two years should be given to this subject in all
medical colleges. This is really done in some of the
New York and other colleges.
The first portion of the book is devoted to simple ex-
periments in elementary chemical physiology, describing
and illustrating the apparatus and technique, chapters
on carbohydrates, fats, proteids, the blood, bone con-
stituents, saliva, gastric juice, bile ; on milk, beef ex-
tracts, flour, water, and air, briefly enter into tests and
general experimental studies.
The second part deals with urinary analysis. This is
especially valuable to the medical practitioner, inasmuch
as it is the most recent exposition of the subject, and
contains a valuable appendix of test- solutions and tables.
A System of Genito-ueinary Diseases, Syphilology,
and Dermatology. By Various Authors. Edited by
Prince A. Morrow, A.M., M.D., Clinical Professor
of Genito- urinary Diseases; formerly Lecturer on
Dermatology in the University of the City of New
York; Surgeon to Charity Hospital, etc With
illustrations. Vol. III., Dermatology. New York: D.
Appleton & Co. 1894.
The third and last volume of this composite product of
American work in the field of Dermatology and Syphil-
ology, surpasses in some respects the preceding volumes,
which have already received favorable notice in these
columns. The list of contributors includes most of the
familiar names in matters dermatological, extending
alphabetically from Allen to Zeisler, and geographically
included within a line drawn from Montreal to New Or-
leans by the way of Chicago.
If the work consisted in a series of monographs by
these authors, written by them to parade each his own
pet hobby, it would perhaps make interesting reading for
those specially engaged in treating skin diseases ; but it
would be of little real value to the physician at large.
As it is, the editor has selected, with apparent excellent
judgment, the man for each particular chapter who was
best suited to give a clear, correct, and at times necessa-
rily concise, account of all that is known upon the sub- .
ject. In this way a practical treatise, for the most part
comprehensive enough for a reference compendium, has
been produced which most creditably reflects our present
knowledge of skin diseases, and while a true exponent
of American dermatology of to-day, does not in any way
neglect those diseases peculiar to other parts of the
world. As the editor tells us in his prefatorial remarks,
some forty diseases have been here described which only
a few 'years ago were not to be found in text books as
distinct clinical entities. Especial commendation is due
the illustrations, which we must say are, as a rule, decid-
edly superior to those of the other volumes. There are
twenty-seven colored plates, twenty-five half-tones, and
over a hundred figures in the text. Some of the new-
process pictures are very life-like. The editorial work
and Dr. Morrow's own article on Leprosy, deserve praise.
The publishers have left little to be desired, but we
think they might have put on a better binding. We pre-
dict for the work a large sale on its merits.
The Horse. Its Varieties and Management in Health
and Disease. Revised and enlarged by George Arma-
tage, M.R.C.V.S. ; formerly lecturer in the Albert
and Glasgow Veterinary Colleges ; Author of "The
Horse Doctor," " The Cattle Doctor," etc. London
and New York : Frederick Warne & Co. 1893.
This little work is written in a simple style and con-
tains, aside from the descriptions of disease and thera-
peutic advice, a rather full chapter on horse-manage-
ment, hints on purchasing, shoeing, breeding, breaking,
etc. Such a large proportion of medical men are of
necessity horse owners, that a work devoted to their
faithful friends cannot fail to interest.
The book before us will not be found sufficiently
scientific for the physician who knows anything at all of
the subject, and he will feel, in reading a considerable
part of the instructions, that they were written for
Englishmen. Still an occasional hint of value can be
picked up.
Text-book of Anatomy and Physiology for Nurses-
Compiled by Diana Clifford Kimber, Graduate of
Bellevue Training School ; Assistant Superintendent
of New York City Training School, etc. Pp. 268.
New York : Macmillan & Co. 1894.
The author informs us that the scheme of this book has
been practically worked out in class teaching. She cor-
rectly surmises that she has. devoted too much space to
minute structural anatomy, which courses be defends by
her experience in teaching. She claims that nurses
59»
MEDICAL RECORD.
[November io, 1894
thus taught would be led step by step to a correct grasp
of the subject, and would thus be trained to think.
We apprehend, however, that the average nurse will
fail to reach the author's ideal. Her style clearly indi-
cates that she has well measured the capacity and de-
mands of those for whom it is intended. The mechanical
execution of the book is creditable to the publishers.
Transactions of the Medical Society of the State
3F New York for the Year 1894. Published by
the Society. 1894.
Among the most interesting of the contents of this vol-
ume of transactions are the discussions — abnormal sur-
gery, diphtheria, and menstruation. There are also a
number of single papers that are well worthy of preser-
vation in permanent form.
Clinical §epnvttawxt.
THE USE OF ANTITOXIN IN DIPHTHERIA
FOLLOWING SCARLET FEVER.
By W. S. GLEASON, M.D.,
NBWBUKGir, N. Y,
At this time, when, as a profession, we are awaiting with
interest the effect of the use of antitoxin upon the human
subject, I feel that the following results should not go
unrecorded :
On the morning of October 5 th I was called to see
John , aged eight, a robust boy, son of vigorous pa-
rents. I found upon examination well-marked evidences
of scarlet fever; temperature, 1040 F. ; pulse, 140; upon
my evening call, temperature, 1050 F. ; pulse, 144.
The temperature, unless reduced by antipyretics, ranged
between 1040 and 1050 F., with but slight variation be-
tween the morning and evening observation.
On the second day of the disease a fibrinous exudate
made its appearance on both tonsils and pharynx, with
intense tonsillar enlargement, and in spite of thorough
pharyngeal disinfection there was great difficulty in
swallowing. Gradually the appearance of the exudate
changed its appearance, and upon the seventh day from
the time of my first call I felt that I had a true diphthe-
ria engrafted upon the scarlatina angina. Starr brings
out the fact in his " American Text-book of Diseases of
Children.11 As we have not the means to make cultures
in our city, I was not able to verify the presence of the
Klebs Loeffler bacilli. The temperature, if unrestricted,
remained at 104$° F. ; pulse, 150; glands of the neck
enlarged, and an excoriating nasal discharge was present.
At three o'clock in the afternoon of October 12th I
made my first injection of Aronson's serum, using twenty
minims, followed by a second injection of forty minims
in six hours. With close observation I could not appre-
ciate the least reaction as an immediate result of the in-
jection. Twenty four hours from the last injection the
temperature dropped to 990 F., with a corresponding
amelioration of the symptoms. There was an evening
rise of temperature to 1030 F., but from that time, Octo-
ber 1 2th, to this date, October 23d, the patient has stead-
ily convalesced, with no decided fluctuation of pulse or
temperature. I combatted the scarlatinal conditions
with carbolized inunctions to the body, lime-water, and
peroxide of hydrogen sprays for throat ; and a judicious
use of quinine and phenacetine as antipyretics. The
diphtheritic manifestations were met with the same spray
for throat, and bichloride irrigations, 1 to 1,000, for both
throat and nares. Internally, full doses of mecuric bi-
chloride. For forty-eight hours preceding the use of the
serum, the heart flagged and required careful stimulation.
The fact that within twenty-four hours after the use of
the serum such a remarkable change took place proved
to me conclusively that the absorption of septic material
ceased at once, and produced a reaction not found in
such intense conditions.
EXTRA-UTERINE PREGNANCY.
By WILLARD McCHESNEY, M.D.,
JANKSVIIXF, WIS.
In the following case of extra-uterine pregnancy with
retained foetus, no reference will be made to die literature
on the subject, as the investigator can readily refer to it.
The case appended presents points sufficiently interesting
to merit its publication.
Mrs. Eugene B , aged forty-two, a resident of
Texas, became pregnant, or at least so pronounced by
her family physician, in the early spring, 1889. The
usual symptoms present in such cases were not lacking, —
there was cessation of menstruation, nausea, tenderness
of the breasts, enlargement of the abdomen, motion, etc.
The husband, from whom the history was obtained, did
not know whether foetal heart sounds had been demon-
strated. Mrs. B says abdomen continued increasing
in size until she had passed the full period of gestation.
At the expiration of her period labor did not come on,
and for two months following there was a period of com-
plete quiescence. At the commencement of the eleventh
month she had pains, quite severe, and the pains were
accompanied by a discharge from the genitals of a sero-
sanguinolent character. The pain and discharge con-
tinued for nearly three months and gradually ceased.
During this time the abdominal enlargement decreased
in size, and at the end of the fourteenth month nothing
remained but a firm tumor occupying the right iliac
fossa. At about this time menstruation was re-established
and the patient considered herself in fair health, as there
was no inconvenience from the tumor. Shortly after
this a consultation was held to decide whether an at-
tempt should be made to remove the tumor by operation.
The husband is not clear as to the conclusions arrived at
at this time, but the consulting surgeon advised no op-
erative interference. Mrs. B— — informed me that the
tumor changed in size, but in view of what was subse-
quently determined, thinks she was in error.
From dates given above until March, 1894, the health
of patient was very good, but during the early days of
March she was taken with quite a severe chill, followed
by fever ; in a few days she had chills coming on irregu-
larly, associated with fever, diarrhoea, and quite severe
sweats. There was also some muscular pain somewhat
resembling the pain of muscular rheumatism. There
was a rapid waste of tissue and strength, and the services
of a rectal specialist were called into requisition for
the purpose of relieving the patient of a very bad case of
haemorrhoids, the operation to be done without the use
of knife, cautery, or ligature (parenthetically, we have no
hesitation in saying that they were not used). Regardless
of the rectal operation, emaciation was rapidly progres-
sive, diarrhoea continued, and was held in check only
slightly by opiates administered by rectal injections and
by mouth, and a northern trip was advised, trusting that
the change might be beneficial. The trip north was un-
eventful, and the patient did not suffer materially from
the effects of her journey. Shortly after her arrival,
however, she became considerably prostrated, and Dr.
Q. O. Sutherland, of Janesville, who was called in to see
the case, diagnosed it as one of extra-uterine pregnancy,
and advised immediate removal to his private hospital,
hoping to get her in condition to undergo an operation.
A strong effort to build her up proved of no avail, and
she died quite suddenly September 20th.
Mr. B kindly permitted an autopsy, which was
held the following morning. On opening the abdomen
the bowels were found to be singularly free from adhe-
sions, and it was at once seen that the right Fallopian
tube was the seat of the difficulty. On its posterior sur-
face the tube was adherent throughout to the pelvic peri-
toneum and the bowel ; the anterior surface was free from
adhesions. On opening into the tube we found the
badly decomposed remains of a foetus, showing a growth of
about seven months. After thoroughly cleansing the foul-
smelling cavity, it was found that a free opening existed
November 10, 1894]
MEDICAL RECORD.
599
between the foetal sac and bowel, and that the tissues in
the vicinity of the bowel were necrotic. It was evident
that an operation, to be successful, should have been per-
formed several months previously.
In reviewing the case several points present themselves
for our consideration. The principal one to consider is,
naturally, the one which questions the ability to have
made an early diagnosis. In looking over the case as it
presented itself at the hospital, and reviewing its history,
it seems hardly possible to have erred in making a diag-
nosis.
1. We have a clear history of pregnancy in so far as
that fact could be determined, and it might have been
possible to have detected the foetal heart- sound, a posi-
tive sign.
2. Pains occurring at the eleventh month, with a dis-
charge, decrease in size of the abdomen, and a firm tumor
left.
3. The very evident signs of septic infection which
first appeared about March 1st, with the previous history,
should have been a prominent factor in establishing the
diagnosis of extra-uterine pregnancy and decomposition
of foetal remains.
In conclusion, the chances were strongly in favor of
recovery had a diagnosis been made sufficiently early to
allow an operation, either by laparotomy, or, as suggested
by Dr. Sutherland, opening directly into the sac from the
vaginal vault, and if cavity was septic, treating it as an
ordinary abscess cavity.
LEAD -POISONING AND THE MORPHINE
HABIT-REPORT OF A CASE.
By R. ABRAHAMS, M.D.,
VISITING PHYSICIAN TO MOUNT SINAI HOSPITAL, OUTDOOR DEPARTMENT.
Besides the unusual mode of acquiring the morphine
habit, and the strange association with it, that of pro-
found lead-intoxication, the history of the case that I am
to report contains an additional item which may well
interest the physician, his inevitable ally, the druggist,
and possibly the public, if it reached their ear.
I presume it is the experience of almost every practi-
tioner to find, at one time or another, his prescriptions
repeatedly renewed without his advice or consent, writ-
ten or oral — whether the prescription orders morphine or
rhubarb, cautious use or ordinary care. My object, how-
ever, is not to discuss the abnormal relation between the
physician and apothecary that such a practice involves,
but rather to point out the serious trouble that it may
lead to, and there is not a better illustrative case than
the following one.
Mrs. K , aged forty, mother of ten children, the
last one still-born, has been in poor health for the last
few years ; pale, emaciated, and complaining of neuralgic
pains at different points of the body ; appetite very poor ;
never felt hungry for meals; bowels moved very irregu-
larly, and colicky pains in the abdomen were of frequent
occurrence. On a Friday in the month of July, the day
being moderately warm, she was suddenly seized with
severe cramps in the abdomen and the legs, incessant
vomiting and diarrhoea. Physicians were hastily sum-
moned, a diagnosis of cholera morbus agreed upon, and
treatment accordingly instituted. The next morning, as
there was no improvement in the patient's condition, I
was asked to see her, and the following is what I found :
Vomiting and diarrhoea every half-hour ; both dejecta
were copious, one green, and the other blackish and mal-
odorous ; the extremities cold ; the face extremely pale,
pinched, drawn in, and covered with a cold, clammy
perspiration. The abdomen was hard and retracted,
very tender around the umbilicus. The tongue was
thickly coated and moist ; the breath peculiarly offen-
sive. The pulse, much to my surprise, was full and regu-
lar, and the rectal temperature a small fraction above
the normal. The patient continually moved her hand
toward the abdomen. Now, this condition of apparent
collapse, with a good pulse and a normal temperature,
were, in my mind, hardly compatible with an attack of
cholera morbus. The clinical picture rather suggested
some form of profound intoxication, which I at once set
about to find out. On a second examination of the pa-
tient I discovered, much to my satisfaction, a blue line
along the gums.
This was a key that unlocked the mystery, and although
the source of the lead supply was unknown, the diagno-
sis, however, was tolerably certain. Later in the day,
the patient's husband volunteered the following informa-
tion : Eight years ago his wife was troubled with haemor-
rhoids, for which the physician in attendance prescribed
" something." His wife got well, but the curative agent
pleased her so much that she continued to take it to that
day. He was totally ignorant of the contents of the
" box," but he was positive that a failure to supply her
with it rendered her unspeakably wretched. By and by,
exercising her womanly prudence, she laid aside a good
stock of her favorite drug for a rainy day, as it were.
She never experienced any difficulty in obtaining it, for
she had a copy of her original prescription in about half
a dozen shops, where she could get it on the presenta-
tion of the old label. In the course of time she became
subject to frequent attacks of colic, which, however,
always yielded to an extra dose of her medicine.
While narrating this unvarnished tale, he called my
attention to a supply of " pain-killers " under her pillow,
to which she liberally helped herself during the present
illness, but with very little benefit. Now, this favorite
panacea was in the shape of a suppository, which, on in-
quiry, I found to contain a third of a grain of morphine
and one- half a grain of acetate of lead. This piece of
etiological enlightenment left no doubt as to the real nat-
ure of her condition. It is hard to estimate the quan-
tity of lead the patient consumed during the eight years ;
for, at times, she told me her colic was so acute and the
desire for relief so intense that she filled her rectum
with suppositories to its utmost capacity, while in the ab-
sence of pain she took the suppositories simply to supply
her craving for the alkaloid, as the habit was perfectly
established. Thus one drug spurred her on to take the
other. The poor victim knew that she could not be
without the suppository ; yet her ignorance of its compo-
sition was only exceeded by her passion for it.
The moral and interest of this peculiar case will be
enhanced by one more, rather amusing, feature of it My
patient was regarded by many a neighboring woman with
pious admiration. Many a pain she relieved, and for all
I know, many a woman, through her agency, is now
suffering from the effects of lead-poisoning and the mor-
phine habit. ♦
From a pathological standpoint, this case strikes me
as being a unique one, for, excepting the anaemia, the
emaciation, the colic, the alternate constipation and
diarrhoea, the neuralgic pains, and the " lead line,"
while sufficient to establish a diagnosis of lead-poisoning,
none however of the great and marked nervous symptoms
were present. In a case of such long standing, one would
naturally expect to see some form of paralysis. Although
the arterial system showed commencing atheroma and
the urine contained slight evidences of renal disturb-
ance, yet the nervous system showed nothing to indicate
any lesion whatever.
Whatever form of plumbism this case may be regarded,
its chief interest, perhaps, lies in its combined features,
and their mode of acquirement.
158 Clinton Street, New York City.
Bogus Degrees in England.— The trade in degrees
from non-existent American universities has recently re-
vived in England. These degrees give no rights, but
their purchasers have the satisfaction of adding a few
more letters after their names. The price charged for
an M.D. or LL.D. is ^30, and for any other degree
wished for, ^25.
6oo
MEDICAL RECORD.
[November 10, 1894
NEW YORK ACADEMY OF MEDICINE.
SECTION ON OBSTETRICS AND GYNECOLOGY.
Stated Meeting, October 2j, 1894.
Malcolm McLean, M.D., Chairman.
Tubal Pregnancy — Rupture, Operation, Death. — Dr.
Charles E. Nammack presented a specimen of tubal
pregnancy in which rupture had taken place about the
forty third day; slight symptoms of collapse, pain, and
hemorrhage manifested themselves ; he advised an opera-
tion. Three consulting surgeons objected, believing that
the hemorrhage was limited by the folds* of the broad
ligament, but the next morning the patient went into
collapse from recurrence of concealed hemorrhage, and
then no difference of opinion existed with regard to the
propriety of operating. It was too late, however, for
the patient did not fully rally, and died fifty-two hours
after removal of the blood- clots and ovum per laparot-
omy. Dr. Nammack said his object in presenting the
specimen was to impress the danger of letting extra- tubal
pregnancy continue, especially after the first signs of
rupture, on the supposition that the pregnancy was ex-
tra-peritoneal and that the hemorrhage would be limited.
In the many cases operated upon by Dr. Joseph Price not
one had been encountered in which the pregnancy was
extra-peritoneal. Yet it was the custom of general prac-
titioners, he believed, to rely upon their ability to say
whether the hemorrhage was extra peritoneal or intra-
peritoneal ; if the former, to wait, and in waiting take
the great risks of recurrent hemorrhage, peritonitis, sep-
ticaemia, and subsequent trouble from a damaged tube.
Dr. Boldt named one justification for temporarily
postponing the operation, namely, shock attending the
rupture.
Dr. J. R. Goffe thought Dr. Nammack need not go
outside of New York to get confirmation of the view that
a prompt operation was demanded in cases of ectopic
gestation. The most prominent gynecologists in this
city had advocated and practised prompt interference
for years, among them being Dr. Janvrin, who had taken
this position as many as ten years ago.
Point of Origin of an Ovarian Tumor.— Dr. J. R.
Goffe presented the sac of an ovarian cyst, on one side of
which, for a distance of eight or nine inches, the fimbri-
ated extremity of the Fallopian tube could be seen spread
out like a veil. Evidently the small cyst which was the
commencement of the tumor had lain directly under the
fimbriated 'extremity of the tube. Part of the other
ovary had also undergone cystic degeneration; two-
thirds of it were removed ; the edges were turned in so
that no raw surface would be exposed to form adhesions.
The patient was doing well.
Sarcomatous Degeneration of Uterine Fibroids. — Dr.
Goffe also presented a uterus with multiple sub-perito-
neal fibroids and sarcoma. This and two other cases
seen by him recently showed the importance of operat-
ing early for uterine fibroids causing symptoms if one
would spare the patient malignant disease.
The Chairman, Dr. McLean, said he had removed an
ovarian tumor weighing over forty pounds, three or tour
years ago, and finding the fimbriated extremity of the
tube spread largely over it, he dissected it off and
dropped it back with the rest of the tube. Two years
later he had occasion to reopen the abdomen of this pa-
tient for another disease, and it was interesting to note
that the tube was healthy and had diminished to its nor-
mal size.
Hew Pelvimeter. — Dr. Herman L. Collver pre-
sented a new pelvimeter, the blades of which could be
taken apart and placed parallel with each other when
not in use ; which registered in both the English and
metric systems ; which would give pelvic diameters up
to fourteen inches, and which cost but two dollars, or a
third to a fifth as much as any other instrument in the
market. Cheapness was extremely important in an in-
strument which every general practitioner should keep,
and yet one which he was not likely to use more than a
few times during a life practice.
Dr. Marx mentioned a case in which the calipers pre-
sented by Dr. Collyer measured the external diameters of
a very large pelvis, which others at his command had
failed to do.
Postal Abnormality. — Dr. E. A. Tucker exhibited
photographs of a child with a left foot and leg connected
apparently by osseous as well as fleshy union with the
upper dorsal spine. The foot was perfectly formed, and
one could make out what seemed to be leg, knee, and
thigh. It was sensitive to touch.
The mother, Irish, twenty eight years old, addicted to
drink, mother of three other children which were born
normally, was brought to the hospital for pain in the left
side caused by a kick from her husband. The os was
somewhat dilated, but real labor did not come on until
six days later. The woman was very positive that the ab-
normality was due to the kick by the husband's left foot,
and was in the nature of a punishment for the act. Of
course, Dr. Tucker said this notion was absurd, since such
a growth must have started long before six days prior to
full term, and doubtless had its origin in a blasted ovule
which became attached to this foetus.
When during the labor Dr. Tucker felt the foot be-
tween the shoulders, he remarked to those present that
there probably would be dislocation of the leg, and was
much surprised later when two other feet dropped out.
Had the case been a breech presentation, this foot
might have caught and caused trouble ; or if a shoulder
had presented first, there would have been great difficulty
in making full diagnosis.
When the waters broke, a small, irregular, soft, whit-
ish mass came away, which Dr. Tucker thought at first
was vernix, but on section was found to contain two cysts,
and was composed of cells, but the exact nature of the
structure was a mystery to Dr. Prudden, Dr. Freeborn,
and others who had examined it. There was a small,
scar-like protuberance on the heel of the third foot, and
the mass was believed to have been attached there.
Extirpation of the Uterus and Adnexa in Pelvic Sup-
puration and Post-Puerperal Septicemia. — Dr. H. J.
Boldt read a paper with this title. Pelvic suppuration
might leave multiple abscesses, it might leave double pyo-
salpinx, it might leave a mass of inflammatory material
enclosing pus — a variety of conditions in which success-
ful treatment often involved operative interference of
grave nature. In quite a considerable percentage of the
cases in which the uterine appendages had been removed
trouble had still persisted, due to the fact that the uterus,
the origin of the primary, or seat of the secondary,
trouble, had been allowed to remain. The author was
led to ask the question, is the uterus of utility to a person
with bilateral disease of the tubes and ovaries to such
degree that they have to be removed ? The answer, he
said, must be in the negative. Some operators who en-
tertained this view made it the excuse for always remov-
ing the uterus when they opened the abdomen and found
double tubo-ovarian disease. But Dr. Boldt had op-
posed such a course for the reason that often disease in
the uterus could be corrected, that abdominal hysterec-
tomy complicated removal of the appendages, and that
if it should finally prove necessary to remove the uterus,
it could be more safely done through the vagina, and
would be unattended by risk of hernia, which was con-
siderable in all abdominal operations. In comparing
vaginal with supra-vaginal hysterectomy, the author
claimed that the former was not attended by greater risk
of subsequent intestinal obstruction, that there was
greater traumatism and consequent shock from handling
the intestines in the abdominal method, also much
greater liability to spread infection, and, as said before,
liability to ventral hernia in spite of all precautions.
November 10, 1894]
MEDICAL RECORD.
601
The author, being an advocate of conservative surgery,
advised the abdominal route wherever there was a possi-
bility of being able to save the whole or a part of an
ovary. But where it was possible to make a positive
diagaosis, which called for removal of the uterus as well
as of the adnexa, he advocated the vaginal method, and
claimed that by it one could reach the uterus, the ap
pendages, and other diseased structures. An important
advantage of the vaginal route was that it gave natural
drainage (by gravity), and also that it enabled the pa-
tient to return home in a much shorter time. In sup*
purative cases clamps had usually to be employed instead
of sutures, but they could be removed in twenty-four
hours, and during that time favored drainage.
Regarding the mortality of the vaginal operation, Dr.
Boldt had lost one patient (almost a hopeless case to be-
gin with) out of seven operated upon ; 542 in literature
gave a mortality of 4 32 per cent., at least 295 of them
having been suppurative. He had serious doubts whether
one could collect 500 cases of abdominal hysterectomy
with a smaller mortality than seven per cent.
In acute general puerperal septicemia he had washed
oat the abdomen in four cases, and they died, had re-
moved the uterus in four, and they, too, had died, yet he
regarded it as more logical to hope for a favorable ter-
mination from vaginal hysterectomy and removal of the
tubes than from removal of the tubes alone where the
uterus was the original site of infection.
Dr. Von Ramdohr thought that in cases of multiple
pelvic abscess in which it had been determined to remove
the uterus, the abdominal route should be selected, since
some of the foci of infection might escape notice through
the vagina. In puerperal cases, also, it was necessary to
open the abdomen in order to find all collections of pus.
Dr. Grandin said that if the paper was intended as a
plea for removal of septic appendages, he agreed with the
writer; but if it was intended as a plea for removal of
such appendages through the vagina rather than through
the abdomen, he disagreed with him. He believed in
seeing as well as feeling what one was about, and it was
for this reason that he was opposed to returning to the
old method of treating these cases through the vagina,
even with the addition of removing the uterus. Extirpa-
tion of the cancerous uterus through the vagina might be
simple in the hands of an expert, but vaginal hysterec-
tomy in disease of the appendages, with all the possible
complications, such as adhesion to the vermiform appen-
dix, etc., might be anything but simple. The danger
of hernia in abdominal operations was greatest where up-
drainage was practised, but such drainage had been aban-
doned in favor of passing gauze down through the vagina.
In acute general puerperal peritonitis he had not
found the infection limited to the uterus, and conse-
quently it would not have been sufficient only to remove
that organ either by the vaginal or abdominal method.
There were multiple abscesses scattered throughout the
abdomen, and it was by opening these, washing out, and
draining under the liver, under the spleen — in other
words, resorting to multiple drainage and cleansing, that
a Western physician had succeeded in saving one patient.
Dr. Goffe had had under observation six or seven
cases operated upon by the method advocated by Dr.
Boldt — the Belgian method — and the impression which
he had received was that it was a very blind, a very
bloody, and unattractive procedure. The abdominal
operation was clearer ; it enabled one to see what he was
doing and should do, and left the way open for either
conservative or radical operation, according to the more
exact diagnosis made possible by touch and sight.
Dr. W. E. Porter could not agree with the author,
particularly in septic disease of the appendages, believing
that, in the very cases in which the vaginal method had
been advocated, there were the strongest contraindications
to its employment. In tubal disease it was impossible,
owing to the frequency of extensive adhesions and com-
plications, to make an exact diagnosis and operate with
safety without abdominal section. In puerperal cases
the simplest operation, one least attended by shock,
would give the best results.
Dr. Robert H. Wylix found it difficult to discuss the
paper because, he said, it dealt with so many other sub-
jects than those indicated in the title. So far as the
mortality rate was concerned in the list of cases of
vaginal hysterectomy given by Dr. Boldt, the result had
been excellent, but it was not yet possible to speak posi-
tively of the remote results, particularly of the occur-
rence of hernia. It was a long time before we learned
of the frequency of ventral hernia following laparotomy,
for operators were too much concerned with other points
to pay much heed to this accident. Might it not be so
with regard to hernia into the vagina following vaginal
hysterectomy? In puerperal septicaemia he could not
see how the author could distinguish between cases in
which the infection was limited to the uterus, and justi-
fied removal of that organ through the vagina and cases
in which it had passed to the peritoneum, which it
might do directly instead of through the tubes. He
would, therefore, open the abdomen and then decide
what should be done.
Dr. Boldt made some closing remarks. He thought
it strange the gentlemen should advocate the abdominal
operation when the vaginal had given so much better
results, that is, in the cases in which alone he had ad-
vocated it.
MEDICAL SOCIETY OF THE COUNTY OF NEW
YORK.
Annual Meeting, October 22, i8p4.
Seneca D. Powell, M.D., President, in the Chair.
Officers. — Many of the candidates having withdrawn,
there remained but two for president, two for first vice-
president, eight for censors (five to be elected), and but
one candidate for the other offices. Dr. Egbert H.
Grandin was elected President; Dr Richard Van Sant-
voord, First Vice-President ; Dr. S. Henry Dessau, Sec-
and Vice-President; Dr. Charles' H. Avery, Secretary;
Dr. William E. Bullard, Assistant Secretary ; Dr. John
S. Warren, Treasurer; Drs. Seneca D. Powell, Charles
L. Gibson, George T. Jackson, Edward D. Fisher, and
Charles H. Knight, Censors.
Report of the Treasurer. — Dr. Warren read his re-
port as treasurer, and it was found correct by the auditing
committee. The receipts for the year had been $4,152 ;
adding balance from last year and subtracting disburse-
ments for this year, which amounted to $4,441, left a bal-
ance of $2,392.
Report of Committee on Hygiene.— Dr. W. A. Ew-
ing, chairman of the committee, read the report They
had found that some of the dispensaries had acted on
their advice and separated children with contagious dis-
eases immediately on entering the dispensary, not allow-
ing them to mix with others in the general waiting-
room. Some of the larger dispensaries, however, had
not yet adopted this most important regulation for the
prevention of spread of disease.
The work of the Board of Health with regard to vac-
cination and report of contagious diseases among school
children, and the management of diphtheria, was com-
mended. Some of the dangers of spreading tuberculosis
were mentioned, and it was suggested that in the lower
tenements it would be much safer to do away with car-
pets than to leave them on the floor as dirty as they
commonly were.
The Communion Cup, the Court Bible, and Syphilis. —
The committee was pleased to report that some churches
were dispensing with the single communion cup and
were using one for each communicant, thereby avoiding
one way of spreading syphilis. In this connection at-
tention was also called to the danger of communicating
syphilis by kissing the court Bible, and it was suggested
that if this custom were continued the book ought to be
covered with a thick layer of iodoform gauze.
602
MEDICAL RECORD.
[November 10, 1894
The Disposal of Garbage.— The habit of the authori-
ties of allowing ash cans to stand until overflowing, and
then of filling carts beyond their capacity and scattering
the ashes and garbage in the streets, was condemned,
and the recommendation was made to burn the garbage.
Beport of Committee on Ethics.— Dr. W. M. Polk,
chairman of the committee, made a verbal report, stating
that few complaints had been brought before the com-
mittee and these had been settled by the delinquents
making prompt amends. Regarding complaints against
members for using the daily press in some foim for ad-
vertising, the committee suggested that they be brought
before the Society itself, with the hope that the greater
publicity given the matter might have some restraining
influence on delinquents of this character.
Dr. Joseph D. Bryant, chairman of the Committee
on Prize Essays, stated that no essay had been received.
On Symphyseotomy, with Beport of a Hew Case. —
Dr. H. J. Garrigues read the paper. (See p. 577.)
Dr. Egbert H. Grandin was requested to open the
discussion. Prior to the rejuvenation of s)mphyse-
otomy in 1890 he was exceedingly sceptical. But per-
sonal experience with it in two cases in which he had
operated, and in three others in which he had assisted,
had since proven to him that it was a distinct advance
in the obstetric art. He did not believe the profession
yet fully realized what symphysetomy meant. It meant
that we were no longer called upon to take life in order
to save life ; to sacrifice the child by embryotomy in
order to save the mother.
Too few operations had been done in this country to
enable anyone to speak dogmatically upon the position
which symphyseotomy was destined to take, for we must
judge by what can be accomplished in America, not by
what has been done in Europe. He believed, however,
that the time was approaching when the general practi-
tioner would have a practical knowledge of pelvimetry
and of aseptic surgery, and that then many children
would be saved by elective symphyseotomy. If the op-
eration were done aseptically, before the woman and
child had become exhausted, there should be no mortality
for the mother, and he thought also none for the child.
Dr. H. C. Cos had peformed symphyseotomy three
times, twice within the past six weeks, but did not feel quite
so enthusiastic about it as the last speaker. Further expe-
rience was necessary to enable one to pass an intelligent
or final opinion upon it He had noticed a good deal
of difficulty in extracting the head, and there had not
been as much gain in the pelvic diameters as he had
hoped there would be. With the conjugate under three
inches he would perform Caesarean section, but where it
was between three inches and three and a half he thought
symphyseotomy should be resorted to, provided the case
were seen at the beginning of labor. All of his patients
were seen early, pelvic contraction was recognized, every-
thing was favorable, but such conditions were not likely
to be present in cases seen in private practice. He had
not yet made up his mind as to the best method of ex-
tracting the child. The cervix not having been fully
dilated there was considerable delay of the head, and
one child suffocated. It would seem, therefore, that the
forceps might be indicated quite as often as version.
Like Dr. Grandin, he expressed preference for the blunt-
pointed bis t out y over the Galviani knife. He did not
believe in working in the dark, but would expose the
full front of the symphysis and see what he was doing.
The operation in this country was still subjudict.
Dr. Charles Jewett agreed with the author's con-
clusions on most points. Symphyseotomy, compared
with Caesarean section, labored under two disadvantages.
The first was the difficulty of determining the size of the
child's head and mother's pelvis, which it was not nec-
essary to know in Caesarean section ; the second, related to
the first, was the fact that if the pelvis were overestimated
the operation would probably prove a failure. There
was greater difficulty, too, in the after care of a case of
symphyseotomy than of Caesarean section. In the for-
mer the bones had to be kept in apposition and the
wound free from contamination with urine. He agreed
with other speakers, that the operation was too recent in
this country to justify sweeping statements. One who
placed the lower limit of the conjugate diameter at three
inches would probably find symphyseotomy a safe open-
tion.
Dr. R. A. Murray thought symphyseotomy could be
done safely in private houses as well as in hospitals, but
we could not hope for the results which had been ob-
tained abroad until, like there, it came to be performed
by those who had had previous experience. He called
attention to the increase in the oblique and transverse
diameters as well as in the conjugate, which rendered the
operation especially suitable for the generally contracted
pelvis, which was the deformity oftenest found in this
country. He also referred to the larger size of the newly
born in this country, the average weight at the City Ma-
ternity Hospital being about seven pounds and a half, as
against about six pounds in Italy. Of course the larger
the child the larger must be the pelvis to justify symphyse-
otomy instead of Caesarean section. Do not try to de-
termine the size of the pelvis by one or two fingers ; in-
troduce the whole hand.
Dr. Garrigues made some closing remarks. Sym-
physeotomy had been recommended where the conjugate
was only two inches and a fourth, but he thought three
inches a safe lower limit in this country, and three and a
half sufficiently high, for above that one should be able
to extract by version or with forceps.
APEX CATARRH OR TUBERCULOSIS.
To ?m Editor of tks Medical Rbcoxd.
Sir : In reply to the very kindly criticism of Dr. H. B.
Moore, of Colorado Springs, concerning an article by
myself in the issue of September 2 2d, allow me to call
his attention to an article on "Apex Catarrh," in the
issue of January 6, 1894. Also to a paper read by Dr.
G. R. Butler, of Brooklyn, N. Y., before the Climato-
logical Section of the Congress of American Physicians
and Surgeons, in Washington, D. C, May 29, 1894.
The title of this paper was " The Methods and Value of
Exercise and Diet in the Prophylaxis of Pulmonary
Phthisis.19 The name apex catarrh is said to be objec-
tionable. The name is as unsatisfactory to me as to any
one else. In the cases called apex catarrh all the mu-
cous membranes of the body are more or less affected —
the gastro-intestinal, as a rule, the most of all. It seems
hardly wise to name the disease with reference to the
localized bronchitis only. Thus far, however, no better
name has been suggested. The term, " the pre- tuber-
cular stage of tuberculosis/9 has been suggested. If all,
or a large proportion of cases of apex catarrh, became
tubercular, this term would exactly fill the requirements,
but such is not the fact. The great majority of cases of
apex catarrh recover within a few months, and only the
exceptional case ever develops tuberculosis. On this
account I have avoided any name calling attention to a
possibility. While it is always possible that a given case
may become a localized tuberculosis, most cases look
back to their condition of depressed health as a time
when they "were a little run down from overwork/'
" had a stomach trouble," etc.
The conditions of apex catarrh and tuberculosis run
into each other. No one can decide when the tubercle
bacilli gain a foothold in the tissues depressed in resist-
ance and vitality by a catarrhal inflammation, and the
case pass from a pre- tubercular into a tubercular con-
dition. A decision can only be arrived at by watchir g
the course of the disease. I early realized my inability
to decide which case would take a bad course (become
tubercular) and which one would recover within a few
months. An apex catarrh does not arise from an acute
November 10, 1894]
MEDICAL RECORD.
603
cold in the majority of cases. A email proportion of
cases cannot well be explained on any other basis, and
yet this question is one concerning which I have much
to learn. A very large proportion of cases of apex
catarrh present themselves to the physician when suffer-
ing from an acute cold, but careful inquiry generally
elicits the fact that the patient did not feel well before
taking the last cold.
As to the examination of the sputa in such cases. If
the patient has no disease of the upper air-passages that
occasions cough no sputa can be obtained. In the great
majority of cases in which the sputa can be obtained no
tubercle bacilli can be found. If they are present then
the case is one of tuberculosis and transcends the limits
of this discussion.
With the assistance of a competent bacteriologist I
pursued this line of examinations for two years, until I sat-
isfied myself that the tubercle bacilli were not to be
found in cases of apex catarrh. The sputa was generally
taken from well- marked cases. Because nothing was
found in such cases I reason that they are not present in
cases in which the physical signs are less well marked.
As to the case cited as having died of a " profuse
hemorrhage/' allow me to say the choice of this case
was unfortunate. It is misleading, I confess. The point
I especially wished to make is the importance of a chest
examination in every case of disease of the ear or upper
air passages. The boy had a mastoid abscess. I sus-
pected chest disease also, as I did not think that the
local inflammation necessarily explained his constitu-
tional condition. He had undoubtedly tuberculosis.
The consultant was much older than myself, and because
he wanted to do so he had ridiculed my ideas as to chest
unsparingly. He suggested calomel and rhubarb because
of the marked gastro- intestinal disturbance. I thought the
chest ought to be examined and creosote given possibly.
My suspicion was that he had an apex catarrh, whether
it had advanced to a tuberculosis I did not know. In-
advertently the report of this case was not complete
enough. I see many cases of apex catarrh. I see only a
few cases of tuberculosis comparatively. My suspicions
were in the line of the greatest possibility. I see prob-
ably a very different class of cases than occurs in Colo-
rado Springs. As a specialist I see the very early cases
of chest disease, whether the cases referred to are pe-
culiar to Cleveland is a question. They are probably as
frequent in other cities in the same latitude, and of the
same elevation. I do not believe that cases of this sort
develop in Colorado Springs. If they do, all reports as
to the freedom of people living in that locality from dis-
ease of the chest is unreliable.
Dr. Moore sees a different class of cases from those I
have attempted to describe. He sees the cases that be-
come a localized tuberculosis, the cases that do not re-
cover at home as rapidly as desired, and are sent to a
higher altitude. In May, 1894, I looked up the record
of the last fifty- four dispensary cases coming under my
care, and found that of this number eighteen, had an
apex catarrh. No one would believe that these cases
had tuberculosis if I took that position. My professional
friends have more often claimed that there was nothing
at all the matter with the chest, that the patient had a
primary disturbance of the stomach, etc. Dr. Moore
thinks that I treat these cases too lightly. Clinically the
only reasonable explanation of these cases is that they
are catarrhal in character. The etiology of tuberculosis
used to be very complicated. It seems to me now to be
very simple. It is simply a question of " soil and seed."
The tubercle bacilli are everywhere. Healthy tissues re-
sist their growth. Tissues or cells weakened in vitality
and resistance through inflammation permit of their
growth and development.
A catarrhal inflammation attacks the epithelium lin-
ing the capillary bronchial tubes or air cells at the apex
of the lung. After a certain stage the tubercle bacilli are
permitted to grow. Then we have a tuberculosis. Why
the bacilli gain a foothold in such a small proportion of
cases is probably explained by the fact that the catarrhal
inflammation in the majority of cases close up before the
vitality of the cells is greatly interfered with. I fully
endQrse the doctor's statement as to the frequency of
tubercular cases and the frequency with which healed
tubercular lesions are found on autopsy. I do not, how-
ever, feel very sanguine concerning cases of chest dis-
ease in which the tubercle bacilli are found. The great
majority of such cases, as I have been hitherto peimitted
to follow them, have died of tuberculosis. Whether the
presence of the tubercle bacilli in the sputa in fair num-
bers necessarily dooms a patient if he remain in Cleve-
land I shall not say. I have a very few caies on record
who have apparently recovered.
The physical signs in an average case of apex catairh
on percussion are — no dulness, sometimes slight tenderness
and slightly increased resistance ; on auscultation trans-
ference of heart sounds, rough breathing, slightly ccg-
wheeled breathing, slightly shortened inspiration, may be
slight suppression of respiration, or may be transference
of heart sounds only. I see many a case in which the
physical signs are never more marked than this. If,
after recovery from this disease the patient should meet
death by accident or otherwise, and an autopsy could
be made, does anyone believe that a pathologist could
find any lesion remaining? I, for one, incline to think
that its location even could not be determined. I do
not believe such cases are tubercular. Neither do I be-
lieve that there is nothing the matter. I believe that the
early detection and treatment of such conditions are of
the utmost importance, and yet I am accused of minimiz-
ing the importance of early chest disease by giving it an
innocent name. From Dr. Moore's remarks I infer that
he either believes a patient to have a healthy chest or
tuberculosis, and recognizes no intermediate stage. I
believe that there is an intermediate stage, a pretubefcu-
lar stage, that in the majority of cases can be diagnosed
with the greatest ease. If I am wrong in my reasoning
I shall thank any one who will point out to me the error
of my way.
Very truly yours,
Howard S. Straight, M.D.
185 Euclid Avbnub, Cleveland, O.
To thb Editor of the Medical Record.
Sir : By allowing a healthy discussion in the columns of
your esteemed weekly regarding the question " Is Apex
Catarrh Tuberculosis? " you will shed abundant light in
minds that are still dark. It goes without saying that a
correct understanding of the pathological process under-
lying the so called " apex catarrh," is of the utmost im-
portance, not alone to the physician's reputation and
success, but to his patient's future life and welfare.
Study and observation have long made me a disciple of
those who maintain that " apex catarrh n is of tubercular
origin. And with a view to further strengthen my
belief and conviction I have, with the splendid assistance
of my friend, Dr. Philip Meirowitz, lately examined the
sputa of a dozen patients, all of whom showed the so-
called "apex catarrh." The patients were all taken
from my clinic (Mt. Sinai Hospital Dispensary) with re-
gard to no special selection whatsoever. In every single
case tubercle bacilli were found. The number of them
was never any too great, but, on the other hand, they
were never entirely absent. In a few cases it was neces-
sary to examine and re examine the same or different
specimens in order to demonstrate the presence of ba-
cilli. A little difficulty in attaining this end lies in the
fact that in some cases there is no sputa to eisminc — the
cough either being dry or the expectoration being ex-
tremely scanty. But this inconvenience is easily re-
moved by resorting to some mild expectorant of one
kind or another.
Now, in view of this and abundant higher authority,
it seems to me that, if all those who agree with Dr. How-
ard S. Straight 1 in regarding " apex catarrh " as " a lo-
1 Medical Rkcord, September 22, 1854.
604
MEDICAL RECORD.
[November 10, 1894
calizsd capillary bronchitis/1 sufficiently invoked the
microscope, they would certainly not be guilty of such
gross pathological blasphemy. And it is exactly in this
form of phthisis that the instrument is worth the invest-
ment. The difficulty of recognizing incipient phthisis
is only exceeded by the importance of the recognition.
The great majority of the patients with "apex catarrh,"
as a rule, do not bear as yet the various tubercular stig-
mata on their constitution. What brings them to the
physician is an annoying cough or blood stained sputum.
The cough is sometimes dry, sometimes moist, or at-
tended with considerable expectoration. I have found
the following physical signs in every case of tuberculosis
of the apex, or " apex catarrh : " 1. Prolonged, harsh,
but more frequently tubercular, expiration. 2. A more
or less audible sibilant or sonorous rale. 3. Moist or a
crepitant rile at the end of inspiration. The tubular
breathing is invariably present, the other two come and
go. I often heard the tubular breathing extending to
some distance below the clavicle. The microscope, when
appealed to, invariably confirmed the significance of this
trinity of symptoms. At the early invasion of the apex,
percussion is not worth trying, especially if the right
apex is involved. Only a little while ago a member of
my family consulted two physicians about a slight sore-
ness in the chest. One prescribed for a subacute bron-
chitis, the other volunteered to relieve him of his tur-
binated bones. On seeing him I suggested a change of
climate, for I made out an " apex catarrh." Two days
liter he was in bed with haemoptysis — in three days he
had nine pulmonary hemorrhages which exsanguinated
him almost to the point of death.
Another instance of unrecognized phthisis of the
apex : A girl, about eighteen years of age, came to my
office with a history of a dry cough of long standing. A
week before she consulted a doctor whose name is famil-
iar to a considerable portion of the profession in this
city. Her mother was told that the girl had only a
slight catarrh of the throat which will pass off in a few
days. But it didn't. On examination I found the three
mentioned symptoms at her right apex, and somewhat
extending a little below the clavicle. On informing
the anxious parent that her child had a " touch of con-
sumption" she immediately expressed a desire to con-
sult a professor, a wish that I am always ready to gratify.
I referred her to one of our most eminent diagnosticians
in town, stating my diagnosis. The following was his
usual cautious reply : " The girl evidently has a chronic
broncho-pneumonia of the right upper lobe. Whether
it is tubercular or not can be known by the examination
of the sputum." The sputum has been since examined
twice, and each specimen revealed bacilli, though in
limited number. I could mention many more such cases
of apex catarrh where the real tubercular nature of the ca-
tarrh was entirely overlooked. Especially is this state-
ment true in cases of apex catarrh associated with disease
of the upper air-passages, for then the impression takes
root in the minds of the superficial observer that the same
inflammatory process that characterizes the mucous mem-
brane of the nose, pharynx, or larynx, exists in the apex.
Dr. Straight states in his paper that with the improve-
ment of the catarrh of the apex the affected upper pas-
sages improve. Certainly so I for it is more than an ordi-
nary likelihood that the catarrh of the apex is responsible
for the disturbance of the upper passages. The same
gentleman states that he derived great benefit from creo-
sote in all such cases. It seems to me that this beneficial
effect of creosote on the disease in question should have
made him think of tuberculosis. There is no other dis-
ease that is so favorably influenced by creosote as pul-
monary tuberculosis — not one. This statement is doubly
true with regard to incipient phthisis. One has only to
see the wonderful improvement of all the symptoms in
pthisical dispensary patients, a class of people mostly
living in wretched surroundings, to be convinced of the
specific: action of creosote.
I have dwelt largely on this question, for I think its
importance cannot be overrated. It is but proper that
we should call things by their legitimate names — and
there is a good deal in a name. In the great science of
modern medicine a rose cannot smell as sweet by any
other name. R. Abrahams, M.D.
156 CuNTOif Strut, New Yohc, October 22, 1894.
IS MALARIA A WATER-BORNE DISEASE?
To tub Editor op thb Mbhcal Record.
Sir: In the Medical Record of September 15, 1894,
Dr. W. H. Daly, of Pittsburg, in a long letter, most
emphatically asserts that such is the case. He gives his
personal experience in the Kankakee swamps, he quotes
other medical men who think as he does, and now Dr.
Norbury, of Jacksonville, 111., in his letter of October 6,
1894, endorses Dr. Daly. Well, I venture to slightly dis-
agree with the sweeping claim these gentlemen make
that malaria is only contracted by drinking shallow well
or surface water. This town has a water works and the
water is considered good. Every care is taken to pre-
vent contamination. It is generally used by all who live
within the village limits.
Some months ago the western part of the town had a
new sewer laid, the streets were opened up, and just as
sure did they begin to dig malaria developed along the
course of the ditch, while other parts of the town were
free. The persons attacked were of all nationalities —
Italians, Irish, Germans, Swedes, Negroes, and last but
not least, native-born Americans. The water they used
was that supplied by the Water Company, and so it went,
as the street was opened in the immediate vicinity were
the sick to be found. My own little boy, two years old,
developed an acute attack. No sewer was laid near my
house. He did not get it from or through any water,
for what he drank was sterilized. It was not his milk,
for that went through the same process. My neighbor
dug up a lot back of my place that had not been dis-
turbed for ages, and I firmly believe that turning up the
soil caused my child to sicken, as the colored servant
girl complained of the well known symptoms a day or
two after.
In my practice it is a common occurrence to find nurs-
ing infants with well-marked malaria — little things that
never drank a drop of water. I saw a woman, sixty-three
years old, develop malaria, the old-fashioned kind as
they say here, chills and high fever (1050 F.), who never
had it before in her life, and who has been living in the
same house and using the same water for six years. I
looked about for a cause, and found that a cellar was
being dug next door. Two days afterward I was called
to see another member of the same family. These peo-
ple attributed their sickness to the turning up of the
ground, and I certainly agree with them.
Dr. Daly's claim that we take in our malaria on the
leaves of turnip-tops, greens, kale, spinach, cabbage, is
very far-fetched, if not absurd. These vegetables are
not used raw. They are boiled, and if lettuce is used
uncooked, the majority of people smother it in vinegar.
I am an unfettered, and I hope an original, observer,
although I do not agree with Dr. Daly, and I claim that
malaria is not a water-borne disease "pur et simple,9'
and that those old dogmas and text-books are deserving
of respect, and were not so far wrong after all. Quinine,
et cetera, were useless in my child's case.
He was treated by Dr. Tifft, of this town. Change
was recommended by the Doctor, and so we sent him to
his mother's native place, Pittsburg, Pa., where he has
made a complete recovery, and now drinks the water
used there, which certainly is not uncontaminated, and,
considering its source, should be fruitful in malaria.
Still I believe Pittsburg has but very little of this dis-
ease.
As to Dr. Norbury's forty Swedes, why he himself
says they were peculiarly susceptible, and from my ex-
perience I agree with him, and further, that newly
November 10, 1894]
MEDICAL RECORD.
605
landed emigrants are specially liable to contract malaria
even in New York City. That it may be and is con-
veyed by water, I admit ; but that it is the only way
that we can become affected my experience has led me
to believe differently.
F. W. Dalrymple, M.D.
Nbw Rochsllv, N. Y., October io, 1894.
THE MARRIAGE OF SYPHILITICA
A Riply, with Explanations, to the Queries of Dr.
Burnside Foster in the Medical Record for Oc-
tober 6, 1894.
To tub Editor or thh Medical Record.
Sir : Hypothetical questions in medico legal cases are
perhaps justifiable, and are frequently resorted to, but as
a role the answers given are so vague that the meaning is
about as clear to the average hearer as a strong infusion
of common earth in water.
The three questions propounded by Dr. Foster may
not be in any sense hypothetical, but the majority of the
readers of the Medical Record who have had any ex-
perience in the management of cases of syphilis will bear
me out in the statement that not one in fifty can an-
swer question No. 3 at all, and I will give my reasons
later on.
As regards query No. 1. To answer it : that he has
seen any case at any period communicated by a patient
under his care, would lead the readers to say that the
physician had been derelict in his duty in not impressing
so forcibly upon his patient the dangers he so constantly
bears about upon his person that he (or she) will not en-
danger the health of others by exposure.
The first aim, the highest duty of every true physician,
is, or at any rate should be, to protect the health of those
who are placed, either directly or indirectly, in such a po-
sition as to be saved by him from any contagious dis-
ease. I believe, through the columns of another journal,
in an original article already accepted, I shall show at an
early day some arguments, based on a large experience
and continuous observation, demanding protection to
the innocent from one of the blighting curses of our
nineteenth century.
Passing on for the present to query No. 2, and no one
among the thousands of readers of the Medical Record
will appear who cannot, from either personal knowledge
or good evidence, furnished in journals and medical text-
books, cite cases almost without limit, where syphilitic
men and syphilitic women have been the parents of
syphilitic children, either alive or still born, at full term,
at all periods after the initial sore, limited only by the
menopause in the female or senility in the male. In
fact, almost every physician will tell you that it is the
rule, almost as certain as that the " day follows the
night," that syphilitic female or syphilitic male will
procreate syphilitic progeny. Admitted that, under
proper treatment of the mother during gestation, an ap-
parently healthy child may be born ; but wait the next
generation and see what is the result, as is too often in-
stanced all about us.
No. 3. Any physician, if allowed to cut query No. 3
off where the query proper ceases, will, and so every
reader of the Medical Record will, answer yes.
With the limiting conditions attached to the end of
the query proper, as I said at the beginning of this paper,
not one in fifty can answer at all. In the first place, our
authorities s'ate, and we have all been taught, that we
should always say to every syphilitic case which comes
under our care, " that two years must be devoted to the
careful attention of the malady." How many of our
readers can keep the case for even two years? How
many have had any individual case " constantly under
observation " during four years ?
If any physician has influence enough over the dulled
sensibilities and selfish natures of their syphilitic cases to
keep them under constant observation for four years, he
certainly should have force of nature sufficient to prevent
the patient exposing the innocent to the danger of com-
munication by contact, either with original lesion or sec-
ondary mucous manifestations ; at any time such danger
may be present, and to carry the influence still further he
should not during that four years permit the possibility
of the syphilitic patient becoming a parent.
To sum up on the queries, I will say : Whether under
observation or not a syphilitic can communicate the dis-
ease at any time, while either the original lesion or any
external or internal mucous lesion is present, in whatever
stage and at whatever period; that they do not do so even
more than they do, is due to the force with which the
true physician impresses the patient with the necessity of
Absolute non-contact A syphilitic man or a syphilitic
woman can, and do, become the parents of syphilitic chil-
dren at all periods after the initial sore, limited only by
the period of ovulation in the woman and the natural
results of age in the male.
Plenty of cases are obtainable where four, fourteen, or
twenty- four years after the initial chancre, under any and
I may say all treatments, that syphilitic men and syphili-
tic women have been the parent or parents of syphilitic
children. And the few cases that can be brought forth
where syphilitic men or syphilitic women have brought
forth healthy children, no matter at what period the anti-
syphilitic treatment has been applied (before or during
gestation) with the mother, are misleading, and are but
a small percentage of births occurring in the families of
parents who have ever suffered from syphilis. And if
such, as before stated, apparently healthy children be
watched to the period of their maturity, you will ficd
weakened bodies, blunted intellects, early decay ; and if
they happen to be the parents of the third generation the
child must come under the Bible declaration and bear
the "sins of the parents." Hydrocephalus, basil-
meningitis, scrofula, marasm, idiocy, and the many
like conditions, are the harvest reaped from past genera-
tions. With a brief expression of my ideas in the matter
of " the marriage of syphilitica," I will close.
No matter what the treatment, and no matter how ap-
parently cured, syphilitics cannot procreate a fully vigor-
ous, healthy, strong, and noble type of manhood.
Where is the benefit to accrue to the nation that is pop-
ulated with weak minded, feeble - bodied humanity ?
Breeders even of stock select but the best with which to
increase their herds — why should man, the noblest work
of God, do any less ? What is the excuse for willingly
permitting marriage of our syphilitic cases? It is our
duty as guardians of the public welfare, and holding
the position, as we do, of guardians of the public health,
to advise all syphilitics never to marry, and use all pos-
sible means to prevent their marriage. There is but one
argument that can be brought to bear in favor of per-
mitting syphilitics to procreate, and that is "That
some wealthy man or woman may have children as heirs
to their estate." It were far better that the estate have
no heir than that the heir must inherit such a physical
body as such parentage bestows. Wealth and a weak
body are a poor inheritance. Physical and mental
strength inherited, and life is sweet.
Professor Richard A. F. Penrose once said to the
students of the University of Pennsylvania, in a personal
lecture for their welfare : " Wnen the superintendent of
a building wishes to rear a structure that shall be an
honor to his name, he selects the best materials for its
construction. From poisoned syphilitic bodies you can-
not raise up sons and daughters that shall be an honor
to yourself and a benefit to jour race. For God's sake,
young men, keep your building material first class."
It now becomes our duty to advise everyone the same,
and also to prohibit, if possible, by strong arguments
and the evidences around us " the marriage of syphilit-
ics," and use every means in our possession to have the
building material of our patients first class.
Frank E. Maine, M.D.
AuBOWf, N Y., October a6» 1894.'
6o6
MEDICAL RECORD.
[November 10, 1894
Contagious Diseases — Weekly Statement— Report of
cases and deaths from contagious diseases reported to the
Sanitary Bureau, Health Department, for the week end-
ing NDvember 3, 1894.
Tuberculosis
Typhoid fever
Scarlet fever
Cerebro-spinal meningitis
Measles ,
Diphtheria
Small-pox
Cttt)i_
Deaths.
84
87
39
14
50
7
0
a
29
3 *
103
29
11
2
The lew Tork Academy of Medicine and the Con-
stitutional Convention. — The following is the report of
the Committee of the New York Academy of Medicine
appointed to confer with the Constitutional Convention :
New York, October 6, 1894.
The President and Fellows of the New York
Academy of Medicine.
Gentlemen: Your Special Committee appointed to
confer with the Constitutional Convention respectfully
submits the following report :
After several meetings the Committee decided to avoid
all questions which could in any way be imputed to po-
litical bias or a desire to push the interests of the pro
fession. Three problems were selected for d iscussion, and
three recommendations made. All are of vital interest
to the community. Your Committee appeared before
the appropriate Committees of the Convention and
recommended the following amendments to the Consti-
tution of the State.
From Art. X., Sec. 1, strike the word " coroners."
Into the same article and section introduce the words,
" Medical examiners shall be appointed by such County
authority as the Legislature shall direct/'
We sought the abolishment of the coroner system on
the following grounds :
(a) There should not be vested in one individual the
functions of a scientist and of a judge ; but the two
should be kept separate and distinct.
(t>) It is the sole purpose of an inquest to detect crime.
Tnat is a judicial function, and the determination of the
question " Has a crime been committed and by whom ? "
rests in the interpretation of facts by judicial inquiry.
(c) It is the sole purpose of an examination to deter-
mine whether a death be due to violence. The exami-
nation should be made by a competent scientist, in order
that facts may be obtained for interpretation by a judge.
(d) The examiner merely ascertains that the death is
one of violence, the judge, that a crime has been com-
mitted. There should be no confusion of the two of-
fices and no association in duties.
The confession of weakness in the present system lies
in the appsintment by coroners of " coroners' physi-
cians." Thus a coroner with judicial powers appoints
and controls him who shall furnish the coroner with the
data requisite to his conclusions. A judge should be
divorced from interest in the premises upon which he
bases his opinions. The proposed amendment seeks the
appointment of physicians only as examiners, and may
be termed "class legislation." But already a "class "
has control of examinations, inasmuch as these are held
by " coroners' physicians." So, practically, no innova-
tion was sought. The provision of a proper judiciary
for acting upon the findings of the examiners we left to
the Legislature.
(<?) It is our belief that the coroner fails too often to
detect crime, does not adequately protect the innocent
because of that failure, and that the present system is
open to abuse.
The Convention has agreed to submit to the people an
amendment striking out of the Constitution all reference to
coroners ; but it refused to substitute any other system for
the present abominable one. This will leave the law gov-
erning coroners upon the statute books. If the amend-
ment is approved, the office of coroner merely ceases to
be a constitutional office. Something will have been
gained when the amendment is adopted.
The second recommendation by your Committee re-
lated to the Regents of the University. Amend Article
IV. by the addition of a Section with these or similar
words : " The Regents of the University shall consist of
such persons as the Legislature shall direct. The Re-
gents of the University shall have the sole power to grant
licenses to practise medicine and surgery, and shall
perform such other acts as the Legislature may direct. '
The RegentB of the University hereafter appointed shall
each serve ten years."
The Legislature has already conferred upon the Re-
gents the sole power to grant these licenses. Therefore,
here again, no innovation was sought. But this power
has been placed in the hands of Regents appointed for
life. Herein lies a possible abuse of power. We, there-
fore, asked that each subsequent appointee should serve
but ten years. Inasmuch as reappointments could be
made, efficient officers could be retained in office, and the
limited tenure of office would preserve the people against
the work of a mischievous clique in the Regents. No
fault may now be found with the work of the Regents,
but we must all confess the possibility of a bad element
getting control. Should such a thing happen, death
alone could put a stop to it. We would call your atten-
tion to the fact that the Regents are the only officers
under the proposed Constitution who hold a life tenure
of office.
For many years the medical profession has striven to
elevate the standard of medical education in the State,
and to have set some one standard of excellence to which
all those seeking licenses shall attain. In these labors
you have been conspicuous. Even though the Regents
become constitutional officers, nothing will prevent
thwarted incompetency and unsatisfied greed getting the
existing beneficent and protecting law annulled. The
profession must be as unceasingly alert as before, lest the
Legislature be induced, unwittingly perphaps, to legislate
unfavorably for the interests of the people. The interests
of the community demand that a law so materially affect-
ing the well-being of all be removed from the possibility
of too frequent change in this vital feature. Unless their
tenure of office be limited the incorporation of the Re-
gents into the Constitution will be a menace to the best
interests of medical education in the State, and for the
reasons pointed out. Merely making them constitutional
officers does not insure to them the permanent and sole
right to grant medical licenses, and does not make diem
answerable to any authority for misconduct. It is alto-
gether a bad amendment. We will have to fight for all
we have gained in the past, and a new issue is introduced,
in that we will be compelled to watch carefully lest evil
men be made Regents.
Our last recommendation related to the great Depart-
ment of Public Charities and Correction, of which so
many of you are officers.
Amend Article X. to read:
Section i. — "Sheriffs, Clerks of Counties, including
the register and clerk of the city and county of New
York, district attorneys, and in the counties of Kings and
New York, one commissioner of prisons and one com-
missioner of charities shall be chosen by the electors of
the respective counties, once in every three years, and as
often as vacancies shall happen."
We submit a brief for our reason for requesting that
the Department of Public Charities and Correction be
made into two county offices :
1. The condition in the counties of New York and
Kings does not exist elsewhere in the State, inasmuch as
the cities of New York and Brooklyn are in themselves
November 10, 1894]
MEDICAL RECORD.
607
the counties named. There is, therefore, no reason why
those city offices should not he made county offices.
2. It is manifestly preferable that where a city is a
county, in all important city and county offices the
power of removal should lie with the Governor.
3. As the present commission is composed of a num-
ber of individuals, it is difficult to punish any one of the
commission for incompetency, the responsibility being
divided. The removing power is at the same time the
appointing. The present system is cumbersome, and
fails, in that more than one must consent to the per-
formance of each single act, thus retarding the business
of the department over which the commission presides.
Or else power must be delegated to one commissioner in
order that work may be efficiently and speedily per-
formed. This latter, in fact, is the method these many-
headed commissions adopt. If delegated power to one
commissioner be sufficiently effective, why a plurality of
factors?
4. The proposed addition to the Constitution deals
with two great classes of the community: those who
merit punishment at the people's hands, and those who
are their wards. A certain system is requisite for the
execution of punitive and correctionary laws, another for
the gratification of the people's charitable impulses.
Prisoners require for their management a system far
different from and a genius almost opposite to that essen-
tial to the proper conduct of hospitals and asylums. In-
asmuch as the cities of Brooklyn and New York are the
Counties of Kings and New York, and as a very large
percentage of th; population of the Counties of Kings
and New York become inmates of their correctionary
and charitable institutions during the year, the impor-
tance of embodying a suitable article in the Constitution
relative to the commissioner of prisons and the commis-
sioner of charities is apparent. As before said, these
cities are unique in being counties. The management of
these vast armies of criminals, paupers, insane, and sick,
by one commission, with two distinct and dissimilar
systems, is not consistent with the best results.
It is questionable if the numerous " Boards of Visi-
tors/' " Aid Societies," and " State Visiting Societies,"
etc., etc., could have originated, if satisfactory manage-
ment marked these departments.
5. Not alone the State, but the country as well, has
been shocked by the results of the recent investigation
by the State Commission in Lunacy.
The fault lies in the entirely wrong association of two
absolutely opposed systems under one commission.
6. The one great argument used by those who advo-
cate this association is that two commissions would
greatly increase the per capita cost of maintaining the
sick and needy, inasmuch as much of the unskilled work
about asylums and hospitals is done by criminals. This
contingency could easily be met by a system of requisi-
tions by one commissioner upon the other, a system now
practically employed.
7. It is a matter of common rumor, as well as a demon-
strated fact, that the present system is a failure.
We therefore request that these two commissions be
made county offices under the Constitution, and thus re-
moved from insecure and imperfect legislation in one
most important particular.
This amendment was refused us. So many more im-
portant questions were before the Convention that the
dominant party feared to load these down with others
which might enlist enemies against their recommenda-
tions to the people. We suggest to you that in the future
there be appointed each year a Committee whose duty
it shall be to watch legislation, and to make to the Leg-
islature such recommendations as you wish to become
laws.
TEe fate of the proposed amendments none can fore-
tell. Should those in which we are so interested be ac-
cepted by the people, we will still have to continue urg-
ing certain changes in the laws.
The regents should serve for such time as will protect
us, while giving us the most efficient work. Sufficient
medical examiners should be appointed by the proper
county authority. There should also be one judge, well
salaried, a man skilled in jurisprudence, whose sole func-
tion shall be to determine whether deaths are due to
criminal violence. He would have to report to the dis-
trict attorney's office. Such a man could do all the
work now performed by the number of coroners. Some
provision should be made for the regulation of the prac-
tice of midwifery. The injustice at present is in com-
pelling an obstetrician to pass a certain examination be-
fore the regents, while a small fee confers almost equal
rights upon a woman, without any inquiry as to fitness.
If license to practise midwifery were conferred upon the
competent only, we believe that the death rate would be
lowered, and one very great cause for diseases of women
appreciably removed.
We would also call to your attention the fact that by
law a medical man is debarred from being president of
the Board of Health, a most unjust discrimination
against the very class of men from whom such officer
should be chosen.
Your committee was courteously received and granted
all hearings requested. Taking into consideration the
dislike which the legislator has to the scientist meddling
in law-making, we have been fairly successful. We de-
sire to express to you our appreciation of the honor you
have conferred upon us, and beg that wherein we have
failed of complete success will be overlooked in the ear-
nestness of our efforts. Respectfully,
William R. Prvor, M.D., Secretary,
The Action of Sunlight on Microorganisms. — The
following correspondence has been sent us for publica-
tion:
Rapids P. Om La., October 15, 1894.
Surgeon General U. S. A.
Dear Sir : I have discovered that the rays of the sun
are a disinfectant and antiseptic. At 1 io° to 1 200 F. they
will arrest decomposition and destroy microbes. I have
directed them on old and new sores on man and beast,
and in an incredibly short time a sun-bath will destroy
corrupt matter and leave a bad sore in a healthy condi-
tion that will heal up in a short time. For instance,
two bad boils on the same person, one treated with
washes, poultices, etc., taking a month or more for per-
fect healing, the other in less than one hour's exposure
to the sun's rays, cleansed and healthy and healing in a
few days. These, with a number of other tests, lead me
to the belief that it will become a successful treatment
for sores, ulcers, etc., of recent and long standing, espe-
cially in hospital practice.
I have called the attention of our local physicians, who
tell me the treatment is not known to the profession, to
their knowledge. I am not a physician, but made the
discovery in the course of butchering animals for market,
the particulars of which and subsequent tests I will send
if deemed of any importance ; if proving to be, I want
it given to the medical profession at large. Not know-
ing just how to reach them I concluded to write to the
Medical Department, United States, which could make
such tests as would prove its efficiency. Mine were
made with the direct rays of the sun on days when the
thermometer ranged 960 to 980 F. in the shade. I have
given much thought as to how, in a northern latitude and
cooler weather, the rays could be directed through a
lens made for the purpose. Also have made the treat-
ment on other ailments besides sores, and the results
prove to me that it will become one more of nature's
remedial agencies in curing and helping many ailments to
which the human race is subject. This may be known
already to the profession, but so far as I am concerned it
is original, and came about as the result of some things
to which my attention was called.
Hoping my motives may be understood in this com-
munication, I am,
Yours respectfully,
'James T. Dezendorf.
6o8
MEDICAL RECORD.
[November 10, 1894
War Department, Surgeon-General's Office,
Washington, October i8, 1894.
Dear Sir : I have read your letter of October 15 th with
interest. Very numerous experiments have been made
during the last few years with reference to the action of
light upon various microbes, and it is well settled that
the direct rays of the sun very promptly destroy the vi-
tality of many disease- germs. Some observations have
also been made with reference to the therapeutic use of
sunlight, and it is certainly desirable, in view of the
facts already known, that further clinical experiments
should be made in this direction. Your own observa-
tions are of great interest, and the spirit in which you
communicate them is highly commendable. If you
authorize me to do so I will publish your letter, and my
reply to it, in some medical journal.
Very truly yours,
George M. Sternberg,
Surgeon- General U. S. A.
Mr. James F. Dezendorf, Rapids Post Office, La.
A Model Surgical Clinic. — Scene, a spacious room.
At a large table in the centre is seated the surgeon ; his
secretary is opposite, an enormous folio register open
before him. A group of students is clustered about the
table. Benches filled with waiting patients occupy the
sides of the room. The secretary calls No. 120,736.
A man aided by crutch and cane limps forward. The
surgeon's examination into the biography and genealogy
of the patient (four folio pages carefully written out by
the secretary) being ended, the attendant removes the
multiple wrappings of the right foot, exposing an inflamed
great toe with ulceration upon one side of the nail. The
surgeon gives it a hasty glance, and turning, addresses
the students as follows: " Gentlemen, a few years ago a
case of this kind — evidently an ingrowing nail — would
have been at once submitted to local treatment, and, I
admit, with fair prospects of obtaining a good result.
But now that we have learned the general interdepen-
dence of the different organs of the body, we feel that a
thoroughly scientific treatment demands the examination
by specialists of these different organs, in order to detect
any conditions likely to be etiological factors in the
case. The attendant will therefore take him and a copy
of his history to the different rooms in succession, and
return here with their respective official reports."
{Some Hours Later.)
Surgeon (loquitur). — "Gentlemen, the patient has
now returned to us, and I ask your attention while I read
the reports of the various specialists."
Ophthalmological Department. — Case No. 120,736.
This patient is myopic. As I recall a case where a simi-
lar visual defect was the cause of injury to the great toe
in a person who " stubbed " it against the curbstone, I
have ordered appropriate lenses to correct the difficulty,
as a prophylactic against the recurrence of the disease.
It is essential, however, that this treatment should be
supplemented by wearing a loosely-fitting shoe.
Otologic al Department. — Case No. 120,736. I find
no defect of audition. As the patient's trouble may have
arisen from want of suitable support to the foot, I have
thought it best to shorten the stapes leather two holes.
Rhinological Department. — Case No. 120,736. A
case of nasal toe nail. Wishing to bring about a radical
change in the parts, I have removed with the curette all
adenoid growths, together with the adherent mucous
membrane, from the cavities and packed them all with
aseptic gauze — which should be removed if the patient
wishes to sneeze.
Department Abdominal Surgery. — Case No. 120,736.
Drs. A , B , and C , in consultation. The
history showing that the patient's mother during life lost
a set of false teeth, Dr. A reasoning that " tooth and
nail" are generally associated in action, is inclined to
think the set may have been swallowed unconsciously and
remained in the patient's stomach. Of course, he advises
an operation.
Dr. B , in view of the accepted belief that " Gal-
lia est omnis divisa in partes tres," thinks it possible that
one of them may have wandered down to the great toe,
and advises an exploratory incision of the gall-bladder
to ascertain if either part be missing. The " Gallic
boot of love," cited by Dr. O. W. Holmes, seems to in-
dicate a tendency of the gall to the foot.
Dr. C concurs entirely with both of these opin-
ions, but on general grounds advises the removal of the
appendix. The patient, however, avers that this has
been already done, and that he has it in a bottle at
home, which 'he will fetch if required. It is therefore
deemed advisable to await further development.
Gynecological Department. — Case No. 120,736. Pal-
pation reveals no abnormal condition of uterus or ap-
pendages. A medical student calling our attention to
the fact that the patient wears pants and has well- devel-
oped male generative organs, we doubt if this is a proper
case for this department.
Department Geni to-urinary Diseases. — Case No.
120,736. Organs apparently healthy. It, however, is
not impossible that the patient may have had a stone
(vesical) which was passed naturally and impinged upon
and injured the great toe.
Department of Neuroses ', etc. — Case No. 120,736.
The result of a careful examination of this case indicates
a deficient innervation of his lower extremities. Two
well-marked areas of impaired sensibility or partial anaes-
thesia are located in the gluteal regions beneath the tuber-
osities of the ischia. His history not mentioning this, we
questioned him as to how long the condition had existed.
His replies were unsatisfactory — merely to this effect, that
he had " sat so long upon those d d hard benches that
his got numb. ' ' A rubber cushion with two holes is
recommended, and the case should be kept under obser-
vation.
"There, gentlemen," continued the surgeon, as he
finished reading to them the reports, "you have the
result of a careful scientific inquiry into this case. I
shall now send the patient to the chiropodist around the
corner, with instructions to have the toe cleansed and a
piece of sheet lead inserted under the roughened edge of
the nail. I counsel you all not to lose the opportunity
of witnessing the operation. Good-morning, gentle-
men ! " — Boston Medical and Surgical Journal.
An Outbreak of Cholera.— The United States Consul
at Sivas, Turkey, reports some interesting facts about the
outbreak of cholera in that city. The city is about five
thousand feet above sea-level, nevertheless the river which
supplies the city with water became polluted with cholera
dejections at a village about a mile above Sivas. The
water which the people drink and use for all purposes
about the house flows in open ditches, where the people
also bathe and wash their soiled clothing and rugs. That
which has served one family for its various needs flows
with all its filth to another. Ultimately the water reaches
the open sewers, or larger streams, which traverse the city
and which receive all the excreta of the population. In
these larger streams the people bathe, wash their clothes
and kitchen utensils, the children wade and play. During
the epidemic this went on as usual. This is just one of
the myriad examples illustrating the spread of cholera by
an infected water-supply; but note that, in spite of the
fact that the whole population drank an infected water
without boiling or other precaution, the consul reports
that only twelve per cent, of the population contracted
the disease, and only one quarter of these died. This in-
dicates that a majority of the people were not susceptible
to the infection. — The Sanitary Inspector.
Antidote to Snake- bite.— Dr. Mueller, of Australia,
claims that strychnine is a certain antidote to serpent
venom. The Indian Government has recently had a
series of experiments conducted with a view to test its
efficacy. The results thus far have not been entirely sat-
isfactory, but the experiments are to be continued for
two years more before a final judgment will be passed.
Medical Record
A Weekly yournal of Medicine and Surgery
Vol. 46, No. 20.
Whole No. 1254.
New York, November 17, 1894.
$5.00 Per Annum.
Single Copies, ioc.
®rijjitml Articles.
THE TREATMENT OF DIPHTHERIA WITH AN-
TITOXIN.1
Based upon a Series of Cases Treated at Willard
Parker Hospital with "Antitoxin Schering/'
By A. CAMPBELL. WHITE, M.D.,
RESIDENT PHYSICIAN WILLARD PARKBR HOSPITAL, NEW YORK.
History and experience tell as the most dreaded of all
enemies of man are the infectious diseases. However
benign the disease or mild the epidemic it always leaves
some mark of devastation in its path ; but one consoling
feature of these so much feared diseases is the immunity
granted by one attack against future invasion. This
power of immunity seems to have been long recognized,
for some centuries ago in India and China self inocula-
tion was practised with virus obtained from the pustules of
smallpox occurring in a mild epidemic ; thus suffering a
mild form of the disease protection was granted during
future and more fatal epidemics. We have the authenti-
cated report of Lady Montague, of England, as early as
1 7 1 7, inoculating successfully her own son with small pox.
Although this practice was carried out to considerable
extent for many years, it finally became very unpopular
on account of its consequent dangers, many of those in-
oculated unfortunately developing the disease in its most
fatal form. The first really practical application of this
point of immunity was made by Jenner in 1798. We all
know the history of his valuable discovery of vaccination
against small pox, and how it has rendered that once
most common and formidable scourge the least prevalent
and least to be feared of all the infectious diseases.
From this time to the present most constant efforts
have been made toward accomplishing similar results in
the other infectious diseases, and the rapid advancement
made in the field of bacteriology during recent years has
rendered great assistance to a more intelligent and prac-
tical knowledge of this power of immunity.
Bacteriology was probably first successfully applied in
this direction by Pasteur in the results obtained through
his experiments upon immunization against certain ani-
mal diseases. He obtained immunity against anthrax
and fowl cholera by the inoculation of weakened or at-
tenuated bacilli. Still later we have the same method
applied to hydrophobia, cholera, and diphtheria with
more or less salutary results.
This entire work is based upon the principle that cult-
ures of the most virulent bacilli can be made less and
less virulent, until finally they are capable of producing
only the mildest form of disease when injected into the
living organism. But however carefully this process of
attenuation has been carried out, however confident the
experimenter may be that the virulence of the bacilli has
been reduced to a minimum, there always must be some
danger attending the inoculation of a human being with
a medium containing the poison of perhaps the most
fatal disease. To be successful some reaction must fol-
low the injection. That this reaction may be greater
and more pronounced than is desired or safe must always
impress the operator and render the method less popular
perhaps than is deserved.
1 Read before the Pediatric Section of the New York Academy of
Medicine, and contained in a report made to the Board of Health of
New York City, November 7, 1894.
Recognizing this danger, others have labored in an-
other direction, i.e,} to obtain the same power of im-
munity without using the disease poison itself. It has
been found that the blood of animals rendered immune
is capable, when inoculated in suspectible animals, of
granting them the same immunity possessed by the
animal from which the blood was obtained. This
method is followed by no reaction. Whether the serum
thus obtained acts directly upon the germ or its toxin,
or whether it causes some reaction in the cellular tissues
of the body rendering them proof against the geim or its
toxin, is still a question of some dispute.
Buchner,1 Tizzoni and Cattani 8 have carried out ex-
periments on the antitoxin of diphtheria and tetanus
which tend to show that the latter theory is the correct
one. Still I believe this theory is not universally ac-
cepted. Whatever its action, this inoculation of the serum-
obtained from an artificially immunized animal is prefer-
able to the attenuated bacilli method. The points in
which the former differ from the latter make the serum
method the safer and more practical of the two. The
differences as described by Aronson * are — (1 ) the effect of
the serum method takes place at once; (2) is accom-
panied by no reaction ; (3) by increasing the amount of
serum (antitoxin) protection against infection of any
strength may be afforded.
This describes rather incompletely the two methods of
bacterio therapy, and it is upon the second, or seium
method, that the treatment of diphtheria with antitoxin
is based ; and to Behring, working in the Berlin Insti-
tute for contagious diseases, is due, more than to any
other, its discovery and development. He found that
not only could he grant immunity to an animal, but by
giving larger doses of the serum of an immunized animal
an attack of diphtheria already artificially developed
could be modified or aborted. The method of obtaining
this serum, as invented by Behring and modified by
others, we will consider as briefly as possible.
First, a pure culture of diphtheria bacilli must be ob-
tained. It has been found that the more virulent the
bacilli, at least after some immunity has been established,
the better the results which will follow. Aronson 4
claims that the strength and efficacy of his antitoxin
depends chiefly upon this point, and describes an elabo-
rate method by which the virulence of the bacillus can
be made fifty to two hundred times stronger than fresh
cultures from the most malignant cases. The extremely
poisonous culture having been prepared, and its strength
having been accurately determined, it is injected into the
animal which is to furnish the serum, beginning with
very small doses, which are gradually increased until the
most powerful poison can be resisted by the animal. It
requires many months to obtain such an immunity, and
the constant liability to the loss of animals from an over-
dose of the toxine is very great. Animals are selected
which have some susceptibility, but of course must not
too readily succumb to the poison. The guinea-pig,
dog, goat, sheep, cow, and horse have all been used.
The horse, being less susceptible and furnishing more
anti-toxin, is used by Aronson,8 Roux, and Yersin,6 and
I believe more recently by Behring. The animal when
1 Munchener Medicinische Wochenschrift, Nos. 24 and 25, 1893.
9 Riforma Medica, October and November, 1893.
* Berliner Klinische Wochenschrift, No. 15, 1894.
« Berlin Medical Society, July, 25, 1894.
* Deutsche Medicinische Wochenscrift, No. 19, 1894.
* Annals de l'lnstitut Pasteur, No. 9, 1894.
6io
MEDICAL RECORD.
[November 17, 1894
it has developed a high degree of immunity is ready to
furnish antitoxin. The blood is obtained from the
larger veins in the body, the animal first having been put
under the influence of morphine or an anaesthetic. The
serum is separated from the blood, and in this serum is
contained the antitoxin. It may be mentioned that ef-
forts have been made with some success to still further
isolate this antitoxin property or to obtain it in a more
concentrated form.1
Of course the serum coming from different animals, or
from the same animal at different times, necessarily varies
in strength, and to be used therapeutically some idea of
its antitoxin power must be obtained. Ehrlich2 de
scribes a method employed by Behring for ascertaining
(relatively) the amount of antitoxin in the blood-serum.
This same method, with perhaps some slight modifica-
tion, is used by all others.8 He first determines the
strength of his te3t-poison, i.e., how much of this poison
is required to kill a guinea- pig. of a given weight in
thirty six to forty-eight hours.. He then takes of the
test poison ten times the necessary dose to kill the ani-
mal, and puts this amount in each one of several test-
tubes, together with different amounts of the serum to be
tested. Salt- water is added in sufficient quantities to
make all of the same bulk. The contents of these tubes
are injected into as many animals. The reaction follow-
ing the different injections determines the power of the
solution tested, i.e., the quantity of blood serum necessary
to neutralize the poison (save the animal) varies accord-
ing to the degree of antitoxin it contains. The strength
of the solution is expressed by giving the amount of se-
rum required to save an animal of a given weight inocu-
lated with a fixed poison, e.g., if it requires 0.001 c.c. of
the serum to neutralize sufficient poison to kill an ani-
mal weighing 300 gr., the strength of the serum is as
1,000 c.c. is to 300 gr., or 1 part of antitoxin to 300,000
parts of body-weight. This can be expressed by simply
saying the serum is a 1 to 300,000 antitoxin solution.
With the addition of a small amount of tricresol to pre-
serve it against decomposition, the serum is ready for
therapeutic purposes.
In appearance the solution of Behring and the " im-
munization solution " of Aronson are alike. They look
like diluted blood serum. But the strong solution of Aron-
son has the appearance and consistency of dirty milk.
I have now attempted to describe the bacterio-therapy
of antitoxin, the process of its development, the methods
for determining its dose, and its appearance ; but before
considering this remedy clinically I wish to call your at-
tention to some of the more important clinical features
of the disease we are to treat.
In considering the results of any treatment for diph-
theria the age of the patients upon whom the trial is made
is always of vital importance in ascertaining its value. Any
one who has had extensive association with diphtheria, at
least in this city, and more especially perhaps in hospital
practice, must have been impressed with the low mortality
among adults. Even those suffering the disease in its se-
verest form generally get well. In one hundred and eighty-
eight cases of diphtheria, over sixteen years of age, treated
at the hospital the mortality was less than three per cent.
The mortality in diphtheria of children between five and
sixteen years, although much higher than in adults, is still
surprisingly low for a disease commonly considered so
fatal. At this hospital the past year the mortality
among children of this age has been 13.6 per cent; in
1893, twenty-two per cent. ; and in 1892, 11. 7 per cent.
Diphtheria, therefore, as far as mortality is concerned,
is essentially a children's disease, and it is among chil-
dren under five years of age the disease causes such ap-
palling disaster. The mortality in five hundred and six
children, under five years, treated in the hospital for the
past two years, has been 42.7 per cent. Therefore any
1 Ehrlich and Brieger, Zeitschrft far Hygiene und Infections-
krankheiten, vol. xiii.
• Deutsche Med. Woch., No. 16, 1894.
» Annals de Tlnstitut Pasteur, No 9, 1894.
treatment for diphtheria should be directed against the
disease as it occurs in young children in order to thor-
oughly test its efficacy.
It has always been noticed, and is mentioned in nearly
every treatise on diphtheria, that the mortality is higher
during certain months in the year, e.g., the highest mor-
tality in the hospital during the last year was in the
months ot February, December, and August, and the low-
est in September, June, and July. The difference in
mortality between September, the lowest month, and Feb-
ruary, the highest, was twenty-six percent.
That some epidemics of diphtheria are more severe
than others hardly needs to be mentioned. That bacilli
vary in virulence we have mentioned before, and this
has been established beyond a doubt by the researches of
Brieger and Frankel,1 Roux and Yersin,2 Aronson/ and
others. So we see the severity of the epidemic and the
difference in virulence of bacilli in different cases of the
same epidemic must also be considered when discussing
the value of any new treatment. Where diphtheria is the
true cause of death, i.e., where death is due to the toxin
generated by the Klebs Loeffler bacillus, the patient
generally dies at some time during the first ten days from
toxic infection, extension of membrane into larynx and
bronchi, or occasionally as early as this a patient appar-
ently doing well will die from sudden heart failure or
paralysis. In those patients who die later than the tenth
day death is generally due to pneumonia or paralysis,
rarely nephritis, while in some rare instances the septic
condition will persist for some time after the membrane
has disappeared, finally causing death. In 170 fatal
cases coming under our observation the past year 135 oc-
curred within five days after admission to the hospital, 17
within ten days, and 18 after the tenth day. Of the 18
cases 9 died of heart-failure or paralysis, 2 of septic in-
fection, 1 of meningitis, and 6 of pneumonia, twenty days
after admission. Excluding the 9 cases of heart-failure
and the 2 of septic infection, all the cases in whom
diphtheria toxin was the cause of death died within the
first ten days after admission, or the first thirteen days
of the disease (the average day of admission in these
cases being the third day of their sickness). Ninety per
cent, of the cases died within the first eight days of the
disease. Thus, taking all these facts into consideration,
a remedy for diphtheria which will prolong the life of
the patient beyond the thirteenth day will carry him
beyond almost all danger of death and can truly be
called a specific.
^ In studying still further these cases which die from
diphtheria toxin, we find the mortality almost entirely
confined to those patients who have false membrane, not
on the tonsils and pharynx only, but added to this diph-
theria of the posterior nares or of the larynx. Those
cases which do not have false membrane in the nose or
larynx generally recover, and a specific remedy tried on
them could give no reliable results.
The proper treatment of diphtheria undoubtedly low-
ers the mortality, and without proper treatment and at-
tention we believe every case of diphtheria affecting the
nose and throat and larynx would die. The mortality
of all cases treated at the hospital during the past two
years has been between twenty-eight and twenty-nine
per cent., and the treatment pursued in these cases we
cannot but believe has had more than a little influence
in maintaining so low a percentage of deaths. The es-
sentials of the treatment pursued in these cases are as
follows : 1. Absolute rest in bed in recumbent position.
2. Fluid diet. 3. The room kept at an even and rather
high temperature (750 to 8o° F.). 4. Thorough, fre-
quent, and complete washing of the nasal and throat
cavities with a normal salt solution. 5. Tincture of the
chloride of iron in large doses. 6. Stimulation and
catharsis as indicated. In addition to this treatment we
have depended almost entirely in the laryngeal cases upon
1 Berliner Klin. Woch., No. 16, 1894.
* Annals de l'lnstitut Pasteur, pp. 385, 1890.
» Berliner Klin. Woch., No. 25, 1893.
November 17, 1894]
MEDICAL RECORD.
611
calomel sublimations and moist heat applied externally!
with operative interference when necessary.
That this treatment faithfully carried out and in-
telligently performed will prevent, in the majority of
cases, extension of membrane, and in all cases the
development of laryngeal stenosis, is evidenced by
the small number of patients who suffer extension of
membrane after entrance, and the extremely rare event
of a case of stenosis appearing after admission. I only
know of three cases developing stenosis after entrance,
and in every one there was an undoubted history of ex-
posure to a draught from an open window. Neverthe-
less, in opposition to all our efforts with this method of
treatment, for which we claim so much, there still con-
fronts us a class of cases that furnishes a frightful mortality,
and makes diphtheria the most fatal of all the infectious
diseases with which we come in contact. The cases we
refer to are always dangerous at any season of the year
or in any epidemic, however mild that epidemic may be,
and it is from this class of patients we have selected the
cases for the antitoxin treatment.
The serum used in our cases is made by Aronson, and
was kindly furnished to us by Schering & Glatz, the
agents for Aronson' s antitoxin in this country. This so-
lution was several times stronger than that first and last
sent over by Aronson, called the " immunization solu-
tion" which corresponds to Behring's "normal anti-
toxin." Diphtheria poison sufficient to kill control
animals weighing from 300 to 400 gr. in thirty eight
to forty-six hours is completely neutralized by .00025
c.c. to .00033 c.c. of the stronger or concentrated solu-
tion. The age of the patient, the duration .of the dis-
ease, and the severity of the case, must all be taken into
consideration in determining the dose to be given. The
injections were made under all aseptic precaution, and
in no case was there any sign of local inflammation fol-
lowing the injection. Instead of injecting the entire
quantity in one place we selected several locations, the
interscapular region and the buttocks.
The following table shows the general results obtained,
the amount of antitoxin injected, and, as far as possible,
describes the local condition of the different cases :
* I
m 11
3d
1
. 7
3-5
4
4th...
. 4 a-8
X
Sth...
. 5' 3-4
X
6th...
. x a.o
,.
7th. .
. a 1.3
..
8ch...
x a.o
••
■is
11
1
<
5tht... ao 3.0
c.c.
8.0
94
5.0
6.5
xa.o
188.0
I'S
u'l'isii
rrrr
z s
I
p.c
a 28.5
So
100
V,
5. »S
* One of these case . was undoubtedly true scarlatina, and another was diag-
nosed as a doubdul case of measles. In the third case the rash disappeared in a
few hours without further symptoms.
t Totals.
This tabulation shows 14 were laryngeal cases, with ad-
ditional membrane on throat or nose. Five of the cases
were operated upon ; 4 intubated, and 1 tracheotomized.
Of these 14 cases, 1 intubation case, three years old, died
on the twenty-fourth day with lobar pneumonia. The
bacilli were absent in this case seven days before death,
and at one time we had considered the child recovered.
The tracheotomy case, two years old, died on the thirty-
fourth day with broncho-pneumonia. In this case there
was a history of exposure to cold four days before death,
and the bacilli had been absent some time. Two cases
not operated upon died : One a girl, six years old (the
only case treated over five years old), died from sudden
heart-failure on the twelfth day. On this patient treat-
ment was not begun until the fifth day, and at that time
the child was in a terrible condition — skin moist and cold,
color bad, stenosis quite well marked, membrane on ton-
sils, uvula, pharynx, and nares, diffuse swelling of glands
in the neck, temperature a little below normal, and pulse,
114, and weak. Could hardly expect child to live twelve
hours. Stimulants were given, irrigated once, and 1 2 c.c.
of antitoxin injected in four places. Twelve hours later
the improvement in general condition was marked ; in
fact, the rapid improvement in this case was more notice-
able than in any of the others. The child continued
doing remarkably well for six days, when we considered
her practically out of danger. But on the following day
the child suddenly went into syncope and died three
hours later, stimulants and restoratives being of no avail.
A slight paralysis of the soft palate was noticed the day
before death, and the membrane at this time had entirely
disappeared. We regret that a larger or repeated dose of
antitoxin was not given in this case. The other death
was from pneumonia, in a child two years old, all signs
of membrane having disappeared twenty days before
death.
Of the six cases which had no laryngeal complication,
but which had membrane on tonsils and pharynx and in
the posterior nares, only one died. This child, five
years old, developed a bad scarlatina, and died fifteen
days after beginning of his diphtheria and five days after
beginning of his scarlatina. The membrane had disap-
peared on the tenth day, and' the child at this time was
in excellent condition. During the course of treatment
large plugs of membrane were removed from the nose.
The case received 20 c.c. of antitoxin, the largest
amount given to any one patient.
Theoretically, the antitoxin could only have prevented
one of these five deaths, the child who died with sudden
diphtheritic paralysis of the heart on the twelfth day of
the disease, for in none of the other four cases was death
due to the diphtheria toxin. Then, excluding these
four cases, we have one death in sixteen, or a mortality of
6. 2 per cent, in cases, the average age being three years,
selected on account of their severity. Including all
deaths the laryngeal cases showed a mortality of 28.5
per cent, as opposed to the regular mortality of over 50
per cent, and the other cases give a mortality of 16.6
percent.
The treatment with the antitoxin was begun in the latter
part of July, having previously used the weaker solution
on several cases, and extended through the following
two months. Twenty cases were selected for treatment
during this time, and every case was one in which a most
unfavorable prognosis would have been given at time of
injection, while in all other hospitals where the serum
treatment has been applied all cases have been injected
without regard to the age or condition of the patient.
The latter method gives a larger number of cases, but is
not so severe a test, unless the treatment extends over a
long period of time. Good results obtained in this way
can be claimed as due to the season of the year, or the
mildness of the epidemic. Our cases differ in another
important respect from most of those already reported, t. e. ,
the treatment consisted entirely of injections of antitoxin,
with the exception of irrigating all cases once on ad-
mission, and two cases several times, for the purpose of re-
moving membrane which completely plugged the nose.
Of course stimulation was given when indicated.
The temperature of diphtheria is so variable, being
sometimes low in the most severe cases and high in
others, it is impossible to tell how much it is influenced
by any treatment. In some of the cases the rise in tem-
perature after the injection was marked, in others there
was no decided change, while in still others there was
considerable fall. This fall of temperature we notice in
many cases soon after the entrance to the hospital, the
temperature on admission probably being the so-called
"ambulance fever. " Streptococci, inflammation, and
other complications also give a high temperature, and,
of course, antitoxin could have no influence on these
temperatures.
6l2
MEDICAL RECORD.
[November 17, 1894
The effect upon the pulse is of much more importance.
In nearly all cases nine hours after the injection the
pulse was much improved in strength, volume, and fre-
quency. The two following representations of the com-
posite pulse and temperature curves of all cases will
show what influence, if any, antitoxin had upon the
temperature and pulse :
ISO
AtTRm
\3 #**n
Itf/'vtitk
J*
Jisr .
ito
/J0
^\
\
/io
\
//Q
too
?*
Fig. i.— Composite Pulse Curve of the Twenty Cases.
Fig. a.— Composite Temperature Curve of the Twenty Cases.
The diphtheritic false membrane disappeared, on the
average, on the ninth day of the disease. This is about
the ordinary duration of membrane in most cases, but is
probably a little early for cases so severe as these. The
persistence of the Klebs Loeffler bacilli, as would be ex-
pected, was not apparently influenced, the average time
for disappearance of bacilli being the nineteenth day.
Antitoxin given early and in sufficient quantity, ought
to prevent post diphtheritic paralysis, as it is now al-
most universally conceded that the paralyses of diph-
theria are due to the toxines absorbed, and generally
follow the more severe cases. Among the cases treated
with antitoxin, four had post - diphtheritic paralysis.
The paralysis was noticed on admission, the tenth, the
eleventh, and the eighth days of the disease, treatment
having b?en begun on the seventh, the fifth, the third,
and fourth days of the disease respectively.
Albuminuria was present in three cases — in two cases on
admission, and in the other case it appeared ten days after
the injection. It lasted no more than three days in any
case. No casts were found in the urine, and no unfa-
vorable symptoms could be traced to the kidneys.
Diphtheritic or septic pneumonia occurred in no case,
the pneumonia complications all coming on very late, as
mentioned before. The pneumonia cases due to exten-
sion of membrane or infection from above, always begin
in the early days of the disease and die within a few
days.
Besides the twenty cases treated with the stronger so-
lution, we have injected twelve other cases with Aron-
son's weaker antitoxin, called the " immunization se-
rum.1' Some of these cases were quite mild, and
received a small amount of the serum. They would
probably have recovered in any case. Several of the
bad cases received as much as 20 c.c. of the serum. On
two patients tracheotomy was performed, one of whom
died on the twenty- first day after the operation, the other
making a good recovery. The age of the former was
four years, of the latter thirteen months. Two cases
were intubated; one died and the other recovered.
Still another case died on the thirty-seventh day with
pneumonia. All of these twelve cases were under five
years of age, and give a mortality of twenty- five per
cent. No death occurred until after the fifteenth day
of the disease. There was not the marked change for
the better in the general condition of the patient some
twelve hours after injection, as was noticed in the cases
treated with the stronger solution. We mention these
cases to show the difference in strength between the two
solutions, and to demonstrate, by giving larger doses of
the " immunizing solution," that it can be used as a heal-
ing fluid.
In drawing conclusions from the results obtained with
the treatment by diphtheria antitoxin, we must first be
satisfied that it has at least some curative power, however
slight or insignificant that influence may be. If we
grant it has any appreciable influence when opposed to
the toxin developed in a patient suffering with diph-
theria, we must concede it is a specific for diphtheria ;
tor the degree or amount of influence it exerts must, from
the nature of the remedy, depend entirely on the strength
of the serum and the care with which it is prepared.
Before deciding this question we may with benefit
consider the results obtained by others, who have given
antitoxin a fair trial. The following reports have, with
two exceptions,come from the hospital of Berlin :
Korte,1 through Vaswinckel, reports 60 unselected
cases treated with antitoxin. Of these, 30 were severe
cases, with fifty per cent, recoveries; 16 were quite se-
vere cases, with eighty- one per cent, recoveries ; 14 were
light cases, with one hundred per cent, recoveries.
Seventy per cent, of all cases recovered. Those cases
having been excluded in which antitoxin could have
had no effect, the total mortality was twenty per cent.
Twenty cases were tracheotomized, with fifty- five per
cent, mortality. The months previous to and following
the treatment gave a mortality of 46.5 per cent, and in
tracheotomies seventy- one per cent, or a total increase
in recoveries under antitoxin of 26.5 percent., and in
tracheotomies a gain of sixteen per cent. He says no
dangerous effects from the serum were observed ; a few
cases had some rash after the injection, and in a few
cases albumin appeared in the urine.
Rinne,2 through Schubert, reports 34 unselected
cases, all of whom happened to be severe diphtheria in
children, with a mortality of 17.9 per cent The 6
patients who died were tracheotomy cases. Autopsies
showed death to be due to septic pneumonia in 2 cases,
mechanical plugging of small bronchi in 2 cases (so that
tracheotomy did not afford relief), pronounced myocar-
ditis and nephritis in 1 case, and the remaining case
died after being discharged from hospital. The observer
considers the serum an effective cure. The local sym-
toms improved rapidly, the effect upon general condi-
tion was more marked than any other (especially true of
those cases with a very weak pulse) and a rash was
noticed in several cases following injection. Much
larger doses were used than experiments with animals
would indicate.
Sonnamberg8 reports 44 cases, with a mortality of
1 Deutsche Med. Woch. , No. 29, 1894.
* Ibid. Cases were treated at the Elisabeth Kxanhenhaus, Berlin.
• Ibid. , June 7, 1894. Cases treated at the Krankenhaus Moabit.
November 17, 1894]
MEDICAL RECORD.
613
twenty-five per cent. Nine tracheotomies give a mortal-
ity of 37.8 per cent. Excluding 6 cases in whom anti-
toxin was not indicated, the mortality in all cases was
l3 3 per cent. Improvement of general condition, rapid
disappearance of membrane, and fall of temperature was
noticed in most cases.
Strahlman1 reports 48 unselected cases, with three
deaths (two of sepsis and one tracheotomy), showing a
mortality of 6.2 per cent. The immunization power was
tried in 94 cases, and seemed to protect from five and a
half weeks to ten weeks. He summarizes as follows:
"The changes caused by injection were marked, the
membrane disappeared quickly, temperature fell consid-
erably, and general condition improved very percep-
tibly."
Rous, Yersin, Martin, and Chaillou 2 have studied clin-
ically in l'Hdpital des Enfants Malades of Paris, and
bacteriologically in the Pasteur Institute, over four hun-
dred cases treated with their 1 to 50,000 antitoxin solu-
tion. They chose those months for the treatment in
which diphtheria attains the highest mortality, and for
comparison had the statistics of l'H6pital Trousseau,
where no serum was used, in the same city, covering the
same period. The mortality for the four years previous
to the treatment was 51.71 per cent, in 3,971 children.
In 448 cases entering the hospital during the serum the-
rapy the mortality was 24 5 per cent. ; covering the
same period the mortality among 520 cases at l'Hdpital
Trousseau was sixty per cent. Therefore 27. 21 per cent,
represents the exact benefit obtained by the antitoxin
treatment as compared with other years in the same hos-
pital, and shows a difference of 35.5 per cent, in favor of
the serum as compared with the regular treatment for
diphtheria in another hospital during the same epidemic
and in the same city. The mortality among pure anginas,
without croup complicating, was twelve per cent., while
daring the same period at l'Hdpital Trousseau the mortal-
ity was thirty-two per cent., and previous to antitoxin in
the same hospital it had been 33.94 per cent. The mortal-
ity in croup with serum treatment was forty-nine per cent. ;
at l'Hdpital Trousseau for the same time it was eighty-six
per cent., and had previously been, at l'Hdpital des En-
fants Malades, 73.17 per cent. Excluding some cases
in which the Klebs-LoefHer bacilli could not be found,
and others in which the serum treatment was not applied,
the mortality among three hundred cases of true diph-
theria treated with antitoxin was twenty-six per cent., or
twenty-five per cent, better than any results obtained by
former treatment for true diphtheria in the same hospital.
We find, then, of four hundred and eighty-six children
(including operative cases) treated for true diphtheria by
various observers, with different strengths of antitoxin
solutions, one hundred and sixteen have died, or a mor-
tality of 23 8 per cent, in a class of cases in which about
fifty per cent, always die.
The first question — " Does antitoxin accomplish any
appreciable good results in diphtheria? " — judging from
our own twenty cases alone, can be answered decidedly
in the affirmative. Otherwise we must believe is is some-
times possible to save over ninety per cent, of children
suffering diphtheria in its severest forms with no other
treatment than rest in bed. When we add to our own
cases the results obtained by others, we cannot help but
believe we have received in antitoxin not only a remedy
that will grant immunity for a short period of time, but
a specific that will, in every case, given early in the dis-
ease and in sufficient quantity, prevent death by the ab-
sorption of the toxine of diphtheria.
Long Life in Greece. — The German statistician,
Bernhard Ornstein, has computed that Greece stands in
the first rank among European countries in the number
of centenarians. He attributes this to its climate.
1 Allgemeine Medicinische Central-Zeitung, No. 58, 1894. Cases
treated in Wildenhausen in Oldenburg.
9 Annals de l'lnstitut Pasteur, No. 9, 1894.
ANTITOXIN IN DIPHTHERIA.
Second Paper, Being Extended Experience in this
City and in Municipal Hospital of Philadelphia,
with Some Practical Points in the Treatment of
the Disease.
By LOUIS FISCHER, M.D.,
INSTRUCTOR IN DISEASES OP CHILDREN, NIW YORK POST-GRADUATE MBDICAL
SCHOOL AND HOSPITAL J PHYSICIAN IN CHARGE OF MESSIAH HOME POR CHIL-
DREN J ATTENDING PHYSICIAN, CHILDREN'S DEPARTMENT, GERMAN POLIKLIN1K.
In the Medical Record of October 6th I published a re-
port of a very successful case of diphtheria treated with
Aronson's antitoxin. Since then I read an elaborate
paper before the Post Graduate Clinical Society, October
13th, giving my results in many consultations, besides
giving a brilliant outlook for the treatment of the septic,
infectious like diphtheria. Moreover, the opportunity for
testing the value of this agent arose in a hopeless case of
puerperal septicaemia, and with astounding results. The
details oi this case will be published later on. It is safe,
therefore, to assume that not only can antitoxin exert
healing influence in toxins generated by the Klebs-
Loeffler bacilli, but that they seem to modify, and possibly
cure, other toxins generated in the human organism by
germs distinct from those known to be the specific cause
of diphtheria. Granted, then, that this is the case we can
not only modify a severer type of the disease, but prevent
complications which we all know to be the sole danger in
diphtheria, besides cutting short the course of the disease
and thus preventing serious damage to the heart and
kidneys.
While no rule has as yet been definitely established as
to what cases are and are not suitable for this new thera-
peutic agent, still extensive experience has already de-
monstrated certain positive facts. They are :
That diphtheria is not a self-limited disease, that it is
always dangerous, and that if treatment is commenced
early to guard against extension of same, we can some-
times avoid complications and save life.
We are, therefore, justified in applying antitoxin not
only when we can already see the local manifestations of
the disease, but when we have reason to suspect that a pa-
tient has been exposed and possibly infected. This will
then bring me to the mildest kind of serum, and which has
been called immunizing fluid.
This serum, made by Aronson, is clear, milkish- white,
having a slight odor of trikresol, of which it contains
0.2 per cent, to preserve it and prevent decomposition
of the albuminous ingredients.
If a child in a given family has diphtheria, it has been
found that other children apparently healthy can, by
receiving small injections of 2 c.c, be kept immune
from diphtheria, and this immunity can be prolonged for
several months.
In fact, Aronson found that when children treated in
this way for prophylaxis, did contract the disease, the
symptoms were so mild as to prove the fact that anti-
toxin had, in all probability, neutralized considerable of
toxic matter in the human organism, and in this way most
likely modified the course of the disease.
This immunity was not only lasting, but could be pro-
longed for some time by repeated injections, and thus the
period of the immunity could be continued for many
months.
The technique of the preparation of antitoxin is one
requiring little or no skill, but owing to the great length
of time required for rendering animals immune, this
period sometimes extends over one year and more, hence
the great difficulty in obtaining large quantities of
serum.
Statistics in this city show from 1 880-1 887, for a period
covering eight years, 5,923 cases, with 2,167 deaths, or an
average of 42.62 per cent.
Nine years ago Henoch reported 319 cases with 208
deaths, in Berlin, or about 65.5 per cent, fatal. At Hos-
pital Trousseau, in Paris, 1883, °f 606 CBses treated, 391
died, or 64.5 percent.
614
MEDICAL RECORD.
[November 17, 1894
So, taking three distinct parts of the world at about the
same time, with most improved form of treatment, we
have-
Berlin mortality 65 5 per cent.
Paris. 64.5 " u
New York 42.62 " u
Since then, the true bacteriological origin of the disease
and our knowledge of antisepsis, tend to introduce a
new course of treatment, although the old bichloride of
mercury has stilln umerous adherents.
Comparing those statistics with the most modern, we
find Katz reporting 128 cases of diphtheria, in a severe
epidemic in the large Kaiser u. Kaiserin Friedrich Hos-
pital in Berlin, with only 13. 5 per cent, mortality.
When Professor Baginsky detailed the method of using
the antitoxin treatment, he especially laid stress on the
fact that this new remedy had influenced the statistics,
and that the mortality fell from thirty-seven per cent, to
thirteen and even eleven per cent. The result has
never yet been equalled by the most improved form of
treatment, and in our mildest epidemic.
How curious to note that under this new form of
treatment all severe symptoms subsided in a few days,
and rarely did an early case of diphtheria develop com-
plications ; and not in a single case was it necessary to
relieve stenosis of the larynx by intubation or tracheot-
omy where the treatment was commenced early.
Even a complicating nephritis seemed to appear milder,
showing a decided influence had been exerted by this
new method.
Professor Roux, in Hdpital des Enfants Malades, in
Paris, had 448 cases; of this number 109 died, a mortal-
ity of 24.33 Per cent., contrasted with average mortality
of four preceding years, when of 3,971 cases, 51.71 per
cent. died.
A critical examination of the statistics for this year in-
volved the drawing of a distinction between cases of true
and false diphtheria. Of the 448 children admitted in-
to the diphtheria portion, bacteriological examination
showed that 128 cases were not infected with true diph-
theria ; further, 20 of the cases were already moribund
when admitted. There remained, therefore, 300 cases
which afforded a fair test of the efficacy of the treatment ;
they yielded 78 deaths, a mortality of twenty six per
cent., which must be contrasted with an earlier series of
cases subject to the same eliminations, but treated by
other methods, which gave a mortality of fifty per cent.
The rule in the hospital has been to give an injection
of the serum immediately after admission of the child.
The injection was not repeated if bacteriological exami-
nation showed that the case was not one of true diph-
theria. In none of these cases was the injection fol-
lowed by any unfavorable symptoms ; it was not painful,
and, if made with aseptic precautions, was not followed
by any local disturbances. In cases of true diphtheria a
second injection was given twenty- four hours after the
first, and as a rule this was sufficient.
If the temperature remained elevated, a third injection
even was given. As a rule a child received an amount
of serum equivalent' to one thousandth of its weight, but
in a few cases the quantity reached one hundredth of
the child's body-weight.
Under the antitoxin treatment, complications were
observed in only a few cases, but in some paralysis
supervened. Occasionally, during convalescence an
urticarial eruption was observed, apparently due to the
injections. The treatment appeared to diminish the lia-
bility to albuminuria.
A further classification was made of the cases of diph-
theria by M. Roux. Taking first the cases in which the
larynx was not involved, he said that in 120 of these
the diphtheria bacillus was present alone ; of these 9
died, a mortality of 7.5 per cent. But of these 9 chil-
dren, 7 did not survive their admission into the hos-
pital for twenty-four hours. Eliminating these, the
mortality was only 1.66 per cent. Further, of the two
remaining children who died, one was suffering from
tuberculous peritonitis, the other from severe measles, so
that it appeared that all cases of pure diphtherial angina
ought to recover if treated in time. The false mem-
brane ceased to develop twenty four hours after the first
injection, and became detached in all but seven cases be-
fore the end of the third day. The temperature fell
rapidly in many cases after the first injection, in severe
cases only after the second or third injection, and then
more slowly. .
In cases of diphtherial angina, complicated by the
presence of other microbes, the results were equally
good, except in those cases in which streptococci were
present ; the number of these cases was 35, of whom is
died, a mortality of 34.28 per cent. This must be com-
pared with a mortality of eighty seven per cent, in cases
treated by other methods.
With regard to cases in which the larynx was involved,
M. Roux distinguished two classes: 1, cases in which
tracheotomy was not performed, of which there were 10,
with 1 death, a case in which the diphtheria bacillus
was associated with streptococci ; 2, cases in- which
tracheotomy was performed, 121, with 56 deaths, a mor-
tality of 46.28 per cent. Among these there were 49
cases of pure diphtheria, with 15 deaths, a mortality of
30.61 per cent. ; but four of the patients died less than
twenty- four hours after admission, and after deducting
these the mortality was 22.44 per cent. Taking all the
cases in which tracheotomy was performed, and eliminat-
ing 14t which died within twenty-four hours after admis-
sion, there remained 107 cases, with 42 deaths, a mor-
tality of 39. 25 per cent.
Good as these results were, M. Roux himself thought
that they might still further be improved by more perfect
isolation of the patients, since many of the deaths after
tracheotomy were due to broncho-pneumonia, and it was
noticed that a series of such cases might follow the ad-
mission of a child suffering from diphtheria of the larynx
associated with the presence of streptococci. In favor
of this argument of isolation may certainly be urged the
larger percentage of recoveries obtained in private prac-
tice in this country, although many of the cases have
fallen into the hands of practitioners with no previous
experience of the serum treatment. It may be also that
the source of the antitoxin had a depreciating influence,
for nothing is stated beyond that the serum was obtained
from the horse. Certain it is that the use of Dr. Aran-
son's antitoxin in the Berlin hospitals was accompanied
by a larger proportion of success.
Dr. Aronson said that in the five months ending with
July, he had treated with his serum 192 patients suffering
from diphtheria, as ascertained by bacteriological exam-
ination. The mortality was fourteen per cent. In 23
cases the children were moribund when admitted ; elim-
inating these, there remained 169 cases, with 19 deaths, a
mortality of 1 1 . 2 per cent. This contrasted with a mor-
tality in the same hospital varying, in three years before
the adoption of the antitoxin treatment, from 32.5 per
cent, to 41.7 per cent.
Eighty-two cases had been treated by the serum in
other hospitals in Berlin, and the general mortality of
the whole series of 274 cases was 15.3 per cent. The
antitoxin serum had also been employed with the ob-
ject of producing immunity in the children belonging to
families in which a case of diphtheria had already oc-
curred. Among the 130 children thus inoculated, a
only contracted diphtheria, and that of very mild type.
Professor Heubner, gives his experience of the use of
antitoxin serum in the children's department of the
Charite* Hospital, in Berlin. He insists upon the im-
portance of early treatment, and pointed out that, as the
seium has no toxic effects, it might properly be employed
in cases which were only suspected to be diphtheritic.
He thought it undesirable to use massage of the part in
which the injection was made, as its use was liable to be
followed by some pain, and it was quite unnecessary, as
the serum was very rapidly absorbed without it. The
points to] which he considered attention should be
November 17, 1894]
MEDICAL RECORD.
615
directed in considering the necessity for repeated injec-
tions, were the effect upon the false membrane and the
swelling of the glands, the behavior of the temperature, the
condition of the urine, and the character of the pulse.
Technique of Injection. — Aronson advised me to use
the asbestos and linoleum syringe holding 20 c.c. for
injecting the serum. This syringe, made in accordance
with these requirements, will soon be imported in this
country by a leading firm. Our own instrument makers
will also manufacture them after the German models so that
they will soon be within reach of all. Having properly
sterilized the syringe by boiling and using 0.5 per cent.
tricresol, I commence by injecting 10 c.c. in mild cases,
and 20 c.c. in malignant cases, by pinching a fold of
skin in the intra scapular region, and allowing the serum
to be slowly injected. I believe it proper, however, to
have a syringe of suitable size and inject the required
amount, rather than inject several places, which is scien-
tifically incorrect, and besides tends to demoralize the
patient by causing pain with each stick of the hypoder-
mic needle. The calibre of the latter must necessarily
be quite large, owing to the thickness of the serum,
which is at times rather mucilaginous. It is proper to
note all differences and effects on the false membrane
and the swelling of the glands, the behavior of the tem-
perature, the condition of the urine, the effect on the
heart, especially the pulse.
There should be no hesitation in injecting on the sec-
ond day, and, if absolutely no effect is seen, repeating
the injection on the third day, as there is absolutely no
risk from the injection. It is a perfectly safe remedy,
and shows no immediate reaction. It differs from tuber-
culin and vaccine in that it causes no reaction. There-
fore, a case of antitoxin treatment will show no symp-
toms directly attributable to the remedy, unless it be in
some cases urticaria. The temperature does not fall by
crisis, but by lysis, with antitoxin treatment. Massage
of the serum after the injection should not be practised,
according to Professor Heubner, Aronson, Baginsky,
and others.
My opportunities for watching this line of treatment
in Berlin last summer, and also my experience with
numerous cases in this city in consultation practice, and
also more recently a series of cases injected and at the
time of writing still under observation, in the Municipal
Hospital of Philadelphia,1 by courtesy of Drs. Welch,
Bemis, Davis, Gould, Kyle, and others, makes me em-
phasize the care of patients and the necessity for per-
mitting absorption to take place without massage.
Practical Points in Treatment.— Let us not lose sight
of the fact that in the use of this rather new agent, we
are still treating diphtheria, and that all discharges, be
they from the nose, throat, or mouth, and possibly faeces
and other excrements, should be subjected to a rigid dis-
infection. This, if possible, before leaving the body.
For this purpose local swabbing of all visible membranes
with a 1 to 2,000 bichloride of mercury solution, using
glass rods with some absorbent cotton — the latter to be
burned immediately after swabbing ; the glass rod to be
put into bichloride solution. We still require most thor-
ough nasopharyngeal antisepsis for this purpose, luke-
warm, 1050 to no° F., normal table salt solution, in-
jecting either nostril until the stream flows out of the other
side, using considerable force at times. Great attention
must be paid to the recumbent posture, which has been
so strongly advocated in Berlin, and I was happy to hear
from Dr. Campbell White, of this city, in discussing my
paper on treatment of diphtheria.3
The usual rules of hygienic measures are in all cases
more rigidly to be looked after in this serious illness than
in any other class of diseases — bathing, temperature of
the room, absolute cleanliness, good light (sunlight) to
*be admitted. The dietetic management to consist of
strong supporting treatment — beef tea, broth made of
1 A complete report of cases will be published in the American Jour-
nal of die Medical Sciences for January. 1895.
9 See Post-Graduate Journal for October, 1894.
veal, mutton, chicken — should be tried. Milk diet, fari-
naceous toods, raw scraped steak, fresh eggs, and kumyss
or matzoon, sometimes buttermilk. Where we have
young children I invariably find them craving for liquids,
and here ice-cream is one of my most favorite articles of
diet. Naturally, cautiously given.
Stimulation should be cautiously followed out. So, for
example, it is wrong to commence stimulating every case
from the beginning. It should be used where there is
weakness of pulse and where heart's action is slowed,
and then, however, if required, it should be freely ad-
ministered. Good Tokay, and Baginsky advises Greek
wines (Mavrodaphne) and other kinds. These latter
wines, being sweet, are very greedily taken by children.
Neither the ice collar nor any other form of external
load application was used, in all my experience abroad or
in this country, with the serotherapy.
As all the reports, therefore, from Berlin, Paris, and
even America, give good results, it is safe to assume that
antitoxin has stood the test of time and is the best rem-
edy therefor used. I do not believe it to be a cure-
all, but that, with careful nursing, proper attendance, and
early use in the disease, it will do more good than any
hitherto known treatment.
The Aronson serum in use in Berlin, London, and
also some in New York, has given me better results by
far than Behring's serum, although it is now claimed that
Behring's serum is as strong as what Aronson recently
made. In once case I used 5 c.c. of Aronson serum with
the same result as 10 c.c. in another with Behring.
Finally, I desire to state, in answer to very many ques-
tions concerning the length of time that serum will keep,
that it will keep in a cool place about a few months. A
great many unscrupulous people, mostly pharmacists,
have already commenced to offer antitoxin, and I would
take occasion to warn against using any substance resem-
bling antitoxin.
Although by cabling to Berlin three times I received
a small consignment, I am assured that we may receive
some in the near future, but that a general supply will
be received about spring of next year.
As Paris has already, similar to Berlin, opened a gen-
eral subscription list for the preparation of antitoxin,
would it not be advisable to have someone brought over
from Berlin capable of making antitoxin, and thus be as-
sured of the proper technique ?
No doubt sterilizing milk benefactors might possibly
be induced to aid a project for the cure and extermina-
tion of one of the most fatal diseases of to-day.
Z87 SfCOND Avhmub.
A Long Term of Service. — Sir George M. Hum-
phry, of Cambridge, England, recently handed in his
resignation as senior surgeon to Addenbrook's Hospital,
a post which he held for fifty two years. He received
his appointment very early in his professional career, and
it was that chiefly which determined his residence in
Cambridge. The governors of the hospital in accepting
his resignation adopted the following resolution : "That
the governors resolve to place on record their grateful
sense of the invaluable services he has during half a cen-
tury rendered to the institution, both as a place for the
relief of the suffering poor, and as an important centre
of medical education ; that, subject to his acceptance of
the office, he be, and hereby is, appointed consulting sur-
geon to the hospital, and that the chairman be requested
to convey this resolution to Sir George Humphry, and
to express the hope of the governors that he may long
be spared to give them the benefit of his counsel and as-
sistance.'1
Fabrics and Odors. — Dress materials vary greatly in
their capacity for retaining odors ; silk allows almost all
odors to pass through without leaving any smell behind ;
linen holds them fast ; wool, though it lets many smells
pass through, retains the odors of decay, like that of a
corpse.
6i6
MEDICAL RECORD.
[November 17, 1894
A CASE OF SARCOMA OF THE PALATE SUC-
CESSFULLY TREATED WITH THE TOXINES
OF ERYSIPELAS.1
By WALTER B. JOHNSON, M.D.,
PATKRSON, N. J.
T. C , male, aged sixteen, clerk. On October 31,
1893, ne w*s admitted to St. Joseph's Hospital, Pater-
son, N. J. He was born of Irish and Irish American par-
ents, and gives no history of any hereditary taint in the
family of the father or mother. No malignant disease
or syphilis has occurred in any branch of either family.
His mother states that when a child she was generally
healthy, except the sickness which resulted from the or-
dinary diseases of childhood; after which she had an
affection of the eyes and an abscess of the neck, which
was lanced and has left a considerable scar. Since that
time she never has been ill except in childbirth; she
has borne eight children, four of which died young, of
convulsions or of the diseases of children. She never
had any still births.
The patient has always been delicate, but has not fre-
quently been confined to the house by illness. He had
measles when seven years old, and two years ago had an
attack of pleurisy which confined him to his bed for fully
two weeks. He has always suffered from catarrhal
trouble and hypertrophy of the tonsils, and generally
during each winter has had more or less frequent attacks
of acute tonsillitis ; these attacks were accompanied by
fever, and he has never been considered either strong or
robust. Six weeks ago he commenced to complain of a
soreness of his throat and accompanying difficulty of
deglutition, thickness of the voice sounds on phonation,
and slight dyspnoea, the respiratory function being per-
formed almost entirely through the mouth. He had
suffered so frequently from attacks of inflammatory dis-
ease of the throat, and had so strong a prejudice against
medical treatment, that he refrained from making com-
plaint and the trouble was somewhat neglected ; it pro-
gressed and assumed a grave condition before any medi-
cal opinion was sought.
On examination, a diseased area was disclosed which
extended over the entire soft palate, pillars of the fauces,
region of the tonsils, forward over the hard palate to
within one-half inch of the incisor teeth, backward and
downward, involving a portion of the pharyngeal wall,
base of the tongue, affecting the epiglottis, and invading
the upper part of the larynx, but not extending to the
true vocal cords. The infected parts were thoroughly
impregnated with sarcomatous deposit, the soft palate
was increased to about three times its normal thickness,
the new tissue consisted of cauliflower like granulations
varying in size from a rice kernel to a good sized pea ;
some of the masses which made up the growth were
undergoing an apparently superficial ulceration and
discharging a purulent secretion ; others contained dis-
tended and tortuous vessels which gave them the
dusky hue frequently observed in sarcomatous diseases ;
the uvula seemed to have been destroyed. There were
several of the cervical glands involved, the largest one,
however, was only about the size of a filbert.
The accompanying drawing (Fig. 1) indicates the
extent of the growth and appearance about the palate
and pillars of the fauces.
The patient did not present a robust appearance, al-
though he seemed to be in fair condition ; there was
no cachexia. Since the present trouble developed he has
been gradually losing flesh, and has become more easily
exhausted on efforts at walking or running. His present
weight is eighty- six pounds. He has increased difficulty
in deglutition, and can only take small quantities of
liquid nourishment. He is unable to breathe through
his nose in consequence of the great thickening of the
soft palate, which compels mouth breathing. A portion
of the growth was removed for microscopical examina-
1 Read at the October meeting, Section Laryngology, New York
Academy of Medicine.
Fig.
tion and submitted to my assistant, Dr. Joseph W. Will-
iams, who subsequently reported the growth to be a spin-
dle-celled sarcoma.
The treatment adopted was the hypodermic injection
of the toxic products of erysipelas and the bacillus pro-
digiosus. The toxines were obtained from filtered cult-
ures of the streptococcus erysipelatosus, and were used
in combination with the toxines of the filtered cultures of
the bacillus prodigiosus. The toxines were kindly sup-
plied by Dr. William B. Coley, of New York, who also
saw the case in consultation in an early stage of the dis-
ease. Some of the solu-
tions were prepared by
Dr. Alexander Lambert,
Fellow in Bacteriology,
College of Physicians and
Surgeons of New York,
and some by Mr. B. H.
Buxton, recent Fellow in
Bacteriology at the Loom-
is Laboratory, New York.
October 31st. — The in-
jections of the toxines of
erysipelas were com-
menced daily with fifteen
minims. The dose was
increased each day until
it had reached sixty min-
ims. The bacillus pro-
digiosus toxines were used
in doses of five minims in
combination after the dose
had reached thirty- five
minims. The injections were sometimes given in the
arm and sometimes in the leg, and generally caused red-
ness, swelling, and pain almost immediately alter they
were given; these symptoms were always present and
persisted from twelve to thirty six hours. The temper-
ature varied. It was elevated after each injection, to a
greater or lesser degree, from 990 to 1030 F. The pa-
tient always felt cold, and after some of the injections
had chills, some of which were much more severe than
others, and were accompanied by nausea, vomiting, and
pain in the back of the head and neck. When the
chills or feeling of coldness had passed away a profuse
perspiration would follow, and the condition of the pa-
tient would be comemuch more comfortable.
The treatment was continued from October 31, 1893,
to June, 1894, during which time it was intermitted on
a number of occasions for various reasons. The patient
developed, during the entire progress of the treatment, a
dozen chills in all ; four of them were violent, and after
one, which was the most severe, his temperature rose rap-
idly to 1030 F. This chill, which was very violent, was
followed by marked cyanosis, pain in the neck and head ;
his pulse became very rapid and feeble, and his general
condition was considered very serious. His nose and
lips were subsequently affected by a severe herpetic erup
tion, and his physical condition was such that he was
obliged to remain in bed for two weeks; during this pe-
riod of time the injections were discontinued. No ex-
planation of the severity of this attack could be given, as
the toxic solutions used had been in use in the same
doses from the same supply, and the same bottle which
was used before, and also after, this attack without any
previous or subsequent marked disturbance.
After the patient had been under treatment for five
months he developed a peculiar variety of keratitis, which
was so severe that the outline of the pupil or coloration
of the iris could not be seen through the opacities which,
although they were apparently punctate, were so closely
coalesced that the entire cornea was opaque; some of
the opacities are still present and visible, although their
character cannot be defined. The injectionc were stopped
for three weeks, during the most severe period of this
attack. m
Frequently the patient became so distressed by the sore-
November 17, 1894J
MEDICAL RECORD.
617
ness of his body caused by the repeated injections, that
an intermission of two or three days was taken, and the
treatment discontinued. Also, on several occasions medi-
cation was stopped in consequence of temporary ina-
bility to procure the solutions for injection.
The result of the treatment was a constant, steady,
but slow, improvement in the condition ; two weeks after
the injections were first given the soreness had left his
throat to such an extent that he was able to swallow not
only fluids, without pain, but also considerable quantities
of solids. His weight increased to eighty-nine pounds.
The granular masses commenced to disappear, this im-
provement continued, and during the period of treat-
ment the deposit of the sarcomatous material was con-
stantly, but very gradually, disappearing, some of the
granulations by necrobosis and some by absorption.
During all this time his general condition steadily im-
proved ; at the end of the fourth month of treatment his
weight had increased to ninety-three pounds. The pa-
tient's temperature was generally not materially in-
creased after the injec-
tions, except as previously
noted. The improvement
was slow and the progress
of the recovery unevent-
ful, although the consti-
tutional disturbance was
marked during the attacks
mentioned above. The
granular swellings gradu-
ally disappeared as the tu-
mor mass decreased in
size. The injections were
discontinued entirely in
June, since which time
there has been no return
of the disease ; the patient
is in excellent physical
condition, his present
weight is one hundred and
seven pounds; he states
that he never felt so well,
and there are no annoying symptoms of any kind pres-
ent at this time, now about one year since the onset of
the disease.
October 1, 1894. — On examination a slight central
prominence and one or two spots of ulceration is all that
remains of the growth ; cicatrization and contraction has
taken place, and white bands of adhesion extend from
the hard palate to all parts of the fauces, as shown in the
drawing (Fig. 2). The uvula and a small portion ot the
epiglottis have been destroyed by ulceration.
Fig. 2.
Jacksonville Meeting of the Tri State Medical Soci-
ety.— The third annual meeting of the Tri-State Medical
Society of Iowa, Illinois, and Missouri was held at
Jacksonville, 111., October 2d and 3d. The attendance
was large and great interest was manifested. Papers
were read by Drs. J. H. Etheridge, Bayard Holmes,
Boerne Bettman, Robert H. Babcock, F. Henrotin, and
W. F. Hubbard, of Chicago ; John Punton, of Kansas
City ; James A. Close and Emory Lanphear, of St.
Louis; W. B. LaForce, of Ottumwa, la.; E. O. Sisson
and F. B. Dorsey, of Keokuk, la.; Frank P. Norbury,
Anne H. McFarland, Carl E. Black, and L. A. Malone,
of Jacksonville, 111. ; Alfred Meyer, of Kankakee, 111. ;
W. M. Catto, of Decatur, 111.; and Charles W. Rook,
of Quincy, 111. The election of officers resulted as fol-
lows : President, Dr. James Moore Ball, of St. Louis ;
Senior Vice-President, Dr. Bayard Holmes, of Chicago ;
Junior Vice President, Dr. L. A. Malone, of Jackson-
ville, 111.; Treasurer, Dr. C. S. Chase, of Waterloo, la.;
Secretary, Dr. Frank P. Norbury, of Jacksonville, 111.
St. Louis was selected as the next place of meeting.
Time — the first Tuesday, Wednesday, and Thursday ot
April, 1S95.
CONGENITAL ANNULAR STENOSIS OF THE
VAGINA— AN IMPROVED METHOD OF OPER-
ATING.
By HIRAM N. VINEBERG, M.D.,
NEW YORK.
INSTRUCTOR IN GYNECOLOGY, NEW YORK POST-GRADUATE SCHOOL OF MEDICINE
AND HOSPITAL ,' ATTENDING GYNECOLOGIST MOUNT SINAI HOSPITAL DISPEN-
SARY, AND MONTEFIORB HOME FOR CHRONIC INVALIDS. .
Acquired stenoses and atresias of the vagina are fairly
common and have received considerable attention in
literature; but not so the congenital stenoses of the
vagina. The literature on the subject is very meagre.
This, doubtless, is due, in part, to the looseness with
which many authors employ the terms "atresia" and
"stenosis." For instance, several authors speak of
" incomplete atresia " — a solecism which should not oc-
cur in scientific medicine. Either an atresia (drp^aia,
from &, priv., and & rptpfc, a perforation) is complete or
it does not exist at all. If there be an opening or a per-
foration, no matter how small, it is no longer a condi-
tion of atresia but of stenosis or stricture.
The meagreness of the literature on the subject of
congenital stenosis may be judged from the circumstance
that, in 1890, L. Klein wachter 8 was able to collect only
twenty published cases, and in only two of these was the
annular stricture situated at the junction of the middle
with the upper third of the vagina. In his paper he re-
ports two cases in which the stricture was situated in this
portion of the vagina. Ostermann and Odebrecht 8 have
each recently reported a similar case. A search through
literature since 1890 has failed to find any other cases.
These six cases, then, form the total number hitherto pub-
lished. The two cases that I am about to report will
bring the number up to eight. I am loath to believe,
however, that the condition is as rare as these figures
would indicate. Many cases, no doubt, go unobserved.
They are frequently overlooked because they may give
rise to no symptoms. When the conditions interfere
with marital intercourse, as in one of my cases, the
woman may have her attention drawn to it and seek
advice. In other instances it is found accidentally, as
in my first case, when the physician makes a vaginal
examination for some uterine disorder having no refer-
ence to the anomaly. In another class of cases the
woman may seek advice on account of sterility ^Klein-
wachter).4 In a further class of cases the condition is
found at labor — Doleris,5 Murphy,6 Hemmer,7 G. Braun,8
Heyder.9 But in the latter class of cases I am of the
opinion that it is frequently overlooked. For unless
the accoucheur made a very careful examination he would
be likely to mistake the thick ring for an undilated os.
As these rings often yield to the intermittent pressure of
the head and the softening processes attending labor, the
true condition would not be revealed.
Case I. — A. A , single, aged seventeen, was seen in
consultation with my friend Dr. J. I. Metzger, March
19, 1893. Has had none of the diseases of childhood.
At five years she had a vaginal discharge, which seemed
so unnatural to her parents that they consulted a doctor
about it. He made light of the matter, and it disap-
peared after a time. In her seventh year she had a simi-
lar discharge, and again in her twelfth year. Since then
the discharge has continued about the same. In her
thirteenth year she had typhoid fever, complicated by
pneumonia, but made a good recovery. Apart from this
she enjoyed good health until six months ago. Men-
struation set in when she was fourteen years of age, and
was regular and painless from the outset. For the past
six months has been complaining of pain in both groins,
backache, and increased vaginal discharge. Exercise,
1 Read before the Section on Obstetrics and Gynecology of the
New York Academy of Medicine, May 24, 1894.
* Prag. Med. Woch., 1890, pp. 589-591.
» Centrlbl. fur Gyn., 1894, No. 5, p. 123.
•Archives de Tocologie, 1886. No. 2, p. 135.
4 Meissner : Frauenzimmer Krankheiten, Bd. I., p. 337.
T Neue Zeitschrift fur Geburtskunde, Bd. IV. , p. 3.
8 Centrlbl. fur Gyn.. 1889, No. 7.
•Archiv. fur Gyn., 1889, Bd. XXXVI., p. 502.
* Loc. cit.
6i8
MEDICAL RECORD.
[November 17, 1894
particularly walking, made the pain in the groin worse.
These pains were relieved during menstruation, which
continued to be regular. Health otherwise fairly good.
She is a tall, slightly built girl, with small, undevel-
oped mammae. The external genitals are normal,
though rather undeveloped, the pubes is thinly covered
with hair. The hymen is ruptured from previous exami-
nation. The examining finger comes into contact with
a membranous ring at about the upper two-thirds of the
vagina. In the centre of this ring is an opening barely
admitting the point of the index-finger. The ring seems
to be about one centimetre in thickness, and is smooth
^
y>
j>er«
**
u*1
Fig. x.
and homogeneous in structure (see Fig. 1), revealing no
evidences of cicatricial tissue. With the finger in the rec-
tum the cervix of a rather small retro-displaced uterus is
felt about one inch above the stenosed part. The left
ovary and tube are normal in size. From the right horn
of the uterus a moderately thick cord can be felt passing
to the right sacro-iliac articulation. The right ovary
can be made out of normal size, but the right tube can-
not be palpated.
Diagnosis. — Annular stenosis of the vagina, probably
of congenital origin, retro-displacement of the uterus.
On June 15, 1893, 1 assisted Dr. Metzger to do the
customary operation of crucial incision and forcible
stretching. At the operation it was found that the vagina
was quite roomy beyond the stenosis. The wound was
packed with iodoform gauze and afterward kept dilated
by Sims's glass plug. This part of the treatment was
rather unsatisfactory, and the stricture was not very much
improved by the operation.
Case II. — B. G , aged twenty-two, was first seen
by me in January, this year, in my service at the Mount
Sinai Dispensary. She was married four months, and
sought advice because coition was painful to her and un-
satisfactory to the husband. He stated that he could
enter only for a short distance, and then "something "
seemed in the way. Her history was negative. She had
always been healthy as a girl, and never had any vaginal
discharge. Had none of the diseases of childhood, as
well as she could remember. She is a well-built, fully de-
veloped woman, mammae and external genitals normal.
At the junction of the middle with the upper third of the
vagina a constriction is felt, formed by a membranous
ring, in the centre of which is an opening just large
enough to admit the point of the index-finger. With the
finger in the rectum a normal-sized uterus is felt, in ante-
version, lying some distance above the constriction.
On January 2 2d, assisted by Drs. Rau and Brothers, I
excised the ring with scissors, flush with the vagina, for
about three-quarters of its circumference, taking care not
to injure the rectum. I then stitched the upper and
lower edges of the vaginal mucous membrane by a con-
tinuous catgut suture. Beyond the first ring the vagina
was funnel-shaped, and at about the level of the cervix was
a second ring, of larger calibre than the first, admitting
the points of two fingers. The portio was very small
and short, and the anterior lip seemed to be continuous
with the second ring (see Fig. 2). I made one attempt
to dilate this ring, tot did not persevere in my efforts as
there seemed no special indication for its removal. I
■0 ^
-t4 ri*
**»
l*s
lb*
le
»y
per
i*i«u
&
Fig. t.
was desirous to dilate and curette the cervix, as there was
some cervical catarrh, but experienced some difficulty in
seizing the small cervix with the volsellum. With the
aid and suggestion of Dr Rau the cervix was drawn down
by catching hold of the second ring with the volsellum
and making traction on it. A dilatation and curettage
were then easily done. The vagina was packed lightly
with iodoform gauze, which was removed in forty-eight
hours. The patient was kept in bed for a week. At
the end of that time the vaginal wound had healed by
primary union. The vagina was now quite capacious,
and the two examining fingers encountered only a small
portion of die ring, which had not been excised. This
now is fully obliterated. Coition ever since the opera-
tion has been satisfactory and unattended with pain to
the woman.
The origin of individual cases of malformation of the
vagina is always a matter of more or less doubt. It is
not always easy to tell whether the pathological condi-
tion is congenital or acquired. During severe attacks of
scarlatina, measles, and typhoid fever there may be an
ulcerative inflammation of the vagina going on without
being observed by the attendant physician. The local
affection is entirely masked by the more severe and
greater disease. As a result of the ulcerative process a
ring-like stenosis may form, which may be smooth and
homogeneous, having all the characteristics of a congenital
formation. It may be well to remember, however, that
in children it is usually the vulva and the region external
to the introitus that are affected with inflammatory diph-
theritis and ulcerative processes.1 This view of the mode
of origin of membranous stenosis of the vagina is based
chiefly on what has been found to follow ulcerative pro-
cesses in the vagina following labor. Some cases in
multipara have been reported (Olshausen and Odebrecht *)
» Henoch : Kinderkrankheiten, Auf. IV. Berlin, 1889.
* CentralbL flir Gyn., 1894, No. 5.
November 17, 1894]
MEDICAL RECORD.
619
in which an annular constriction was found in the va-
gina, apparently showing no traces of cicatrization, and
which, were it not for the prior history, might have been
looked upon as of congenital origin.
Bearing all this in mind, and recognizing the difficulty
in deciding in a given case whether it is congenital or
acquired, I think it may be safely assumed that both of
the cases reported to-night were congenital. In Case I.
some doubt might arise, from the existence of a vaginal
discharge at the age of five and seven years respectively.
Bat this discharge was evidently no more severe than is
frequently witnessed in young girls, and probably would
not have excited the attention of the parents had it not
been for its appearance at what appeared to them an un-
natural age. A condition severe enough to be attended
with an ulcerative process would not have been treated
lightly by the doctor that had been consulted. In Case
II. there seems to be no room for reasonable doubt
The patient had always been healthy as a girl, had had
no severe illness, and had had no vaginal discharge.
Still, the existence of a second ring, and a very small,
poorly developed cervix would speak in favor of an ul-
cerative process. But this may have been, and no doubt
was, of intra-uterine origin. In fact, Breisky1 and
others maintain that the cause of congenital vaginal
stenosis is to be sought in foetal inflammatory processes,
and that they probably most often occur during the later
period of intra-uterine development. On the other
hand, some other observers, notably Dohrn,* hold that
they develop in the same way as the hymen. A third
theory is that they are due to anomalous development
of MUller's ducts. Olshausen ' claims that it is difficult
to explain the origin of vaginal stenosis on the theory
of an anomaly of development, and for this reason alone
doubts their congenital origin.
The diagnosis offers but very little difficulty. The
examining finger comes against a ring-like constriction
in the upper part of the vagina, with an opening varying
in size from a few millimetres in diameter to that which
will admit the point of one or two fingers. An examina-
tion per rectum will reveal the cervix lying two or three
centimetres above the constriction.
An apparent stenosis is not infrequently observed in
pregnant women. It is situated in the upper part of the
vagina, not far below the vault, and though the constric-
tion may be considerable, it never offers an obstruction
to labor. E. Martin already had called attention to it,
and stated it was a constant occurrence in primiparae at
the sixth month of gestation (A. Martin,4 Olshausen §).
It is said to be produced by a pressing down of the va-
ginal vault, forming a duplicative of the vaginal wall.
The treatment usually adopted consists in forcibly
rapturing the membranous ring, or making a crucial in-
cision and stitching the torn or incised membrane to-
gether in the direction of the long axis of the vagina.1
The crucial incision was the method followed in the first
case, and seemed to me unsatisfactory in that it required
considerable after-treatment with vaginal plugs to prevent
recontraction and the immediate result was far from
gratifying. It occurred to me in the second case that it
would be better to excise the ring and stitch the upper and
lower edges of the mucous membrane together, which I did.
No after-dilatation was necessary, and the result was per-
fect. Union had taken place by primary intention.
There was no constriction to be felt at the old site of the
stenosis excepting a small portion of the ring that had
been left on the anterior wall. In a similar case I would
excise the whole ring, though now in my case scarcely a
trace of any constriction can be detected. In fact any-
one examining the patient now for the first time would
find some difficulty in locating the site of the former
» Cyclopaedia of Obstetrics and Gynecology, vol x.t p. 355. Will*
iam Wood & Co.
* tTber die Entwickelurig des Hymen, Schriften der GeselL fur Be-
forderung der gesam. Naturwissen. zu Marburg, Bd. X.
» Loc. cit
♦Centrlbl fur Gyn., 1894, No. 5, p. 125.
•Ibid., p. 124.
stenosis. The late C. C. Lee, in his excellent article on
Vaginal Atresias, in the " American System of Gynecol
ogy," 1 and, by the way, he also employs the paradoxical
term "incomplete atresia/' speaks of dissecting out the
atresic bands. He followed this method in one case, but
left the denuded surface to heal by granulation. " The
process was slow, from the necessity of constantly main-
taining effective dilatation, but by degrees it resulted in
obtaining a perfectly formed vagina." In my search of
the literature on the subject I find that Hey der,2 in 1890,
pursued very nearly the same course that I did. He
divided the membranous ring into two by a Paquelin
cautery, excised each half with the scissors, and brought
the mucous membrane together by fine silk. Healing
occurred in eight days. There was only a slight con-
striction to be felt afterward.
In cases where the stenosis is not too long, that is when
its thickness is within moderate limits, excision of the
constricting ring, with subsequent stitching of the upper
and lower edges of the mucous membrane, forms, to my
mind, the ideal method. The loss of blood may be re-
duced to a minimum by beginning with the continuous
suture as soon as a small portion of the ring is excised,
and following up the cutting with suturing. This plan I
pursued in my case, and the hemorrhage was only trifling.
By introducing a finger in the rectum and holding the
urethra well up with a sound, there should be no danger
of wounding either of these structures.
127 East Sixty-tost Street.
CIRCUMCISION— DANGERS OF UNCLEAN SUR-
GERY.
By HENRY LEVIEN, M.D.,
NSW YORK.
Hebrew male children are generally circumcised on the
eighth day of their birth. This operation is postponed
only in case of the child's sickness, or when the babe,
for some reason, is in such an enfeebled condition that
it is feared the operation may prove fatal. Then it is
postponed for a week or for a succession of weeks.
Circumcision is practised as a purely religious rite ; the
origin of its appearance is to be looked for in the sacred
literature of the Jews, and as remote as the narrative of
Abraham, the Hebrew, who performed the operation upon
himself when ninety- nine years old ; and since that time
his descendants keep it up as a peculiar sacrifice which is
acceptable to God. There are some allusions, in the
ancient and prehistoric literature, to the effect that this
operation has been performed for the sake of cleanliness.
Herodotus (ii., 37) ascribes the origin of the custom to
the Egyptians. The same cause is given on the author-
ity of Philo the Jew ; 8 other causes being avoidance of
carbuncle, purity of heart. Sanitary reasons may have
been the object in view ; but this, as well as the previous
considerations, are not very well accepted, for the reason
that other nations of that epoch, not less intelligent than
the Hebrews, have not accepted it.
Ethnographically considered, circumcision is of a Se-
mitic origin, taken by the Hebrews most probably from
the Arabs, though there are certain reasons to presume
that the Egyptians were the ones whom the Hebrews
imitated in this practice, the only inexplicable feature
being, why do Hebrews circumcise on the eighth day,
while the Arabs, Egyptians, and those small tribes prac-
tising it in the western hemisphere, perform the same on
the approach of puberty.
To this short sketch we will add only that this opera-
tion was performed in ancient times, as* seen in the
Bible, with sharp-edged stones, and that a part of the
foreskin only was removed.
How is circumcision performed at present, at the house
of a Hebrew, under ordinary circumstances ?
A look into the operating-room, and a short acquaint-
1 American System of Gynecology, vol. Ji., p. 27. * Loc. cit
• Opera, ed. Maugey, ii., 210.
620
MEDICAL RECORD.
[November 17, 1894
ance with its surroundings, as well as with the ceremony
connected with the operation, I believe, will be of in-
terest to those of my colleagues who have never wit-
nessed it, and will probably never have the opportunity
to do so. Allow me to preface the description by say-
ing that there is no mystery connected with it, but cer-
tain peculiarities of a rather fanatic nature are adhered
to, merely because it is a custom kept up for ages. As
an illustration, I will mention the custom of hanging up
slips of paper, written or printed, containing a psalm
and some cabalistic names of some angels, designed to
protect child and mother from the grasp of the devil.
These slips are to be seen attached to the bed, walls, and
doors of the bedroom, and remain there for about twelve
weeks, the time limit for the satan to exert his demoral-
izing influence upon the new-born and his mother.
All religious ceremonies and prayers are best accepted
by God when they are performed in the presence of at
least ten adults (men, not women). When the eighth
day approaches, friends are informed of the coming
event, and are invited to be present at the ceremony and
at the dinner following it. On this day the father at-
tends church, where a special prayer is given and a
hymn sung. In the rural districts the infant would be
carried to the synagogue and there operated upon ; but
this is done mostly by the poor, whose apartments are
too small to accommodate fifteen or twenty people*
Otherwise, the father, accompanied by all his friends,
goes home, where preparations are being made for the
operation. The male guests find seats in the front room,
which will serve as the operating-room, while die female
relatives and friends crowd the bedroom, assisting to
dress the baby. By " preparations" is not meant that
nurses, or at least one nurse, is in attendance, preparing
boiled water, sterilized towels, trays for instruments.
Not at all. You see only crowded rooms, where the
nearest relatives busy themselves by carrying pillows
from bedroom into operating-parlor. One feels there is
something remarkable going on, or something remarkable
going to take place. To comfort the weary and hungry
visitors the father, greatly agitated, goes from one guest
to another, telling them that " he n will come soon.
By " him " is meant the chief personality of the day,
the surgeon-in-chief, the Mohel. He is a busy man.
The Hebrews are a prolific nation, and the surgeon per-
forms often three or four operations in one (Sty. But
who is he ? Where did he study ? Why is he entrusted
with the life of a human being ? Nobody can tell. All
we know is, that he witnessed this operation several
times, and announced himself competent enough to per-
form the same. Generally, but not always, the surgeon
is more or less conversant with the teachings of the Tal-
mud, and especially with that part of it which treats of
the anatomy of the generative organs. Lister, being
born in this century, could not have imparted his ideas
to the surgeons of the Talmudical era; consequently
the Mohel, who receives his information on this subject
from that source only, bravely goes to operate without
any knowledge of asepsis and antisepsis. He has come.
Fresh murmurs begin to circulate in the rooms; con-
sultations are being held by husband and wife as to
upon whom to confer certain honorary rites in handling
the infant during operation. At last appointments are
made. One man is to serve as the operating* table (a
highly honored position). This man will be seated on a
high chair on pillows, and on his lap the baby will lie
during operation. Next a young couple is appointed,
generally a maiden and a boy ; the first is to take the
baby from the mother's hands and transfer it to the
young man, who in his turn brings the child into
the operating-room, and hands him over to the by-
standers. Then the assistant surgeons are appointed.
When the father reports to the Mohel that everything is
ready, the latter calls the assemblage to order. The
man-operating-table takes up his high position, the sur-
geon his place, the assistants crowding around him.
Now let us have a look into the surgeon's armamen-
tarium. All you find is a wooden case-box, with one
double- edged knife in it. It is not hard to discover on
the knife suspicious spots of dried-up blood, left from
some previous operation or operations. I recently called
the attention of the Mohel to the condition of his in-
strument, upon which I discovered a few bloody spots ;
to satisfy me he tried to rub the blood off with his finger-
nails, and believed asepsis was fully attained. I was
compelled to interfere and make him do what I consid-
ered proper. The operation in its primitive form, as
will be seen later, is divided into four parts, each being
performed by a separate individual, though improve-
ments and modifications are being instituted.
The signal is given. The baby is on its way from the
bedroom, and when it reaches at last the operating-room,
the Mohel meets it with a phrase : " Blessed be he who
has come ! * ' which is repeated by all present. The baby
is kept on a pillow, and in this state it is placed on the
lap of the high-positioned man. The operation begins.
The surgeon goes to work. There is no washing of
hands, no scrubbing of finger- nails.
First part: The surgeon steps bravely forward, ad-
justs the baby in the right position, and baring the penis,
grasps the foreskin with the thumb and forefinger of his
left hand, says a prayer, and cuts it off. His work is done.
He steps aside to give place to No. 2, who with the
pointed nails of his thumbs tears and divides the mucous
membrane covering the glans and pushes it backward to
the corona. When this is done, forward steps the third
party, who takes the bleeding, tender organ into his
mouth, which is never cleaned before, and may be full
of decayed teeth and purulent gingivitis, and sucks it
three, four times, spitting the blood into a specially
prepared receptacle with some special (Palestine ?) sand
in it. Into the same is placed the cut-off foreskin.
Fourth. The surgeon-in-chief resumes his duty again,
and an attempt is made to dress the wound. It consists
in placing a handful of some pulverized decayed wood
which is supposed to have astringent power, and cover-
ing it with some rags.
To quiet the child during and after the operation, it is
customary to put a rag with some predigested food into
the infant's mouth, thus preventing him from yelling too
much.
Now the child is taken from the operating-table and
transferred to some honorary member of the assemblage.
A prayer is sung by the Mohel, while keeping a glass of
wine in his right hand, and when a certain point in the
hymn is reached, he wets the tip of his left-hand little
finger in the wine, and saying, " Live with thy blood/9
he smears the lips of the infant with it. At the same
time the name is officially given to the child, he con-
cludes his prayer, drinks the wine, and the ceremony is
at an end. The child is now again handed over from
one to another, until it reaches the young man, who
transfers it to the young lady, the last returning the
baby to the anxious mother. Tables are now set in the
operating-room, and the feast begins. The dangers of
infection the new-born has been exposed to may be seen
by the readers themselves.
The improvements in this procedure, as mentioned
above, are being instituted in large cities only, where the
Mohel comes in closer connection with the physician,
and consist in the following modifications : The Mohel
does the whole work himself, and instead of sucking
with the bare lips, he employs a glass tube through which
the suction process is performed. The advanced surgeon
uses also a metal plate with a long and narrow hole in
it, and uses it as a clamp ; he pulls the foreskin through
the hole, pushing meanwhile the plate toward the glans,
thus protecting the last from direct injury. Again, in*
stead of the traditional powder, plain or even iodoform
gauze is used for dressing. But this additional instru-
ment, the plate, serves very often as a new source of in-
fection. I found on this metal piece dried- up blood, and
had to insist on its disinfection.
I will cite now two cases I recently came across,
November 17, 1894]
MEDICAL RECORD.
621
which, I believe, will serve, on one hand, as an illustra-
tion of the dangers the new-born Hebrew children are
exposed to ; on the other hand, with the above considera-
tions and the following facts in view, they may be treated
as a friendly warning and advice to those of my col-
leagues who axe engaged in obstetrical practice among
the Hebrews, to make it their business and a matter of
conscience to be present at every operation, and super-
vise the whole procedure.
Case I. — I was called to see child R on the 30th
of March. Infant, aged thirteen days, was circumcised
on the 25th ; child was not well since operation, but
became worse on the 28th. The Mohel was then called
in, who ordered an ointment which did not do any good.
Present state : Acute inflammation of the penis, ery-
sipelatous oedema of scrotum and on pubic region. In
the cervix, behind the glans, I detected a small ulcer,
which was probably the nidus of infection. Tempera-
ture, 1050 F.; pulse, 160; respiration, 60. Child very
restless, crying as if in great pain. Every time the
child would pass urine it would scream and have con-
vulsive movements.
* March 31st. — The dressing and local applications I
ordered seemed to control the pain, but the erysipelatous
process was not arrested, and spread farther up, reaching
a point midway between the symphysis pubis and um-
bilicus. Slight diminution in the oedema of scrotum.
Temperature and pulse not changed ; respiration labored.
April 1st. — Child is reported to have had two distinct
convulsions; was very restless. The abdomen very
tender on palpation ; slight tympanites ; redness up to
the umbilicus. Baby too weak to nurse ; pulse hardly
perceptible at the radial artery. There was certainly
very little hope to save the child, and I told the parents
my opinion.
April 3d. — Have seen the child at 2 p.m. The lower
abdomen, penis, scrotum, and upper part of both thighs,
cyanotic, just as if gangrene had set in. Child died at
4 P.M.
Case II. — I was called by a Mohel to see a baby whom
he operated upon the same day. The trouble, severe
hemorrhage somewhere on the penis, which hemorrhage
he could not control by any means known to him. He
was very anxious, and justly considered himself respon-
sible. On arrival I learned that the child was bleeding
the whole day and had lost about three ounces of blobd.
It was very hard to locate the bleeding point, as the
penis was wrapped up in rags, soaked in a solution of
liquor ferri chloridi, and on removing the rags the whole
penis appeared dark and swollen. At last I discovered
the artery of the corpus cavernosum eroded and laid
open at the internal layer of the prepuce. It took con-
siderable time to secure the vessel and compress it, on
account of the swelling and tenderness of the parts.
Having applied an antiseptic dressing, I left, instructing
the mother to call me at once if the hemorrhage re-
curred. When I called on the next day I found the
hemorrhage stopped, the swelling less, but ulcerations of
different degrees traversing the mucous layer and the
glans. The erosions were caused probably either by the
misapplied dressing, or while pushing the mucous mem-
brane toward the cervix. The child recovered.
In view of the above considerations and other facts,
the question presents itself: Shall the medical profession
and boards of health look upon these mutilations from
the hands of ignorant people indifferently, or shall we
join with the State of Ohio in introducing a bill prohibit-
ing circumcision entirely?
In attempting to solve the question we should care-
fully consider the pros and cons before expressing a pfosi-
tive opinion. I will therefore lay before the medical
world some considerations for and against prohibition.
For prohibition speak partly the facts and morals of
this paper, i.e., injuries and even death inflicted upon
the new-born; secondly, humanitarians find circumci-
sion an act of cruelty and barbarism, especially as prac-
tised among the poorer classes of Hebrews.
Thirdly, many consider the whole procedure entirely
unnecessary, and in proof of it say that hundreds of
millions of people live and prosper, not being circum-
cised.
Against that bill the following reasonings suggest them-
selves:
First, circumcision is a religious rite, besides being a
custom of a race for about three thousand years, and we
believe that no free government has the right to intrude
upon anybody's religious convictions.
Secondly, it is a recognized fact that the Jews are less,
than uncircumcised nations, prone to venereal ailments,
and when so affected are sooner cured than others.
Phimosis and paraphimosis, due to venereal infection, is
almost unknown among the Jews.
Thirdly, the operation itself, in the hands of skilful
and intelligent men, is not a severe one, and children
bear it well ; and,
Fourth, I would hesitate to stop a process, though a
depletory one, in a nation in whom the depletion for
hereditary reasons may be a necessity for the well-being
of the race, and may prove disastrous if this operation is
denied.
There are but few men of the younger generation who
have decided to do away with circumcision on their
children, and we cannot draw any conclusions yet. I,
for my part, would suggest to meet the question in such
a way as, on the one hand, not to offend the religious sen-
timents of a people by passing State laws on their behalf;
on the other hand, to protect the innocent young ones
from maltreatment.
This could be materialized by introducing a bill pro-
hibiting, not circumcision, but " circumcisers," from per-
forming operations in the way they do now, and passing a
law that, at each and every operation, a duly registered
and practising physician shall be present, or such physi-
cian should be sent from the local board of health. The
physician shall superintend the operation, and shall be the
responsible party.
Certainly no good can be attained by licensing circum-
cisers, having them undergo a certain examination, etc.
The licensed midwife furnishes us a good example of
things half done. Midwives, being allowed to go on in
their practice so far, will always take one step further,
and a good deal of mischief to the patients under their
care is the result. Circumcision is an operation requir-
ing as much care and dexterity on the part of the sur-
geon as in any other surgical work, and should be per-
formed by a competent surgeon, or at least under his
direct supervision.
C39 East Broadway.
The Comma Bacillus and Cholera. — A statement has
appeared in more than one of our lay contemporaries of
the death from Asiatic cholera of Dr. Oertel (who must
not be confounded with the distinguished Munich pro-
fessor), of the Hygienic Institute at Hamburg, while en-
gaged in bacteriological investigations of specimens of
infected water from the Vistula. It is said that he
succeeded in making cultures of the cholera bacilli
from this water, and in one account it is circum-
stantially related how he introduced into his mouth a
minute portion of the cultures, and, although recogniz-
ing the gravity of the accident and resorting to the free
use of germicides, he developed symptoms of the disease,
which rapidly proved fatal. If substantiated, this sad
occurrence not only adds one more to the list of fatali-
ties among experimental investigators, but would form a
verification of the value of Koch's discovery; for, al-
though more than one experimenter has ventured to
swallow these bacilli with impunity, their negative re-
sults cannot weigh against a clearly proved positive one.
It is, of course, quite as likely that the disease was con-
tracted in another way, and that the case affords another
of the numerous coincidences in which medical history
abounds. — The Lancet.
622
MEDICAL RECORD.
[November 17, 1894
A PLEA FOR IMMEDIATE CCELIOTOMY IN
RUPTURED TUBAL PREGNANCY.1
By CHARLES E. NAMMACK, M.D.,
NEW YOKK.
The object of this communication is to endeavor to re-
move the impression existing in the minds of many
medical men, that ruptured tubal pregnancy does not re-
quire immediate coeliotomy. Tins impression seems to
be founded on the old teaching that when the sac rupt-
ures in the early weeks of pregnancy, the escape of
blood may be moderate and run the course of ordinary
hematocele. Even so recent a book as the " American
Text-Book of Surgery" says (p. 972) that when the
hemorrhage is into the connective-tissue interspaces of
the broad ligaments, the treatment should be purely ex-
pectant, but that intra-peritoneal hematocele requires
abdominal incision, etc. It also gives the differential
points between the two varieties of hematocele, but the
average practitioner who waits until this differential diag-
nosis shall be demonstrable, will, in the average case,
have waited until his patient has lost more blood than
she can regain.
However doubtful and problematic the diagnosis of
tubal pregnancy in its early stages and prior to rupture
may be,2 there is fortunately a very clear clinical picture
presented after rupture has occurred. The marked symp-
toms are summed up by Joseph Price,* and form a group
which should be promptly recognized and immediately
treated by primary operation in all cases. Price's statistics
show ninety-six per cent, of recoveries in personal cases op-
erated on, as against fifty per cent recoveries in the cases
of others when treated expectantly. Duhrssen * reports
twenty-nine cases of coeliotomy for ruptured tubal pregnan-
cy, with three deaths — almost ninety per cent, recoveries.
It has been the writer's lot to see the consequences of
delay in two cases since January, 1893. The first of
these he reported in the Medical Record of March 18,
l893> P- 343. It was a case in which the surroundings
and previous history of intra-pelvio suppuration in the
patient were considered by two eminent gynecologists
to be sufficient reasons for postponing operation until
patient could be moved to a hospital. But the hemor-
rhage recurred in a very few hours, operation was per-
formed by a third consultant, when all hope had been
abandoned by the patient's relatives, and she was liter-
ally snatched from the jaws of death. The second case
emphasizes so clearly the lesson taught me in that first case
that the recital of it may help to firmly fix in the minds
of others the conviction that a woman with a ruptured
tubal pregnancy should not be left until it is extirpated.
Mrs. Mary L , thirty- five years of age, consulted
me September 8, 1893, and was found to be suffering from
tuberculosis of the lungs and larynx. She was treated at
intervals until April, 1894, the pulmonary process not
advancing beyond the stage of consolidation, and during
this time her menstrual periods were regular. Her last
child had been born seven years before. She went two
weeks over time in April, 1894, but the desired flow finally
came in response to hot foot baths, etc. She then men-
struated regularly and normally in May, June, and July,
her last flow beginning July 13th. On September 3d she
felt a sharp stinging pain in right groin, followed by slight
show of blood. The pain yielded to recumbency and
the application of a hot water bag and the patient was up
and around next day. On September 16th she lifted a
basket of coal from the elevator and immediately the pain
recurred, she became nauseated' and faint, and had an-
other slight bloody vaginal discharge. The pain after
this being persistent, and the weakness and fainting at-
tacks progressive, she sent for me September 21st, and,
pending my arrival, called in a neighboring physician,
1 Read before the New York Academy of Medicine, Section on Ob-
stetrics and Gynecology, October 25, 1894.
* T. M. Baldy : Mbdical Record, September 21, 1889, p. 310.
• Medical and Surgical Reporter, September 30, 1893.
4 American Journal of the Medical Sciences, May, 1894, p. 601.
who told her he suspected tubal pregnancy. The evi-
dences of rupture and internal hemorrhage were plain at
the time of my visit. Surgical assistance was at once
summoned, and upon the arrival of the operating surgeons
a consultation was held. My opinion that an immediate
operation was demanded was overruled, the other men
being unanimous in the belief that the hemorrhage was
limited to the layers of the broad ligament, and, there-
fore, extra-peritoneal, and that nature would be com-
petent to absorb it, or that, at least, expectant treatment
was justifiable. The next morning that patient went into
collapse from recurrence of the concealed hemorrhage,
and there was no longer any difference of opinion as to
the proper procedure. Preparations for immediate opera-
tion were hastily made, chloroform being chosen as the
anaesthetic on account of patient's pulmonary condition,
and because vomiting had become a prominent symptom.
Abdominal incision revealed a quantity of loose clots and
fluid blood, estimated by the operator at three quarts, and
a ruptured tubal pregnancy with the foetus protruding.
The ovum was developed so close to the uterus that the
extirpation was difficult and tedious, and the patient's pulse
stopped when it was finished. She rallied under inhala-
tions of amy 1 nitrite and the hypodermatic use of strych-
nia and brandy, with injections of hot salt solution into
the cellular tissues and rectum. During these procedures,
the operator flushed the abdominal cavity, damped the
cut end of the tube at the uterine junction, and packed
with iodoform gauze without waiting to suture the tis-
sues. The patient was then put to ted, collapsed from
hemorrhage. Despite all efforts and efficient nursing,
she never rallied, and died fifty-two hours after operation.
What the result would have been under operation twenty
hours earlier cannot be positively stated, but there is no
doubt that a recognition of, and prompt operation for,
her condition on September 3d, when the first symptom
appeared, would have saved her life.
And now a word as to the different indications for treat-
ment, depending on whether the rupture is intra-peri-
toneal or extra-peritoneal. According to the " American
Text-Book of Gynecology," p. 541, " the safest rule is to
prepare at once for operation," if intra* peritoneal rupture
has occurred, but if the hematoma is extra-peritoneal,
" the treatment is usually non-operative/1 p. 542.
This leaves the patient exposed to the fourfold dangers
of 1, recurrent hemorrhage ; 2, peritonitis ; 3, septicaemia;
4, subsequent trouble in the damaged tube. While not
denying the possibility that a pelvic hematoma may re-
main extra- peritoneal until it is absorbed, the writer con-
siders that the probability of recurrent hemorrhages caus-
ing it to burst into the peritoneal cavity is so great as to
make primary operation the only safe procedure. On
this point Joseph Price l speaks with no uncertain sound
when he says : " With an experience of eighty- three sec-
tions for ectoptic pregnancy, I remain in surgical ig-
norance of extra-peritoneal hematocele, not a single case
did I encounter." Munde's experience with twelve cases
of ectopic pregnancy 2 form an interesting study and show
the value of prompt operation.
»9 Ea»t Twbnty-foukth Stxekt.
A Census of Medical Ken in Alsace-Lorraine shows
that there were in those provinces in the first of this year
619 physicians, 10 diplomaed dentists, 123 veterinary
physicians, and 230 pharmacists. Of the physicians
there were 529 with German, and 90 with French
diplomas.
4 Cure for Dyspepsia. — A minister in Ohio was de-
posed some months ago on account of immorality. He
admitted the charge of having had irregular relations
with some of the women of his flock, but defended him-
self on the plea that his physician had recommended it
as a cure for dyspepsia.
1 Medical and Surgical Reporter, September 30, 1893, p. 5091
* American Journal of Obstetrics, vol. xxix. , No. 5, 1894.
November 17, 1894]
MEDICAL RECORD.
623
gwgress of iJfcjeflfccal j&cteujc*.
Cardiac Syphilis and Angina Pectoris. — At the Ber-
lin Medical Society Dr. A. Fraenkel recently demon-
strated a specimen of cardiac syphilis from a woman,
thirty-six years of age. When first seen last year, she
had aortic regurgitation and suffered from frequent head-
aches, which were occasionally associated with fainting
attacks. The heart disease was supposed to be conse-
quent on acute rheumatism. The husband was syphi-
litic, and the woman herself had suffered from swellings
on the head, which had ulcerated and left scars. She
improved at first and left the hospital, but was read-
mitted this year with severe attacks of angina pectoris,
in one of which she died. At the necropsy the left cor-
onary artery was found quite permeable, but the orifice
of the right coronary was completely obliterated by a
process of arterio sclerosis (much in excess of the pa-
tient's years), and its proper position could only be de-
termined by probing backward along the lumen of the
artery. There was a gummatous tumor, 4^ ctm. long,
in the septum ventriculorum, and Fraenkel thinks this
shows that the arterial changes were really of syphilitic
nature. The arterio-sclerotic changes in the aorta reached
down to the bifurcation. Fraenkel, moreover, remarks
on the part played by syphilis in the etiology of aneu-
risms. Walsh thought that sixty per cent, of true aneu-
risms were due to syphilis, others think still more.
Fraenkel himself, during the last four years, has seen 19
cases of aneurism of the thoracic aorta in which there
were necropsies; 3 cases were in women, 16 in men.
Of the 19 patients, 9, that is, forty-seven per cent., had
had syphilis, and these were all under fifty years of age.
The case illustrates the relation of precocious arterio-
sclerosis and syphilis. — Berliner klinisehe Wochen-
schrift.
Pancreatic Colic. — Dr. Minnich has observed a case
of this kind in a man sixty-eight years of age. At the
age of forty he became troubled with attacks of colic
which were attended with jaundice, and continued dur-
ing a period of three months, but disappeared upon
treatment. In the stools were found typical biliary cal-
culi. There then followed a period of freedom from
attacks for ten years and a half, when attacks of colic
recurred. These again yielded to suitable treatment.
Seventeen years later the man was suddenly awakened at
night by an attack of colic resembling previous attacks.
A second attack took place on the next day, and a third
several months later. At this time there appeared a
sense of oppression in the epigastrium, together with loss
of appetite and distaste for fluids. This condition per-
sisted for about a month, without the occurrence of an
actual attack of colic. At the end of this time the man
was seized with diarrhoea, lasting for three days, and
ending with an attack of colicky pain, referred to the 16ft
hypochondrium and to the epigastrium. The patient
was well nourished, and presented no oedema. The
scleras were a little yellowish and the skin dry and of
normal warmth, but not icteric, although the seat of
annoying itching and a chronic desquamative eczema
upon the exterior surfaces of the arms. The temporal
arteries were slightly tortuous, but there was no other
evidence of arteriosclerosis. There was an absence of
abdominal tenderness, so that deep palpation could be
practised, but without yielding positive information.
The liver was not enlarged, and the gall-bladder could
not be appreciated. The spleen was likewise not palpa-
ble, and the area of splenic percussion dulness was not
increased. There was no evidence of dilatation of the
stomach, and a peritoneal effusion could not be detected.
The patient described the paroxysm as beginning with a
sense of dull, heavy, constricting pain above the epigas-
trium and in the left hypochondrium, increasing in in-
tensity and localizing itself deeply in at one point below
the left costal margin, just within the mammillary line.
At the height of the attack the pain extended from this
point circularly to the vertebral column in the course of
the costal arch, thence radiating beneath the left scap-
ula. At the termination of the attack pain was still per-
ceptible at the point below the costal margin, in an area
about an inch and a half in diameter. Careful explora-
tion of this region failed to disclose any morbid condi-
tion, excepting slight tenderness. The attack abruptly
came to an end at the expiration of two hours, and was
followed by a sense of hunger. The urine passed at this
time was free from albumin and sugar, and did not re-
spond to tests for biliary coloring matter. From this
time the attacks were repeated almost daily, usually set-
ting in toward the end of the day and lasting from a
fraction of an hour to several hours. The condition re-
sisted the ordinary treatment for hepatic colic An ex-
amination of the stools failed to disclose the presence of
fat or fatty crystals, or biliary calculi. On several occa-
sions, however, light-gray, round calculi were found,
which could be crushed between the fingers, and micro-
scopically proved to be constituted of amorphous matter.
They dissolved in chloroform, leaving a turbid solution.
They fused in the flame, giving off a dense vapor having
an aromatic odor. The residue yielded the reactions of
calcium carbonate and calcium phosphate. Subsequent
attacks of pain occurred, but no more calculi or other
abnormal matter was found in the intestinal evacuations.
The condition was regarded as one of calculous forma-
tion resulting in obstruction of the excretory ducts of the
pancreas, and giving rise to attacks of colic. The sub-
sequent history of the patient is not given, however, and
the diagnosis therefore lacks confirmation. — Berliner
klinisehe Wochenschrift.
Valerianate of Amyl. — Dr. Blanc describes valerian-
ate of amyl, which is the odoriferous principle of the
apple, that is, the essence extracted by distillation to-
gether with alcohol. Cider has long been believed by
the laity to have some effect on calculous formations, and
this seems to be borne out by the fact that valerianate
of amyl really has some solvent action on cholesterin.
It is a colorless liquid, of pleasant taste when taken in
small quantities, and can be prepared in the laboratory
by the action of valerianic acid on amyl alcohol ; 1 grain
of cholesterin is dissolved by 4^ grains of valerianate
at 370 C. and by 3 grains at 400 C. (British Medical
Journal'). Physiologically the action resembles that of
ether, but the special qualities lie in its being a stimu-
lant and sedative to the liver in cases of hepatic colic.
It not only immediately subdues the attack, but it pre-
vents recurrences. If the stomach is irritable, ft may be
necessary first to employ sulphuric ether, following this
with two to three capsules of fifteen centigrammes each,
given every half-hour until the crisis is past, and con-
tinued at longer intervals during the following days. In
nephritic colic the drug acts as an antispasmodic and gen-
eral stimulant only, but no effect is produced on the
renal calculi. Muscular rheumatism is frequently re-
lieved, and much benefit is also derived from its use dur-
ing menstrual uterine contractions. As a sedative, it is
of value in hysterical manifestations. Its toxic proper-
ties being very slight, as many as five to six capsules can
be taken daily, but it is necessary to guard against gas-
tric disturbance.
Syphilid and Aphasia. — Dr. Jolly reported at the
Congress of German Physicians, Vienna, a case of cerebral
syphilis in which he was able to demonstrate by autopsy
the dependency of word deafness and aphasia on a com-
plete destruction of the entire parietal lobe, the two first
temporal lobes, the angular gyrus, prsecuneus and cu-
neus. The patient was unable to read his own name, to
write from dictation. The word deafness Jolly considers
was due to the lesion in the temporal lobe, and the loss
of speech possibly to the entire destruction 'of the audi-
tory centre and areas.
624
MEDICAL RECORD.
[November 17, 1894
Medical Record:
A Weekly Journal of Medicine and Surgery.
GEORGE F. SHRADY, A.M., M.D., Editor.
Publishers
WM. WOOD &. CO., 43, 45, & 47 East Tenth Street.
New York, November 17, 1894.
THE CHANNELS OF INFECTION IN TUBER-
CULOSIS.
The subject of tuberculosis is to-day the gravest one
with which the physician has to deal, and the necessity
of lowering its frightful mortality by preventing it, rather
than by treatment, was never more keenly appreciated.
Although the general principles of infection have been
well worked out, the channels of infection is a subject
that pathologists are not entirely agreed upon. Dr.
Sims Woodhead has recently made a communication in
The Lancet which has contributed much to our enlighten-
ment. He concedes that the tuberculous virus may be
directly inoculated into the tissues, but this condition is
comparatively very rare. Heredity, to which has been
attributed such an important rdle in the past, plays an
altogether unimportant part in the spread of tuberculosis,
ranking only with such factors as insufficient and imper-
fect food, and defective hygienic conditions.
Tuberculosis attacks the lungs and alimentary canal by
preference, because it is here that the bacillus most easily
finds the moist mucous membrane with defective epithe-
lial covering for which it has a special predilection.
When the tubercle bacillus is carried into the alimentary
canal by the saliva, by food-stuffs, etc., it is rendered
innocuous in more ways than one ; but perhaps the most
effectual way is by its being taken into the substance of
lymphocytes, which make their way out and in from the
lymphoid patches, and which have the power of taking
into their substance the tubercle bacilli. These lym-
phocytes return with their evil burden to the lymph-
glands, and the glands assist in the complete destruction
of the bacilli. This is the performance that is continu-
ally going on, and as the result infection, local and sys-
temic, is prevented. If, however, the lymphoid patches
be devoid of epithelium, or if the tissues be so weakened
that their power of resistance can be readily overcome by
comparatively few micro-organisms, then infection will
probably follow. Masses of adenoid tissue, whatever
their situation, if the cells are active, are means of pro-
tection, in so far as they consist of an enormous number
of active cells which are capable of taking up large num-
bers of micro-organisms.
Masses of adenoid tissue are found at the entrance of
the two great avenues through which the tubercle bacil-
lus most commonly seeks entrance to the system, viz.,
the alimentary and respiratory. In certain animals and
in man there is a ring of lymphoid tissue surrounding the
entrance to the larynx, and a similar ring surrounding
the.entrance to the oesophagus. In the pharyngeal ton-
sil we have simply an enormous local development at the
two poles of the latter ring. So long as these tonsils, with
their accessory lymphoid tissue forming the protective
ring for the pharynx, remain healthy, or so long as they
are not attacked by an extraordinary number of micro-
organisms, they are capable of resisting attack, and of
dealing with micro-organisms even of what would be
called a most virulent type.
When the lymphoid tissue is diseased, then it may serve
as the locus of infection. The lymphoid cell returning
with its burden of a tubercle bacillus, is taken into the
tonsil or the adenoid tissue in that vicinity, where, under
healthy conditions, it is destroyed or disintegrated. In
its depraved state it cannot destroy the bacillus, but, on
the contrary, the bacillus liquefies the lymphoid cell, the
protoplasm of which then serves as a nutrient medium
for the bacilli. This infection does not take place in the
tonsil so frequently as in the glands which lie beyond
the tonsil, and which the leucocytes include in their
itinerary when returning to the circulation.
Lucases where there is no distinct lesion in the tonsil
itself, it must be held that the leucocytes, although able
to take the bacilli into their substance, have not been
able to kill them, and then they carry the bacilli to the
gland in its immediate neighborhood, where they suc-
cumb, and infection takes place at this point. A multi-
plication and reinforcement of the bacilli by their
progeny at this point, will carry the infection farther,
with the result that a chain of lymphatics and lymph-
glands has ultimately become affected.
In many of these cases the process can be traced from
the glands in the tonsil down into the neck, and so on
to the thorax, by the mediastinal and post-sternal glands
and by the intercostal lymphatics and glands.
What has been stated concerning the lymphoid tissue
of the tonsils and surrounding cervical glands, might be
repeated almost verbatim for the lymphoid patches of
the intestine and mesenteric glands.
The very cells, then, which in health have to do with
the destruction of bacilli, and with protecting the organ-
ism against their invasion, are those which appear to be
immediately responsible for the conveyance of tubercle
bacilli from the outer surface to the tissues beneath.
The rdle played by the tonsil and the surrounding
lymphoid tissue is, therefore, seen to be a very important
one in preventing or facilitating infection in tuberculosis.
An important lesson to be learned from this is, that ton-
sil has an important function to perform in the economy,
that endeavors directed toward keeping it in a physio-
logical condition, militate against the dangers of tuber-
culous and other infection, and that its removal other
than for disease which might predispose it to infection, is
hazardous.
Scarcity of Doctors in the Chinese Army and Havy.
— The horrors of war now going on between China and
Japan appear to be greatly accentuated by an almost
inhuman lack of medical men on the Chinese side.
From a letter of Captain M'Giffen, Commander of the
Chinese war-ship Chen Yuen, we learn that there are
only two Chinese doctors to twenty ships and an army
of over 300,000 men.
November 17, 1894]
MEDICAL RECORD.
625
SMALL-POX FROM CRADLE TO COUNTER.
The fourteen victims of small pox who sailed up the
East River on Monday morning last, en route for North
Brothers Island, furnish a most instructive object-lesson.
In the first place, the number was considered unusually
large for this city to furnish at one time, indicating that
the disease is becoming rare as compared with former
periods. Secondly, the subjects all came from a very
circumscribed quarter of the city's area; and thirdly, they
had all contracted the disease from the same source : a
sick baby in the rear of a grocery shop, the mother going
from cradle to counter, waiting upon the customer and
then upon the child again, until she had sent out the
germs to the whole neighborhood along with their pur-
chases of tea and sugar.
A NEW DEPARTURE IN MEDICAL JURISPRU-
DENCE.
The American Journal of Insanity for October publishes
three articles by eminent alienists all bearing on the
topic which heads this editorial. The departure referred
to was connected with the trial of a man named Schnei-
der, a resident of Washington, D. C, who murdered his
wife and brother-in-law in January, 1892. He was tried
in March of the same year, and condemned to death, no
plea of insanity having been put in at the time. The
decision was confirmed by a Court of Appeal. In the
following fall, a stay of proceedings was granted on the
ground of alleged insanity. In January, 1893, the Su-
preme Court of the District of Columbia, consisting of
Chief Justice Bingham and Justices Hagner and Cox, or-
dered that a commission of experts, consisting of Dr.
Allan McLane Hamilton, Dr. John B. Chapin, and Dr.
Charles L. Dana, be constituted, with power to examine
the prisoner and also employees and officials of the jail
in which he was confined. Counsel for the prisoner was
also permitted to secure the services of three experts with
authority to make special examinations. After the in-
vestigation by the experts had been finished the case was
tried before the full bench, but without a jury. The
prisoner's counsel brought forward his witnesses, includ-
ing his medical experts. The examination of these lat-
ter gentlemen was made for the most part by the experts
appointed by the court. The prosecuting attorney then
presented his evidence in favor of the prisoner's sanity.
The whole proceedings lasted over a week. At the end
the Commission appointed by the court made a report in
which they unanimously reached the conclusion that the
prisoner was not insane. The judges, basing their opin-
ion upon the evidence given at the trial and upon the
report made by the Commission, found the prisoner sane
and he was executed.
The comments upon this new mode of judicial proced-
ure are made by Dr. John B. Chapin, Superintendent of
the Pennsylvania Hospital for the Insane, who was one
of the Commission, and by Drs. W. W. Godding and E.
N. Brush, who were both experts for the defence. These
gentlemen all speak, on the whole, favorably of the
method. It is suggested that there was no need in such
a procedure for the appointment of experts for the de-
fence, and also that there should be opportunity for the
prisoner to appeal from the decision of the Commission
if it was unfavorable to him.
Dr. Brush says : " I think I voice the sentiments of all
my associates called as experts by the counsel, by the
prisoner, that never has it been our experience to have a
more fair, considerate, and, touching the case at hand,
more intelligent examination than in this case. . . .
The examination was undertaken in a dignified manner,
and attracted the closest attention of the court. It was
undertaken, not with the intention of producing contra-
dictions, or of surprising the witnesses into making
faulty or questionable admissions, but to get at the facts
of the case and the processes by which the witnesses
reached their conclusions. In these respects the inquiry
was satisfactory and admirable."
The new departure in medical jurisprudence is one
which reflects credit upon the Supreme Court of Wash-
ington. While it may need some modifications it is one
which deserves the attention of those who desire to see
justice secured in difficult medico-legal cases.
READING NOTICES IN MEDICAL JOURNALS.
In these times of intense commercial activity it is not
strange that, even the most reputable and high- toned
chemists and manufacturers of pharmaceutical prepara-
tions should seek every legitimate means of commending
their products to the medical profession, who are their
chief customers. The time has been, and past, when the
leading dailies and monthlies of this country did not hesi-
tate to insert in their papers editorial commendations of
articles advertised in their columns. It may probably be
said with absolute correctness, that none of these at the
present time insert anything of this sort without having
appended to it in italics the abbreviation "Adv." It
seems to us that it is particularly incumbent upon the
editor of a medical journal, that he should keep his pages
so clear from any suspicion even of anything which would
appear to be in the interest of those who advertise in it,
that his subscribers may feel the most implicit confidence
in his desire to supply them only with that which is dis-
tinctly in their interest. It is no doubt a fact that often-
times preparations advertised by first-class houses are
worthy of high commendation, but if once it is found that
an advertisement is the means of obtaining directly, or
indirectly, editorial notice in any medical journal, the
confidence of the patrons of such a journal in its disin-
terested presentation of scientific facts must surely be more
or less weakened. No editor is in a position to speak
well of one, and not of another. The only safe course,
the only possible course, is to adhere to an inflexible rule,
to admit no article and to print no editorial which either
favors or condemns the wares of any advertiser. With
all the care which is exercised to prevent the insertion of
articles which even accidentally commend or condemn,
sometimes by inference only, goods advertised in the
pages of this journal, articles sometimes creep in which
violate this rule, and give not only a great amount of
trouble, but have again and again caused the loss of thou-
sands of dollars by the withdrawal of advertisements which
were being paid to us by first-class advertisers, responsible
houses, worthy the trust and confidence of the profession.
Holding these views as to the proper conduct of a medi-
cal journal, we notice with regret that one of our es-
teemed contemporaries has recently published, not only
an article highly commending the product of a house ad-
626
MEDICAL RECORD.
[November 17, 1894
vertising in their pages — with which house or product we
have no controversy whatever — but it has also, most
strangely, commented favorably in an editorial upon the
same article. We have no doubt that this is eminently
satisfactory to the advertisers, but cannot believe that it
will increase the respect to which the usual conduct of
this journal entitles it.
The true value of any journal to an advertiser is not
only the extent of its circulation and the character and
standing of its subscribers, but equally, if not more so, the
estimation in which a journal is held for absolute im-
partiality and fairness toward all, and its single eye to the
interests of its subscribers.
THE DANGERS OF BUTTER AND BREAD.
A short time ago we called attention to the investiga-
tions of certain Swiss and Italian bacteriologists, who
showed that the butter of the markets was not sterile, and
might contain pathogenic organisms. Now it appears
that bread is not sterilized by baking, and takes its place
with butter as a possible germ-carrying food. It would be
sad indeed to find that the staff of life was really a staff
of death, and that the very fundamentals of plain and
happy living, bread and butter and kisses, were really
things of evil, except under conditions of perfect asepsis.
Drs. F. J. Waldo and David Walsh {The Lancet) have
made cultivations from sixty-two loaves of bread taken
from various bake-houses in London. Someone of thir-
teen kinds of bacteria were found alive in all these
loaves. Here is the appalling list :
Bacteria (or their Spores) found in a Living Condi-
tion in Freshly Baked Loaves of Bread: Bacillus sub-
tilis, Variety 1 (hay bacillus) ; bacillus subtilis, Variety
2 (hay bacillus) ; bacillus subtilis, Variety 3 (hay bacil-
lus) ; sarcina (a), large ; sarcina (£), smaller than (a) ;
bacillus A (large, thick, rounded ends) ; bacillus B (large,
thick, smaller than A) ; bacillus C (small, copious spore
formation) ; bacillus D (smaller still, some spore forma-
tion) ; bacillus E (bacillus figurans) ; micrococcus A
(small white colonies) ; .micrococcus B (rosaceus (?), ac-
cidental) ; staphylococcus (very regular, larger than
staphylococcus aureus).
From a number of experiments made on loaves baked
in a small laboratory oven, it was found that : 1. The
average maximum temperature in the middle of an ordi-
nary quartern loaf during baking, varies from 163.40
to 186.8 F., and in small- loaves from 186.80 to 2030 F.
2. There is a steady increase of temperature in the cen-
tre of any loaf during baking ; thus, in a quartern loaf
during one hour it rises from 25 ° to 75° C, and in a half-
quartern loaf from 250 to 88° C. during the same time.
For the first forty minutes the maximum temperature is
probably not more than 480 or 50° C. The practical
inference is that any organisms that might be present in
the centre of a loaf would be exposed for a short time
only during baking to a maximum temperature of 730
to 86° C. (163.40 to 186.80 F.) in a quartern, and of
86° to 95° C. (186.80 to 2030 F.) in a half-quartern
loaf.
It is known that most bacteria are not destroyed by
an exposure to the temperatures above mentioned as the
average for the centre of a loaf during baking. The
death-point of bacteria has been generally expressed by
Koch and Wolfhugel in the following passage: 1.
Sporeless bacteria are destroyed in one and a half hour
by hot air at a temperature slightly exceeding ioo° C
(2120 F.). 2. Spores of fungi require one and a half
hour at uo° to 1150 C. (2300 to 2390 F.). Spores of
bacilli require three hours at 1400 C. (25 20 F.). It
should be noted that these statements apply to dry heat
only. In the middle of the loaf there is presumably
moist heat, which is, of course, more destructive to or-
ganisms, and on that account we must make a consider-
able reduction in the figures of Koch when we apply them
to fungi and their spores inside a loa£
The authors draw this significant conclusion :
We see no particular reason why the origin of many
mysterious septic invasions of the human body may not
eventually be traced to the agency of bread. A genera-
tion ago milk was not suspected of being the means of
spreading disease, and a similar observation applies to
water. At any rate, the subject dealt with in this paper
seems to us to be well worthy the attention of all who
are interested in the scientific developments of prevent-
ive medicine, no less than in the protection of the
public that consumes the bread.
No specific remedy is suggested by the writers, except
that bake-houses and bakers should be kept clean, and
that the whole process of bread-making be placed under
sanitary control.
BERI-BERI IN NEW JERSEY.
It is not often we are called upon to announce the pres-
ence of beri-beri in or about New York. On several oc-
casions, however, during the past few years, one or more
cases have been discovered among the crews of incoming
vessels. It is on this account, and especially because of
the very fatal nature of the disease, that interest is awak-
ened just now in the ill- favored human cargo of a vessel
from Navassa, which has entered port at Perth Amboy.
Four had died during the trip, several have since suc-
cumbed, and ten or more are ill. There seems to be no
doubt that faulty hygiene and lack of suitable food were
the factors determining the outbreak. Beans furnished
the principal food, it appears, during the two weeks1
voyage, and, strange as it may seem, this is just the
article of diet which Dr. Simmons recommended in a
monograph on the subject in 1880.
One of the chief symptoms is a condition of pro-
nounced feebleness, and it is this which gives the name,
made emphatic by repetition. Other symptoms, accord-
ing to Aitken, are: "Anaemia, culminating in acute
oedema, and marked by stiffness of the limbs, numbness,
and sometimes paralysis of the lower extremities; op-
pressed breathing ; a swollen and bloated countenance."
The urine is secreted in diminished quantities, the oedema
is general, and effusion of serum into the serous cavities
often occurs. Muscular spasms accompany the acute
dropsy. Some of the older authors have supposed the
epidemic affection to be confined to Japan, while others
have looked upon it as a disease peculiar to Malabar and
Ceylon.
Such instances as the present would tend to show that
misery and privation go far to determine an outbreak in
any quarter, though the chief endemic centres are in
China, Japan, and India. In 1886 a vessel arrived in
November 17, 1894]
MEDICAL RECORD.
627
New York from Hong Kong, with twelve out of the
crew of eighteen affected with what was supposed at the
time to be beriberi. Several died, including the cap-
tain. The food and water were in this instance found
to have been far from wholesome.
Recent studies would indicate that the nature of the
disease is a multiple neuritis, and not being contagious,
there seems no fear that it will spread beyond the unfort-
unates who, in returning home from a life of hardship,
were subjected to most unfavorable conditions.
THE " INEXCUSABLE ATROCITIES " OF SPORT.
The President of the Society for the Prevention of
Cruelty to Animals says :
" It is an inexcusable atrocity to subject any animal
to pain which can be prevented by a conscientious use of
anaesthetics."
It might be supposed that the gentleman was attack*
ing hunters and sportsmen generally, who are commit-
ting these inexcusable atrocities every day. As a matter
of fact the writer, while swallowing the camel of sport is
straining at the gnat of vivisection. There are said to
be over one hundred thousand men and boys in this
country who go out with guns. They mutilate and half-
kill birds, they maim the rabbits, deer, and other ani-
mals, subjecting them to exquisite pains before they die ;
they chase deer into the water and murder them in their
helplessness, they ride after frightened foxes and drive
them to a death of agonizing exhaustion ; they hook up
fish by the sensitive mucous membrane of the mouth and
tear them from their wounds, all for sport
There are, perhaps, half a dozen places in this country
where vivisection is done on anaesthetized guinea-pigs,
rabbits, and occasionally dogs.
Why doesn't the sensitive anti-vivisectionist attack the
sportsman ? Is it because he is afraid, or because he is
a sportsman himself?
fjje«rs 0f Itue Wte&k.
Motormen and Conductors. — In St. Louis men seek-
ing employment on the rapid-transit street-cars are
obliged to submit to an examination of their eyes by a
competent ophthalmologist. This is done by the street
railway companies for their own protection, and is a
plan that should be pursued by every street railway com*
pany.
A Medical College Burned. — On November 3d the
Indiana Medical College at Indianapolis was burned to
the ground.
The Horace Wells Anniversary Celebration. — The
following circular has been issued : Members are doubt-
less aware of the action of the American Dental Associa-
tion at its recent meeting, held at Old Point Comfort,
Va., with reference to holding a national celebration of
the fiftieth anniversary of the discovery of the anaesthetic
properties of nitrous oxide by Dr. Horace Wells. The
Committee, by vote of the American Dental Association,
was instructed to secure two papers to be read at the
celebration. One upon the " History of Anaesthesia/'
by Professor Thomas Fillebrown, of Boston ; and one
on the " Benefits of Anaesthesia to Mankind," by Pro-
fessor James E. Garretson, of Philadelphia. The Com-
mittee was further instructed to arrange for a banquet to
follow the meeting, at which distinguished speakers shall
make appropriate addresses; to prepare a full report of
the celebration, including the papers and addresses, to be
printed and issued as a permanent souvenir of the occa-
sion. Arrangements have been completed to the extent
of securing favorable responses from the essayists named,
whose papers are now in course of preparation. The
banquet arrangements are also largely completed. To
cover the expenses attending the celebration, the fee for
admission to the banquet has been placed at $6. It is
necessary that the Committee shall have ample notice of
the number who will be in attendance, in order that
places may be provided for all who may desire to attend.
Subscriptions will be invited later for the souvenir vol-
ume, at a price sufficient to cover the cost of publication.
The celebration will be held in Philadelphia, in Associa-
tion Hall, Fifteenth and Chestnut Streets, on Tuesday,
December n, 1894, at 2 p.m., and the banquet at the
Union League, at 6.30, same evening. You are cordially
invited to participate in this event, which should enlist
the enthusiastic support of every member of our profes-
sion. To that end you are requested to send your check
and notify the Chairman of the Anaesthesia Committee,
at the earliest date possible, in order that an official in-
vitation may be sent to you. It will be proposed at the
meeting that subscriptions be invited for a permanent
memorial, to take such shape as the meeting shall decide.
— J. D. Thomas, Chairman, 912 Walnut Street, Phila-
delphia.
Medical Congress of Mexico. — The second biennial
Medical Congress of Mexico was held November 5 th
to 8th, at San Luis Potosi. Dr. Eduardo Liceaga was
President ; and Dr. Luis Ruiz, Secretary, both of the
city of Mexico ; Dr. Jesus E. Monjaras was Chairman of
the Local Committee of Arrangements, San Luis Potosi,
Mexico.
Medical Society of the State of Hew York.— The fol-
lowing Business Committee has been appointed by the
President of the Medical Society of the State of New
York: Dr. W. C. Phillips, of New York City; Dr. H.
I* Eisner, of Syracuse; Dr. H. DeV. Pratt, of Elmira.
Medical Announcements in the Press. — A New Or-
leans physician sends the following inquiries to the
Journal of the American Medical Association; "Please
inform me if there is anything in the Code of Ethics to
prevent a practitioner : 1, From announcing in the daily
newspapers that his practice is limited to the diseases of
special organs ; 2, ditto in the medical papers ; 3, from
announcing, in sealed circular letters to the medical pro-
fession at large, that his practice, etc.; 4, ditto to laymen
at large, etc."
To which the editor replies : " Article I., Section 4 v
Duties of physicians to each other and to the profession
at large : It is derogatory to the dignity of the profes-
sion to resort to public advertisements, etc. 2. While
in some parts of the country physicians do publish cards
in medical papers, it is not regarded as wanting in the
true dignity of a physician, but as a question of taste.
3. Certainly, there can be no objection to a sealed cir-
cular to the profession, announcing that practice is lim-
ited, etc. But we find that when a physician is limiting
628
MEDICAL RECORD.
[November 17, 1894
work to a specialty, it soon becomes known to the pro-
fession of his town, and by his papers on that subject in
the medical journals he soon attracts a clientele. 4. A
circular to laymen cannot fail to produce in the minds
of those who receive it, a doubt as to the ability of the
one sending it.
" A large acquaintance with the profession in all parts
of the country causes us to believe that the dignified
earnest practitioner can acquire a practice without re-
sorting to any of these plans."
And we would add that no physician should do any of
these things, except that in smaller towns it seems to be
a harmless practice to place a simple card announcement
in the local paper.
Alma Mater, A Sonnet by Oliver Wendell Holmes.
— The following sonnet, hitherto unpublished, was sent
to the Boston Medical and Surgical Journal by Dr. H.
P. Bowditch, with the statement that the poem was writ-
ten at the request of Dr. Bowditch, and read by him be-
fore the Harvard Club of New York :
" Yes, home is sweet I and yet we needs must sigh,
Restless until our longing souls have found
Some realm beyond the fireside's narrow bound
Where slippered ease and sleepy comfort lie, —
Some fair ideal form that cannot die,
By age dismantled and by change uncrowned,
Else life creeps circling in the self-same round,
And the low ceiling hides the lofty sky.
Ah, then to thee our truant hearts return,
Dear Mother, Alma, Casta, — spotless, kind !
Thy sacred walls a larger home we find,
And still for thee thy wandering children yearn,
While with undying fires thine altars burn
Where all our holiest memories rest enshrined."
Our Medical Students.— England has but 552 medi-
cal students ; there are 8,006 in the Germany universi-
ties, but the United States has 13,000. We could loan
England a few thousand and have plenty to spare.
Care of Epileptics and Insane in Minnesota. — The
board of physicians appointed by the Governor of Min-
nesota to investigate the insane hospitals and report on
the needs of the insane, have suggested in their report
the establishment of an institution for the care of epilep-
tics, and another State insane hospital, the latter to be
in the vicinity of St. Paul and Minneapolis.
Association of Southern Hospitals for the Insane. —
An association has been formed with the above name,
and will hold its first meeting at Birmingham, Ala., on
November 20, 1894.
The Temperance Reform League of Massachusetts
and the Keeley Cure.— Dr. B. D. Evans, the Medical
Director of the New Jersey State Hospital for the In-
sane, has been admitted to membership in the Temper-
ance Reform League of Massachusetts. This ends a bat-
tle between Dr. Evans and the Keeley cure, as far as
Massachusetts can decide it, with victory in favor of the
former. Dr. Evans, it will be remembered, gathered
statistics from insane asylums over the United States and
among the one thousand insane patients in the hospital
of which he has charge, compiling valuable and detailed
" tables of cases of relapse, suicide, mania, and demen-
tia subsequent to the graduation at the Keeley Institute. M
His article, which was published in the Medical News,
of May 6, 1893, was reprinted in Boston papers, and his
report was laid before the Temperance Reform League.
It was bitterly denounced by the " Keeley Cure," which
applied to the Temperance Reform League for an exam-
ination, for this organization by its charter from the
State is a quasi court, whose functions are those of a
judge who examines conflicting medical evidence in a
suit for malpractice and announces the result. The end
of the trial has been reached, and Dr. Evans is honor-
ably welcomed into the society, and thanked for his ser-
vices in exposing pseudo-reform, while the Keeley offices
in Boston have been abandoned.
Randall's Island Hospital, Hew York.— Dr. Samuel
E. Milliken has been appointed surgeon to Randall's
Island Hospitals.
Ho Doctors' Quarrel Over the Czar.— The daily
papers have tried very hard to make out a quarrel be-
tween the attending physicians of the Czar. As a matter
of fact there has been no real evidence that any special
differences of opinion existed, and the following cable-
gram to The Sun confirms this view. The correspondent
says: " Professor Leyden, since returning to Berlin, has
spoken frankly about the case of the dead Emperor.
He said that the statements circulating at St. Petersburg
about serious differences between himself and Dr. Zak-
harin were not quite correct. There had been, now
and then, diverging opinions, but in consultation the
doctors always arrived at an amicable compromise. The
statement that a quarrel had taken place about Dr. Zak-
harin's frankness with the late Czar was a misunderstood
report. It was the Czarina, not the Czar, from whom
the German professor wished to conceal the truth as
long as possible, out of regard for her delicate health
and because he believed the full knowledge of the situa-
tion could be of no use to her. Professor Zakharin was
of a different opinion. It, however, is not probable
that a quarrel between the doctors will ensue, as in 1888,
after Emperor Frederick's death."
A Co-operative Medical Warehouse. — A considerable
number of medical men in Berlin have started a " War-
enhaus," or warehouse, for the supply of many other
things besides medical stores. It is proper and right for
medical men to unite and club together for their own
benefit, and indeed it is proper and right for any indi-
viduals of any class to act in a similar manner.
Errata.— Dr. H. J. Garrigues writes:— "Will you
kindly correct the following misprints in the Medical
Record of November 10th: Page 578, second column,
29th line from bottom, for 'separated' read ' sup-
purated.' Page 579, first column, 8th line from top,
for € introduction,' read ' induction.' "
Attempts to Revive the Electrically Executed.— The
idea has violently seized some gentlemen that people
executed by electricity are not killed by the shock ; and
the Governor of New York has been petitioned to allow
experiments to decide whether those who have been
" electrocuted M can be revived.
The Treatment of Diphtheria by Antitoxin. — The
first report on the therapeutic value of Behring's an-
titoxin in the treatment of diphtheria has been com-
municated to the Budapest Society of Physicians by
Professor Johan Bokai, the well-known pediatric phy-
sician. He used the serum at the Budapest Stephanie
November 17, 1894]
MEDICAL RECORD.
629
Hospital for Children from September 21st till October
2 2d, when the treatment had to be stopped on account
of the lack of the serum, which had not been obtainable
since then from the German clinical establishment at
Hoechst, near Frankfort. During the time stated above
35 cases of diphtheria were treated with the serum.
There were 9 cases of pharyngeal diphtheria! 7 cases of
pharyngeal diphtheria combined with nasal diphtheria,
4 cases of pharyngeal diphtheria combined with slight
laryngeal diphtheria, and 15 severe cases of laryngeal
diphtheria. There were, therefore, thirty-seven per cent.
of mild and sixty-three per cent, of severe cases. The
oldest patient was twelve years of age, and the majority
of the cases (20) were below four years of age. Five of
the 35 cases died, giving a mortality of 14I per cent.
This result seems very satisfactory if compared with the
statistics of the previous epidemics. The following table
shows the number of children treated from October,
1891, to 1894:
October.
1891,
1892.
1893.
1894.
Admitted.
Died.
Recovery.
74
72
32
56
24
32
60
37
*3
35
5
30
Percentage of
Recoveries.
43-2
sZb1
§5.6
Regarding the immunizing power of the serum, the re-
sults were less favorable, and there were cases which un-
derwent relapse, though injections of the serum had been
made. It seems that the serum is excreted within from
eight to seventeen days after the injection, and that the
organism loses its immunity in the course of this short
time. — Z7ie Lancet.
A Quarrel Over the Diphtheritic Antitoxin.— There is
an unpleasantness in Berlin over the diphtheria antitoxin.
Professor Behring, who has been made Professor of Hy-
giene at Halle, recently published an article in a lay
journal in which he claimed priority in the matter of the
discovery and use of the serum, and accused Professor
Virchow of not giving him credit and of recommending
the use of Aronsohn's serum. It seems that Aronsohn,
as soon as Behring's discovery was made, at once went
to work and manufactured a serum by the same methods,
but made one that was stronger, and put it promptly on
the market Professor Virchow publicly disclaims any
claim for himself or others, however. Evidently there
has a good deal of the commercial spirit crept into the
manufacture of the antitoxines.
Diphtheria Antitoxin in France.— C. W. Chancellor,
United States Consul at Havre, has just made a report to
the Secretary of State recommending that the antitoxin
should be supplied by every State and Municipal Gov-
ernment in the United States. The difficulties in the
way are foreshadowed somewhat by recent experiences in
Paris. He says :
So far, Dr. Roux has been unable to meet the demand
for the serum, and he has had to confine himself to send-
ing to the provinces only a sufficient quantity for urgent
cases ; and it is to be feared that this state of things
must continue for some time. To provide for the needs
of the entire country, the Pasteur Institute would have to
possess a permanent establishment of over a hundred and
fifty immuned horses/and, in addition to the heavy expense
thereby entailed, the present accommodations are insuffi-
cient. Already, it has been suggested that auxiliary in-
stitutes be established in all the principal towns of
France, the expenses to be sustained by the various
municipalities. The city of Marseilles has decided to
establish an institution, and the municipality of Hon-
fleur, in this consular district, has contributed a liberal
sum of money to be applied to the production and dis-
tribution of the serum for that particular community.
A plan has also taken practical shape at Rouen and
Havre to aid in this great humanitarian work. Indi-
vidual subscriptions have been made to the extent of 40,-
000 to 50,000 francs (£7,720 to $9,650) in the two cities
to supply the necessary means of accomplishing the de-
sired end. At Havre, a healthy young Normandy horse
of four years of age, that has never been put to work,
has been purchased and is now under observation in the
stables of the veterinary department of the Government
at this place. In order to take every precaution, and to-
insure the success of the experiment, this horse has al-
ready been inoculated with tnafcine, an agent which,.
when inoculated on a perfectly healthy animal, produces
negative or harmless results. After this, the horse, if
perfectly healthy, will be successively and slowly ren-
dered immune by injecting beneath the skin of the neck
or shoulder gradually increased doses of the toxine made
by cultivating virulent diphtheritic bacilli exposed to
the air. Immunity being thus established in the horse,
which requires from six to eight weeks, the serum of the
blood of the animal when drawn and injected subcuta-
neously into the human subject will produce the desired1
preventive and curative action.
Post-Graduate Hedioal School.— Dr. George T. Elliot
has resigned the Professorship of Dermatology at the-
Poet-Graduate Medical School.
Library of the Academy of Medicine. — To meet an
apparent demand, it is announced that the library of the
New York Academy of Medicine will be open until
10.30 instead of 10 p.m. The new regulation will be
made permanent only in the event that the use of the
library between the hours named shall be sufficient to
justify the increased expense.
Ether as an Intoxicant.— The Lyon Medical states
that the habit of getting drunk on ether, which origi-
nally came from England, has existed in France for the
last five or six years. The number of persons addicted
to this form of debauchery seems to be growing greater^
and cases are not uncommon in which persons drunk
with ether are arrested in the streets.
A Biological Laboratory for the Philadelphia Board:
of Health. — At a recent meeting of the Philadelphia
Board of Health the Sanitary Committee presented a re-
port recommending the establishment of a Biological
Laboratory and the engagement of a competent bacteriol-
ogist and such assistants as may be required for the pur-
pose of conducting investigations of contagious diseases,,
and facilitating diagnosis, of investigating water supplies
and food supplies, and of indicating and, as far as possi-
ble, providing the appropriate remedial measures.
The " Laziest " Man has at last met with his just re-
ward. Dr. George Ross reports the death of a man from
peritonitis due to rupture of the bowel brought about by
630
MEDICAL RECORD.
[November 17, 1894
a novel and labor-saving method of taking an injection.
This ingenious man simply fastened the rubber hose to
the bath-room faucet and turned on the spigot. The last
time he gave it one turn too much and hence the result.
— Times and Register.
Belative Standing of the Graduates of the Various
Medical Colleges examined by the State Board of Medi-
cal Examiners, representing the Medical Society of the
State of Pennsylvania, June 11 -14, 1894.
Medical College from which applicants
graduated.
No.
exam-
ined.
No.
failed.
I
2
5
3
3
1
5
. 9
Perct
of
fail ores.
Aver,
grade*
University of Pennsylvania
Woman's Medical College
76
18
67
26
44
1
26
I-3«
II. II
7.46
6.82
33-33
62.50
34.6l
IO.82
87.76
8344
82.48
81.13
80.68
75.81
7477
Jefferson Medical College
Medico-Chirurgical College
Western Pennsylvania College
College of Phys. and Surgs. (Bait.) .
Baltimore Medical College
Miscellaneous Colleges
Total
268
29
82 18
— Medical News.
The Craig Colony for Epileptics.— The managers of
the Craig Colony for Epileptics met in Albany, N. Y.,
November 14th, and consisted of Dr. Frederick Peterson,
of New York ; Mrs. J. B. Wadsworth, of Geneseo ; George
M. Shull, of Mount Morris; Mr. Cudderback, of Buffalo ;
and Dr. C. £. Jones, of Albany. A report was adopted
which will be presented to the Legislature recommending
an appropriation of 300,000 dollars for the permanent
establishment of the colony and the construction of the
necessary buildings. The colony, which is situated in
Livingston County, a few miles from Mount Morris, where
r,8oo acres have been purchased by the State, is to be
modelled after the German Epileptic Colony on the
cottage plan. The managers are of the opinion that the
colony can be made self-supporting with the introduction
of appropriate industries for the patients. There are
12,000 epileptics in the State, 1,200 of whom are now
cared for in the State hospitals.
Dr. William P. Spratling, of New York City, was elected
Superintendent of the colony.
Twelve Hundred Physicians have already registered
as medical practitioners in Massachusetts.
Tulane University.— Dr. Tiffany, of Baltimore, suc-
ceeds Dr. tyiles in the chair of surgery.
Typhoid Fever at Wealeyan University.— An epi-
demic of typhoid fever has broken out among the stu-
dents of Wesleyan University, and ten cases were re-
ported on November 3d and 4th. One death has already
occurred (a Freshman), and one of the faculty is danger-
ously ill. The origin is thought to be the water from an
old well which has been found to be contaminated.
For the Religions Care of Medical Students. — A re-
ligious guild, called the Guild of St. Barnabas, has been
started in London for the benefit of medical students.
In making the announcement The Guardian remarks
that probably the class most overlooked by the Church,
amid all her various forms of work, is the class of edu-
cated young men generally. The urgency of the case,
so the writer thinks, becomes even more obvious when
the intellectual temptations of the necessary studies of
medical men are considered.
Johns Hopkins Medical School. — The second year of
the Undergraduate Department in medicine opened on
October 1st. There were 31 entries, making in the two
years 50 students in all. Of these, 13 are graduates of
Johns Hopkins University, 8 of Yale, 5 of Harvard, and
the others of the smaller colleges.
AMANDA SANFORD HICKEY, M.D.,
AUBVUf, N. Y.
Amanda Sanford was born in Rhode Island in 1838.
When seven years of age she came with her widowed
mother to Scipioville, in Cayuga County, N. Y. In later
years, when speaking of this time, she said : "I am
glad I was poor." Her education was obtained at the
Friends' Academy in Union Springs. After graduation,
in order to recover her health, which had suffered from
school work, and to earn money for the furtherance of
her plan to study medicine, she started a vegetable gar-
den, the while applying herself to Greek as a diversion.
At the end of a year, one hundred dollars in pocket and
restored in strength, she began teaching at the Hawland
School, in Union Springs, and reading medicine by her-
self. In two or three years she was able to enter the
Woman's Medical College in Philadelphia. After grad-
uating there, she spent eighteen months in the New
England Hospital in Boston, and in the autumn of 187 1
went to Ann Arbor, Mich., graduating there the follow-
ing spring with the first honors, the only woman in a
class of ninety. In 1872 she settled in Auburn, and was
rapidly successful in practice. The year 1879 was spent
in study in Paris and London. She was a member of
the original staff of the Auburn City Hospital, and con-
tinued an active member till her death. She married
Mr. Hickey, of Auburn, in 1884.
These are the outlines of a career, unusual in the im-
pression left upon the hearts and minds of associates and
friends. She was a woman of dignified and stately pres-
ence, which, united with natural reserve, would have
made her appear cold, had it not been for her finely
modulated, sympathetic voice, and the gracious serenity
of her smile. She possessed in a rare degree the gifts
of silence, deliberation, and perseverance. But though
self-reliant and self-contained, as all strong natures are,
she won the affection as well as the esteem of those with
whom she came in contact. The gratitude of patients,
poor as well as rich, and the warm attachment of persons
of varied temperaments, attest the charm and unselfish
devotion as well as the power of her personality ; while
the thorough-going confidence and respect of her col-
leagues rewarded the honor and magnanimity of her pro-
fessional relations. In her calling die possessed courage
and skill, operating with success in cases of varied intra-
abdominal disease. It was, however, as the trusted fam-
ily physician, friend, and counsellor, that her gifts and
character best expressed themselves. Many mourn for
her as for an ideal and an inspiration lost.
Dr. Hickey died October 17, 1894, of pneumonia,
contracted, it is supposed, by chill after assisting at a
tedious abdominal operation in an over-heated room.
Death did not take her unawares. Her intuition was,
even in her own case, not at fault, for she foresaw the
danger while yet distant, and with characteristic calm
made dispositions for the future. In accordance with
her wish, her body was committed back to earth in the
village cemetery at Scipioville, where her life of study
and labor and high usefulness in this vicinity had its be-
ginning.
November 17, 1894]
MEDICAL RECORD.
631
ShntetB Reports.
NEW YORK ACADEMY OF MEDICINE.
SECTION ON PEDIATRICS.
Stated Meeting, November 8, 1894.
Joseph E. Winters, M.D., Chairman.
Ductus Omphalo-entericus Persistent. — Dr. Sara Welt
presented for the second time the child which had had a
tumor first observed soon after birth at the site of the um-
bilicus, and which was proved by recent removal to be
formed on the ductus omphalo-entericus persistens. There
was but little hemorrhage, and it was checked by cautery.
Antitoxin Treatment of Diphtheria, Based upon a
Series of Oases Treated at Willard Parker Hospital.—
Dr. A. Campbell White read the paper. (See p. 609.)
Observations in Berlin. — Dr. Herman M. Biggs
opened the discussion, and spoke essentially as follows :
Perhaps it may be of more interest to you if I simply give
an account of my own observation of work done in the
antitoxin treatment of diphtheria in Berlin the past sum-
mer. The institute for infectious diseases in Berlin was
founded by the German Government under special act,
and is devoted solely to experimental, original investiga-
tion. It has a corps of men connected with it, the very
best men in German scientific medicine, such as Koch,
who is director, Ehrlich, Behring, etc. ; men who have
been known for a long period for their observations in
bacteriology. Attached to the institute is a hospital for
infections diseases. A large part of the work on the anti-
toxin treatment of diphtheria has been done in the insti-
tute, or in connection with it. We must remember, in
judging of its value, that it is not, as with most other dis-
coveries, or alleged discoveries, in bacterial therapy,
simply a discovery. It is an original development, the
result of a long series of scientific observations which have
been going on for years.
In going over the work in Berlin I was very much im-
pressed by the fact that, among these men who had been
working up the subject for two or three years, or longer,
and who had treated a large number of cases of diphtheria,
the first series of five hundred having just then been com-
pleted, there was not the faintest shadow of a doubt as to
the value of the antitoxin treatment. They seemed to
feel absolutely convinced that the experimental stage had
been passed, and that the value of antitoxin as a specific
in the treatment of diphtheria was a thoroughly established
met. That seemed to me a most surprising and a most
encouraging feature of the question at that time. And
when one turns to the other side and considers for him-
self the evidence to justify belief in the treatment, it seems
to me he has even a stronger basis for confidence than the
positive testimony of others.
Observations in bacteriology have shown conclusively
that, so far as infectious diseases are concerned, the con-
stitutional manifestations are not due immediately to the
micro-organisms, but rather to the products of their life-
processes, and that death, whenever it occurs, is almost
invariably the result of chemical poisoning, the absorp-
tion of these bacterial products. That these toxins, or
tox-albumins, or ptomaines, whatever they may be, de-
pend on the micro* organisms and are their main offensive
weapons, and that without them the micro-organisms be-
come almost harmless, and are unable to compete with
the tissue-cells in their struggle for life. We know fur-
ther that in all the infectious diseases, one attack gives
more or less complete and more or less permanent im-
munity against future attacks. It has been shown further,
experimentally, that this immunity can be induced arti-
ficially, not only by the inoculation of animals with the
micro-organisms themselves, but also by inoculation with
the chemical products obtained through cultures of such
micro-organisms. Further observations along this line
have shown that this immunity is due to the development
of something in the circulation. This something gives
immunity by neutralizing the products of the infectious
organisms.
Now, it has been possible to separate these chemical
substances in some of the infectious diseases ; they are the
most powerful and virulent poisons we know of. In
diphtheria it has not yet been possible to separate the
toxin, but we can measure its strength biologically by
its influence on susceptible animals, and a standard has
been fixed for determining the strength of the toxin.
A normal toxin solution is one of which one-tenth of
a cubic centimetre will destroy a guinea pig in a definite
time, about forty-eight hours. This forms the standard
by which the dosage is determined, as already stated ; we
do not know what the antitoxin is which is developed in
the circulation as the result of inoculation with the
chemical products of micro-organisms, but we suppose
that it is an albumin ; it is certainly allied to albumin.
But we do know that it has the power to neutralize the
poison of the micro- organisms which produce a specific
toxin. We know that the amount of antitoxin in an
animal can be enormously increased by repeated inocula-
tion with the toxin. At first small doses are employed
and gradually increased. Tolerance is thus rapidly in-
creased. This increased tolerance is due to increased
antitoxin in the circulation of the animal which is being
immunized, until finally the amount of the neutralizing
principle is relatively enormous.
The amount of antitoxin action can be measured by
the amount of the normal toxin solution that it will neu-
tralize. The blood-serum which has been taken from
the immunized animal is mixed outside the body with
the toxin solution, and by the amount of toxin solution
which it neutralizes is its strength and curative value de-
termined.
There is no reason why this antitoxin should not have
the same power inside the human body that it has out-
side. We know that the toxins cause the poisoning in
diphtheria, producing constitutional manifestations and
death. We know that the antitoxin serum derived from
animals which have been immunized, will destroy this
toxin outside the body, so that it becomes absolutely
harmless. We know further that the value of the anti-
toxin serum in the treatment depends upon its dosage
and its strength; that the dose must be graded not
only to the strength of the serum, but also to the age and
body- weight of the individual. This is further confirma-
tion that it does not act in a biological way, but chemi-
cally. It acts by neutralizing directly, and its action is
proportioned to its strength and its amount.
It seems to me that it is the history of the development
of the antitoxin treatment of diphtheria which gives it
peculiar significance, and gives the greatest encourage-
ment for belief in its efficacy. It is not a discovery, an
empirical observation, but it is a logical development
from a long series of careful and thoroughly confirmed
scientific observations.
Dr. W. H. Park said : I shall try, in discussing the
-antitoxin treatment, to avoid, as far as possible, repeat-
ing what has already been said, and will speak a little
more in detail of animal inoculations, as showing what
we may expect in the treatment of disease in man. All
know how difficult it is to tell in human beings just what
the therapeutic effects of drugs are, and perhaps in no
disease is this more true than in diphtheria. Some of
you may have read Professor Loeffler's recent article, in
which he described a new method of local treatment of
diphtheria, stating that in about seventy nine cases he
has not had a single death, and he apparently believes
that in this local treatment he has almost a sure cure for
diphtheria, leaving out, of course, laryngeal cases. Now
and then we read of some person having treated a num-
ber of cases with bichloride of mercury without the loss
of a patient. Yet we know that in neither bichloride
nor in a mixture of alcohol and other substances which
Professor Loeffier uses, can we hope to have a much
better percentage of recoveries in all cases of diphtheria
than we have had ordinarily, for it is in little children
632
MEDICAL RECORD.
[November 17, 1894
that the laryngeal and the fatal cases occur mostly, and
in them such local treatment cannot be carried out. So
I think it is well to look a little more at the experimen-
tal evidence regarding the antitoxin method, in order to
judge of its value in the treatment of diphtheria in hu-
man beings.
When bacteria are grown in broth or other culture
mediums, they at the same time develop the toxins
which produce lesions, and you have been told that
when these toxins of bacilli are injected in animals,
large or small, in less than fatal doses, the animals grad-
ually get tolerance ; so that in three or four months you
can give them what ordinarily would be fatal doses, and
produce no symptoms. Doses which would kill a thou-
sand guinea-pigs will cease to have any effect upon a
single guinea pig which has been thus immunized, so
that something marvellous has occurred and has pro-
duced antitoxin in the blood. As you have already
heard, we do not know what this antitoxin is chemically,
but we know it is there, since we can measure it by its
results. It neutralizes the toxins. But how ? Different
observers have different ideas on this question. It cer-
tainly does not destroy them. The antitoxins have been
injected into animals and into human beings, and the
toxins have thereupon ceased to produce their harmful
effects, yet they are still there — both antitoxins and tox-
ins. That is proven in a number of ways, and it is
only necessary to mention the fact here. In diphtheria
they are so much alike that you cannot separate the tox-
ins and the antitoxins when mixed. But it has been found
that if you put a certain amount of antitoxin in with a
certain amount of toxin, there will be no effect from the
injected fluid, while the toxin taken separately would
kill speedily. Now, it has been found that if you inoc-
ulate an animal with toxin and immediately afterward
inject antitoxin, a very small amount of the latter will
suffice to prevent the development of diphtheria. If
three or four hours elapse, it will take a larger dose of
the antitoxin; after twelve or twenty-four hours the
dose will have to be very greatly increased, and if the
animal is already dying, no amount of antitoxin will save
it. So in diphtheria treated by antitoxin in the hospi-
tals, it has been found that where the injections have
been begun on the first or second day, they have done
very well and have required only one or two doses ; while
in cases treated not before the third or fourth day, it has
required repeated large doses, and even then one may
not succeed in curing the patient.
Differs from Tuberculin. — Now, some of us may have
a misty idea that this antitoxin treatment is like that by
tuberculin, and is liable like it to inspire too great hope
to withstand the test of time. But the two are quite dif-
ferent processes. With tuberculin we inject a toxin to
develop antitoxin in the body, while in diphtheria we
first produce antitoxin in the bodies of animals, and only
inject the antitoxin, which is absolutely harmless, into the
patient afflicted with diphtheria.
You know that when serum from certain flwiir^lf is in-
jected into man it may create some disturbance, and this
will account for the rash which has been produced in
some instances of the antitoxin treatment of diphtheria.
It was not due to the antitoxin. The serum from the
horse scarcely ever produces any symptoms.
We have, then, in this treatment of diphtheria, a
method which need not interfere with any other being
carried out at the same time, and one which will do no
harm to the patient.
My own experience with the antitoxin treatment has
been chiefly in watching the cases, through the kindness
of Dr. White, at the Willard Parker Hospital. Outside
I have had only two cases, and these I believe would
have recovered any way, but they probably recovered
more quickly under the antitoxin treatment. The physi-
cians in attendance were struck by the almost immediate
improvement in the patients following the injections.
Effeot on the Membrane. — Now, it may strike some
that if the antitoxin has no effect upon the duration of
the membrane and on the duration of the bacilli, it
shows it has not much influence on the disease. It must
be remembered, however, that the antitoxin is not to any
marked extent a general antiseptic. It is not what we
may have been seeking, something to kill bacilli without
killing the patient. It is quite different It simply neu-
tralizes the poisons which the germs develop, but does
not directly influence the growth of the bacilli, nor di-
rectly affect the membrane, except in so far as it may
neutralize the effect of the poisons in producing mem-
brane upon the throat. In animals, however, in which
large doses have been employed the membrane has always
separated much more quickly than it usually does.
In looking over the cases treated by this method I
found about 1,180, the mortality of which, instead of
being forty-four per cent, as it ordinarily is under ex-
actly the same conditions, fell to twenty per cent. Al-
though we cannot judge in local epidemics by figures, I
think that in general hospitals, where all the other condi-
tions remain about the same, we may be pretty sure any
marked reduction in the mortality is due to the special
treatment employed. I certainly feel that we have in
this antitoxin treatment a great outlook, and I hope we
shall soon have the remedy accessible for use in every
case here as well as elsewhere.
Dr. George F. Shrady supposed that he had been
invited to make some remarks on the subject on account
of his connection with the Willard Parker Hospital, and
because of the opportunities which were thus afforded
him for verifying the reports and endorsing the state-
ments of Dr. White in his very interesting and instructive
"paper. He could therefore give his impressions of the
results of the antitoxin treatment only from a clinical
aspect, and as one who had survived very many epidemics
of specific remedies for diphtheria. So far as present
results showed in Berlin, Paris, and New York, antitoxin
appeared to give better statistics than any other form of
treatment. Then it was so simple in its administration
that anyone could use it. He was much struck with the
remarkable change for the better which occurred in some
of the cases related by Dr. White, seeming to prove that
some profound and radical curative processes had mani-
fested themselves in the general system. The remedy
appeared to reinforce the natural vital resistance to sys-
temic poisoning. The rationale of treatment was founded
on a sound bacteriological basis, and commended itself
accordingly to progressive clinicians. Indeed, the prin-
ciple of immunization would doubtless prove as impor-
tant to therapeutics as had been asepsis to operative
surgery. It seemed to him that we were, as far as the
fundamental principle was concerned, on the eve of
brilliant discoveries along that line.
The present difficulty in testing the remedy was its
great scarcity, and the difficulty of obtaining supplies in
the near future. A month ago he had cabled to Berlin
for antitoxin, and had received a limited supply, but not
enough for extended experimentation. Aside from the
opportunities of witnessing Dr. White's cases, Dr.
Shrady's personal experience had been limited to one
case, which was sent to him by Dr. Fischer from the Mes-
siah Home for Children. The antitoxin (Behring's) was
injected into the intra-scapular region, with the result of
relieving the grave systemic symptoms, and eventually
curing the child. Thus far he believed that the remedy
deserved a more extended trial, and he hoped that soon
the supply of the antitoxin would be equal to the demand.
Dr. W. P. Northrup thought the paper of Dr. White
hopeful. Like the opening chapter in a novel, it prom-
ised well, and one felt like turning over to the back
pages to see how it would come out. There were several
things which had to be proved at so hopeful a period of
any remedy. In the first place, the cases treated may
have occurred at a time when everybody suffering from
diphtheria got well. As far as he had been aide to
learn, the percentage of recoveries in institutions at tins
particular time was especially good. He wished to join
in the general hopefulness of Lthis occasion. But he
November 17, 1894]
MEDICAL RECORD.
633
would not forget that we had had in the past many dis-
appointments in remedies.
Dr. Northrup had observed, with others of his col-
leagues, that in some of the European hospitals they
claimed to get results by certain methods of treatment,
say by intubation, which were much more favorable than
had been obtained here. He mentioned the fact as one
to be borne in mind when judging of the value of any
method of treatment based on experience over there.
He had had some of the antitoxin sent him for use in
diphtheria, but had not been able to find a case in which
to employ it, at the Foundling Asylum or elsewhere.
This showed very well the sporadic nature of the disease
at this time. A special test of the new treatment would
be found in rather rare cases of rapid toxaemia from the
commencement, in which death sometimes took place
within twelve hours from the first symptoms of diph-
theria. In such cases nothing else than possibly the
antitoxin could have any effect. It seemed that the in-
fluence of the antitoxin on the pulse was the most hope-
ful indication.
Dr. Louis Fischer spoke of his observations in Berlin
of two methods of treatment, one by Aronson, the other
by Beginsky. The latter informed him that the mortal-
ity in diphtheria had fallen from thirty-seven per cent,
to thirteen per cent, under antitoxin treatment The
course pursued was to inject at once every case brought
to the hospital with a pseudo-membrane. Next day, the
bacteriological examination having been made, the cases
of pseudo diphtheria were separated from those of true
diphtheria, and in the latter the antitoxin treatment was
continued. Dr. Fischer had had some personal experi-
ence with the treatment very recently, in a hospital in
Philadelphia, and it would appear to have had more in-
fluence on the membrane in the throat than had been
described by others. Although he had been favorably
impressed by the antitoxin results, he did not think it
safe to become too enthusiastic.
Sceptical. — Dr. Henry Berg said the difficulty in
judging of the value of any method of treating diphtheria
related to prognosis, or our ability to judge of the sever-
ity of the cases. Frequently the very ones which we ex-
pected to terminate favorably died, while those which
we expected to die took on a marked change for the bet-
ter in a few hours, and went on to recovery. He had
seen nearly all the cases treated by antitoxin by Dr.
White at Willard Parker Hospital, and while he could
not say that all of them were not severe cases, yet he
could not say that they were. Some of them seemed to
him to be only ordinary cases of diphtheria, while some
seemed to be very severe ones, although he was not posi-
tive that he would have made a fatal prognosis. These
facts simply showed that if we were going to draw deduc-
tions with regard to the efficacy of any given treatment
in diphtheria from figures, the number must be very
large, and the only way to test the new method was to
place the antitoxin in the hands of all the physicians of
the city. Dr. Berg thought statistics here and those
abroad would point to the fact that our treatment of
diphtheria was either better, or that epidemics here were
less severe.
Hew Syringe for Cleansing the Nostrils.— Dr. Som-
merset presented a syringe for cleansing the nasal cavities
in diphtheria, and said that with it one could give more
force to the stream than with the Davidson syringe, which
was necessary in rare cases where the occluding mem-
brane held tenaciously and had to be removed to prevent
sepsis.
The chairman, Dr. Winters, testified to the value of
this syringe. Regarding statistics of mortality-rate as
basis for judging of the efficacy of the antitoxin treat-
ment, he thought they were apt to be misleading. Or-
dinarily the entire number of deaths was meant, but in
some of these special statistics certain cases of death had
been excluded, which, of course, would make a better
showing for the antitoxin. It seemed that abroad the
mortality rate without this treatment had been placed
enormously high. In this city the Board of Health
record gave a death-rate of only twenty- five to thirty-
three per cent. This must necessarily be too high, if
it was remembered that all fatal cases were reported, while
many non-fatal cases were not reported at all. He
thought it certainly did not exceed twenty- five per cent.
Again, he doubted whether there was any serious infec-
tious disease so badly treated as diphtheria. Faulty
methods being omitted under the antitoxin treatment,
would in itself cause a better mortality- rate. Further,
mortality statistics were usually made up from cases to
which a reputable physician was not called until the dis-
ease had well advanced, say after three or four days.
These facts had to be taken into consideration in judging
of the value of the new antitoxin treatment. It would
be necessary to wait until long use by many physicians
had tested the method.
Dr. Andrew H. Smith said a very good nasal syringe
could be made out of any ordinary one, by attaching to
it a rubber nipple the opening in which was smaller than
that in the end of the syringe, so that the nipple would
be made to dilate by the stream and fit closely to the
nostril Regarding antitoxin, he thought it would
prove of inestimable value if it had no other effect than
to stop the pernicious practice of applying frequently
local remedies against the struggles of the little patients.
Dr. White closed the discussion.
SECTION ON LARYNGOLOGY AND RHINOLOGY.
Stated Meeting, October 24, 1894.
Dr. D. Bryson Delavan, Chairman.
A Case of Sarcoma of the Palate Successfully Treated
by the Toxins of Erysipelas, was the title of a paper
read by Dr. W. B. Johnson, of Paterson, N. J. (See
page 616.)
Dr. W. B. Coley said : I saw this case before treat-
ment was begun. The case was grave, and I had no
hope of treatment doing more than giving temporary
relief. The result of my experience with toxins up to
last May I reported at Washington, before the Section on
Surgery, Congress of American Physicians and Surgeons.
The cases reported were 25 of sarcoma, 9 of carcinoma,
and 2 or 3 where examination was not made. Of these
cases, I reported in detail 5 which I hoped to cure. None
of them have shown any signs of recurrence of the
trouble. Since that time 3 cases have gone over a period
of three years ; 2 over two years, and others over one
year. Since the publication of the paper, I have treated
10 cases of sarcoma, 3 having been extraordinarily suc-
cessful. One was an enormous sarcoma of the ilium,
filling the right side of the abdomen. I began toxin
treatment, then the tumor began to break down and
slough out, and after five weeks of sloughing the injec-
tions were stopped. The result of treatment and conse-
quent breaking down of the tumor was depressing to the
patient, but by stimulation and careful nourishment he
began to recover, and I showed him a week ago without
any tumor left On August 1 5 th he weighed 115 pounds ;
now he weighs 140 pounds.
I have a case of a girl, aged sixteen, with a sar-
coma of four months in left scapular region, attend-
ing to the median line in back, and filling axilla to
median line in front, attached to chest -wall. In
three weeks she was able to raise her arm. Injections
were given in scapular region only. Improvement im-
mediately was marked, and she is now cured. I had and
have other cases, the results of which are similar. The
preparation which Dr. Johnson used was erysipelatous
and prodigiosus toxin, used in separate bottles, given
in small doses in combination. The two cultures are
now grown together and subjected to heat; 58° C. is suf-
ficient to kill the germs without destroying the chemical
toxin, and no loss occurs as in filtration ; after subject-
ing to heat add sufficient thymol to make a saturated so-
634
MEDICAL RECORD.
[November 17, 1894
lution. The value ot the toxin lies in the virulence of
the culture.
The Chairman, Dr. D. Bryson Delavan, said no efforts
that we can make will be too great to further the success
of these experiments, which have gone so far as to prove
that they amount to something more than mere experi-
ments. They have cured one case of malignant disease
of the palate, at least.
PRACTITIONERS' SOCIETY OF NEW YORK.
Stated Meeting, October 5, 1894.
Henry F. Walker, M.D., President, in the Chair.
Angioneurotic (Edema.— Dr. Charles L. Dana pre-
sented a man with this affection. He was twenty-seven
years of age, a bar-keeper, had used alcohol moderately
since early youth, and had used tobacco excessively since
the age of twelve, smoking, since his twentieth year, as
many as thirty to fifty cigars a day. He had never had
any venereal disease, malarial affection, rheumatism, or
digestive disorder. He had been rather nervous, but
that was all.
One morning last February, he awoke to find the
right foot swollen. The swelling went down, but
next day the leit toot was affected in the same way,
then the face; and since then all parts of the body
had been affected by such (Edematous swellings, mostly,
however, the face, hands, feet, and scrotum. The
swellings would increase until the skin became very
tense and hard, resisting pitting, and would disappear in
from two hours to twenty- four, none having lasted longer
than a day and night. Some would make their appear-
ance while others were fading away. They were whitish
m color, with a little rose tinge, but never resembling
wheals. Sometimes one side of the face would be swollen
to the point of closing the eye, and present a white ap-
pearance ; sometimes the hand would be of enormous
size. The patient stated that he could sometimes bring
the swellings out on the face by scratching, and quinine,
which some physicians had prescribed for him, had been
quickly foUowed by their appearance. There was no
organic trouble with the kidneys, lungs, or heart. The
pulse had been rather fest, about ninety, and of very low
tension, but not intermittent. He complained a good
deal of palpitation. There was no scotoma, no evidence
of alcoholic injury of the optic nerve.
Dr. Dana said that in his experience these cases were
rare, and their cause and progress was involved in consid-
erable obscurity. Some of the causes which had been
mentioned were malarial affections, fright, trauma, ex-
hausting influences of various kinds. This man's case
seemed directly due to tobacco, and that which seemed
to promptly relieve him was to stop the use of this arti-
cle. He had had scarcely any trouble since he had
given up smoking. In addition, Dr. Dana had prescribed
a tonic of mineral acid and strychnia.
The speaker had observed that the excessive use of to-
bacco, beginning early in life, sometimes produced curi-
ous vasomotor disturbances. The tobacco seemed to
have a special effect in some cases on the vasomotor
nervous system. Writers on angio neurotic oedema
classed it as having some relationship to urticaria, giant
wheal, and like conditions, but in this case there was no
dietetic influence nor resemblance of the swellings to the
wheals of urticaria. Until lately, the patient had not
been free from the swellings since February, except two
weeks in June.
Dr. Francis Delafield had hoped to hear of some
particular treatment of the disease. He recalled two
comparatively recent cases in women who gave no neu-
rotic history, had no bad habits, were in comfortable cir-
cumstances ; the swellings continued to develop without
apparent cause for several months, and then ceased.
He did not know why they had the affection, nor why they
stopped having it. It seemed to be not very uncommon,
and an efficient plan of treatment would be a great con-
venience.
Dr. Dana remarked that the cases were probably seen
oftener by the general practitioner and dermatologist
than by the neurologist. He had seen but three, and had
not been able to keep track of them, but knew that two
got along fairly well.
The president, Dr. Walker, had seen a man in a few
of the several attacks which he had been having for two
or three years, consisting in great swelling of the tongue,
causing it to protrude from the mouth, and less swelling
of the lips, the condition gradually disappearing after
some hours. At first there was fear the glottis or larynx
might become affected and cause strangulation, but this
fear had passed off. The man was a smoker, a moderate
drinker, had a rather gross appetite, slight rheumatic
trouble, no constitutional disease.
Dr. G. L. Peabody had also had a case in which the at-
tacks of swelling were confined chiefly to the lips and
tongue, in a man of thirty- five, without bad habits, not a
smoker, but of gouty heredity. Dr. Peabody prescribed
colchicum, and since then the patient had taken this drug
when there was a recurrence, but had now been free a long
time. He was unable to say whether the colchicum had
given the relief.
Extirpation of Tongue for Cancer ; Taste and Speech
soon Regained. — Dr. Robert Abbe presented a man,
fifty-three years of age, whom he had first seen about five
months before, when he presented a cancer on the back
portion of the tongue, beginning on the left side and ex-
tending to the right. There was a little glandular involve-
ment under the left jaw. The patient was dribbling saliva,
was unable to masticate, was markedly cachetic, and in
deplorable general condition. Dr. Abbe performed
Kocher's operation for removal of the whole tongue,
and showed the patient because of the remarkable power
of speech which he had regained since the operation, four
months ago. He had no difficulty in making himself
understood in a large room, and was able to utter all the
sounds of the alphabet except k, which he pronounced p,
saying, for instance, pip for kick. The general health
had again become perfect. There was a slight recurrence
on one tonsil, which it would be necessary to remove.
Dr. Dana elicited from the patient the fact that he
had power of taste, recognizing sweet, bitter, salt, acid,
etc. Dr. Dana confessed his inability to explain the ex-
istence of this power where the tongue, with the nerves
of taste and taste buds had been almost entirely extirpa-
ted. It was supposed that normally there was slight
sense of taste in the soft palate, but he had himself never
been able to recognize taste in that locality.
Dr. Sexton brought out the fact that the patient had
a slight burning sensation at one part of the stump, and
stated that he had frequently found division of the chorda
tympani followed by a feeling as if the tongue were
scalded.
Remarks on the Education of the Stomach. — Dr.
Samuel Sexton read the paper of the evening, bearing
this title. In having chosen as the subject for his paper
one which most of those present were better able to dis-
cuss than he, he wished to elicit a discussion which might
add to the comfort and more perfect manhood of the com-
ing generation. He was of the opinion that most people
greatly abused their stomachs by taking too much food,
and food of improper or injurious kind. It was especially
the excessive quantity and variety consumed at a single
meal which had most forcibly attracted his attention at
the hotels and in private families. He cited several
notable examples of gluttony on the part of children at
the expensive hotels here and in Paris, where they did
not fail to partake of all the numerous courses printed on
the m£nu. The parents, so far from reprimanding them
for their greediness, took pains to have the little heroes
or martyrs fill their pockets with such dainties as might
prove tasteful between meals. The author thought it
was necessary, for a healthy development, to accustom
the stomach to plain, simple, but nutritious food, in rea-
November 17, 1894]
MEDICAL RECORD.
635
sonable quantity, with periods of intermission sufficient
for complete digestion and rest. The agonies which
children suffered from colic and frightful dreams consti-
tuted a part of the punishment inflicted upon them
through the ignorance or thoughtlessness of parents who
permitted and even tempted them to make their stomachs
a dumping ground for all possible foods and drinks, and
many things which were neither food nor drink.
During the discussion Dr. Beverley Robinson said he
supposed all would agree that most people ate too much,
but he thought there was a tendency among intelligent
people to educate the stomach and limit the food of their
children. Sweets were ruled out, and the food was given
in moderate quantity and at stated intervals.
Gluttony not an American Characteristic — Dr.
Dana could not agree with Dr. Sexton if he meant to im-
ply that over-eating and gluttony were at all characteris-
tic of the American of to day — that was to say, the edu-
cated American, the type we were developing in this
country. It seemed to him the tendency of the times
and of the race was to eat rather less, and he believed it
would become still more so. A neurotic people, he
thought, would have to live simply and on a small
amount in order to retain their health, and the Ameri-
cans appeared to be learning that feet. His observation
had been that it was rather hard to get children of ner-
vous temperament to eat enough. They often left the
breakfast table after having eaten very little, and they
ate a light dinner. He did not mean to say they carried
this to an unhealthy extent, but he certainly had not
seen gormandizers among children of a fairly healthy
neurotic type. When one did see gormandizing in a
child it was almost always a sign of a degenerative taint
in that particular person. It was a perfectly well-known
characteristic of the epileptic and imbecile or partially
developed children, and he supposed, as Dr. Sexton had
suggested, that gormandizing was some evidence of ata-
vism. He also thought the paper was quite correct in
teaching that we, as a neurotic race, who lived on the
nerves and drew largely on the brain, must eat plainly
and simply. The only point where Dr. Dana differed
from the author was, that he thought Americans had
found this out largely, and did live in that way. He
had always thought that the American's stomach was a
great safeguard to him; it was delicate, and he soon
found out that he could not eat excessively, drink exces-
sively, nor smoke excessively. He could not do as the
Germans aad English.
Dr. Peabody remarked that the Germans had no term
expressing dyspepsia, and agreed with Dr. Robinson that
they probably had better beer if not better food.
Dr. Dana said he had not stated that the Germans
had dyspepsia, but he thought that if the same classes
here, as lawyers and teachers, should eat and drink as
they did in Germany, they would get sick.
Becoming a larger and Fuller Developed Baoe. —
The President thought he had observed that the chil-
dren and youth in New York to-day were larger and bet-
ter formed than those of eighteen or more years ago, and
that it was due to their tetter feeding and manner of
bringing up. In other words, the tendency seemed to
be toward a larger and fuller developed race.
Dr. Peabody queried whether that was not due to
athletics, and Dr. Walker agreed that athletics had
something to do with it as a part of the better training.
Brewers Drink a Keg of Beer a Day. — Dr. Sexton
said he once had occasion to examine men who worked
in a large brewery, and learned that it was the custom
of those who had free access to the beer to drink a keg
apiece each day. It was not uncommon for Germans in
this country to drink twenty- five glasses or more a day.
Children in this city, he thought, had too little exercise
and were over- fed, and were not properly educated with
regard to diet. One way of entertaining a child was to
feed it. Possibly he was wrong, but he believed a very
large amount of nervous energy was consumed in diges-
tion, and that over-feeding deprived the heart of a good
deal of nervous power which it should receive. The con-
dition of many patients was markedly improved simply
by diminishing their food supply.
Stone. — Litholapaxy is the operation when the patient
is an adult with a capacious and tolerant urethra, with a
bladder free from severe chronic iDflammation, aid with
a small or medium-sized stone, or, if large, of soft consist-
ence. The suprapubic is the best operation for large
and hard calculi. The medio-bilateral operation should
be chosen in all other conditions, because it is the easiest,
safest, and best. — Briggs.
Carbolic Acid applied in officinal strength in surgery.
1. No systemic absorption attends its use, and hence
no danger, no shock.
2. It is a local anaesthetic. Hence there is not as
much pain after the operation.
3. It is in a measure a haemostatic, acting especially
upon the capillary vessels.— Gardner.
Ingrowing Toenail.— Remove all of the redundant,
hypertrophied, or granular tissues of the skin, and leave
the nail alone. — Nuding.
Lung Surgery. — In tuberculous cavity the advan-
tages do not seem to be of sufficient magnitude to war-
rant an operation, except in a very few instances. Re-
moval from the lung of pieces affected with tuberculous
infiltration is obviously in the realm of pure experiment.
— Chaplin.
Bepeated small rectal injections, it is said, will relieve
the intense thirst following abdominal operations.
Local AnflBsthesia. —A mixture of ten parts of chloro-
form, fifteen of ether, and one of menthol, used as a
spray, is recommended as an excellent and prompt
means of obtaining local anaesthesia lasting for about
five minutes.
Cracked Ice, Sawdust, and Salt thoroughly mixed and
applied over abscess, felon, tumor, or bubo, will deaden
the skin sufficiently to allow of painless incision.
Alcohol will be used less and less in surgery, because
scientific investigation has shown the causes of many of
the evils it was imagined to counteract, and because,
thanks to Sir Joseph Lister, these causes have been got
rid o£ — Horsley.
Hydroceles of the Heck, after tapping and iodine in-
jection, either quickly refill, or such extensive inflamma-
tion is set up as to endanger life.— Stokes.
Granular Lids. — Curetting and brushing with corrosive
sublimate is successful in mild, but not suited to bad
cases. — Trousseau.
Palpation of the Vermiform Appendix. — Pressure
deep enough to recognize distinctly the posterior abdom-
inal wall, the pelvic brim, and the structures between
them and the examining finger, forms the whole secret
of success in the practice of palpation of the vermiform
appendix. — Edebohls.
Eectal Tube. — As a means of diagnosis, or in treating
stricture beyond the reach of the finger, tubes of any
kind are absolutely useless. — Cripps.
Acetanilide is curative in wounds, lacerations, and
internal haemorrhoids. It is cleanly, odorless, antiseptic.
— Woods.
Castration for Hypertrophy of Prostate.— Existing ev-
idence would certainly seem to establish the claim of the
operation to further and much more extended trial;
and it shows, I think, that even on a basis of experiment
and theory alone, I was justified in suggesting it to the
profession. — White.
636
MEDICAL RECORD.
[November 17, 1894
Peat Fibre, as now prepared for surgical purposes, is
a fine, brown, glossy wool, with a faint aromatic smell.
It feels a little rougher than fine absorbent wool, but
makes a more comfortable dressing, as it is much more
elastic. Its chief advantage seems to be that it is a
deodorant. — Burgess.
Spinal Cord. — In compound fractures, in fractures of
the spinous processes and laminae, with injury to the
cord, in simple fractures and dislocations of the bodies
of the vertebrae, if there is a reasonable probability that
the injury is due to hemorrhage, operation is advisable ;
but in all other cases, laminectomy is not an eminently
valuable surgical procedure. — Thorburn.
T Internal Haemorrhoids.-— The ligature is the safest
method of operating for internal haemorrhoids, as there
is less likelihood of its use being followed by hemorrhage,
stricture, or ulcer. — Dundore.
Sterilize Catgut by means of the vapor of alcohol
heated to 1200 C, verifying the sterilization by placing
bouillon in the same tubes with the gut ; if the bouillon
becomes turbid the ligatures should be rejected, as the
tubes are infected.— R*pin.
Management of the Intestines after Abdominal
Section. — When the general condition of the patient is
fairly good and the abdomen is not distending, and
when there is not much colic, let things take their
natural course. This advice holds for the great majority
of cases.
When the physician is summoned to a case of intesti"
nal obstruction, he should at once point out to the patient
the possible necessity of an operation. The neglect to
do this has cost many lives, for a considerable time usu-
ally elapses before a seriously ill person consents to a
dangerous operation. — Gersung.
Hypnotic Insensibility to pain can be applied to such
operations as extirpation of the breast without the pa-
tient manifesting the slightest sign of pain. — Schmeltz.
Stricture. — External urethrotomy with Syme's staff
and Teale's probe gorget, is preferable for all strictures
of the deep urethra where gradual dilatation is impos-
sible.— Rosenstein.
Catgat Drains. — By interlacing in a gabion-like
manner the separate filaments of catgut, a tube of any
desired size and length can be made. It has the advan-
tage of being capable of perfect sterilization, does not
present the inconveniences of decalcified bone, is not
rigid, has all the advantages of rubber, resorption can be
accurately calculated, and by reason of the openings
along its whole extent realizes an ideal drainage. — Des-
<5UIN.
Intubation. — The comparison of the results from tra-
cheotomy and intubation gives, in the first two years of
life, better results from intubation than from tracheotomy.
— Von Rankl.
Hysterectomy. — The operation should always be begun
with the intention of performing the intra-peritoneal
method, and removing the whole organ if possible, but
the operator must be prepared to adopt any method,
should it seem best to do so when the exact conditions
are found out during the progress of the operation. —
Keith.
* In Cancer of the oesophagus a gastric fistula should be
established as soon as the scales show a steady decrease of
the patient's weight. — Meyer.
Depressions of the skull in the new-born should be
treated by immediate resort to operation, if there are
symptoms calling for its performance. — Jennings.
Uterine Fibroid— In all cases of simple myoma or of
diffuse progressive hyperplasia (the "soft fibroid" of
many authors), complete removal should be practised as
soon as the diagnosis is established. — Reed.
OUR LONDON LETTER.
(From Our Special Correspondent.)
OPENING MEETINGS OF THE ROYAL MEDICO-CH1RURGICAL
AND PATHOLOGICAL SOCIETIES — SURGERY IN SEPTIC
PERITONITIS — LAPAROTOMY IN PERFORATING ULCER —
MEDICAL SOCIETY OF LONDON — TREATMENT OF CAN-
CER BY CINNAMON — PAY- PATIENTS IN HOSPITALS.
London, October vj% 1894.
The Royal Medico Chirurgical Society held its first or-
dinary meeting on Tuesday evening, when Mr. Lock-
wood read an important paper on the Surgical Treatment
of Diffuse Septic Peritonitis. In the cases he referred to
the inflammation had no defined limits, the membrane
was smeared with lymph, and the cavity contained thin
purulent fluid, often with a fecal odor, or it might be
full of gas. The intestines were paralyzed and distended.
In these very rapidly fatal cases Mr. Lockwood had
operated for fear of overlooking a mechanical obstruc-
tion rather than with a view of curing the peritonitis ;
but he had had success when there was not mechanical
obstruction and now detailed the proceedings he
adopted. To meet the exhaustion, collapse, and disten-
tion he used strychnine and brandy, before operation —
and warmth both at the time and afterward, also nutrient
enemata, stimulants, and warmth as required. Rapid but
methodical operation was important. He punctured the
several coils of intestine to withdraw the gas and then let
out the faeces through an incision, which he afterward
closed. Then of course he irrigated and drained. Two
successful cases were described. The object of the paper
was not to bring forward novelties, but to insist on the
methodical use of known proceedings, and the general
feeling seemed to be that the cases related were encour-
aging. In the discussion some interesting points were
raised. Thus Mr. Hulke regarded the paper as valuable,
but mentioned that he had sometimes found the intes-
tines so soft that the puncture continued to leak and the
attempt to close it by ligature only increased its size. He
thought no surgeon would hesitate to enlarge by incision
a perforation he found to exist. Mr. Knowsley Thorn-
ton regarded the combination of puncture with incision
and the protection of the patient from shock as the essen-
tial features of the treatment advised and regretted that
he had not been more careful in the past to* guard against
chill, shock, and prolonged exposure. He had long rec-
ognized the danger of distention as well as of the septic
material spread over the surface for which thorough irri-
gation was necessary. Mr. Harrison Cripps congratu-
lated the author on showing how to deal with cases which
were the bane of abdominal surgery. In cases after child-
birth or erysipelas or operations, he thought the poison
had passed into the system and was beyond the reach of
surgery. Mr. Alban Doran thought so too and doubted
if it would be justifiable to operate in truly pyaemic cases,
as the viscera were in them almost always affected with
secondary deposits. Dr. Norman Moore said some of
the collapse might be due to the size of the opening, and
mentioned a case he had seen within two hours of rupture
of a gastric ulcer. Death occurred in seven hours and
very few signs of peritonitis were found at the autopsy.
Mr. Marmaduke Shield had often punctured through the
abdominal wall for chronic obstruction, but the punctures
were apt to leak and set up peritonitis. The trocar should
be as fine as a sewing-needle and passed obliquely
through the muscular coat, so as to make the opening
somewhat valvular. Mr. Bowlby said two incisions, one
above and one below the umbilicus, were necessary to en-
sure complete flushing when the peritonitis was due to
gastric or duodenal rupture.
Laparotomy for perforations was also discussed this
week at the Medical Society of London, where Mr. Mar-
maduke Shield read a paper on Ulcerations of the Duo-
November 17, 1894]
MEDICAL RECORD.
6 37
denum, with special reference to the latent perforating
ulcer of that part, and related two cases in which he had
operated. In both the fluid found in the cavity was
sweet, and he thought if laparotomy was performed early
in such cases the fluid would be found very different from
that met with when the perforation was in the caecum or
lower. The importance of thorough flushing, a second
incision for this purpose, and other points were insisted
on by the author and the speakers who followed.
The Pathological Society opened its session with a
good show. Mr. Stephen Paget showed a specimen of
ventral hernia from a woman of fifty years of age. Lap-
arotomy had been performed, but she did not rally. He
also showed another specimen — tuberculous recto-vesical
fistula from a man of about fifty years of age. At the
autopsy both lungs were tuberculous, the right testis a
caseous mass, and the cord thickened ; the wall of the
bladder had miliary deposits ; a mass of old tuberculous
glands and scar- tissue lay between the bladder and rec-
tum, and two fistulous tracks were traced in this, one of
which led from the bladder to the rectum, the other from
the rectum to the mass, and back again to a lower rectal
opening. Mr. H. Fenwick thought the fistula originated
in a tuberculous deposit of the vesiculae seminales which
had broken into both bladder and rectum. Mr. Bowlby
was also of this opinion, and Mr. Paget said he would
make a careful examination of the vesiculae, and report
the result.
Dr. Rolleston showed a tumor growing from the upper
end of the left supra- renal capsule. It was as large as a
chestnut; on section firm, brown, with hemorrhagic
spots.
Mr. Targett showed a polypoid tumor of the oesopha-
gus, which appeared like a fibrous growth which bad
been invaded by epithelioma. There was an ulcerating
carcinomatous growth four inches below, and as cathe-
terism had been sometimes ineffectually attempted, Mr.
Shattock suggested it had so become inoculated. Had
the positions between reversed it would have been possi-
ble for auto-inoculation to have occurred — not so as it
was. It was stated that the cervical glands were full of
epitheliomatous growth, but no secondary nodules were
found in mucous membrane.
Mr. Jackson Clarke gave some account of his investi-
gations into variola and vaccinia. He said his recent
work confirmed his conclusions regarding carcinoma and
sarcoma. Drs. S. M. Copeman, Rufter, and D'Arcy
Power controverted the views of Mr. Clarke, who re-
plied to their criticisms. We shall probably hear more
about protozoa during the session.
Cancer is always a topic of sad interest. Yet, not-
withstanding many disappointments, how naturally one
listens to any reasonable suggestion as to its treatment !
Chian turpentine has had its day. Now, another
medicine is proposed. Neither more nor less than cin-
namon in the form of decoction administered freely.
Dr. Carne Ross, of Manchester, is responsible for reviv-
ing this remedy. I say reviving, as I believe is has been
previously employed and fallen into desuetude. I should
state that Dr. Ross distinctly disavows all pretence that
cinnamon is a specific, but he has found it useful in
mitigating pain, so much as to be a substitute for mor-
phia. Moreover, in some of the cases related the
progress of the disease seems to have been delayed or
arrested. Still we know that this sometimes occurs
under other treatment or none, and further trials are
needed before subscribing to the expectation of being as
fortunate as Dr. Ross seems to have been in his run of
cases. I have no doubt that cinnamon will be largely
prescribed for a time and so we shall be able to judge
whether it is of use, and if so, to what extent.
Great indignation is felt and has been expressed at the
determination to admit pay patients into the Great
Northern Central Hospital. These patients are to have
the attendance of the Honorary Staff. A petition against
this proceeding, signed by upwards of two hundred medi-
cal men in the northern suburb, has been presented by an
influential deputation, but has not turned the committee
from their purpose. It is certainly open to question
whether the committee are within legal rights to use a
building provided for charity, to let as lodgings for in-
valids who are able to pay. The injustice of thus rob-
bing local doctors of their patients is obvious ; but we
have made our services so free that the public sets little
value on them, and the reasonable protest of the practi-
tioners affected will be called selfish jealousy and trade-
unionism. So let it be, the general practitioners have
their positions to maintain, and if the consulting staff
will not listen to reason, should adopt the trade-union
plan which will be attributed to them, and boycott the
staff. Mr. Spencer Watson has resigned his surgency
rather than be a party to the contemplated injustice.
He has thus set an example which his colleagues should
not have left him to do single-handed, and which they
would be well advised to follow at once and in a body.
GOAT SERUM IN TUBERCULOSIS.
TO THE KDITOK Or THB MEDICAL RSCOKD.
Sir : Referring to the present treatment of tuberculous
disease by "immunized serum," it appears from Viquer-
at's investigations that he found the ass and mule to be
the only non-tuberculous domestic animals — though he
admits that the immunity enjoyed by these is not abso-
lute.
There are, however, two other domestic animals which
enjoy a far greater resistance to tubercle than the ass or
mule, viz., the common goat and the ewe. The im-
munity of the goat is particularly noticeable in Ireland,
where consumptives abound, and where the goat — an
omnivorous feeder — has been known to eat paper and
other articles covered or contaminated with the expec-
toration of consumptives, without injury or any loss of
health. Warm goat's milk has been highly regarded as
a remedy in consumption or " decline," since the days of
Galen (who, by the way, was the first to treat tuberculosis
by strychnine — or rather " Ignatius Bean "), and ewe's
milk boiled with mutton suet was at one time a famous
remedy in all chest diseases.
Perhaps it may be worth while to test the natural and
artificial immune serum of the goat in future experi-
ments. C.
IS SALMON POISONOUS TO DOGS?
To thb Editor of tub Medical Record,
Sir : There is a widely spread belief among people in
Oregon and Washington, that salmon is very dangerous,
and in many cases fatal, to dogs, when eaten. It is
claimed that the flesh, and blood more particularly, con-
tain something that is poisonous to the canines. Now,
I am very sceptical in regard to this salmon theory, and
find that many intelligent persons disbelieve it, and point
to the fact that dogs in Alaska are fed on salmon almost
exclusively, and no harm results.
There is no doubt but that more dogs die here than in
the East, but they ail have the same symptoms, which are
there known by the general term of distemper, which is
in reality a catarrhal fever with dysentery. A young
dog will be taken sick and mope around the house, re-
fusing to eat. The nose becomes hot and dry. The
ears, feet, and lips feel cold, and the mouth has a bluish
tint, eyes are suffused. Constipation is present at first,
but is soon followed by the most offensive dysenteric dis-
charges, until finally the poor dog succumbs from exhaus-
tion. This is a type of the so called salmon poisoning.
I have never seen, in any work on diseases of dogs, men-
tion made of " salmoning," as it is commonly called,
and doubt the existence of any such thing as dogs dying
with the above- described symptoms miles from any
streams ot water. Myths die hard, and superstition is as
widely diffused as it ever was, only it continually changes
its form. I should like the opinion of the readers of the
638
MEDICAL RECORD.
[November 17, 1894
Medical Record, either through its columns or by letter,
on this subject, as it is one of much interest to dog owners
in this part of the world. Yours,
F. W. Van Dyke.
Grant's Pass, Orb.
THE RESORCIN TEST FOR FREE HYDRO-
CHLORIC ACID.
To the Editor of tms Medical Record.
Sir: I have read with interest Dr. Julius Friedenwald's
article on the use of the resorcin test of Boas for hydro-
chloric acid. For the last eighteen months I have used
this test to the exclusion of the phloroglucin vanillin test
and have found it sensitive and convenient. " Although
I have occasionally verified my tests with known dilu-
tions of hydrochloric acid, I have made no such ex-
haustive study as that of Dr. Friedenwald. Still, as
practical experience is always good evidence, I am moved
to add my mite and to thank the doctor for his careful
research.
A. L. Benedict, M.D.
Buffalo, N. Y„ October 13, 1894.
CAR SANITATION.
To tub Editor of thk Medical Record.
Sir : The letter in the Medical Record of November
3d, by W. Washburn, M.D., on the subject of "Car
Sanitation/' is of great interest, and I beg to point
out an additional source of danger and cause for com-
plaint.
To those of us who are obliged to ride on the elevated
trains in the late afternoon, it will be remembered that
there is a peculiar disagreeable odor, quite distinct from
that due to the presence of a large number of people.
Indeed, it is more often observed when entering trains at
either terminus of the road, when the cars are empty. This
odor is due to the imperfect combustion of the oil-
lamps, which produces carbon monoxide (CO), instead
of, as is the case when combustion is perfect, carbon di-
oxide (CO,). This carbon monoxide, as is well known, is
a very poisonous gas, and the milder symptoms of head-
ache and malaise resulting from it I have frequently
observed, after riding in these cars for twenty minutes.
The reason of the existence of this condition is a total
disregard on the part of the railroad authorities for the
welfare of its patrons. The blame cannot be thrown by
them upon the passengers, as perhaps might be done in
the case of collection of filth from expectorated matter. It
is all owing to their desire for economy. The lamps are
lighted in the early afternoon, before they are needed,
and then the wicks are turned down as low as possible.
Complaint to the guards is of no avail, they have their
orders from those in authority, and cannot be blamed for
the existing condition*
Perhaps this has bsen pointed out before. If so, my
excuse for writing now is the fact that the condition
still exists, and only by continual agitation of these
questions of vicious abuse of power on the part of cer-
tain corporations, can we hope to have them removed.
Frank A. Bottoms, M.D.
New York.
The Song of the Girdner Telephone Bullet Probe —
After the "shootin's" over,
After the scrap is done,
After the " Dago's " punctured,
After the cowboy's fun (?)
Many's the gun " not loaded,"
I can attend to all ;
Merrily I will meander
After the Ball.
S Morris Conant.
Urn instruments,
A NEW SERRATED NASAL SCISSORS FOR THE
REMOVAL OF HYPERTROPHIES AND TUR-
BINATED TISSUES.
By D. N. RANKIN, M.D.,
ALLEGHENY, PA.
The Serrated Nasal Scissors devised by me has proven
a very valuable instrument for the removal of hypertro-
phied turbinated tissues, warty growths of the nares, and
exostoses of the septum. In many instances it has taken
the place of the nasal saw, from the fact that it requires
less time, pain greatly diminished, and less hemorrhage
in removing the growth. The accompanying cut will
show its appearance, and is one-half the actual size of the
scissors. This instrument was made for me in a most ex-
cellent manner by Feick Bros., 49 Sixth Street, Pitts-
burg, Pa.
ptedical Stems.
Contagious Diseases — Weekly Statement— Report of
cases and deaths from contagious diseases reported to the
Sanitary Bureau, Health Department, for the week end-
ing November 10, 1894.
Tuberculosis
Typhoid fever
Scarlet fever
Cerebro-spinal meningitis
Measles
Diphtheria
Small-pox
117
77
16
3
S3
4
a
3
»5
a
137
37
19
0
The Chinese Imperial Medical College of Ken Tain.
— The honor of establishing the first medical school,
where the healing art will be taught after western models,
belongs to Surgeon-Captain F. S. Heuston, of the Brit-
ish Army. The president of the new Medical College is
His Excellency the Viceroy Li Hung Chang. The vice-
presidents are Sheng Taotai, Lu Taotai, Lohfeng Luh
Taotai, and Mr. A. Irwin, F.R.C.S.I. The two last
and Dr. Lin Leien Fai are the directors. Mr. F. Sb
Heuston is the professor, and he is assisted by the fol-
lowing instructors: Dr. Kin, Dr. Chow, and Mr. Li.
The dean is Dr. Lin, and the proctor Dr. Kin. The
rules, subjects of study, and examinations are compre-
hensive. Candidates for the degrees in medicine and
surgery of the College, before they are allowed to present
themselves for the first professional examination, must
produce evidence that they have passed a preliminary
examination in general education and have been regis-
tered as medical students. Before receiving his diplo-
mas to practise medicine and surgery the student must
be over twenty-one years of age, and must have success-
fully passed each of the four professional examinations of
the College. There are two sessions : spring (from
after Chinese New Year to 1st of July) and autumn (from
September 1st to Chinese New Year) ; and the examina-
November 17, 1894]
MEDICAL RECORD.
639
tions are held at the close of the latter session. There
are four professional examinations, held at the end of
each year of study, and directed by a specially appoint-
ed Board of Examiners. At least two thirds of the lect-
ures must be attended.. Before admission to the second
professional examination, evidence must be produced of
haying attended a medico chirurgical hospital for a pe-
riod of six months after the first professional examina-
tion, and of having taken notes of surgical and medical
cases to the satisfaction of the medical officers of the hos-
pital. Attendance at a hospital for six months is also
required for the third examination. At the same time
the candidate must take personal notes on six medical
and surgical cases, which are to be produced for inspec-
tion, if required by the professor. A two months' course
in the compounding department of a hospital, under a
qualified person, is also necessary. The fourth, or degree
examination, requires a further six months' attend-
ance at a medico-chirurgical hospital, attendance at the
out-door dispensary, and notes, taken daily, on at least
five cases of fever (typhus, typhoid or enteric, scarlatina,
small-pox, or measles). The candidate must also pro-
duce evidence of having attended surgical operations at
the hospital, and of having received practical instruction
on the treatment of ophthalmic and aural cases. — The
Medical Magazine, October, 1894.
Cauterizing Ovaries instead of Removing them. — Dr.
Pozzi, at Hdpital Broca, has now practised cauterization
of painful ovaries for over two years, and considers the
plan very successful. In one case, in which he operated
upon both ovaries, the woman has since given birth to a
child. He performs his laparotomies in the ordinary re-
cumbent position ; draws the ovaries out of the abdominal
opening. If the ovary is totally diseased, he removes it ;
but if a part is found to be healthy, he amputates the
affected portion, cauterizes the stump, then sews the end
with silk. If there are some small cysts, h% opens them
by touching with the Paquelin point. The ovary being
returned to the abdomen, he examines and treats the
other in a similar manner. Often as many as six small
cysts are opened in this way in each ovary. — Therapeutic
Gazette.
The Collection and Preservation of Anatomical Ma-
terial.— At the last meeting of the Association of Amer-
ican Anatomists, a committee was appointed to consider
the question of the collection and preservation of ana-
tomical material, and to report, at the next meeting,
what, in their opinion, are the best means of accomplish-
ing these objects. In order to make the work of the
committee as comprehensive as possible, and to obtain
information which will be of service in arriving at defi-
nite conclusions as to the best methods of accomplishing
the purposes indicated in the resolution, it has been
deemed desirable to send to the teachers of anatomy, in
this country and abroad, a circular letter, with the fol-
lowing questions appended :
1. Is anatomical material obtained in accordance with
a legal enactment, wholly or in part ? 2. If there is an
anatomical law in your country or State, please send a
copy of it to the chairman of this committee, Dr. J.
Ewing Mears, 1429 Walnut Street, Philadelphia, Pa.
Please state whether the law is satisfactory, whether it is
readily obeyed by those upon whom duties are imposed
by it, and mention any improvements you would sug-
gest as to its requirements? 3. Is the material received
in good condition? 4. What disposal is ultimately
made of the remains? 5. Please state what means are
employed to preserve anatomical material for the pur-
poses of dissection or operative surgery. If injections of
preservative fluids are used, state their composition and
the methods of use, at what point injections are made,
whether at the heart or in the large arteries, and their
effect in accomplishing the preservation, with any
changes in the color or character of the tissues. What
length of time can material be used in dissection by the
methods employed by you ? If preservation by means
of " cold storage " is employed, please state the cost of
the machinery which it was necessary to construct for
this purpose, and what means are taken to prevent de-
composition after the subject is placed upon the table
for dissection. 6. Please state the cost, by the method
employed by you, for each subject, (a) for receiving it,
(J>) for injecting and preserving it. 7. Do you obtain
an adequate supply of material for the purposes of ana-
tomical instruction ? How many students are assigned
to each subject, and what is the method of allotment ?
8. Please give any information which you may deem of
importance. As the report will be general in character,
the name of the informant or institution will not be
mentioned by the committee unless requested.;
Education and Crime.— Sir John Lubbock recently
addressed the Sociological Congress in Paris upon the
effect in England of education upon crime. Since 1870
the number of children in English schools has increased
from 1,500,000 to 5,000,000, and the number of persons
in prison has fallen from 12,000 to 5,000. The yearly
average of persons sentenced to penal servitude for the
worst crimes has declined from 3,000 to 800, while juve-
nile offenders have fallen from 14,000 to 5,000. Sir John
Lubbock sees in these figures a confirmation of Victor
Hugo's saying, that "He who opens a school closes a
prison.1' In France, according to the Paris Temps,
criminal statistics and the statements of magistrates show
that as schools have been opened prisons have filled, and
that the diffusion of education has been accompanied,
apparently, with increase of crime, and especially of
juvenile crime. In attempting to acccount for this phe-
nomenon the Temps points out that in France, under
the republic, education is simply intellectual instruction.
In England there is not only instruction, but training.
Moral and religious influences are brought to bear upon
the children.
Bacteriology of Hospital Bed -Cards. — Dr. Trou-
sholiavski, in an inaugural dissertation recently presented
to the University of St. Petersburg, gives the results of
some curious researches made by him on the bacteriology
of hospital case- books and papers. Before use these are
almost free from microbes. Old case-books which have
been used at the bedside, and have afterward been shut
up in drawers from eighteen months to two years, also
contain very few microbes. On the other hand, papers
which have been close to, or in contact with, patients,
yield a large number of micro organisms. In forty- six
bed- cards and admission- cards examined for the purpose,
the average number of micro-organisms found was 43 per *
square centimetre of paper. By the side of indifferent
micro-organisms, pathogenic microbes such as B. pyocya-
neus, the bacillus of tubercle, and streptococci were found.
Virulent microorganisms placed on dry sterilized paper
preserved their virulence for a considerable time; the
comma bacillus from five to fourteen days, the typhoid
bacillus for sixty-three days, the diphtheria bacillus for
thirty-eight days, the streptococcus for ninety-eight
days. — British Medical Journal.
Chicago is Almost the Healthiest City in the World,
if its own statisticians and health officers are to be be-
lieved. According to a report of the Health Commis-
sioner there is but one city, Berlin, that had a lower
death-rate for the year 1893, that being 16.3, while
Chicago's rate was 16.9. The population is estimated at
over 600,000 above the United States census of 1890,
and the area of the city includes a large tract of territory
that is practically open prairie, where the death-rate is
naturally much below that of cities.
Frost Burns. — In the accidents which have attended
the manipulation of liquid air and other substances in his
laboratory, M. Raoul Pictet has distinguished two de-
grees of burns from the intense cold. In the first the
skin is reddened, turning blue the next day. The spot
doubles in area on the following days ; there is intense
itching, and five or six weeks are usually required for
640
MEDICAL RECORD.
[November 17, 1894
healing. In the more severe burns, those of the second
degree, the skin is rapidly detached. A long and stub-
born suppuration sets in, and healing is very slow, and
altogether different from that of burns from fire. On
one occasion, M. Pictet, while suffering from a burn due
to a drop of liquid air, seriously scorched the same
hand. The scorched portion was healed in ten or twelve
days, whereas the cold burn was still open six months
afterward. — British Medical Journal.
Acromegaly and Gigantism. — Dr. Sternberg con-
cluded, at the Congress of German Physicians, that the
study of the skeleton of the giant showed that there exists
a physiological and a pathological gigantism, and that the
latter are cases due almost entirely to acromegaly. He
thinks that gigantic growth and acromegaly can exist in
the same individual. Twenty per cent, of the patients
with acromegaly show evidences of gigantism, and forty
psr cent of giants have acromegaly. Gigantic develop-
ment predisposes to vegetative disturbances, and especi-
ally to acromegaly. Enlargement of the thymus he
thinks is a part of the natural history of acromegaly.
Thyroid feeding was productive of slight amelioration of
the symptoms of the disease in one case in which it had
been employed.
The Use of Quinine in Influenza. — Dr. Moss* (Acad-
emy of Medicine of Paris) concluded from his researches
that quinine, when given in moderately large doses,
tends to exert a preventive action on the manifestations
of influenza infection. In three cases of severe pneu-
monia complicating the grippe, recovery, which the
writer attributed to the use of quinine, resulted.
The Decline of the Pessary. — " No one invents a
pessary nowadays, in strange contrast to the time when
scarcely a man prominent in the practice of diseases of
women did not invent one. " One may conclude from this
that either all available pessary devices have been in-
vented, or that the use of the pessary is to be discouraged.
It is the latter view that Dr. J. G. Blake holds in a com-
munication to the Obstetrical Society of Boston, April,
1894 ; his alternative for the pessary, is, of course, surgi-
cal procedure. His complaint is more of the abuse than
the use of the pessary, although he quotes Fritsch, a
German writer, who declared that he had spent ten years
in learning the treatment by pessaries, and considered it
the most difficult in the whole range of gynecology, and
that it is easier to perform a laparotomy than to apply
an accurately fitting pessary. The same author criticises
their use, declaring that the pessary heals palliatively, but
injures definitively ; for it distends the fornix vagina so
enormously, that even after it has been worn for years,
a cure is not to be hoped for. On the contrary, retro-
flexion of the uterus returns after the removal of the pes-
sary. The longer the uterus has been displaced, the
longer the time necessary to enable the reflexed liga-
ments to return to a normal condition ; and a few days
have been sufficient, after its withdrawal, to have the
uterus fall back into its old position. Among the means
for attaining permanent cures, Blake mentions narrowing
the vagina ; pregnancy followed by prolonged rest in
bed ) dilating and curetting ; and shortening the round
ligaments. The first, he says, is only called for in com
plete prolapse, where no instrument, without external
support, will keep the uterus within the vagina, but where
it can be accomplished by narrowing the canal and out-
let : these cases are comparatively rare. The operation
of dilating, curetting, and packing is particularly adapted
to the cure of anteflexions, and to the removal of enlarge-
ments which attend all forms of backward displacement.
The combined dilating, curetting, and Alexander, is to
his mind the true solution up to date of the vexed prob-
lem of backward displacements. Ventral fixation, by
opening the abdomen, and by various other methods
(the vaginal, for instance) of fastening the uterus, has
been advocated by many writers. He sees no advantage
in them over the simple, harmless, and in most cases
effective, operation in proper cases, and of dispensing
with pessaries. He thinks no one has yet devised a
simpler, less dangerous, or more effective measure for the
emancipation of women from the wearing of pessaries,
than the two operations of dilating and curetting, and
Alexander. — Omaha Clinic.
The Treatment of Basedow's Disease by Thyroid
Feeding. — Dr. P. Brand reported at the recent meeting
of the Congress of German Physicians (Vienna), that fa-
vorable results had followed the feeding of sheep and
calves' thyroids in several cases of exophthalmic goitre in
which he had followed this plan of treatment. Of 12
cases so treated, 9 showed marked improvement, reaching
to cure in some, while 3 cases were not affected. In all
cases, with one exception, the treatment was well borne;
in this case the sinister symptoms produced were head-
ache, nausea, anorexia, tachycardia, and loss of flesb.
The symptoms disappeared when the thyroid feeding was
stopped.
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A Weekly yournal of Medicine and Surgery
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Original Qxticlts.
CCELIOTOMY IN ECTOPIC GESTATION WHERE
THE FOETUS IS LIVING AND VIABLE, WITH
THE REPORT OF A SUCCESSFUL CASE.
By X. O. WERDER, M.D.,
PITTSBURGH, PA.
fbllow or the American association op obstetricians and gynecolo-
gists ; GYNECOLOGIST to mercy hospital.
Ectopic gestation is still a fruitful and interesting topic
for discussion, particularly that rare form in which the
foetus has survived the dangerous catastrophe of primary
tubal rupture, and continues to develop to maturity. The
question of the proper treatment of those cases of ad-
vanced ectopic pregnancy in which the foetus is living and
viable is still in a somewhat unsettled state, and the cases
encountered so rare that the history of every such case
forms an interesting contribution to the study of this un-
common condition ; and also, especially if successful,
assists in the development of a proper technique in its
operative treatment. For this reason I will ask your kind
attention to the report of the following case. On January
23d I made the following entry in my case book :
Mrs. F. McC , referred to me by Dr. Wallace, of
East Brady, Pa., aged thirty-five, had one child, nine
years old, since which time she remained sterile. Her
puerperium was complicated by a slight febrile attack last-
ing a few days only, after which her convalescence was
normal. Health fairly good until three years ago, when
she was under treatment for some uterine affection, of
which she was relieved until August of last year. Menses
regular, duration one week, moderate in quantity, accom-
panied by some pain, especially in her back ; rarely cramps.
Last regular menstrual period began July 16, 1893. In
August they were delayed one week, and when they re-
turned they lasted fully six weeks, but never profuse.
Daring the first three or four weeks she was able to be on
her feet, though she complained of some occasional pains,
was sick at the stomach, and felt weak. In the latter part
of September she was suddenly seized with very severe
cramps and a feeling of faintness, which returned in parox-
ysm? for several weeks, confining her to bed for at least
six weeks. In the early part of November she was able
to leave her bed for short periods, but was unable to be
about until Christmas. She is still very weak, anaemic,
and emaciated, and has pains in her abdomen, especially
in her left side and in her back. Her menses have never
reappeared since October ; no leucorrhoea ; bowels obsti-
nately constipated. Micturition frequent, sometimes ac-
companied with bearing down pains. Appetite poor.
Since Christmas she has noticed an enlargement of her
abdomen, especially on her left side.
The lower part of her abdomen is enlarged by a tumor
of the size of a five or six months' pregnancy, two-thirds
of which occupies the left side and extends to a line mid-
way between symphysis pubis and umbilicus, which is
tender on palpation. Distinct foetal movements can be
felt, but the heart-sounds are inaudible. The breasts have
become enlarged lately and present the characteristic ap-
pearances of pregnancy. The external genitalia show the
peculiar discoloration of pregnancy to a slight degree.
The cervix presents a bilateral laceration to the vaginal
fornix ; -it is soft and patulous. To the left of the cervix,
pushing the uterus over against the right iliac bone, is the
tumor, reaching low down into the pelvis and filling out
Douglas's space. The uterus in its lower two-thirds can
be felt distinct from the tumor and is enlarged, and when
under the influence of an anaesthetic, the following day,
the upper third or fundus could be palpated ; but the in-
ternal or left cornu and the border of the body seemed to
merge into the tumor to such an extent that they were
unrecognizable to the palpating finger. The examination
without anaesthesia was very painful, and she seemed un-
usually sensitive about her pelvis.
The diagnosis made was ectopic gestation at six months
with a living foetus, which was subsequently confirmed by
my friends Drs. F. Blume, J. J. Buchanan, and John M.
Duff. The patient was advised to remain at the hospital,
where she could be under constant surveillance and re-
ceive prompt attention should occasion demand it. In
spite of our earnest solicitations she went home, a dis-
tance of seventy- five miles, but was prevailed upon by Dr.
Wallace to return a month later. An examination cor-
roborated our former diagnosis, and also noted a percepti-
ble increase in the size of her abdomen. She had suffered
less during the last month than previously, and her gen-
eral health had improved. She remained now at Mercy
Hospital for six weeks, going about her room and through
the building, and enjoying fairly good health, though she
complained of a more or less constant soreness in her ab-
domen. It was decided to defer operation to about two
weeks previous to the end of her term, unless some change
in her condition should demand earlier interference.
After the usual preparations the operation was per-
formed April 4th of this year, at Mercy Hospital, in the
presence of over twenty physicians. Having placed her
on the operating-table another vaginal examination was
made, when a finger could be introduced into the uterus
up to the fundus without any difficulty, proving con-
clusively that the uterus was empty. The incision was
made in the median line and a yellowish-white cystic
tumor was exposed. As the placenta at previous exami-
nations had been located a little to the right of the median
line, the sac, the walls of which were very thin, was
opened cautiously by a small incision a little to the left
of its centre, through which at once the child's scrotum
prolapsed. The opening was rapidly enlarged with the
fingers, the feet seized, and the child extracted. The
head was in the left iliac fossa, with the occiput and back
pointing to the spinal column. Only a few drops of
amniotic fluid escaped from the sac ; the child had no
other foetal covering except the cyst-wall. The anterior
surface of the cyst was perfectly free from adhesions, but
above and on the left side of the sac numerous loops of
intestines were found adherent ; on the right it terminated
between the folds of the broad ligaments at the uterus,
which was enlarged to the size of a two months' pregnancy.
It was decided to extirpate the sac if at all possible, and
separation of the intestinal adhesions was therefore begun,
when all at once a terrific hemorrhage from the bottom
of the sac, evidently the placenta, put a sudden stop to
our efforts. While my assistant used sponge pressure, I
rapidly clamped the ovarian artery in the infundibulo-
pelvic ligament very close to the ileum, and with another
forceps compressed the branches of the uterine artery along
the left border of the uterus, which at once controlled the
bleeding. The placenta, which was spread out over the
spinal column and the right posterior wall of the pelvis,
and adherent to intestines only by a small portion of its
upper margin, could now be separated with comparatively
642
MEDICAL RECORD.
[November 24, 1894
little loss of blood. It was of rather larger size than an
ordinary placenta, and devoid of any foetal membranes.
Another effort was now made to peel off the very thin
cyst-walls from the intestines, but the adhesions were
firmer than the membranous sac- wall, which tore at every
such attempt, and was therefore abandoned. The free
portion of the cyst was now excised, the ovarian and
uterine arteries compressed by clamp forceps, tied with
strong silk ligatures, the forceps removed, and the re-
mainder of the sac gathered and drawn together by silk
sutures attached to the parietal peritoneum, the cavity
packed with a Mikulicz dressing of iodoform gauze, and
the abdominal incision closed, as far as the gauze dress-
ing permitted.
The child, which at first was considerably asphyxiated,
soon responded to the efforts of resuscitation made by
Dr. J. M. Duff, and seemed hearty, strong, and well de-
veloped, though sadly deformed. There was marked
asymmetry of the head and face ; it had club feet, and on
the left side of the thorax there was an ulcerated surface
about an inch square, probably produced by the pressure
of the left elbow against that side of the body. The first
two days it seemed to be thriving ; it took its nourish-
ment— sterilized milk — readily, but on the third day it
became very restless, its breathing was rapid, and the tem-
perature 10 40 F., in which condition it continued until it
died, four days after birth. The cause of death was sup-
posed to be pneumonia, but no autopsy was held.
The patient rallied well from the operation, and the
convalescence progressed very favorably and smoothly,
and she never gave rise to the slightest anxiety. She
was discharged from the hospital perfectly well, excepting
a small fistulous opening in her abdominal wound, and
has remained in excellent health ever since, as a letter
received from her a few weeks ago indicates, though she
has never menstruated since last October.
Anatomically, the case was undoubtedly one of tubal
pregnancy primarily, with rupture between the folds of
the broad ligaments ; but that it was not a purely intra-
ligamentous pregnancy was shown by the fact that a
part of the sac seemed to be formed of amnion only.
There must, therefore, have been a secondary rupture
during the course of pregnancy, at which the largest por-
tion of the ovum became extruded into the abdominal
cavity, while a part still continued to develop within the
broad ligaments. When this secondary rupture occurred
is not clear from the history of the case, but I am in-
clined to the belief that it happened early during her
gestation, as there were no symptoms pointing to any
such accident after the sixth month.
In looking over the literature of this subject I have
been able to find sixteen successful cases of celiotomy for
ectopic gestation with living foetus at or near term,
not counting my own, the operators being Jessup, A.
Martin, John Williams, J. Lazarewitch, August Breisky,
Hector Treub(two cases), Joseph Eastman, R. Olshausen
(two cases), Carl Braun von Fernwald, G. Rein, John W.
Taylor, Professor Schauta, Mordecai Price, and William
T. Lusk. In Schauta's and Lusk's cases the operation
was performed before viability of the child, namely, at
the end of the sixth month, but as the technique is the
same as at the end of term, I have included them in my
list. In eleven, or with my own, in twelve cases, the
placenta was removed at the time of operation with com-
plete or partial enucleation of the sac, namely, by Mar-
tin, Lazarewitch, Breisky, Treub's two cases, Eastman,
Olshausen (one case), Carl Braun, G. Rein, Schauta, and
Lusk ; in the others the sac and placenta were left and
drained. The latter class of cases had, without excep-
tion, an unusually stormy and protracted convalescence,
complicated by sepsis, venous thrombosis, etc., so that
Lusk very properly remarks that the " fortunate results
belong to the domain of miracle and do not invite to im-
itation," while the cases with removal of placenta, par-
ticularly those in which the whole sac could be enucle-
ated, made uneventful and speedy recoveries.
The gravest element of danger in removing a living
placenta is, as is well known, uncontrollable hemor-
rhage, which has induced many of the older operators to
postpone operation until after the death of the foetus, be-
cause after the placental circulation has ceased the risk
from hemorrhage is comparatively slight. Though this
method finds a few advocates even at the present time,
the fear of sepsis in the ovisac, which so frequently fol-
lows the death of the foetus, aided by a commendable de-
sire to save the child's life, has undoubtedly been work-
ing a rapid change in favor of operative interference
during foetal life, especially as this has been justified by
the more favorable results obtained in this operation
during late years by an improved technique.
The blood supplying the placental circulation must, un-
doubtedly, be derived mainly from the ovarian artery and
its anastomosing branches of the uterine artery. That
these are the principal feeders was well shown in my case,
in which compression of these arteries checked an alarming
hemorrhage at once. Just as conclusive an example of
the correctness of this anatomical fact we have in a case
reported by Sippel,1 in which he enucleated an ectopic
sac at seven months, with a living child, with comparative
ease, until it tore at the placental insertion, followed by
a very profuse hemorrhage which compression of the pla-
centa did not affect, but which promptly ceased after
ligation of the ovarian artery — unfortunately too late for
the patient, who succumbed to the acute anaemia one
hour after operation. He strongly emphasizes the im-
portance of securing the ovarian artery previous to the
removal of the placenta. Olshausen and Breisky also
call particular attention to this point in the technique of
this operation, which has been followed by Lusk and
Schauta. On account of the very extensive anastomosis
of the internal ovarian with the uterine artery it seems
safer to me to ligate both vessels, as done in my case.
If further experience bears out the correctness of this
view in regard to the relation of these bipod-vessels to
the placental circulation, an important advance will have
been made in the technique of this operation, and the
cases in which, at least, the placenta cannot be removed
will be very exceptional, and limited to that class in which
it has formed extensive intestinal adhesions. Consider-
ing the great danger of packing and draining, usually
practised in such cases, it would seem preferable to me
to leave the placenta without drainage, sealing up the
abdominal wound hermetically. That the placenta can
become absorbed, if undisturbed, is demonstrated in
those cases in which the foetus has died, and in which
everything has disappeared excepting the foetal bones.
Braithwaite* reports a case in which the placenta was
left and nothing escaped from the abdomen subsequently
except a very small piece. Dr. Austin Lawrence re-
ports two cases before the British Medical Association,
held at Bristol, 1894,8 in which he left the placenta ; in
one case it was absorbed, in the other the patient died
from septicaemia on the twenty fourth day. He advises
leaving the placenta, but reopening the abdomen if symp-
toms appear. Cullingsworth, at the same meeting, nar-
rated a similar case, with living child, in which the open-
ing in the membranes was sutured and the cord cut
short. There was satisfactory progress for three weeks;
on the twenty fourth day, however, a rigor occurred, and
on the twenty sixth he reopened the abdomen and found
purulent fluid in the remains of the amniotic sac, which
he washed out, but the patient died the same day. At
the autopsy he discovered that there was no suppuration
in the substance of the placenta, but the sepsis arose
from the remains of the amniotic sac, which being of non-
vascular tissue, was more likely to decompose. He ad-
vises, therefore, to leave the placenta, allowing it to
bleed from the divided end of the cord, so as to lessen
its size ; to cut the cord quite close to the placenta, and
to remove all the amnion possible, stripping it off from
the placental surface, and to reopen the abdomen at once
» Centralblatt fittr GynSkoL , 189a, p. 992.
a Transactions of the London Obstetrical Society. voL xxviii. , p. 33.
■ Mbdical Record, New York, September 1, 1894.
November 24, 1894]
MEDICAL RECORD.
643
Period
of
Gestation.
Result to ChQd.
Details of Operation.
References.
Living, but died at
eleven months
from croup.
Alive, cord pulsat-
ing, but did not
breathe; had a
large encephalo-
cele.
Died in a few min-
utes.
Lived 96 days.
Living, weight over
4 pounds. A year
later a strong,
healthy boy.
Alive and well,
weight 5 pounds,
but died 3 weeks
later from phle-
bitis of umbilical
Living, weight 4
pounds. Died at
8i months from
pneumonia.
Living, weight 5
pounds, when a
year old weighed
14 pounds.
Placenta not removed ; no sac, foetus free in abdominal
cavity among intestines.
Placenta removed after ligation at three points.
9 Feb. 11, Carl Braun von, .. ,
1889. Fernwald, Vi- I I
enna. j |
1 i
i
R. Olshausen, ' » '
Berlin. ! I
10 , Feb. 27,
11 Feb. 4,
1890.
1a 1891.
End of
term.
4 9 months.
G. Rein, Kiew, 35 :
Russia.
John W. Taylor,
Birmingham,
£ng.
13 Jan. 10, ' Prof. Schauta,
1 1801. - 1 Vienna.
14 Oct. 23, Dr. Mordecai
189a. Price, Philadel-
I phia.
15 Aug. 19, Wra. T. Lusk,
1893. New York.
16
1894.
17 April 4,
' 1894.
Hector Treub,
Ley den.
X. O. Werder,
Pittsburgh.
37th 11
, 9 months.
. Living, weight over
6 pounds. Died
72 hours after
birth from lobular
i pneumonia due to
I inspiration of am- 1
1 niotic fluid. |
Alive, but very much ,
deformed. Died
> iX hour after
1 birth. I
I Living, weight 6
pounds ; slight
asymmetry of
head. Two years
1 after operation
I was hearty and 1
welL
Living.
Placenta not removed, sac drained.
1 Placenta and cyst drawn out, pressed up in the abdominal
I wound ; ligated and large portion removed.
After incision of the sac, which bled freely, placenta was
I perforated with hand, and after extracting child bleed*
I ing was controlled by compressing each half of placenta
I by the hand of operator and assistant until removed ;
I portion of sac extirpated, the rest intimately adherent to
l mtestines, sewed to abdominal wound and packed with
I Mikulicz dressing. Supposed to have been an ovarian
I pregnancy or a pregnancy in tubo-ovarian cyst.
j Tubalintra-ligamentous pregnancy. After removing child
1 from the sac, the latter was drawn out, ligated at its
juncture with the uterus and removed, containing pla-
centa and membranes, and cavity drained. Mother re-
covered perfectly in three weeks.
Intraligamentous tubal pregnancy. Clamped uterine end
of tube and broad ligament, and enucleated foetal sac
containing placenta intact, and quilted the pedicle with
cobbler's stitch, using iron- dyed silk.
Foetus free in abdominal cavity, also largest part of pla-
centa, between loops of intestines ; the latter adherent to
right broad ligament with only about one- third of its
periphery. This last portion was easily surrounded and
proved so thin that two mass ligatures of silk were suffi-
cient to securely tie off the placenta with attached portion
of broad ligament. Only shreds of foetal membranes
were attached to placenta.
Child free in abdominal cavity, placenta adherent to pos-
terior surface of uterus and nght broad ligament, extends
deep into Douglas's cul-de-sac, and firmly attached to
descending colon. After ligating right broad ligament in
number of places, placenta can be detached in a number
of places without much hemorrhage. But removal of sac
necessitated elastic ligature around uterus to check
bleeding and supra-vaginal hysterectomy.
Sac and placenta left undisturbed and drained with iodo-
form gauze packing. Spontaneous expulsion of placenta
on thirty-fourth day. Interesting is the daily copious dis-
charge of fluid per vagina during the eighth month, which
was undoubtedly amniotic fluid draining away through
tube. No amniotic fluid present during operation.
Intra-ligamentous tubal pregnancy. Sac, placenta, and
foetal membranes removed entire by enucleation from the
peritoneum, in the same manner as practised in removal
of intra-ligamentous ovarian cyst.
Tait on Diseases of
Women and Ab-
dominal Surgery,
vol. i., p. 495*
Berlin. kGn. Woch-
enschrift, Decem-
ber 36, 1881. R.
P. Harris, Extra-
uterine Pregnan-
2', Am. Jour, of
e Med. Sciences,
September, 1888.
Brit. Med. Jour.,
December 3, 1887.
R. P. Harris, ibid.
Vrach, St. Peters-
burg, 1886. R.
P. Harris, ibid.
Zeitschrift fur Ge-
burtsch und Gy-
n2k, Band xv.,
p. 384, 1888.
Wiener med. Woch-
enschrift, 1887,
Nos. 48, 49, and
56; and J. East-
man in Am. Jour,
of Obstet, vol.
xxi., 1888.
Am. Jour. . of Ob-
stet, 1888, p. 929.
Deutsche med. Wo-
chenschrift, 1890,
p. 171.
Archiv fur Gynik.,
Heft ii., 1890.
Deutsche med. Wo-
chenschrift, 1890,
p. 171.
! Centralblatt fur Gy-
I nakol., No. 50,
1892.
I 7 months. Living.
I Living.
6 months. ' Lived 24 hours.
I
3 weeks be- |
fore l
a weeks be-
fore term.
Lived several
weeks.
Lived 4 days.
Foetus free in abdominal cavity, placenta left behind and
drainage-tube introduced, and umbilical cord drawn out
of the lower angle of the wound. Patient recovered after
very protracted convalescence complicated by sepsis,
thrombosis of left iliac, the inferior cava, the right iliac
and right renal veins.
After tying ovarian artery at the peritoneal fold, which con-
stituted the residue of the llgamentum infundibulo-pelo-
isum, he incised the peritoneal covering in a circular line
corresponding nearly to the largest circumference of the
sac. The enucleation of the latter was readily accom-
plished without rupture of sac-walls. Considerable
hemorrhage resulted from detachment of the ovum from
the uterus, which was temporarily controlled by pressure
and later by sutures. The peritoneal borders of the
cavity were then sutured to the parietal peritoneum, and
the cavity itself was drained by a Mikulicz tampon.
Placenta attached to uterine attachment of left tube and
the entire pelvic viscera of the left side from the spine at
the back, and extending up to the kidney and covered the
descending colon. It was slightly wounded in the ab-
dominal incision and the cause of considerable hemor-
rhage ; this was controlled by clamping forceps, which
were allowed to remain until first dressing. The child
was enveloped only by amniotic sac, to which were at-
tached the transverse colon and also small intestines to a
slight extent Placenta left and sac packed with iodo-
form gauze. Last portion of placenta removed on thirty-
fifth day.
Pregnancy started in right tube and subsequently devel-
oped to a great extent between the folds of broad liga-
ments. Tied ovarian and uterine arteries of right side,
and then enucleated entire sac with placenta.
Foetus free in abdominal cavity. Supra-vaginal amputa-
tion of uterus ; removal of placenta and sac. (Private
communication from R. P. Harris.)
Child enveloped in amniotic sac and also partly by folds of
broad ligaments. Placenta removed after clamping and
subsequently tying ovarian and uterine arteries of left
side. Part of sac incised, but portion had to be left on
account of firm intestinal adhesions. Edges of sac and
stump of left broad ligament drawn together by sutures
and attached to parietal peritoneum, and drained by
Mikulicz gauze packing.
Obstet Trans, of
London for 189 x,
?. 1151 ; and Wm.
'. Lusk in New
York Jour, of Gy-
necol, and Obstet.,
July, 1803.
Beitrage fur Casu-
istik Prognose und
Therapie der
Extra -Uterine
S c h wangerschaft,
Prag, 1891 ; and
Wm. T. Lusk in
New York Jour, of
Gynecol, and
Obstet, July,
1893.
Transactions of the
State Medical So-
ciety of Pennsyl-
vania, 1893, P- *5*«
Wm. T. Lusk, Tech-
nique of Primary
Cceliotomy in Ad-
vanced Ectopic
Gestation, in N.Y.
Jour, of Gynecol,
and Obstet, July,
1893.
Bulletin Mem. Soc.
Obstet. et Gyne-
coL de Paris, 2894.
644
MEDICAL RECORD.
[November 24, 1894
should septic symptoms appear.1 In addition to lessen-
ing the size of the placenta by allowing it to bleed from
the severed cord, I would suggest to tie the ovarian ar-
tery on that side, and by so doing its blood-supply would
be greatly diminished, though sufficient circulation would
remain from the adhesions to keep it alive. Consider-
able shrinkage of the placental tissues would, no doubt,
follow this interference with its normal circulation, and
absorption could take place more readily. The method
of leaving the placenta and sac and draining it, causing
them to slough out, is certainly such an unsatisfactory
procedure, fraught with the greatest risk to the patient,
that it has little to recommend itself, and I feel confident
will have no place in the future treatment of these cases.
The time of operation in advanced cases of ectopic
gestation with a living child, is still a matter of discus-
sion. In my case I followed the advice of Tait,2 who
advises the careful guarding and watching of the mother,
though I did not go as far as he, to wait until false labor
sets in before operating. Werth and Olshausen,' on the
contrary, advocate operation regardless of the child's
life, from the fact that such children only very rarely
live long after birth ; the latter says, " on the mother's
account it is wise to operate as soon as possible, because
every delay is apt to become dangerous, and in intra-
ligamentous pregnancies the technical difficulties will
only increase." While no doubt the welfare of the
mother is first in importance, we owe some considera-
tion to the life of the child, and I think we are justified
in postponing operation in the interest of the child, pro-
viding we do not jeopardize the chances of the mother
thereby. We should, therefore, be largely guided by
the condition of the mother; she should be carefully
watched and prepared for emergencies, but as long as no
untoward symptoms require prompt interference, the
period of viability should be waited for. In a similar
case, however, I would not postpone operation much
beyond viability, but would perform celiotomy between
the seventh and eighth months, in order to save the
mother a long, anxious suspense, and because the child
would be smaller, and therefore, especially in the ab-
sence of amniotic fluid, less subject to compression and
consequent deformity.
It is a matter of considerable interest to ascertain the
fate of the ectopic children which were delivered alive.
I have been able to obtain the record of 40 such chil-
dren. Eighteen of these died within a week after birth ;
5 within a month ; 1 died at six months, of broncho-
pneumonia ; 1 at seven months, of diarrhoea ; 2. at eleven
months, 1 from croup, in the other, cause not given ;
1 at eighteen months, from cholera infantum — making a
total of 26 deaths, and leaving 14 children to be ac-
counted for. Of these, 5 were reported as living and
well after operation, with no subsequent report ; 1 was
strong and healthy after three weeks, but no report
since; 1 was well at six months, then lost sight of; 1
well at last report ; 2 live and are well at one year ; 2
living and well at two years ; 1 (Beisone's case) well at
seven years ; and 1 (Tait's case) well at fourteen and a
half years. In regard to the latter, Dr. R. P. Harris has.
kindly furnished me the following interesting informa-
tion : The child is Marian Sylvester, who is in good
health and has grown to be quite a comely girl, living
near the Woman's Hospital in Birmingham. Her
mother, Mary Ann Sylvester, was thirty-three years of
age at the time of operation ; pregnancy in right broad
ligament; she died on February 4, 1880. Operation,
January 31 (Tait), or Sunday, February 1, 1880 (Savage).4
1 Mbdical Record, New York, September i, 1894.
* Diseases of Women and Abdominal Surgery, p. 516.
* Deutsche med. Wochenschrift, 1890, p. 195.
* Tait operated on but one ectopic case in which the child lived.
The boy seen in Tait's house, and generally regarded as an ectopic
child, is Hemlingford Powell, son of Elizabeth Powell, delivered by
Caesarean section on October 11 , 1881— a private case, delivered near
Tait's house. Woman died ; boy, believed to be now living, was seen
last at Tait's, in December, 189a. The confounding of these two
cases lies at Tait's own door. This boy became ectopic, and the girl
was not mentioned.— R. P. Harris in private communication.
The greatest mortality of ectopic children occurs,
therefore, during the first few days after delivery, almost
fifty per cent. ; of 22 surviving that period, 8 are known
to have died within the first year and a half; 5 cases
were said to be strong and healthy at birth, but no sub-
sequent report. Five lived from six to eleven months ;
5 from one to two years ; two, seven and fourteen and a
half years, respectively.
While this table does not present a very hopeful pros-
pect for the saving of ectopic children at a viable period,
the fact that some of them have survived the most dan-
gerous periods of childhood, more than justifies us, in my
opinion, to postpone operation until the viability of the
child has been reached in all those cases where we can
do so without danger to the mother.
The list appended contains all the successful cases of
coeliotomy for advanced ectopic gestation with living
children which I was able to find in literature up to the
present time, with such important data as may prove of
interest in connection with the report of this case.
A CONTRIBUTION TO THE STUDY OF THE
ETIOLOGY OF TUBERCULOSIS.1
By HERBERT M. KING, M.D.,
GRAND RAPIDS, MICK.
In the light of the masterly discussion upon the etiology
of tuberculosis by Professors Gibbs, Vaughan, ttal., at the
recent meeting of the Michigan State Society, to which
many of us had the pleasure of listening and which it will
soon be our privilege to peruse at leisure, in the volume
of the Transactions of the Michigan State Medical So-
ciety, 1894, the remarks and suggestions which I offer for
your consideration this evening will possibly seem very
like a repetition, in which much of the more delicate def-
inition and technique is lost, and only the grosser and
possibly more superficial elements are preserved.
The case which I shall report, however, has in some of
its features such a direct bearing upon this subject of etiol-
ogy that I am induced to submit it for your discussion,
together with my interpretation of the evidences de-
duced, from the clinical as well as the pathological as-
pects of the case, which, I am convinced, are in support
of the theory of the bacteriological origin of the disease
in question. A theory to which the great majority of
modern pathologists incline, and one which would have
little or no opposition were it not for such indefat-
igable observers as Professor Gibbs and Dr. Shurley,
who, when least expected, and when scepticism has been
lulled by the constantly accumulating proofs on the part
of the German school, published reports, the results of
their observations and experiments, well calculated to
stagger confidence in preconceived ideas and shake the
faith of any save the most persistent germ theorist
At best, it seems to me, we are still groping in the
dark for the missing links, which shall, when found, con-
nect the bacillus tuberculosis in an intelligible manner
with the morbid processes of phthisis and make complete
the fabric of our etiological scheme. I believe that these
" links " exist, and will sooner or later be discovered and
understood. But whether as a result of the efforts of the
microscopist or of those of the physiological chemist, it
remains to be seen.
That the bacillus itself is not the absolute and direct
cause of those earlier changes in the parenchyma of the
lung, which if unchecked, lead on to cavity, I think all
must concede, in view of recent investigation, which has
established by repeated experiment two facts which seem
to me to be insurmountable objections to the theory of
the direct relationship existing between the bacillus and
the destruction of tissue, even to the most sanguine cham-
pion of the renowned Koch.
1. In the earliest stages of tuberculosis, the hyperplastic
interstitial tissue, while clearly showing the presence of
1 Read before the Grand Rapids Academy of Medicine, May 28,
1894.
November 24, 1894]
MEDICAL RECORD.
645
an inflammatory condition characteristic of tubercle, and
while still having present all of the other elements found
in any stage of the series of changes which follow, except,
perhaps, pus, does not invariably contain the bacillus
until the degeneration of the infiltrated tissue supervenes.
Since, therefore, the bacillus is not necessarily present,
it cannot be the direct and only cause of the localized
hyperplasia which constitutes the tubercle.
a. Tubercle bacilli can be produced by repeated cult-
ures which, apparently possessing all of the character-
istics of the specific micro-organism in question, are inert
to cause the disease, even when inoculated into the most
susceptible animals.
This is not quite so convincing an argument when taken
alone, for it can easily be imagined that in the process
of artificial cultivation the bacillus may lose its virulency ;
but taken together the two facts mentioned offer an argu-
ment which cannot well be met on the theory of the
bacillus itself being the direct cause of the first morbid
changes.
On the other hand, I am thoroughly convinced that
the bacillus is the ultimate and essential factor in the
production of tuberculosis ; that without its agency, no
matter how predisposed by heredity, cachexia, or diathe-
sis one may be, one can never develop tuberculosis.
The exact nature of that agency, however, and the
rationale of its action are still subjects for speculation.
In considering the few points which I wish to discuss
here, it will be necessary to call attention to one or two
etiological factors, which, I think, are pretty generally
established.
i. Phthisis involves, necessarily, a predisposition to
the disease, either by an inherited tendency or an ac-
quired cachexia, constituting what may be termed a pre-
tuberculous state.
2. The disease itself arises from causes which invariably
originate outside the body, and
3. Tuberculosis in its incipiency is never a local mani-
festation of a general disturbance, but is, in the first place,
a purely local lesion.
This theory is fully as tenable as that of the local
origin of cancer. The encroachment of the disease from
its local origin, however, is so very insidious and the
symptoms arising from the local disturbance so masked
by those arising from the early absorption of the specific
poison generated, and which are the expression of its
effect upon the vasomotor system, that it is not strange
the theory is slow to gain credence. That such a theory,
however, if generally adopted, would have a material
bearing upon our treatment of the disease, must unques-
tionably be conceded.
The communicability of phthisis from the sick to the
well is no longer a question, and I am lately advised that
in many parts of the country health boards and railroad
managements require the same precautions to be taken,
with respect to the shipment of bodies of persons dying
of phthisis, as with those in which death has resulted from
any other of the infectious diseases. How far this course
is justifiable I am not prepared to say ; but in my opinion,
if some like precaution could be taken in the transporta-
tion of the many thousands of tuberculous patients who
migrate semi-annually throughout the country, it would
be serving a far more reasonable purpose ; and while we
might not, for many years to come, be able to estimate
with any degree of certainty the value of such a pre-
caution, the end, I am sure, would justify the means.
Arguing, then, upon the premise that tuberculosis is
communicable, we have arising at the start, three ques-
tions: 1. What is the direct agent of communication?
2. What is the vehicle or medium of that agent; and 3.
How does that agent reach the point at which the first
serious pathological changes take place, viz., the intersti-
tial tissue of the lung.
This last consideration, I am aware, has really more
to do with the subject of the pathology than that of the
etiology, but may with propriety, perhaps, be touched
upon in this article.
In answer to the first question, it may be said that
while at present we have no positive proof that the bacil-
lus may not, in some instances, itself be the immediate
irritating presence which causes the infiltrated deposit of
tubercle, we do know pretty conclusively that certain
matter which contains absolutely no bacilli, is capable,
when inoculated into the bodies of susceptible animals,
of producing morbid changes identical with tubercle,
and furthermore, that the pathological product thus gen-
erated, does not, at first, at least, contain bacilli, but
simultaneously with the breaking down of this new
tissue, appear the bacilli. Thus some of our most con-
servative observers still incline to the belief that the
bacillus is the effect and not the cause of the disease.
Without entering into an exhaustive discussion upon
this question, I may say that I am induced to take the
following view of the subject; i.e., the mature bacillus
itself is not the immediate irritating presence ; neither
is any ptomaine to which its existence and presence
give rise, the direct cause for which we are searching ;
but, those forces upon which are dependent the growth
and development of the spores of the micro-organ-
ism in question, require and necessitate that hyper-
plasia, degeneration, and ulceration which constitute the
tuberculous process, and that each step of this process,
as it were, marks a certain stage of embryonic develop-
ment on the part of the bacillus. Furthermore, if this
process of infiltration of hyperplastic tissue be positively
arrested for a sufficiently long time, the spores become
devitalized and the bacillus never develops. Thus it is
seen often in sections made in hyperplastic lung tissue
in close proximity to a softened tuberculous mass, swaim-
ing with colonies of bacilli, absolutely no bacilli are to
be found, and yet the appearance in every other respect
is pathognomonic of the specific disease. With this in
view, it is still an open question whether certain agents,
not necessarily germicides, but exercising a specific ac-
tion upon the interstitial tissue by preventing or aborting
the hyperplasia, would render impossible the conditions
upon which depend the development of the bacillus. I
very much doubt if the mature bacillus itself ever gains
access from without, through any natural channel, to
those points where tuberculous disease apparently orig-
inates. It seems to me far more reasonable to suppose
that the spores deposited in the epithelial layer of the
lining membrane of the bronchioles and terminal vesi-
cles are absorbed by the lymphatics and conveyed to the
contiguous connective tissue and undergo development,
either along the course of such absorption or in tissue
immediately adjacent.
In short, that if bacilli exist in the infectious matter
received, that particular generation of bacilli never
reaches a point further than the epithelial lining, and
only the infinitely minute spores which are beyond the
possibility of demonstration, by the microscope, at
least, reach the point at which subsequently the tubercle
appears.
In answer to the second question, it is only necessary
for us to consider what is generally conceded to be the
common source of infection ; viz., the sputum from per-
sons or animals suffering from tuberculous disease of the
lung, and to this may be added the various excreta from
those in whom the disease is located at points more or
less remote from the lungs. Thus the urine, the seminal
fluid, the faeces, and in some instances even the perspira-
tion, might be, under favoring conditions, the vehicle
of infection ; and here again, it is worthy of considera-
tion that it is by no means necessary that the material
of infection contain one single bacillus sufficiently de-
veloped to be recognizable as such. Of course the
sputum from tuberculous patients in the vast majority of
instances contains colonies of bacilli, easy enough of
demonstration, and naturally such a product is much
more infectious than that which contains only the ele-
mentary molecules, simply, however, because in it there
is correspondingly a greater quantity of infection.
The manner in which the infectious material is most
646
MEDICAL RECORD.
[November 24, 1894
commonly conveyed to the vulnerable parts of the sus-
ceptible individual in the case of pulmonary tuberculosis,
is generally thought to be by means of dust, which has
either been in contact with, or is made up in part of,
the expectorated matter from the unfortunate sufferer.
We have no proof, however, that the vapor in the ex-
pired air may not contain infectious molecules, and al-
though the probabilities are against it, I think we are
justified in exercising precautions with respect to its
possible conveyance in that way. It is an interesting
question, and one which has a very practical bearing,
just how long matter which in the first place is highly
infectious, can retain its virulency. Experiments with a
view to determine this question have recently been
made, and I have been surprised to be unable to find an
instance where such experiments have proved that tuber-
cle bacilli, in a non-parasitic state, have retained their
virulency for a period of six months. In a series of ex-
periments conducted by Dr. G. A. Heron and Dr. T,
H. A. Chaplin (London Lancet, January 6, 1894), both
of the City of London Hospital for Diseases of the Chest,
a number of guinea pigs (the number is not given) were
inoculated with tuberculous sputum three months old.
Most of the animals died from septicaemia within a week
after the operation. The few that survived were in due
time killed by chloroform, and of these not one showed
any signs of having developed tuberculosis. The authors
in this instance regret that the number was too small to
be a very valuable addition to statistics, but thought it
remarkable that two months after inoculation with stale
sputum three months old, in which colonies of bacilli
swarmed, five guinea-pigs were free from tuberculous
disease.
My third question is answered in part with the first.
The spores having found their way into the epithelial
lining of the mucous membrane, are with more or less
avidity, according to the subject, taken up by the lym-
phatics and carried to and deposited in those parts for
which they appear to have a peculiar predilection, nat-
urally locating in that particular part best suited for the
conditions which their development necessitates and
always as near as possible to the seat of absorption.
Thus in the bronchial glands the interstitial tissue of the
lung, the mesenteric glands, the lymphatic glands, points
in and about certain of the bony articulations, the testi-
cles, etc.
The case which I cite illustrates to a certain extent, I
think, some of those features in the early history of the
development of phthisis which have been and are still
objured in the uncertain light of speculative theory.
It is one of acute tuberculosis, and the short time
which elapsed from the development of the earliest
symptoms to its termination, the rapidity with which the
several stages supervened upon each other, and my con-
stant association with the case, all conduced to make my
opportunities for close observation rather unusual in the
experiences of private practice.
The patient, a young man, aged twenty one, medium
height, of better than the average physical development,
owing perhaps to a military training, which he had re-
cently enjoyed, consulted me first, on December 5, 1893,
having been placed in my care by his family physician.
He was unmarried and his occupation was that of a clerk
in a dry-goods establishment. A Canadian by birth, of
Irish extraction.
Family history : Father and mother, paternal grand-
mother, five sisters and one brother living, all in appar-
ently good health. The others of his grandparents died
at old age, and none from any lung disease, as far as
could be learned. One younger brother died about a
year previous from phthisis; the last few months of
whose illness were passed in the same house and in ordi-
narily close intimacy with the patient. The habits and
hygienic surroundings, which form no'inconsiderable fac-
tor in the etiology of phthisis, were in this case as follows :
The patient, occupying alone a small but comfortable
room at home, was surrounded with all the necessities
of life and those of the luxuries which over-fond parents
and a very moderate purse could bestow upon a favorite
child. The house, isolated from its neighbors and situa-
ted upon a hill, had all the advantages of light and pure
air ; but, on the other hand, ranged against these, aj
it were, the patient himself had lived a life of dissipa-
tion in late and irregular hours, sexual excesses, and
indiscretions in the matter of food and drink for a num-
ber of years prior to the inception of the disease ; and
thus a constitution, which might otherwise, perhaps,
have withstood the encroachments of the disease, or at
least have so mitigated its course as to have prolonged
life, by making the conditions essential to the acute form
impossible (when, to theorize, the case might have been
one of the ordinary form or, what is possible, that variety
known as fibroid phthisis), was undermined and the pow-
ers of resistance were greatly enfeebled. The history
given was in brief as follows :
The general health had always been good, save for a
tendency to contract influenza upon the slightest expos-
ure, which had been noticeable for several years. In the
summer of 1892 the patient had malarial fever. For
about a month, however, he had noticed a more or less
persistent cough, especially annoying in the morning,
unproductive of expectoration ; but four days prior to my
examination an acute exacerbation of the cough, together
with severe laryngeal symptoms, had supervened and now
appeared a very slight expectoration of tenacious mucus,
which, on one occasion after smoking, had been streaked
with blood.
Physical examination revealed the following signs:
Temperature, 98. 6° F.; pulse, 80; respiration, 24.
The pharynx and larynx showed evidence of intense
congestion. The membrane was hyperemic and the
vocal bands could not be distinguished by difference of
color from the adjacent walls. Speech, above a whisper,
was impossible. Inspection and palpation of the chest
gave negative results, while percussion elicited a barely
perceptible dulness over the left apex, by no means suf-
ficient of itself to go far toward establishing a diagnosis.
Auscultation revealed a somewhat prolonged expiratory
sound, a slight increase in vocal resonance, and just a
perceptible lessening of the normal vesicular murmur.
On the 5 th, 8th, and 13th of the month the expectora-
tion was saved from six o'clock at night to eight o'clock
on the following morning and carefully examined with
the microscope. As many as ten mounts were made from
each of the first two specimens and in none were any
pathological elements to be found. Meanwhile, the in-
flammatory condition in the pharynx and larynx subsided
without ulceration. From the sputum of the 13th several
mounts were made, and owing to a mere chance of staining,
I believe, the specimen was obtained which was the only
one of the whole number of mounts which showed the
existing condition, and I therefore attribute my success in
this instance to some fortunate accident in the process
of staining. There was no pus present, and no free
bacilli. Throughout the whole specimen the same con-
dition existed, and so far no yellow elastic fibres were to
be found. In some of the other mounts epithelium
cells were present. Indeed in very few were they ab-
sent; but in none could the presence of bacilli, either
free or, as in this particular mount, involved and seemingly
embryonic in the protoplasm of the cells, be demon-
strated. The cells, in a number of instances, were found
to be apparently swollen, and to contain between the
periphery and the nucleus a cloudy or granular mass, on
the outer edge of which, but still within the protoplasm,
were found the minute particles which gradually approach
the appearance of bacilli as they near the periphery, until
at the outer edge, and in some even breaking through
the cell wall, they appeared as fully developed bacilli.
In most of these cells the nuclei appear granular and in
all, even those in which the cloudy swelling is not dis-
cernible, an unusual appearance is manifest.
Up to this time and for two days subsequent there
had at no time in any of the thirty odd mounts, ap-
November 24, 1894]
MEDICAL RECORD.
647
peared the least evidence of breaking down of tissue, no
pus, and no yellow elastic fibres. Wherever bacilli ap-
pear about to emerge from the cell, it is noticeable that
they are more fully developed and that they take the
stain in a more characteristic manner. (I might say
nere that the staining process employed was a modifica-
tion of that recommended by Ehrlich, requiring an im-
mersion of about twenty-four hours. I do not think that
any of the more rapid methods would have demonstrated
this condition.)
On December 15 th, began a series of severe and ex-
haustive attacks of haemoptysis, recurring at intervals of
from two to twelve hours, up to the 24th. These hem-
orrhages originated from the bronchial walls, in close
proximity with that portion of the upper left lobe which
had previously given the slight evidences of partial con-
solidation.
On January 1, 1894, the blood having pretty thor-
oughly cleared from the expectoration, another micro-
scopical examination of the sputum was made. Bacilli
were scattered here and there throughout the specimen,
not in large colonies, but taking the stain in the usual
manner, and perfectly pathognomonic. Some pus was
also found. The evidences of breaking down of lung tis-
sue were also distinguishable by the elastic fibres which
now made their appearance in the matter expectorated.
On February 14th, less than a month before death,
another examination of the sputum was made, in which
were seen evidences of the rapid destruction of tissue and
the vicious ravages of the tuberculous process. Pus ap-
peared in large quantities, while bacilli were seen in
thickly crowded colonies. Yellow elastic fibres were
found in increasing amounts, and particles of sloughed
tissue, even perceptible to the naked eye, could be distin-
guished, while physical examination revealed a rapidly
growing cavity. Death occurred on March 10th, from
asthenia. No autopsy was held.
Now, in conclusion, the point which I wish to make is
this : It is not the presence of the fully developed bacil-
lus to which is due the destructive process of tuberculo
sis.
I believe, not that the bacillus originates, de novo, in
the tubercle, but that its development from the spore is
the result of the disease process, to which the necessary
requirements of the life and growth of that spore give
rise ; that furthermore, when the bacillus is mature and
has deposited its elementary spores in the body, it has
fulfilled its mission, is no longer an element of disease
and is cast from the body as an effete product. How
visionary may be my deductions I leave to your discus-
sion to determi ne.
86 Jkffskson Avenue.
The Etiology of Cancer. — The French Surgical Asso-
ciation recently held its eighth annual congress. The
etiology of cancer was the most important question dis-
cussed. According to M. Bard, who opened the debate,
the differentiation of malignant tumors in a pathogenic
sense is an error, whatever may be their origin or their
structure. All the tissues of the human organism may
engender cancer, and there is no reason for applying
this term to epithelial tumors. Each tissie may be the
seat of a specific cancer, and this cancer owes its origin
to a young cell endowed with an exaggerated power of
reproduction. It is superabundant vitality which differ-
entiates the cancer cell from the normal cell. M. Bard
rejects the microbic theory as to cancer. Considerable
diversity of opinion on this point was expressed by other
speakers. It is decided that in future the French Surgi-
cal Congress will always meet at Paris in October, at the
same time as the General Assembly. Many of the con-
gressisles who visited the Lyons H6tel-Dieu were dis
appointed to find the old white bed curtains (which have
been discarded elsewhere), the old hospital smell of by-
gone days, and the food being prepared in the wards.
M. Poncet's wards are being remodelled.
THE RECENT TYPHOID EPIDEMIC AT WIND-
SOR, VT.
By J. D. BREWSTER, M.D.,
WINDSOR, VT.
In compliance with the request of our secretary and
others, I will endeavor to give a brief account of the
epidemic of typhoid fever which prevailed in Windsor,
beginning in March, 1894. The first case reported was
on March 15 th. This case was in a family residing at
the extreme southern limit of the village, and at the
time no apparent cause could be found. No other case
developed until March 24th and 25th, at which time a
large number of people were attacked, almost simulta-
neously, with a febrile condition which soon showed itself
to be unmistakably typhoid fever. These cases were
among all classes of people, rich and poor alike, but all
within the village limit.
Observation soon showed the disease was confined
entirely to families using the village water supply, those
having wells being entirely exempt, except in cases of
children who drank the village water at school. This
fact led immediately to the examination of the water
system. Windsor was supplied by a series of springs
situated about two miles or more from the centre of the
town ; these springs formed a small brook, which ran
along a valley for about a mile, passing six farms and
dwelling-houses, and then emptying into a reservoir,
whence iron pipes conveyed the water into the houses of
Windsor.
Now, about forty rods above the source of this brook
a farm-house is situated, where it was ascertained a per-
son had, the previous January, suffered from a fever-
ish condition about four weeks. It was supposed to be
a non-infectious form of fever, and was not reported to
the local board of health, and consequently no care was
taken of the discharges of the patient, and they were
thrown into the vault ; and to make matters worse, the
sink drain was frozen at the time, so all wash-water was
thrown out upon the snow. During the very warm
weather which we had the first week in March, the snow
melted, and all this accumulation easily found its way
into the brook, and thence into the reservoir and our
homes.
This explanation was unanimously indorsed by the
State Board, who made an official visit to the place soon
after the outbreak. The local Board at once issued
orders to have all water used for cooking and drink-
ing purposes, boiled. At the same time the town pro*
vided a water cart to deliver water from an adjoining
spring.
From March 24th to 30th, about eighty cases were re-
ported ; from this date to April 27th, the cases became
less frequent, this time being probably the limit of the
primary cases ; the later ones were secondary, and mostly
occurred in families already suffering from the disease.
Up to July 28th there vcre 130 cases, these occurring in
sixty eight families. The largest number afflicted in one
family being 5, the majority only 1. The ages ranged
from ten months to ninety-two years, but the majority
were under twenty years of age, and a large per cent, were
children ; the latter withstood the disease to a remarkable
degree, even with a protracted evening temperature of
104 ° F. The population of Windsor is 1,300, so about
ten per cent, of the inhabitants were affected by the dis-
ease. We were fortunate in having only'seventeen deaths,
or thirteen per cent. Six of the fatal cases had intestinal
hemorrhage.
S. H , aged forty four, died from complication
of erysipelas. One died from perforation. Mr. V. «
had temperature of 1060 F., at death, and there was a
rise of a degree a short time after.
M. K , a girl fourteen years of age, was afflicted
with infantile paralysis. She died in the tenth week,
and at death had seven bed sores, those on each hip
leaving bone exposed, which was also carious. Three
648
MEDICAL RECORD.
[November 24, 1894
died before the end of the second week, the average
fatality was at about the end of the third or beginning of
the fifth week.
I will now give a brief history of a few of the cases
which have recovered. Perhaps the most remarkable
one was Mrs. C , about thirty years of age. She
showed all the symptoms of typhoid — coated tongue, en-
larged spleen, rose spots on abdomen, etc. ; but devel-
oped no fever until the fifty-first day, when the evening
temperature was 990 F. It ranged from this to 99^° F- >
until the sixty-third day. Convalescence being very
protracted after the thirteenth week.
A. A , aged seventy, had typhoid symptoms,
with evening temperature of 1030 to 1050 F., with
croupous pneumonia, rusty sputa, which continued to the
twelfth day; from the 14th to the 21st, no fever. From
twenty-second to thirty-second day average temperature,
1020 F.; symptoms wholly abdominal ; rose spots pres-
ent. Temperature normal to the fortieth day, from the
fortieth to fifty fourth there was fever, the highest point
reaching 101 ° F. Symptoms: Catarrhal pneumonia.
Convalescence protracted.
C. A had relapse on the twenty- first day
with remarkable eruptions, some thirty or forty large
papules which soon became vesicula and many of them
pustular, while one was a true adenitis which went on to
suppuration, the abscess containing one-half drachm of
pus. This certainly was due to sepsis. This same case
at the beginning of convalescence had suppurative otitis
media and inflammation of the mastoid, with one recur-
rence.
G. B had evening temperature of 1050 F. first
week, delirium beginning on the fourth day. On the
twenty-first day had subsultus and picking of clothing,
and insomnia, continuing for a week. Temperature
ranging from 1030 to 1040 F. at night. Convalescence
set in after the seventh week, but delirium continued
two weeks longer.
Two cases had phlebitis of the leg. Ten cases had in-
testinal hemorrhage.
Mrs. B was confined on the fourth day. Tem-
perature, 1 040 F. The fever ran the usual course, and
recovery took place after the fifth week.
Arthur K , aged thirteen, after a mild form of the
fever, appeared convalescent, when malaria made its ap-
pearance. Temperature, 1050 F. After the second day
the same symptoms recurred with the usual course of
malaria. A large dose of quinine prevented a return.
His history showed he had had malaria eight years
before.
The most prolonged case was that of Henry S ,
who had a temperature for one hundred and two days.
This case had severe hemorrhages on the forty-ninth
day. He was not moved from his bed for one hundred
and sixteen days. After convalescence he gained twenty-
three pounds in twelve days.
I could give many more interesting cases, if time would
allow.
From July 28th to August 30th only two cases were re-
ported, but during the month of September there have
been twenty cases, thus making a hundred and fifty cases
in all since the beginning of the epidemic. All of these
later cases, with two or three exceptions, have been among
the poorer classes, living in tenement- houses. Two of
these died of perforation; in both cases the patients
having been in a state of collapse for forty eight hours
before death. Temperature, 930 to 970 F., and pulse,
125 ; abdomen extremely distended. The accidents in
each case being sudden, when everything seemed pro-
gressing to a speedy convalescence.
One fact is worthy of mention : in several cases there
seemed to be secondary infection coming from four to
six days after apparent convalescence, when there had
been no change in diet or management of the patients ;
they usually had fever for seven days, when true conva-
lescence occurred.
Throughout the whole time the sickness prevailed, all
possible precaution was taken to disinfect discharges and
the clothing of persons afflicted. The discharges were
buried after disinfection with either corrosive sublimate
or copper, and the clothing was put in boiling water.
We all know how difficult it is to impress the impor-
tance of this upon everyone, and doubtless, among some
of the more ignorant classes the instructions given were
disregarded, thus causing the later outbreak of the disease
among that class.
Windsor has -for twelve years been remarkably free
from the disease, not averaging more than five to seven
cases a year. I will here state, that the prison was en-
tirely exempt from the disease, the water-supply being
from a different source.
The village voted to discontinue the old supply, ex-
cept for motor purposes, and now have their water from
springs which flow from the hillside directly into a
covered reservoir, from which the water is pumped into
a stand pipe, also covered. The springs are for distant
from any dwellings, and furnish no possible opportunity
for pollution. No water supply that is exposed to
drainage from dwelling-houses can be safe, for only the
most untiring vigilance can prevent some accidents
which will involve its consumers in as sad an experience
as Windsor, after using the water system for over fifty
years.
I cannot close this paper without paying some tribute
to the noble way in which our citizens responded to the
needs arising from such a calamity ; a mass meeting was
held in one of the churches, and a committee appointed
to solicit money and clothing, such as was needed for
the sick, and to provide food for the needy ones. Many
volunteered as watchers, and every day the village was
canvassed to ascertain the needs of all; the sum of $700
was raised to provide nurses for those who could not
provide themselves. Twenty-eight nurses were employed,
coming from Burlington, New York, Hartford, Ct., Wor-
cester and Boston, Mass., thus aiding the physicians in
no small degree. No disease needs more careful watch-
ing than typhoid fever, and many owe their lives to the
never-tiring care of the faithful nurse. Windsor may well
be proud of the generosity of her people, as this test has
proved them. May the time be far distant when any
other town shall be called upon to prove herself her
equal.
Removal of the Kestiform Body. — Dr. Biedl showed
(Royal Medical Society, Vienna) a cat in which the resti-
form body had been completely removed a fortnight
previously. The first symptoms after the excision were
rotation in the opposite direction, rotation of the eye-
balls, and forced decubitus. After a few days, when the
cat essayed to walk, it found great difficulty in doing so,
not, however, on account of paralysis, but because of loss
of cognizance of place and surroundings. The head was
held toward the left and near the ground, and the itin-
erary was toward the left in a circle. Disturbance in co-
ordination of the muscles of the right side of the neck
and throat caused it to eat on the right side. The ex-
perimenter thought the conditions presented by the ani-
mal could be explained on the supposition of functional
suppression of a track along which nerve stimulation pro-
ceeds from the cerebellum.
Von BGlow's Brain. — Hans von Billow, the eminent
pianist and conductor, who died at Cairo, in February
last, had for years been a martyr to maddening head-
aches. In accordance with his often expressed wish,
after his death Professor Kaufmann, of Cairo, who per-
formed the post-mortem examination, extracted the
brain, and sent it to a German physician for examination.
It now appears that the surface origin of two nerves lead-
ing to the scalp was imbedded in a scar, left by an attack
of meningitis in early youth. Whether this scar can be
held responsible for the great artist's many eccentricities
must remain an open question.
November 24, 1894]
MEDICAL RECORD.
649
A PLAN OF INFANTILE MEASUREMENTS.1
By HENRY DWIGHT CHAPIN, M.D.,
rxorsssoc of diseases or children at the new yokk post-graduate medi-
cal SCHOOL AND HOSPITAL.
The extremely rapid growth of the infant after birth
makes a careful observation of all the phenomena con-
nected therewith not only interesting but important to
the physiologist and practical physician. As a partial
index of this growth an accurate system of measurements
is desirable, not only as noting a proper rate of evolu-
tion, but also for comparative purposes, after a suffi-
ciently large number shall be made. In proposing a plan
of measurements two extremes are to be avoided ; first,
in having too few for valuable data, and, second, in ad-
vancing a system too cumbersome or complicated for
general adoption. It is with an effort to avoid these
evils that the present plan is submitted. All that is re-
quired is a tape measure, a strip of sheet-lead, a pencil,
a pair ot calipers, and a table.
«A»U|1i
Fig. i.— Sketch of Skull for Measurement*.
Age. Sex.
Nationality.
(Parents.)
Name
Date.
Great circumference.
Naso-occipital arc.
Naso-bregmatic arc.
Bregmato-lambdoid arc.
Lambda-occipital arc Configuration.
Binauricular arc (through bregma).
Binauricular arc (through lambda).
Diameters of anterior fontanelle } jjjjjf P°»terior'
Cephalic index.
Facial length.
Circumference of chest.
Circumference of abdomen.
Length of body.
Weight of body.
Diet.
Notes.
The rapid evolution of the brain during infancy, and the
fact that the future efficiency and well-being of the indi-
vidual depend so largely upon its normal and healthy
growth, renders a study of the head of great interest, and
accordingly ten of the measurements are made upon the
skull. As the skull is fairly representative of the brain
daring the years of its development, the measurements
> Read by invitation before the Section on Diseases of Children of
the British Medical Association, at Bristol, August 2, 1894.
taken during infancy are more instructive as to brain size
and development than those taken in later years. The
skull changes considerably in its proportions during the
first three years of life, and then more slowly up to the
end of the seventh year when it has very nearly attained
its full size.
The circumference is taken by passing the tape hori-
zontally around the head, passing over the glabella and
a point just above the external occipital protuberance.
When this is procured, the following data will give a
very rough approximation of the volume — x : circum-
ference:: 1350: 50. Thus, if the circumference is 42
ctm., the approximate volume will be 1.134 cu. ctm.
The naso-occipital arc is measured from the glabella to
the external occipital protuberance. Before removing
the tape, the three arcs composing the naso-occipital
can be read off, namely, the naso-bregmatic, the breg-
mato-lambdoid, and the lambdo-occipital arcs. In order
to do this accurately, the bregma and lambda should be
previously marked, and I have employed an aniline pen-
cil for this purpose. These points are
much more easily indicated in an infant
than in the adult. Where the anterior
fontanelle is widely open, a line in con-
tinuation of the frontal sutures is marked.
The binauricular arcs are measured by
starting, in both cases, from the anterior
rim of the meatus, and passing the tape
respectively over the bregma
and the lambda. When the
anterior fontanelle is open,
the antero-posterior and later*
al diameters are taken. The
cephalic, or length-breadth
index, is measured by calipers,
which are applied at the great-
est biparietal and antero pos-
terior diameters. The for-
mula for obtaining this in-
dex is as follows — Length:
Breadth : : 100 : x. All ceph-
alic indices falling below 78
are classed as dolicocephalic;
from 78 to 80, mesocephalic;
and above 80, brachycephalic
The facial length is measured from the root of the nose
to the extremity of the chin, and, in the absence of the
teeth, falls considerably below the adult The chest is
measured at the nipple line, and the abdomen at its point
of greatest circumference.
The length of the body is measured by extending the
child upon a graduated board with a movable slide at
one extremity, although a flat table with a couple of
large books will answer.
The configuration of the skull is taken by carefully
applying a strip of sheet-lead horizontally around it, just
above the ear, the free ends always being on the right
side, for the purpose of uniformity.
The tracing is put upon the chart by running the
point of a sharp pencil just inside the lead. It is well
to mark the%centre of the lead in front, so as to be
able approximately to draw a median line through the
configuration and thus detect asymmetry. It is not
contended that this is an absolutely accurate method
of obtaining a configuration of the skull, as the metal
is so yielding that there is a possibility of its spring-
ing somewhat in transferring it from the skull to the
chart.
With care, however, it is fairly accurate, and will
exhibit any form of asymmetry that is at all marked. I
have tried harder substances, such as block tin, but
found it more difficult and somewhat painful to apply,
without being appreciably more accurate.
A lateral configuration is taken by applying the
lead over the parietal region, from one meatus to the
other.
Ninety-eight cases, from birth up to two years, have
650
MEDICAL RECORD.
[November 24, 1894
been carefully measured and are incorporated in the ac-
companying table.
cocephalic; and from eighteen months to two yean,
dolicocephalic. None of the averages being below 70
•M9
IcLg
«8
I8
IS
Great circumference
Approximate volume,cu.c.
Naso-occipital arc
Naso-bregmatic arc
Bregmato-lambdotd arc. .
Lambdo-occipital arc. . .
Binauricular arc (through
bregma)
Binauricular arc (through
lambda)
Diameters { Ant. -post . . . |
ant,-fonL ) Lateral
Cephalic index
Facial length .
Circumference, chest
Circumference, abdomen.
Length of body i
Weight of body !
Ctm.
34-73
9*7.44
92.33
0.22
§.94
4.16
22.00
ai.6x
4.00
300
9.11
-=79.63
xi.44
4-94
S3
49- 7«
8 lbs. 6 ozs.
I
Ctm.
3509
969.03
»3-o5
9.80
8.90
4.80
22.95
! 23.05
445
3.70
9.95
,".30
1 3«-«7
[ 30.90
7 lbs. 5 ozs.
, Ctm.
37.*5
! xoo5«7S
1 94.86
! 9-55
33-55
I 33-75
4-oS
3.t6
^ = 78.«4
575
l 34"
I 32.00
8 lbs. lots.
Ctm.
38.55
X040.85
; 35.83
10.05
I 10. xx
566
' a4.38
i *5°J
3-33
xo.xx
— "76*47
13-33
1 58.38
xo lbs. 12 ozs.
Ctm.
3894
1051.38
36.05
0.83
10.16
6.05
23.83
95.22
3-77
338
13.44
31.77
10 lbs.
I
Ctm.
4*«3
1x15.x
27.9
xx.6
9.0
7-3
26.6
26.9
3.6
3.9
XX.2 .
_ = 81.15
6.3
37'1
12 lbs. x or.
g o 9
§ ! H
J*'
Ctm.
49.68
1150.36
28.81
SX.X9
XX.06
6.69
26.68
96.68
3-00
! a-75
xx.37
Ctm.
44-9«
1212.57
30.4X
X9.4I
8
14.62"
77.77
6.05
66.06
14 lbs. 13 ozs
28.33
97.66
3.00
9.41
1*2? -
150
**33 77Z,
Ctm.
46.81
1263.87
31.00
12.68
10.68
7.6a
28.31
29.25
1.87
1.68
12.00
= 76.82
Ctm.
4741
1280UJ7
32.83
13.16
xi.41
8-95
39-33
d£2L
Closed.
19.16 _
- 74-4*
15.62 ' 16.33
6.75 o-68 I 7.05
41.16 . 41-81 47-35
38.9* I 39-75 46.33
6925 73-35 .78.16
13 lbs. 20 lbs. 4 ozs.
While broad and positive generalizations cannot be
made from so few cases, a study of the table is not with-
out some interesting suggestions. It must be remem-
bered that they were all hospital cases, taken either from
the Infant Asylum or the babies' wards, and many were
thus much below par. This will explain the low average
weight, being actually less in the cases from one week to
one month old, than in those under one week. Infants
collected together in numbers, especially in a hospital,
nearly always lose weight, if kept very long. This ten-
dency to scant weight does not seem to have had much
influence upon bony diameters, in comparing the skull
measurements of the table with adult measurements
already published. The shrinkage falls principally upon
the adipose tissue. While the degrees of health, and the
irregular number of cases give some varying results in
the ten classes into which the cases are divided, yet it is
believed, on the whole, they represent a certain type of
infant development. With increase in the age of the
infants there is noted a gradual and steady enlargement
of the great circumference of the skull, and, from this,
of its estimated volume. The naso-occipital arc likewise
increases at about the same general rate as the great cir-
cumference. In comparing the naso-occipital arc with
the great circumference, there is an increasing difference
as the children grew older. Thus, the difference under
one week is 12.39 ctm., while at two years it is 14.58
ctm. The naso-bregmatic and bregmato-lambdoid arcs
are very similar in the series, but after seven months the
former arc becomes slightly larger from the development
of the frontal part of the brain. Although no intellect-
ual growth can be said to take place under two years,
there is an active evolution of the front of the brain, with
increase of the perceptions. The binauricular arcs
through the bregma and lambda are quite similar, the
average of the eight cases between nine and ten months
being identical. The size of the anterior fontanelle, as
shown by the antero-posterior and lateral diameters,
varies according to the development of the infant.
Where the fontanelle remains widely open with the in-
creased age of the infant, there will always be marked
symptoms of rickets elsewhere. Thus, in Case 49, a boy,
aged ten months, with both diameters 5 ctm., die con-
figuration shows a markedly rickety head, and the notes
give other symptoms of the disease. By eighteen months
the fontanelles were all closed.
The cephalic indices showed the cases to be divided as
follows: Under one week, mesocephalic ; from one
week to one month, dolicocephalic ; from one to three
months, mesocephalic; at three and four months,
dolicocephalic; five and six months, dolicocephalic;
seven and eight months, brachycephalic ; nine and ten
months, dolicocephalic; eleven and twelve months,
brachycephalic ; from twelve to eighteen months, doli-
or above 90 could be considered abnormal. In a few
individual cases, however, the head was abnormal. Thus,
a Polish infant of eight months gave a cephalic index of
|| = 92.30. The fecial length increased slowly, as would
be expected from the absence of teeth, except in the older
infants.
A study of the configuration shows slight asymmetry
in all the cases, but only in a few instancrs is it well
marked. It is interesting
to note that the posterior
transverse diameters of the
configurations are nearly al-
ways greater than the ante-
rior diameters. This would
be expected, as the sensori-
motor parts of the brain are
more developed in infancy
than the other areas. I re-
gret that horizontal config-
urations were not taken high-
er up, through the parietal
bosses, as I believe the con-
trast would have been greater.
Through the courtesy of Dr.
Peterson I have made configurations upon two fetal
skulls in his possession, one between three and four
months, and the other at seven months. The first
shows an oval, undeveloped brain, and the second ex-
Fig. a.— Fetal SlraQ. between Three
and Four Months.
Fig. 3.— Fetal Skull, Seven Months, showing the
forcing: out of the Parietal Bosses by the Develop-
ment of the Sensori-motor Area of Brain.
hibits the forcing out of the parietal bosses by the rapid
evolution of the sensori-motor area of the brain, while
the front of the skull appears stationary, from the size of
the configuration. ,
November 24, 1894]
MEDICAL RECORD.
651
The circumference of the chest is several centimetres
larger, on an average, than that of the abdomen. There
would probably be a greater difference were it not that
so many of the cases presented evidences of rickets. In-
deed, I have come to look upon a disproportion of the
measurements of the chest and abdomen as a handy way
of recognizing rickets. In some cases the circumference
of the abdomen was greater than that of the chest, and
then the other evidences of rickets were equally well-
marked. Thus, in one case, the chest was 23 ctm. and
abdomen 29 ctm. ; in another, chest 38 ctm. and abdo-
men 38.5 ctm., with bony changes severe. An acute
digestive fermentation will not produce the enlargement
of the abdomen that is seen in the chronic flatulent dis-
tention of rickets. Hence the ratio between the cir-
cumference of the abdomen and chest is not only a sign,
but, to a certain extent, a measure of the degree of rick-
ets. The length of the body increased steadily in all the
cases measured. The breast-fed babies invariably pre-
sented larger measurements than those artificially fed.
The sketch of the skull seen upon the chart was de-
signed by Dr. C. L. Dana, and I am indebted to him for
its use.
AN ACCOUNT OF THE LATE EPIDEMIC OF
TYPHOID FEVER IN MONTCLAIR, N. J.
By THOMAS HORTON, Sanitary Engineer,
MONTCLAIR 1 N. J.
During August of this year there appeared in Montclair
a small epidemic of typhoid fever numbering in all nine-
teen cases, resulting in one death. Its close succession to
the more severe epidemic in the early spring caused a
natural anxiety in the town, and placed the Board of
Health in a responsible position. As agent and inspec-
tor of such board much of the work was left to me, and
an outline of the epidemic and the efforts of the Board of
Health in dealing with it is briefly as follows :
About July 20th there appeared simultaneously in the
town two cases of typhoid fever, one in a hotel and the
other in a French bakery and ice-cream saloon situated
about half a mile from the hotel Little attention was
given these cases beyond the ordinary precautions of the
attending physician until about August 1st, when the
appearance of two new cases, one in each of the above
buildings, caused a slight suspicion of an outbreak. All
the cases were removed to the hospital, and on the devel-
opment of five more cases by August 4th, a systematic
investigation was begun to discover the course of the
epidemic
I visited the house of every case, made an inspection
of the premises, left instructions to be observed in the
care of the patients, and filled out a blank form to aid in
discovering any common source of infection which
might exist In each instance the water, milk, and ice-
cream supply was investigated, and the date of sickness and
the occupation and place of business of the patient ob-
tained. Of the nine cases thus far developed, nothing was
found in common but the public water-supply and the use
of a few of the old wells which are so numerous in the
town, and which, in many instances, I knew to be badly
polluted. At this time I hardly suspected the wells because
three or four would have been involved, and I thought it
very improbable for so many wells to be infected at once,
and, besides, two patients claimed not to have used well-
water at all. We made, however, an investigation of
the public water* supply, which is a mixture derived from
driven wells and the Newark aqueduct. There was prac-
tically no typhoid in Newark and other places supplied
by the aqueduct, at the time, so that only the well- water
was examined. Samples taken from the driven wells and
suspicious, large crevices in the pump-wells, showed the
water to be of high organic purity and that the typhoid
had presumedly no connection with it.
Being confident of the purity of the milk and public
water-supplies, I again turned my attention to the wells and
the possibility of secondary infection. On closer investi-
gation I discovered that, in the case of the hotel, the first
patient was a transient guest who had arrived only two
weeks before developing the disease. Two weeks is
barely within the " incubation period " for typhoid fever,
and the assumption is more strongly in favor of this being
an imported case than that infection took place almost
immediately on arriving in Montclair. Continuing on
this assumption, I discovered further that great carelessness
had been practised, in the care of the patients before the
attending physician had been called, and that the four
cases which developed later in the hotel were either in
the direct family of the first patient, or among those who
had acted at times as nurses. This information, added
to the fact that the cases developed in successive inter-
vals during three weeks, seemed to justify my opinion that
these cases spread through secondary infection, being
transferred from one to the other through some of the
many conceivable ways where careless habits and igno-
rance prevail. In fact these cases may be considered a
small epidemic in itself, being situated away from, and
having no connection with, the other typhoid cases in the
town.
The other portion of the epidemic, numbering four-
teen cases, was confined almost wholly to the locality of
the bakery, and I am inclined to believe originated in
much the same manner, being infected in some way
from an old case in the building a month previous. On
inspection the bakery was found to be a filthy place, kept
by filthy people. The cellar, from leakage and want of
proper drainage, was little more than a mire, and was
dark and mouldy. Old cloth sacks, bottles, and ice-
cream cans were piled promiscuously on the floor, and
the ice was delivered through small windows on to a
wooden grating, or into the mud, as chance happened.
On learning that the ice-cream was made in this cellar,
and further, that those who made the ice cream and
worked in the bakery had helped in the care of the first
patient, I saw the dangers which might possibly follow.
Moreover, by this time another case had already devel-
oped in the house, and if, as it appeared, the case was
secondarily infected from the one a week previous, there
was a great possibility that the ice-cream might be in-
fected also and the disease spread very rapidly.
I had the bakery immediately closed, and to leave no
stone unturned I began an analysis of the suspicious
wells in this vicinity. The worst two wells I had closed
— one of which was used by the bakery, and, as was soon
seen, by most of those who developed typhoid later.
That this well was infected at the time of die outbreak
I very much doubt, or else the remaining cases would
have developed earlier. That it could have been in-
fected by the people in the bakery is very possible, for
the germs may have been washed from infected hands or
utensils on to the floor of the well, or into a wooden
catch-basin connecting with the pump, and from thence
sipe through into the well.
At all events ten cases developed within the two weeks
following the closing of this well and the bakery, and, of
these, eight had used the ice-cream and milk from the
bakery, and seven had used this one well. Whether
both these influences acted together, or whether the use
of the well was merely incidental from its public loca-
tion, can hardly be settled. But since all these cases
developed within the following two weeks and a half, or
within the "incubation period," there seems the strong-
est evidence that they originated from one or both of the
above sources, and that by cutting off these sources of in-
fection we prevented a further spread of the epidemic.
After this epidemic no case of typhoid fever appeared
in Montclair for over two months and a half.
Cremation in England makes slow progress. A crema-
tory recently erected in Liverpool is only the third in
the country, the other two being at Woking and Man-
chester.
652
MEDICAL RECORD.
[November 24, 1894
BERIBERI ON THE BARK ROBERT S. PATTER-
SON AT PERTH AMBOY, N. J.
By ALBERT S. ASHMEAD, M.D.,
NBW YORK.
The bark Robert S. Patterson, of a gross tonnage of
seven hundred and fifty eight tons. Captain Henry L.
Burton, thirteen days from Navassa, West Indies, arrived
at Perth Am boy on November 10th, with a European crew,
all in good health, and seventy surviving negro passengers,
the whole number of these colored people having been at
the outset seventy -five; the wanting five had died of
some distemper during the passage. . .
In company with Health Officer Dr. Ramsey and Mr.
Tsuchiya, of Japan, I visited the ship and found that ten
of the seventy survivors lay sick in the hold. One lay
dead, having died after reaching port; across his chest
lay another dying ; two others whom I examined were also
dying ; seven others were in various stages of the same dis-
temper. I examined them all, and found that the distem-
per was beriberi. One of the ten sick men had acute
pernicious, four of them moist, and five, dry beriberi.
These seventy five men, who had worked in the phosphate
quarries at Navassa, had been shipped by the company,
in a space less than five feet high, thirty feet wide, and
fifty feet long. This space had no portholes. Two
hatchways, each four feet square, were the only ventila-
tion. The hatchways had no sail, nor pipe appliances
for ventilation. A considerable part of the space was
taken up by straw mattresses, baggage, ship stores, and a
largequantity of red phosphatic earth, the cargo of the ship.
It appears that in a space of less than seven thousand
five hundred cubic feet seventy-five men, at any rate
seventy men, lived for thirteen days and thirteen nights,
with the least possible ventilation, with four lanterns
consuming part of the oxygen necessary for life, with
all the foulness engendered by breathing, defecation,
and urination; these seventy-five men being poorly
clad, and coming from many hardships suffered in a
tropical dime, who were so apathetic that nothing could
have induced them to go on deck for fresh air, or for any
care of health or cleanliness.
The crew was composed of eleven Europeans, none of
whom was, or had been sick ; they occupied a part of
the ship which was thoroughly ventilated.
I am informed by a leading manufacturing company
of this city that phosphatic earth, at which these
negro passengers had been employed, and which com-
posed the ship's cargo, is made up of sixty per cent of
bone phosphate of lime, silica, alumina, and iron, and is
a natural fertilizer.
Here is another instance to strengthen the theory
which I have so often maintained and illustrated by a
great variety of facts : charcoal fumes in Japan, carbo-
nized unripe coffee cargoes from Java (the immature cof-
fee is more liable to fermentation), fermenting sugar and
grain cargoes, overcrowding in hospitals (Richmond In-
sane Asylum, Dublin), disintegrating graphite (pure car-
bon) cargoes from Ceylon, etc.
It was evidently in this case, too, carbonic poison that
was the cause of the outbreak. It could not have been
the diet. Even if this had been much worse than it
seems to have been they could have borne it for thirteen
days. The disease broke out five days after leaving port,
that is at a time when carbonic poison could have pro-
duced its effect while the diet could not.
I do not even admit the joint operation of carbonic
poisoning and insufficient diet to produce the outbreak
on the Robert S. Patterson. In corroboration of this
opinion of mine, I quote Dr. J. A. Wetherill,1 speaking
of the outbreak at the Richmond Asylum, Dublin.
" Whilst medical officer at Wyndham, East Kimber-
ley, Western Australia, I had under my care sixty ab-
original native prisoners. These were chained up at
night in a galvanized iron one roomed building 30 by 14
by 12 feet. The only ventilation was by means of four
1 British Medical Journal, October 27, 1894.
small barred open windows. The floor was of jarrah-
wood. Two iron buckets were allotted to every three ox
four men— one into which the excreta were passed, the
other containing drinking-water. The jail was built on
piles on the edge of a marsh not twenty yards from the
water of Cambridge Gulf. The external night tempera-
ture was never below 750 F., and frequently up to 900
F. During the day they had as food, per man, one
pound of bread, three fourths pound of meat, generally
salted, one-hali pound of rice, with three pints of sweet-
ened tea without milk. Occasionally broth was served
and the rice was supposed to act as a substitute for fruit
and vegetables, which were not procurable. It must be
remembered that the natives had been accustomed to
roam unclothed, wild in the bush, free and unrestrained,
living on kangaroo, iguana, honey, fish, roots, barks, etc,
sleeping on the ground with nothing but the canopy of
heaven as a roof.
" Under these conditions a number of them — I regret
I did not retain the details— developed beriberi ; the prin-
cipal feature of which was the extensive oedema, and lia-
bility to sudden death apparently from syncope.
" The white inhabitants of the town, none of whom
were affected, called the disease scurvy, but scorbutus it
was not, for there were none of the classical symptoms
of that disease, such as hemorrhage into joints, from the
gums, etc., nor would it prove amenable to the adminis-
tration of citrate of potash, vinegar, onions, etc. Beri-
beri could not have been introduced among the niggers
from without, for there was no one either entering or
leaving the place, a steamer calling but once every two
months. It must, therefore, have had a de novo origin,
and is, so far as I know, the first time beriberi has ever
been seen in the aboriginal natives of Australia.
" From what I have read of the epidemic in the Rich-
mond Lunatic Asylum, Dublin, and judging from my
experience abroad, I should undoubtedly say the disease
in the asylum is beriberi."
In the case of the Robert S. Patterson the poison-
ing was not the result of the fermentation of the
cargo, as I have no doubt it was in several former
inafmiNi studied by me. The overcrowding caused
the presence of an excess of carbonic gases, the cargo
had nothing to do with it. This is the conclusion
which I draw from what President John H. Fowler
of the Navassa Phosphate Company of Baltimore writes
me: "There have never been landed at Baltimore
(whither most of the phosphate is shipped), coining
from Navassa Island, any cases of sickness similar to
those on the Robert S. Patterson. In regard to the sub*
stance contained in the cargoes from Navassa, we sell
our phosphates on the basis of the contents of bone phos-
phate of lime, and therefore do not have full analyses
made of the different lots as received. We, however, find
upon referring back to our books that in 1891 one of the
cargoes sent abroad contained 3. 98 per cent, of carbonic
acid out of one hundred component parts."
I have had a sample of this phosphate analyzed ; there
were found only three to four per cent, of carbonates.
Dr. Daland asks me " What was the condition of the
pork eaten by the beriberi cases that landed at Perth Am-
boy ? Was there any evidence of decomposition ? ' '
It is Dr. Daland's opinion that pork, in a decaying
condition, is a cause of beriberi, he having examined a
ship in Philadelphia, the Lanark, on which a beriberi
outbreak had taken place, attributed the disease, not to
the carbonic cargo, 5,000 tons of sugar, but to the pork.
Strange to say, all these cases were Mohammedans, who,
as everyone knows, abstain from pork. In answer to
Dr. Daland, I have to state that if the pork on the Rob-
ert S. Patterson was bad, it was eaten as well by the
European crew, who escaped the disease, as by the
negroes who caught it. I have said in the above
article that this European crew slept in a well-ventilated
room. Why, should I ask Dr. Daland, again, have they
so much beriberi or kakke in Japan, where no pork is
eaten at all ?
November 24, 1894]
MEDICAL RECORD.
653
That diet has very little, if anything to do with this
matter, is sufficiently shown by WetheriU's cases, which I
have already quoted. His prisoners were very well fed,
and yet contracted the disease from being confined in
insufficient space.
As to the surprise which has been expressed at finding-
that beans were the principal article of diet of these Navassa
negroes, when Dr. Simmons (as well as every other doc-
tor in Japan) avers that the Japanese bean (adzuki,
phaseolus radiatus), is the very nutriment to give to beri-
beri patients, I call attention to the fact, that the Japan-
ese bean is used in this case simply as a diuretic, it hav-
ing extremely powerful diuretic virtues.
grogttess at fPsflical Jfocteuce.
The Signs of Heart Failure in Fevers. — M. Hu-
chard has made an important statement to the Societe
Medicale des Hdpitaux regarding the signs of heart fail-
ure, which, he thinks, should not be limited exclusively
to the determination of the weakening or the disappear-
ance of the first sound. There are, beside this weaken-
ing, two other symptoms which he has observed ; these
he has named the embryocardiac and the bradydiastoliac,
or prolongation of the cardiac diastole (The Sanitarian).
This last symptom was studied some time previously by
M. Huchard as a new prognostic symptom in diseases of
the heart. He insists upon these facts, and advances
proofs to support their correctness, and to show that
there are often great errors committed in the diagnosis
of acute myocarditis in fevers, and especially in typhoid
fever. In this disease the autopsies he has made have
proved to him satisfactorily that often, in very grave
symptoms of heart trouble, there were hardly any ap-
preciable lesions of the muscular constituents of the
heart, and reciprocally. On the other hand, there may
often appear in cardiac sclerosis considerable myocardiac
lesions, and that even while life may last for a great
length of time. In emphasizing these conditions, the
results of his personal observations and of the previous
observations of Bernheim, of Nancy, in 1882, he has
shown that many of the symptoms attributed to myocar-
ditis of typhoid fever must be referred to the effect of
functional disturbance, or to lesions of the cardiac ner-
vous system. In all these cases it is certain that the
symptoms of myocarditis of infectious conditions, ad-
mitted by the greater number of authors, do not exactly
reproduce those which he has studied since 1870, with
Desnos, in cases of variola. This latter disease may
produce myocarditis ; typhoid fever causes myocarditis
with cardiac nervous troubles, which exert a preponder-
ating influence, and the grippe, which resembles typhoid
in this respect, as determining myocarditis, but causes
other disturbances of cardiac innervation which he
studied four years ago,1 long before Sampson, of Lon-
don, who has made a report on the subject to die Medi-
cal Society of that city. These researches and these con-
siderations have a great practical importance ; they show
clearly that the poison of typhoid acts on the heart like
digitalis ; this agent should not be employed indiscrimi-
nately in the treatment of a case of typhoid fever com-
plicated with cardiac symptoms. Injections of caffeine,
of ergotine, and even cold baths, should be employed in
preference.
M. Hayem described, in 1886, symptomatic myolitis,
after having examined the hearts of a great number of
patients who had died from varioloid and from typhoid
fever. He attributed the alterations of the muscles to
changes in the blood and in the blood-vessels. Myocar-
ditis is much more marked in typhoid fever than in vari-
ola, which is contrary to the statement of M. Huchard.
Sometimes even a vitreous degeneration of the muscular
fibres is found in typhoid, a condition which does not
1 Soc Med. des H6piL, 1890, et BuL Med, 1892.
exist in variola. It is difficult to attribute death to
alterations of the muscular fibres, for it seems due rather
to a toxhsemic condition, the effects of which are di-
rected as much to the vessels as to the muscles and the
nerves of the heart and other organs. M. Siredey has
also found that myocarditis was more frequent in typhoid
fever than in variola. In typhoid, the changes in the
heart are often limited to the arteries. M. Huchard has,
on the contrary, always observed that the fibres in myo-
carditis were much more deeply changed in variola than
in typhoid. The following consideration goes to prove
that in typhoid the nervous element should be added to
the myelitic In proportion as sudden deaths are rela-
tively frequent in the cardiac complications of typhoid
fever, they are rare in variola. If the cause of death is
of equal force in the two affections, why are the results
so different?
Milk Diet and Mioro-Organisms in the Alimentary
Tract. — In the Dietetic Gazette are given the results of
some recently published work by MM. Gilbert and
Dominici (Action du regime lactfe sur le microbisme du
tube digestif, Comptes Rendus de la Socifetfe de Biologie)
on the number of bacteria in the alimentary tract after
the ingestion of milk. A milk diet exercises a remark-
able influence on the number of bacteria present in the
faeces of man and of animals. A healthy adult man sub-
mitted for five days to a diet consisting in part of 2.5
litres of milk daily. The faeces after ordinary food con-
tained 67,000 bacteria per milligramme. At the end of
two days under this new diet they contained only 14,000
bacteria ; at the end of three days, 5,000 ; after four days,
4,000; after five days, 2,250. The weight of the faecal
matter, which ordinarily amounted to 175 gm. per day
in this individual, was reduced to 73 gm. ; accordingly
the number of bacteria daily excreted by way of the
rectum was reduced from 11,725,000,000 to 164,250,-
000, /.*., the milk diet thus had the effect of reduc-
ing the bacteria of the faeces to one seventy-first of the
normal number.
The above results were obtained after the use of non-
sterilized milk. In the case of a patient suffering from
ulcer of the stomach, who had been nourished on an ex-
clusive milk diet for twenty days and had received noth-
ing but sterilized milk for ten days, 3,000 bacteria per
milligramme were found in the faeces. This number is in
close agreement with the lowest figure previously recorded.
Similar modifications were produced in the faeces of the
dog by a diet of sterilized milk, the number of bacteria
decreasing from 25,000 or 21,000 to 1,000 or 500. In
rabbits, non-sterilized milk caused an increase in the rel-
ative number of -bacteria and a decrease in the absolute
number. Two animals whose faeces normally contained
thirty- five and forty-eight bacteria per milligramme were
fed for twenty days on non-sterilized milk — one litre daily
— containing 1 25 to 150 bacteria per milligramme. From
thirty five, the number of bacteria increased to fifty seven,
and from forty- eight to eighty-nine. Before the feeding
of milk, the daily quantity of faeces was, in the case of
the first animal, 175 gm. ; in the second, in gm. ;
the total number of bacteria, 6,125,000 and 5,328,000
respectively. Since the milk diet reduced the daily
amount of faeces to 5 gm., it is evident that the to-
tal number of bacteria was diminished to 285,000 and
445,000. Sterilized milk, however, decreased both the
relative and the absolute number of bacteria. After being
submitted to a diet of non sterilized milk for twenty days,
the two rabbits above referred to were nourished upon
sterilized milk. From fifty- seven and eighty-nine, re-
spectively, the number of bacteria in the faeces fell to
seven and ten per milligramme. The total per day thus fell
to 35,000 and 50,000, or one one-hundred- and-seventy-
fifth and one one-hundred-and sixth of the normal num-
ber. In the case of man, the dog, and the rabbit, the
absence of those species of bacteria which liquefy gelatine,
and of moulds was noted during milk diet.
Milk diet exercises its peculiar action not only on the
654
MEDICAL RECORD.
[November 24, 1894
faeces, but on the entire gastro-intestinal contents, putting
the alimentary canal in a condition of partial asepsis.
This does not result from any antiseptic power of the
milk, since, as is well known, it forms a good nutrient
medium for many species of micro-organisms and the coli
bacillus readily grows in it. The true explanation is,
perhaps, rather to be found in the character of the
changes which milk undergoes in the digestive tract It
is readily attacked by the digestive ferments, the products
formed are readily absorbed and but a small residue re-
mains, consisting of nuclein. In this connection it is to
be remembered that Dr. Vaughan has lately called at-
tention to the germicidal action of the nucleins outside*
of the body. The failure of bacteria to multiply in the
intestinal canal during milk diet may then be due to the
lack of nutrient materials suitable for their development,
and, further, to the antiseptic action of any nuclein pres-
ent. From a dietetic standpoint, the value of milk as an
accessory food, at least, is apparent in certain gastric
disorders attended with the growth of micro-organisms,
in acute or chronic enteritis accompanied by diarrhoea, in
typhoid fever, dysentery, and a large number of diseases in
which the toxic products of intestinal putrefaction are the
ultimate causes of the particular symptoms manifested.
Apooynum Cannabinum in Heart Disease.— Dr. Glin-
ski after having proved by experiments on cold-blooded
and warm-blooded animals that the root of the apocy-
num cannabinum contains a strong poison which in
large doses paralyzes die heart, and when given in small
quantities retards and strengthens its beats, decided to
take it himself, as he is suffering from hypertrophy of the
left ventricle, with intercurrent attacks of dilatation of
the organ, mitral murmur, dyspnoea, etc. {The British
Medical Journal.) The dose was fifteen drops of the
fluid extract three times a day. As he found that all his
symptoms disappeared in two days, he gave it also to
other patients in the same quantity in cases of palpita-
tion, disturbed compensation, in which strophantus,
and adonis vernalis had failed and digitalis seemed con-
traindicated. He gives a. full account of some of his
cases, and summarizes his experience in the following
conclusions : 1. The action of the root of apocynum
cannabinum is similar to that of digitalis, without being
cumulative. 2. In cases of dilatation the fluid extract
rapidly diminishes the area of dulness. 3. It increases
the daily amount of urine, stops the palpitation, and pro-
motes the absorption of transudations. 4. With the ex-
ception of increased pulsation of the arteries of the head,
it has no bad secondary effects. It was used either in
the form of a decoction ( 3 j. to 5 viij ), 3 to 4 table-
spoonfuls a day, or tincture (1 in 10), 5. to 10 TTl, three
to four times daily, or fluid extract in doses of xo TTl to
half a teaspoonful three times daily.
A Rare Tumor of the Parotid Gland.— -Dr. SchUller, of
Berlin, reports the following interesting case in the
Arztlicher Prahtiker, No. 3a, 1894. A lady, twenty-
three years of age, had a hard swelling in the region of
the right parotid gland. As she said, there had been re-
moved, nine years previous, a glandular swelling at the
same place. The new swelling had first developed rather
slowly, and only later had it grown rapidly. When she
came to Dr. SchUller, March 30, 1894, the tumor was the
size of a pigeon's egg, was hard, and apparently blended
with the surrounding tissue. It was immovable from its
base, and felt like a soft elastic mass imbedded in a tense
sac. Close to it and below, could be felt a second,
smaller tumor, of the size of a bean. Dr. SchUller op-
erated on April 4, 1894. He found the main tumor
situated between the origin and the anterior ascending
ramus of the sterno-cleido-mastoid, below, and close to
the ear. It was blended with the surrounding tissue. At
the base it appeared to be a continuation of the parotid
tissue, where it could not be separated from the gland,
and entered deeply into the retro-maxillary fossa.
The tumor was carefully dissected from the nerves, ves-
sels, and muscles ; unavoidably a part of the parotid had to
be extirpated. Besides the main tumor there were re-
moved nine to ten glands, from the size of a bean to that
of a cherry. The main tumor presented on transverse
section the appearance of a dense fibrosarcoma sim-
ilar to those found occasionally in the testicle. The
-microscopical picture, however, was not that of a sar-
coma. There was found an exceedingly dense granulat-
ing tissue, rich in cells, which enclosed centres of shrunken
and partly fatty-degenerated cells, here and there with
isolated giant cells. Cheesy degeneration was nowhere
present The granulation tissue is traversed in some
places by extraordinarily thick-walled blood-vessels.
Metamorphoses of tissue such as this tumor presented are
(according to Virchow) characteristic of gumma forma-
tion. The main tumor consisted in its periphery, appar-
ently, of a lymphatic gland which had undergone gumma-
1 tory change, and the parotid gland itself was gummatory.
The other glands showed nothing but hyperplasia caused
by simple chronic inflammation. The process was evi-
dently one of hereditary syphilis.
Treatment of Phthisis.— Dr. C. Theodore Williams
has presented in The Lancet some practical recommen-
dations from thirty years9 experience in the treatment or
phthisis. After placing sunlight and fresh air as the
first and most essential things in the treatment of phthisis,
he adds a number of practical recommendations for the
relief of symptoms. Cough, he says, should always be
treated by promoting expectoration, one of the best
forms of expectorant being the effervescing carbonate of
ammonia draught night and morning, which will gener-
ally clear the bronchial passages for several hours. If
there be a good deal of fruitless hacking before expecto-
ration, causing annoyance to the patient, the addition
of a few minims of dilute hydrocyanic acid and half a
drachm of syrup of poppy or codeia, will do no harm and
considerably allay the reflex irritation. Where the cavi-
ties are large, or deep, or basic, and consequently re-
quire great expiratory effort to clear, combinations of sal
volatile and spirit of ether with camphor water, as in the
form of the pharmacopoeia of the Brompton Hospital,
answer admirably, while for old or feeble persons cham-
pagne will often serve the same purpose. But the most
satisfactory way to reduce the cough of chronic phthisis
is by counter^irritation to the chest-wall — best by blister-
ing. It will be found that relief will follow in propor-
tion to the amount of serum drawn by vesication, and
fly- blisters or acetum cantharidis, or the strong but very
efficient liquor epispasticus, answer the purpose. Night
sweats, when they are a mere flux from the vessels or
lymphatics, and not a relief of pyrexia! processes, ought
to be checked, and this can generally be done by arsen-
ate of iron, y& gr. to yi gr., at bedtime, or picrotoxine,
A fc7- t0 4w &•> or nitrate of pilocarpine, ^ gr., or the
old fashioned oxide of zinc in from 3-grain to 5-gndn
doses, which generally succeed and do no harm. Prep-
arations of belladonna and atropine, though they are
effectual controllers of night sweats, are less satisfactory,
because their continuance for a long period often induces
dryness of throat and mouth, dilatation of the pupils, and
disturbance of sight accommodation. The treatment of
pyrexia depends very much on its cause. Where it ac-
companies tuberculization it probably will subside of it-
self when the tuberculous process quiesces, and even if
persistent will only prevail in the afternoon. An effer-
vescing saline, with a few drops of tincture of aconite or
a few grains of quinine, is all that is then wanted. But
pyrexia accompanying acute excavation, or acute excava-
tion and tuberculization, is very troublesome and some-
times quite intractable. Antipyretics, of which there
are any number, according to my experience only give
temporary relief, and often do harm by depressing the
patient's constitutional powers and producing collapse.
I have seen the temperature depressed from pyrexia to a
subnormal reading by doses of antipyrin or phenacetin,
but always with bad results, and after the use of the med-
icine has been omitted, the temperature has risen as high
November 24, 1894]
MEDICAL RECORD.
655
as ever before. The great object in the treatment of this
form of pyrexia is to keep the patient quiet in bed or
lying on a couch, and, if possible, in the open air, d la
Dettweiler ; to feed him frequently ; and to supply alctf-
hol to repair tissue waste, while administering only suffi-
cient antipyretics to keep the temperature within moder-
ate bounds. Quinine in small doses, in effervescence, be-
fore the rise or during the rise of temperature, will often
suffice, or Henn's well-known pill twice a day. Anyone
who studies the phenomena of lever knows that temper-
ature rise is only a small portion of the process, and that
by lowering the chart we do not get rid of the factors of
heat production or of the wear and tear of the tissues;
and so our best line is rather to keep up strength and
weight by a frequent supply of food. The diarrhoea
which accompanies tuberculous ulceration may be checked
by sulphate of copper and opium, if the ulcerative process
be limited in extent ; but if there is much ulceration, and
it is the ileum and large intestine which are involved,
injections are best. The enema opii of the British Phar-
macopoeia is excellent under these conditions, but I have
seen a few of the most obstinate cases yield to large in-
jections of linseed tea, which has a most soothing influ-
ence on the irritable ulcers.
©liutcal §tvnvtmmt,
VARICOSE ULCERS SUCCESSFULLY TREAT-
ED BY A NEW AND PAINLESS METHOD.-
By J. WILL SUMMERS, M.D.,
using Merck's methyl violet, grs. v., aqua destillata, f ij.
This forms a harmless and entirely painless application.
I would not hesitate to use it on any chronic ulcer.
The bandage has been worn most of the time, and to
this date there has been no return of the ulcers.
To put at ease the mind of anyone who may think
the internal treatment and bandage are deserving all the
credit, I will state that both had been used, with the
accepted local treatment, with but little success by other
physicians, at intervals, for several years. Also ulcers
that began forming under the bandage were invariably
- arrested in their course by methyl violet. Its action we
believe to be germicidal and highly astringent.
October 6, 1894.
Mas. B , aged fifty- six. History of struma during
childhood. Is the mother of two children. General
health fair. Veins much dilated4rom knees down, with
very poor cutaneous circulation. Has suffered from
chronic ulcers for many years.
Was first seen by the author December 8, 1893 ; at
that time she presented one or two ulcers that had not
been healed for five years, and others of more recent date.
The manner in which these ulcers appear is as follows :
First, a macule which soon becomes papular, and later
capped by a vesicle which soon ruptures, liberating a
bloody serum. The mass continues to enlarge, forming an
ulcer the size of a quarter of a dollar or even larger. Dur-
ing the formation and growth of this ulcer it is highly sen-
sitive and constantly painful. At the time of my first
visit, after cleansing the ulcers with a solution of soda
bicarbonate, I applied a solution of methyl violet —
care being taken to bring it in contact with the entire
area of the base and margins. After allowing it to dry,
each stained ulcer was covered by a small bit of absorb-
ent cotton. Mechanical support was furnished by Mar-
tin's elastic bandage. This entire procedure was re-
peated every morning. On the second or third day it
was evident that the healing process had begun.
At my first visit a new and very painful ulcer was
forming on the left leg. This I treated for a few days
with subnitrate of bismuth, boracic acid being tried
and found too painful. No benefit was derived from
either. Pain was constant ; on the third or fourth day
I painted it with methyl violet, and to my great surprise
and the patient's comfort, the pain at once ceased.
After two or three daily applications the sensitiveness
had so far subsided as to render bandaging of that part
of the leg possible. All of the ulcers were thenceforth
dressed daily. At the appearance of any new vesicle I
applied methyl violet, which prevented further develop-
ment. Internal treatment consisted of potassium iodide,
grs. x. to xv. t.i.d.
The patient continued her duties as housekeeper, and
at the end of six weeks only cicatrices remained to mark
the site of her former ulcers.
An ideal solution, as used by Dr. M. F. Coomes, of
Louisville, Ky., in the treatment of lupus, is made by
PASTILLES AS A SUBSTITUTE FOR GAR-
GLING TO PREVENT DIPHTHERITIC IN-
FECTION.
By A ROSE, M.D.,
MEW YORK.
Ws have to confess that the control of the course of
diphtheria is very limited. In view of this fact we are
reminded of the noblest of our duties, the duty of pro-
phylaxis. It is true we are experimenting with anti-
toxin, and it is to be hoped that we shall succeed in se-
curing immunity against diphtheritic infection by means
of inoculation of this new serum, but as long as this, our
sanguine hope in regard to antitoxin, is not yet real-
ized, we have to welcome every prSposition to guard
against diphtheritic infection.
It is generally understood that a healthy pharynx is of
as much importance in regard to diphtheria as a healthy
stomach is in regard to cholera. All writers on prophy-
laxis against diphtheria speak of the importance of keep-
ing the mouth and throat in aseptic condition. Among
the measures to this end gargling " the throat " has always
been considered to be a prominent part. As everybody
can convince himself by experimenting with some col-
ored syrup, gargling is an illusory measure as far as the
disinfection of the pharynx is concerned ; except when
it is done in a certain skilful manner, as only adults can do
it after having been well instructed, not one drop of the
gargle enters the pharynx, not even reaches the tonsils.
Dr. A. Szara1 recommends therefore to disinfect
mouth and throat with lozenges composed of resina
guajaci, saccharin, etc. He experimented with these
and found that they possessed germicidal power, that
they actually did disinfect the mouth and pharynx, that
the aseptic condition lasted for one hour. He does not
give the proportion, at least I did not find them given in
the extract of his paper which came to my view.
Messrs. Eimer & Amend, the drug firm, made lozenges
for me which have the following formula :
Q. Resinae guajaci 0.75
Saccharine 0.01
Sacchari et succi liquiritise 0.75
They are agreeable to take, and may also serve in all
cases of pharyngitis where tinctura guajaci is generally
given. They are certainly more palatable than the tinct-
ure, and much more serviceable than those lozenges of the
London Throat Hospital made with red and black cur-
rant jelly and containing only a small part of resina
guajaci. Dr. J. Bergman 8 recommends lozenges which
he calls diphthericidium pastilles, which have the follow-
ing formula :
3. Thymol 0.002
Sodae benzoit o 02
Saccharin 0.015
And some gum-like constituent.
Either of these pastilles recommends itself to be
given to our little ones going to school in place of candy
or chewing-gum.
1 Ueber eine neue Methode die Mund- und Rachenhdhle zu desin-
ficieren. Pester med.-chir. Presse, 1894, No. &
a Un neuer Vorschlag zur Prophylaxe gegen diphtheric Algm.
medL Central. Ztg. 1894, No. 1.
656
MEDICAL RECORD.
Medical Record:
A Weekly Journal of Medicine and Surgery.
GEORGE F. SHRADY, A.M., M.D., Editor.
Publishers
WM. WOOD & CO., 43, 45, & 47 East Tenth Street.
New York, November 24, 1894.
SOME MINOR MEASURES IN THE DIAGNO-
SIS AND TREATMENT OF DYSPEPSIA.
No doubt the conscientious general practitioner feels that
he is often very much behind the times in his diagnosis
and treatment of some gastric disorders. Medical liter-
ature is full of elaborate descriptions of the different
kinds of dyspepsia, of hypoacidity, hyperacidity, motor
disturbances, catarrhal disorders, etc. The methods of in-
vestigating the stomach have also become greatly refined,
the test meals, the washings, syphonings, and electric ex-
plorations appear very formidable to the doctor, and still
more to the patient. We do not in the least wish to
deprecate the use of all the methods of modern research
and treatment. It is always best to know exactly the
facts, and not guess at them from data furnished by the
tongue and descriptions of subjective states. Still Dr.
Dujardin Beaumetz has struck a fruitful topic in a re-
cent lecture on " Minor Methods of Diagnosticating*and
Treating Dyspepsias " {Bulletin g'en'tral de la Tterapeu-
Hque\ Exact science cannot always be applied, he
says, and there exist a number of minor measures which
are always useful and often sufficiently effective. In
order to determine the kind of dyspepsia from which a
patient suffers, he should be made to take a few " test
meals.91 The best meal for this purpose is the breakfast.
This should consist of coffee or tea, with milk and a lit-
tle sugar, and one or two rolls or slices of bread without
butter. The quantity of liquid should always be the
same and never over a pint. With a normal stomach
the repast will be digested unnoticed. If, however, two
hours after eating there is a sense of heat in the stomach,
and a burning and acidity, then the patient is suffering
from hyperacid dyspepsia. If, on the other hand, there
is abundance of gas, a sensation of weight and fulness,
and of food being still in its place, then there is hypo-
acid dyspepsia. When there is at the end of a quarter
of an hour a sensation of epigastric pain, which gradu-
ally increases, then there is probably some gastro-duo-
denal irritation or inflammation. Finally, the patient
may suffer from cramps, pains, and even vomiting, and
then there is probably some muscular and nervous dis-
order of the stomach.
Beaumetz insists that in hyperacidity the heat and
burning are most severe three or four hours after a meal,
and are oftener felt at night between n p.m. and 1 a.m.
In hyperacidity, also, the ingestion of food often relieves
for a time the disagreeable sensations. A knowledge of
the occupation and habits of the patient naturally helps
[November 24, 1894
greatly in diagnosis. Beaumetz thinks that dyspeptics
ought to sleep on the right side, because this facilitates
the passage of food from the stomach into the duode-
num. To promote the same end he advises the drinking
of a cup of very hot water, or preferably, some aromatic
infusion, such as chamomile or anise, etc., an hour or an
hour and a half after eating. He docs not recommend
mineral waters charged with carbonic-acid gas, but does
advise still alkaline waters taken half an hour before
meals in small doses. Finally, massage of the stomach
is recommended, both to stimulate the stomach walls and
the secretion of gastric juice.
THE OYSTER AS A TYPHOID FEVER CAR-
RIER.
A year ago or more, reports were rife of cases of typhoid
fever in Berlin, due to eating raw oysters. Not much
attention was paid to the story at the time, because no
positive verification of it was made.
Quite recently the matter has come up in a most strik-
ing way, through the development of an epidemic of
typhoid fever among the students at Wesleyan Univer-
sity, Middletown, Conn. We give elsewhere a report of
this epidemic which was published in The Evening Post
of November 19th. While we do not, as a rule, place
much confidence in newspaper accounts of medical in-
vestigations, the present one bears the marks of being
carefully written and authoritative. Thirty cases oc-
curred altogether, with one death. All were among
college students who had attended certain society sup-
pers where raw oysters were served. Among the students
who attended other suppers, where the oysters were
cooked, no typhoid developed. The oysters had been
placed by the oysterman in the tide-water shallows of a
river near New Haven. Typhoid fever had been pres-
ent in the family of the oyster grower, his house was near
the river, and his sewage drained into it. This is the
extent of the evidence so far as we can learn. No ty-
phoid bacilli have yet been found in the oysters still
present in the river, but this branch of the investigation
is unfinished.
On the other hand, it is known that typhoid fever germs
do not live in salt-water, and furthermore, it is a fact that
just now typhoid fever is unusually prevalent in certain
parts of New England. Thus, for the week ending No-
vember 8, 1894, the percentage of deaths from this dis-
ease on the total deaths was, in Springfield, Mass., 7.69 ;
in Newton, Mass., 25 ; in Pittsfield, Mass., 33.33 ; in
Newburyport, Mass., 35 ; in Brockton, 12.50, and in
New Bedford, 1 1.76. The percentage in New York was
only 3.00, and in Philadelphia, J..62. There is perhaps,
therefore, some unusually important epidemic influence
that must be taken into consideration.
If one looks over the mortality lists for the different
large cities of this country, he will find that there is no
excessive prevalence among the seaboard cities, where the
raw oyster is consumed in enormous quantities.
The consequences of establishing the fact that the raw
oyster may be a means of propagating typhoid fever,
would be very far-reaching and would affect not only
consumers, but would destroy in a measure an extensive
and important industry. The matter should, therefore,
be investigated with the greatest care.
November 24, 1894]
MEDICAL RECORD.
657
THE SUNNY SIDE OF PHYSIC.
We have discovered in The Lancet, and published else-
where, "The Song of the General Practitioner." Our*
readers will find it a rather lugubrious refrain, yet they
will probably say that it tells the truth. Nearly all
poems on the medical art are written in the same pa-
thetic key. It is always the poor doctor who works
hard and continuously, who never rests or sleeps, or gets
paid for his trouble.
There must be some truth in it all, but the public who
read might legitimately ask why, if the doctor's life is
such a depressing one, do the doctors' ranks continue so
crowded ? The more we deplore our lot, the more do
the youth of the land select it. Is it the spirit of altru-
ism, or is it that in the halcyon days of youth such things
as hard work and poor pay and no final rewards, furnish
no terrors ?
Or is it that the public and the doctor know the pict-
ure to be overdrawn ? We suspect that the latter ele-
ment is a very potent one in directing young men into
the rugged ways of medical life. Some doctors work
hard all the time, and all doctors work hard some of the
time, but all doctors, he thinks, do not work hard all of
the time. Besides, he sees that many of the profession
get comfortable incomes and live in comfortable homes.
They are not waked up every night to drive ten miles in
the darkness and cold. A great many of their bills are
paid ; a great many patients are grateful and loyal, and
sound their favorite physician's praises in a way that is
solacing to vanity and provocative of larger practice.
The average duration of life of the doctor is not quite as
long as that of the clergyman — the good die young, or
at least younger ; but still, if he has good luck, he may
grow old, for some doctors do reach a green age. There
are, in fact, a great many pleasant things in the doctor's
life, and we trust that some time a school of more cheer-
ful medical poetry will arise than that which exists at
present.
THE REFRACTING OPTICIAN.
The optician has given a great deal of trouble to our
medical brethren of Philadelphia. At rather frequent
intervals in the past we have read most denunciatory ac-
counts of his demoralizing and unethical work. Our
esteemed contemporary The Medical News, which gen-
erally discusses the problems of human life with great
philosophy, has little patience with the optician — that is
to say, if he refracts. For it is the so-called R. Os., or
refracting opticians, who are really to blame. We have
been receiving circulars from this class of practitioners in
New York recently and have learned some particulars of
their deadly work. It seems that the R. O. makes the
following examination :
"For hypermetropia, myopia, astigmatism, presby-
opia, heteraphoria, corneal opacities, lens reflex, vitreous,
fundus oculi, and visual acuity."
This really does seem to go beyond the simple limits
of refraction and physics. The R. O. offers to de-
termine the condition of the cornea, of the vitreous, of
the retina, and of the eye-muscles. He offers rather too
much for the price of a pair of glasses, particularly when
the doctor's own family gets them at half-rates.
It may be seriously questioned whether the R. O.
is not practising medicine if he diagnosticates a corneal
opacity or an optic atrophy. He must draw the lines
much more closely or be put in the lists of the unli-
censed.
There is no reason, however, why a modest and genu-
ine refracting optician should not perform a useful ser-
vice to society. Many people suffer from hypermetropia,
myopia, and astigmatism who cannot afford to go to a
specialist. They must, therefore, either rely on their
family physician, go to a dispensary, or to the R. O.
Now we advise such to go to their family doctor and let
him decide whether the optician is sufficient, and we
advise the family doctor never to send his patient to the
refracting optician who proclaims his ability and readi-
ness to diagnosticate almost every chronic abnormality
of the eye.
Utetxrc of tfee W&zzX
The Moxon Medal of the Royal College of Physi-
cians.— The Moxon Medal of the Royal College of Phy-
sicians, for distinguished services in clinical medicine,
has been awarded to Sir William Jenner.
Dr. Timothy M. Ingraham, one of the best-known
physicians in the suburbs of Brooklyn, died at his home
in Flatbush, on November 4th, of cerebral apoplexy.
He was born in Amenia, Dutchess County, in 1821. He
received his collegiate education at Wesley an University,
Middletown, Conn., and the degree of M.D. from the
Vermont Medical College, in 1847.
Typhoid Fever from Oysters.— There is an outbreak
of typhoid fever now at the Wesleyan College in Mid-
dletown, Conn., in which the contagion appears to have
been carried in oysters. According to a despatch in the
Evening Post the story of the disease is as follows:
The first case developed on October 2 2d, the student
being the son of a physician in Vermont. The patient
was taken home and died. This case was followed
rapidly by others — one fatal — until they now number
about thirty. They began to develop about ten days
after the initiations of six societies at Wesleyan, a supper
being given by each. As all the sufferers had attended
these suppers investigation was turned in that direction.
The Middletown city water and also the water from a
well on the campus were examined and both found to be
innocuous. The milk used at the initiation suppers was
next looked into and was found to be perfectly whole-
some and obtained from farms where the conditions
were healthful. It was next found that, while at all six
of the suppers oysters were used, at three only were raw
oysters supplied, and that all the victims had partaken of
them. These oysters were bought from a Middletown
dealer, who obtained them from an oyster grower living
on the east shore of the Quinepiack River, near New
Haven. He, like the many other growers owning oys-
ter establishments on the Quinnipiack, is accustomed to
take the oysters from the deep waters of the Sound and
lay them down before opening for some twenty-four
hours in the shallows of the river. This makes the oys-
ters absorb the fresher water of the stream, swells and
658
MEDICAL RECORD.
[November 24, 1894
whitens them, the technical phrase among the oyster-
men being " giving the oysters a drink." The next dis-
covery was that the oyster-grower's wife had died of
typhoid fever about the time of the outbreak at Wes-
leyan, and his daughter also has been ill of the disease.
His house stands not far back from the river, and its
short drain empties into the latter near the place where
the oysters are bedded temporarily. In addition to the
Wesleyan students there were visitors from Yale and Am-
herst, and two of these, one from each college, are also
ill with typhoid. The same paper from which we have
quoted reports that a gentleman in New Haven recently
gave an entertainment at which raw oysters were served,
and six of his guests are now suffering from typhoid.
The bed of the Quinepiack River is extensively used
for oysters by the growers of Fair Haven and East
Haven, which for many years have been centres of the
Connecticut oyster trade. Many sewers empty into it,
and it is to be hoped that the discovery of the source of
the Wesleyan outbreak may lead to the discontinuance
of the custom of temporary bedding and to taking the
oysters directly from the main beds in deep water.
Dr. Zaeharin's Future.— Dr. Zacharin, the eccentric
Russian physician who attended the Czar Alexander III.
during the greater part of his illness, has not a very
cheerful future to look forward to. The present Czar
Nicholas is said to be so displeased with Dr. Zaeharin's
conduct that he has suggested that he confine his prac-
tice henceforth to Siberia.
A Bon-mot of Dr. Holmes.— Dr. Arthur P. Perry
writes to the Boston Medical and Surgical Journal : " A
bon-mot made by Dr. Holmes at the time one of his sons
was born, was lately written out for me by a physician
who was a student at the time ; and, as it is as good as
all Holmes's sayings were, and I think has never been in
print, I thought it might appear in the Journal. I give
it verbatim as it was sent me. 'In the forties Dr.
Holmes was one of the instructors in what was known as
the Tremont Medical School, which gave instruction to
quite a large number of students between the lecture
terms of the Harvard Medical School. Usually prompt,
we were one day surprised by his non-appearance at the
beginning of the lecture-hour, but we waited. Finally
he entered the room, hurriedly glanced around with a
smile and said, " Gentlemen, I know I am late, but there
is a little stranger at my house." And then with an ex-
pression such as only Holmes's face could assume, he
continued, " Now can any one of you tell me what well-
known business firm in Boston he is like ? " There was
no answer. " He is Little & Brown," said the doctor,
with a twinkle in his eye.' "
Hew Tork State Medical Examinations. — At the
September examinations for State medical license by the
board representing the Medical Society of the State of
New York, the number of candidates was seventy- six, of
whom fifty-one were successful and twenty-five unsuccess-
ful.
Tuberculous Infection in a Laboratory. — We regret
to hear the report that Dr. John M. Byrom, Director of
the Bacteriological Department of the Loomis Labora-
tory, is suffering from tuberculosis which he contracted by
inhaling its germs while engaged in his professional work.
A SuooeMful Operation.— Dr. Pulser : Did you re-
move old Bonder's vermiform appendix ?
Dr. Cutter: Yes.
Dr. Pulser : And was there anything in it ?
Dr. Cutter : A cold two-fifty for me.
The Ceremony of Unveiling the Statue to Claude
Bernard took place on October 28th. Many members
of the Academy of Sciences, and all the professors and
students of the Lyons Faculty, betides many notabilities,
military and political, were present. The statue, the
work of Aubert, a sculptor of Lyons, represents Claude
Bernard in a standing position, holding a lancet in his
hand and inoculating a frog with curare.
Anxiety as a Cause of Granular Kidney. — It is inter-
esting, in relation to the ailment of the Cxar, to recall a
paper read by Professor Clifford Allbutt at the annual
meeting of the British Medical Association, at Sheffield,
in 1876. The subject he took up was " Mental Anxiety
as a Cause of Granular Kidney," and by an analysis of
his case books he showed what an abnormally large pro-
portion of the patients showing symptoms of granular
kidney had been subject to the depressing influence of
prolonged anxiety. He says : " During the last two
years I have made notes of thirty-five cases of gran-
ular kidney occurring in private practice, and I find
a marked history of mental distress or care, or both, in
twenty-four of them." This is a large proportion, even
if we admit that the pushing inhabitants of West York-
shire worry abnormally concerning this world's goods.
Several illustrative cases are given, and one especially in
which as a consequence of an unfortunate investment, a
man, in a good position, for three years " went to bed
night by night ignorant whether he might not be gradu-
ally drained of his all." Dickinson is in some sense in
accord with Allbutt on this question, although not so
positive. Prolonged mental disturbance, anxiety, or
grief as a cause of granular kidney is, he says, " perhaps
problematical ; the mode of its operation is not obvi-
ous, but must be surmised as through the nervous system.
A lowering of nervous force is to be recognized at least
as predisposing to every form of albuminuria. I have
seen so many instances in which granular degeneration
has been immediately sequent upon trouble that, in the
absence of other causes, I am fain to conclude that men-
tal conditions are sometimes concerned in its produc-
tion."— British Medical Journal,
A Hew Method of Producing Local Anssatheaia.—
At the meeting of the Hufeland Society, on October 25th,
Professor Oscar Liebreich presiding, Dr. Schleich read a
paper on, and demonstrated, what he terms a new method
of anesthesia, called " Infiltrations anaesthesie." Dr.
Schleich has for some time made use of this new form of lo-
cal anesthesia, not for trifling operations only, but for com-
plicated ones, such as laparotomy, etc He uses a very
weak solution of cocaine — 1 per mille. The cocaine is
not dissolved in distilled water, Liebreich having shown,
in his inquiry on " ansesthetica dolorosa " that distilled
water injected subcutaneously has a toxic effect ; the sol-
vent used is the physiological salt solution of about half
the usual concentration, that is, about 0.2 to o 3 per
cent, of common salt. Schleich's method is as follows :
A small spot of the skin near the field of operation is ren-
dered insensible by chloride of ethyl, and here a few
November 24, 1894]
MEDICAL RECORD.
659
drops of the cocaine solution are injected. At the spot
of infiltration a bulla immediately arises, which is abso-
lutely without sensation. Pushing the point of the syringe
through this area of insensibility, Schleich again injects a
few drops; another bulla arises close to the first, and
proceeding from bulla to - bulla round the field of opera-
tion the whole is infiltrated and rendered quite anaes-
thetic This is done extremely quickly, as Schleich
showed in the case of a man with a large syphilitic ab-
scess on his arm, who was operated on before the meet-
ing. The man felt absolutely no pain ; and the duration
of the operation, including the anaesthesia, was only
eight to ten minutes. Dr. Schleich said that he had em-
ployed his method of anaesthesia for about three thousand
operations with unvarying success, and without any bad
after-effects. It does not seem to us that the method pre-
sents any great elements of novelty.
A French Congress of Internal Medicine was recently
held at Lyons, October 25th to 29th. The organizers
were MM. Potani, L6pine, and Bard. This is the first
national medical meeting ever held out of Paris, though
Congresses of Surgeons and of various specialists have
had successful meetings for several years. The French
physicians are trying to get away from the complete
dominance of Paris in medical matters.
Massage Establishments and Prostitution.— The Brit-
ish Medical Journal presents a report on London mas-
sage establishments couched in words of what it evidently
considers " decent plainness." One part of the report
is as follows :
" In the summer months the establishments are closed
for the most part. When London fills up again they
become active. We will leave for another article the ex-
plicit statements which we have to make as to the nature
of the practices which go on in many of these places;
but for the present it may be sufficient to state shortly
what kind of place the casual inquirer will find if he goes
for the first time to some of the addresses we refer to.
He will find probably a fiat of four or five rooms, in a
fashionable West End locality. In many cases the es-
tablishment is on the first floor over business premises.
The approach to it is guarded by various arrangements
for privacy. As the visitor enters, an electric bell rings
automatically and he will find himself received in a well-
famished room by a lady of middle age, with a certain
capable air of respectability. She will make no inquiry
as to his name, and probably none as to his complaint.
He will be invited, with little loss of time in prelimina-
ries, to adjourn to a room luxuriously furnished, where
he will find a bed or couch spread with blankets. He
will be informed, unless it is assumed that he knows it
already, that the terms are for an hour a guinea, but that
he can stay as long as he pleases by the same rate. In
some instances it will be suggested to him that it would
be a good thing to have a bath first and massage after-
ward. It will be assumed, as a matter of course, that he
intends to have ' general massage,1 that he will want a
young lady to do it, and that he will undress completely.
Madame will then leave him to his own devices. In
two or three minutes the lady assistant will appear, and
the 'treatment' will be duly administered. He will
not be interrupted, nor, in fact, will he see ' madame '
again until he pays her as he leaves the house. This
state of things in itself will be admitted by everybody to
be sufficiently risky. What it leads to we shall feel it our
duty to indicate with decent plainness in another article."
It does not seem as though any sequel to the above
was really needed. Such establishments are freely adver-
vised in Chicago daily papers, especially since the Lexow
Committee's work.
Hew Medical Colleges. — A new medical college was
organized the other day over in Alabama. Also a new
one at Fort Worth, Tex. About one month ago two
members of the faculty of one of the Nashville schools
resigned their chairs on account of personal differences,
and are now industriously at work " organizing another
school." More schools than this have been established
from no better motive. Out in St. Louis the opening of
a new medical college has gotten to be almost a joke.
In a word, there is absolutely no need for these colleges.
There is every need, God knows, for better medical edu-
cation, but the way to accomplish it is not by increasing
the number of colleges. Since 1880 there have been
more than fifty medical schools chartered in this country,
a great many more than there was any necessity for.
Fortunately several have died. There are 1 1 0,000 doctors
in the United States. More than 3,000 belong to the
faculties of medical schools. Of this number Ohio, with
16 schools, contributes 408 ; New York, with 12 schools,
540; Missouri, with 16 schools, 405; Maryland, with 7
schools, 170; and Tennessee, with 8 schools, 160, etc.
In all we have one medical school for every 43°>000 °*
our population, or one for every 730 physicians. — Atlanta
Medical and Surgical Journal.
Safeguards against Smallpox.— Dr. J. M. Worth-
ington, health officer of Anne Arundel County, says the
county has adopted a complete system to detect the ap-
proach of small-pox and to prevent the spread of the
contagion. He said : " To provide against an epidemic
of small- pox the county commissioners, at a recent meet-
ing, appointed two vaccine physicians for each election
district, making fourteen for the county. With tbis
wise provision it would be difficult to have a case in the
county without its being at once known and attended
to. Isolation, disinfection, and vaccination are the
best-known means to lessen the disease. The family
physician is the man of all others to commence the
work, and if he does his duty there will be little occasion
for panic or alarm. As a rule, he knows what to do and
how to do it. In some special cases he may need the
assistance of the district vaccine physicians for the poor
and unprotected. He 'should at once notify the health
officer of his county, whose duty and pleasure it would
be to report to the State board of health. It should be
a rare case of emergency or necessity to appeal for aid
or comfort to the Surgeon-General's office at Washington,
D. C. A recent notable small- pox scare, affecting the
family and their physician, a man of ability and high
personal character, could have been nipped in the bud.
A messenger on foot or horse, a railroad, double track,
all-steel rails, United States mail, telephone, and tele-
graph, all should have been exhausted to reach the doc-
tor and ascertain the facts before the slander was spread
upon the wings of the wind."
Errata. — Dr. R. Abrahams writes: Will you kindly
correct the following misprints in the Record of Novem-
66o
MEDICAL RECORD.
[November 24, 1894
ber 10th. Page 604, first column, fifteenth line from
top, read " tabular " for " tubercular." On the same
page, twentieth line from bottom read " observers " for
" observer/' Page 599, second column, ninth line from
bottom, read " grave " for " great"
Randall's Island Hospitals, Hew York.— Dr. Charles
W. Allen has been appointed Visiting Dermatologist to
the Randall's Island Hospitals.
Professor Dr. Klebs, of bacillus fame, is on a visit
to this country, and is at present the guest of Dr. Karl
von Ruck, of Asheville, N. C.
longevity. — Our esteemed contemporary The An-
nals of Hygiene makes the astounding assertion, in its
issue for July of this year, that one person out of every
four thousand born reaches the age of one hundred
years. This may be so in the home of our contempo-
rary, but elsewhere life is too rapid for any such blissful
extension of it as this.
" The Burst-up of listerism M is the way Dr. Donald
Campbell Black, of Glasgow, speaks of the modifica-
tions which have taken place in the practice of antiseptic
surgery. He apparently harbors no kindly feelings for
Sir Joseph Lister, though at this distance we are unable
to guess the cause of his enmity. He relieves his mind
in a long tirade against the one to whom, more than all
others, the world owes the principle of antiseptic surgery,
and closes with the following splenetic deliverance :
" I read in a recent number of an influential medical
contemporary that Sir Joseph Lister had been awarded
the Albert Medal of the Society of Arts ' for the discov-
ery and establishment of the antiseptic method of treat-
ing wounds and injuries (what is this?), by which not
only has the art of surgery been greatly promoted and
human life saved in all parts of the world, but extensive
industries have been created for the supply of materials
for carrying the treatment into effect.9 If it be
' science ' to give a transient impulse to the manufact-
ure of ' putty ' and calico, then I have certainly misin-
terpreted the term ' science ' during all the years that
I have lived."
A Medioal Library Association has been recently or-
ganized in Grand Rapids, Mich. The purpose of the
Association is the formation of a reference library upon
medicine and allied sciences. The new organization
starts out with a membership of about fifty. One of the
features of the Association will be the admission of non-
residents to membership, whereby for a small annual fee,
physicians outside of the city may avail themselves of the
advantages of the library. A competent librarian will
be secured, and the most approved methods of catalog*
uing and indexing will be made use of. Books and jour-
nals are being liberally donated by those interested in
the project, and the success of the enterprise is assured.
The following officers have been elected: Dr. G. K.
Johnson, President; Dr. S. G. Milner, Vice President;
Dr. W. A. Dorland, Treasurer; Dr. Reuben Peterson,
Secretary.
South Carolina State Medioal Examining Board. —
The second meeting of this Board, created by act of the
Legislature in January last, was held at Columbia, Octo-
ber 9 th and 10th. Of fourteen candidates four were re-
jected. The next meeting of the Board will be on the
fourth Tuesday in April, 1895. Anyone wishing to enter
the State to practise, between the meetings of the Board,
must appear before the chairman and secretary to be ex-
amined, and upon their being satisfied as to his qualifi-
cations will issue to him a temporary license, which
license is only good until the next meeting of the Board.
The Secretary of the Board is Dr. C. F. McGahan, of
Aiken, S. C.
Cannot Experiment on the Body of Wilson, the Murder-
er.— Attorney-General Hancock has written an opinion
in answer to an inquiry from Governor Flower in regard
to the resuscitation of Wilson, the murderer. The opinion
says : " In my judgment neither the Governor of the
State, the Superintendent of State Prisons, nor the War-
den of Auburn Prison has authority to deliver the body
of a convict, after the execution of the death penalty and
a post-mortem examination, to Dr. Gibbons or any
other individual not a relative of the person executed.
If the body is not claimed by a relative, it becomes the
duty of the authorities in charge to bury it, and not to
deliver the same to any individual for the purpose oi
experiment."
The H6w Tork Society for the Belief of Widows and
Orphans of Medioal Men elected these officers lately :
President, Dr. Ellsworth Eliot ; Vice-Presidents, Dri.
David Webster, J. H. Emerson, and Charles H. Teale;
Ireasurer, Henry Tuck. President Eliot said that tie
funds of the Society had been increased almost $60,000
in the past year.
The Mew Tork Pharmaceutical Club. — Fifty mem-
bers of the Pharmaceutical Club sat down to their first
Club dinner at 7 p.m., November 21st, in their pretty
new rooms at 37 East Nineteenth Street No papers
were read nor speeches made. The Club was incorpo-
rated in August, and has now one hundred and sixty-five
active members. Its membership will be limited to the
number of pharmaceutical men in good standing in the
drug business who care to join.
Papers on scientific subjects connected with the drug
business will be read every Thursday. The officers are
as follows : President, Robert J. Bell ; Vice-President,
John W. Bachelder; Treasurer, Frank A. Barnes; and
Secretary, Velie A. Wood.
The Proportion of Successful Candidates in the Med-
ioal Staffs of the Army and Havy. — During the year
ending June 30, 1894, thirty-seven candidates for the
medical staff of the army received permission to appear
for examination before the Medical Board ; of this num-
ber five were found qualified. In the navy, thirty can-
didates were invited to come up for examination, of which
number three only were found qualified physically and
professionally for appointment to the rank of assistant
surgeons. There are eight vacancies in the naval medi-
ical staff; in the army medical staff there are none, ow-
ing to the action of Congress in reducing the number of
assistant surgeons to one hundred and ten.
Br. Beid Alexander, of Topeka, Kan., died in that
city, in October, of perforation of the bowel. He was a
graduate of the Medical Department of the University oi
Pennsylvania, in the Class of '85, and at the time of his
death was President of the Topeka Academy of Medicine
and Surgery.
November 24, 1894]
MEDICAL RECORD.
661
NEW YORK ACADEMY OF MEDICINE.
Stated Meeting, November 1, 1894.
D. B. St. John Roosa, M.D., President, in the
Chair.
Perkins'i Tractors. — Mr. Isaac Wood, of Rah way, pre-
sented to the Academy, through the Chairman of the
Library Committee, Dr. Grandin, a set of Perkins's
tractors, an instrument at one time in use for the cure of
disease.
Wanted, $100,000; Half of it Immediately.— Dr.
Grandin reported gifts of books to the library since
last spring. He then added that the term of office of
the present Committee on Library was about to expire,
and they wished before retiring to make another -urgent
appeal to the public for an endowment fund. The
library was as free to the use of the public as to the pro-
fession, yet the latter had out of their own pockets
erected the best stack room in the country, and the pub-
lic, especially the wealthy portion, were now urgently
invited in their own interest to contribute before the
first of January 150,000 of the much needed endowment
fund of $ 1 00,000 dollars.
Library Hours Lengthened. — The library will here-
after be kept open until 10.30 p.m., until time 'shall show
whether use after 10 p.m. will justify the added expense. '
Question of Dues. — Dr. A. M. Jacobus gave notice on
the part of the Council of an amendment to the by-laws,
providing for reduction of dues of members residing in
the State, but outside of the counties of New York,
Kings, Queens, and Westchester, to $5 a year, the dues
in the counties named remaining as at present, $20 a
year. The unfairness of taxing the more distant mem-
bers equally with those residing near the Academy, with
its library, was self-evident.
The President announced that the anniversary dis-
course would be delivered by Dr. Charles L. Dana,
Wednesday evening, November 28th. The profession
who have friends among the public who may feel some
interest in the Academy are requested to send their names
to the Librarian, Mr. Browne, who will forward them
cards of invitation. This, the President said, was one
means for making the public acquainted with the work
of the Academy and with its invaluable services to it. It
was wonderful how little most of the sixteen or eighteen
thousand citizens who, out of the total two millions, con-
stituted the generous donors to worthy public purposes,
knew about the Academy. If they were informed of its
catholic spirit, of the fact that it was not a private med-
ical school, that it was established in the interest of the
public welfare, and opened its library to the use of all, he
thought the endowment fund for which the Chairman of
the Library Committee had made so eloquent an appeal
would be forthcoming at once.
Intra-lobular Occlusion Jaundice. — Dr. William H.
Porter read a paper with this title, which implied that
the jaundice was due to occlusion, but not to a form of
occlusion, such as pressure by a tumor, after the bile had
entered the bile-ducts. In order to elucidate the subject
he outlined the minute anatomy of the hepatic lobules,
the mechanical processes connected with the secretion of
the bile, and also his views of the chemical and physio-
logical processes involved in the same act. To start
with, he rejected the old explanation of jaundice, based
on the view that the constituents of the bile were reab-
sorbed into the blood.
The mechanism connected with the production of bile
was based on the minute anatomy, as already suggested.
Masses of protoplasm in the form of epithelial cells in
the acini by virtue of a function peculiar to themselves
secreted the bile from the blood brought to the locality
through the portal system, the bile thus secreted enter-
ing the radicles of the bile ducts, and being finally car-
ried to the duodenum. The bile was made from proteid
compounds, during which oxygen brought from the
lungs consumed carbohydrates and evolved heat, and it
was by the influence of the heat that the nerve-terminals
were stimulated and enabled to perform their function.
During the act the cells were alternately swollen and re-
laxed, but when abnormally irritated by toxic agents,
such as might gain entrance to the portal circulation in
the form of chemicals or bacterial products, they remained
unnaturally congested, their nutrition was impaired, their
function interfered with, and they underwent retrograde
metamorphosis. In this abnormally swollen state the
masses of protoplasm were forced into the primary radi-
cles, which thus became occluded. As it had been proven
that the blood- vessels could not absorb the biliary con-
stituents, there remained but one channel through which
they could enter the circulation, namely, the lymphatics.
Passing from the hepatic lymph- channels into the tho-
racic duct, they finally reached the general circulation
and were carried to the different parts of the body, and
unless eliminated they stained the tissues and caused jaun-
dice and pathological changes in other organs. The
kidneys took a principal part in the elimination of the
bile constituents. There might be various degrees of
intra-lobular occlusion jaundice, depending upon the
amount of toxic agents absorbed from intestinal indiges-
tion and decomposition, etc., and the chronicity of the
case would depend upon the continuation of the active
cause and the change induced in the liver-cells. There
was never complete occlusion of all the biliary radicles,
but often sufficient to cause various degrees^f jaundice.
The diagnosis of this form of jaundice was to be made
by excluding other forms of mechanical obstruction ly-
ing between the biliary radicles and duodenum. The
prognosis was usually good in acute cases, especially in
persons of good general health whose attack had been
brought on by temporary indigestion. Where the kid-
neys were badly damaged, the prognosis was unfavor-
able. Much depended upon the treatment
The author followed the circle of injurious results of
intra-lobular occlusion jaundice, a chief one being the
depriving of the intestine of a fluid necessary to perfect
digestion and antisepsis — the bile. The nutrient pabu-
lum going to the various organs of the body became in-
termixed with a toxic principle which interfered with
their proper nutrition, a fact which gave one indication
in treatment. One must look to the diet, to artificial
digestives, to intestinal antisepsis, to sunlight and exer-
cise, to hepatic stimulants, to the excretory functions.
The digestive system must not be overtaxed by either too
much food or food of wrong quality. The author had
found by experience the following diet suitable to many
cases, according to their severity : For breakfast, two
ounces of wheat bread, two eggs, eight ounces of milk,
with a little butter, making a total of fourteen ounces.
For the mid-day meal, three ounces of wheat bread, a
little butter, seven ounces of meat. In the evening, two
ounces of wheat bread, a little butter, eight ounces of
milk, seven ounces of meat. Before retiring, eight ounces
more of milk. If milk could not be tolerated, use a fer-
mented milk. Fruits and vegetables should be avoided
because they were prone to excite, by their fermentation,
abnormal decomposition of proteid compounds and de-
velopment of toxic substances.
Artificial digestion for a time within the alimentary
canal was best aided by ox-gall and pancreatic extract
given before meals, and hydrochloric acid and pepsin
after meals. In some cases an additional intestinal anti-
septic might be called for. Give some laxative or car
thartic to overcome constipation and prevent toxic ab-
sorption. Sluggish action of the heart and circulation
was to be met by muriate of caffein and strychnia. The
biliary radicles were best reached by calomel or bichlo-
ride of mercury and arsenic.
Dr. Alfred L. Loomis was called upon to open the
discussion. He believed Dr. Porter had presented to us
the more advanced, the more recent views with re-
662
MEDICAL RECORD.
[November 24, 1894
gard to the histology and physiology of the hepatic lob-
ules, and he had no criticisms to make on that part of
the paper. When it came to the general question of
jaundice, of course we were entering upon a subject
which had been discussed from very different stand-points
and with very different ideas in the minds of those who
had token put. From the time that he began its study
as a medical student, it remained obscure to him until he
•came to take the position, as he did long ago, that there
was no jaundice which was not obstructive. He be-
lieved that was the position which we were compelled to
take even today. The question then arose, just where
was the obstruction in any given case? It might be out-
ride the liver, it might be internal, along the larger ducts,
and it was difficult to exclude obstruction at times along
•the smaller ducts. For instance, there might be a ca-
tarrhal jaundice without evidences of catarrh on the in-
testinal side of the duct, in which event it would be diffi-
cult to say just where or how far up the catarrh existed.
Regarding infectious jaundice, it had seemed to him
for a number of years that the only satisfactory explana-
tion lay in the hypothesis that the function of the liver-
-cells was interfered with in some way. He need only
•mention the different forms of degeneration of the liver-
cells, and would say that the author's explanation of the
manner in which these cells obstructed the radicles
seemed clear and satisfactory; that is, that the cells
themselves became the obstructive cause of the jaundice,
and that when, such obstruction arose jaundice was
brought about by the entrance of bile-products into the
circulation* through other channels than the hepatic
ducts, and by other means than reabsorption into the
blood. The symptoms of such obstruction were made
•evident by influence on the nervous system and in icterus
before local changes took place in special organs, as in
the kidneys.
While listening to the reading of the paper the query
had suggested itself to his mind whether in all forms of
obstructive jaundice, including cases in which the obstruc-
tion was in the larger ducts, the icterus was not prima-
rily due to obstruction at the radicles of the hepatic duct
He had noticed that in chronic jaundice, jaundice which
had continued for years, the chief change, according to
-his observation, had related to connective tissue develop-
ment shooting down from the surface into the centre of
the lobules like a framework, and attended by corre-
sponding changes in the liver-cells. He was, therefore,
-of the impression that in jaundice occurring in connec-
tion with interstitial hepatitis or some other diseases of
the liver, the change leading to the jaundice began in
•the radicles and that the secondary changes were in the
connective tissue.*
Dr. Loomis could confirm all Dr. Porter had said with
^regard to diet being the most important factor in the
treatment of these cases, yet it seemed to him that hardly
-sufficient stress had been placed on oxidation. He be-
lieved from clinical observation that all patients with
'jaundice did best when most in open air and sunlight.
As to diet, he thought quantity as important as quality.
He did not like plain milk, as a rule, but buttermilk or
milk which had been made to undergo some fermenta-
tive change. Patients had not digested plain milk so
well. With life in sunlight and open air at a moder-
ately high altitude, say from fifteen to twenty-five hun-
-dred feet, and away from the sea, it was wonderful how
-rapidly some cases of jaundice would improve.
The Theory Insufficient.— Dr. Andrew H. Smith
was unable to explain certain cases of jaundice which he
-could recall on the theory advanced in the paper, that it
was entirely intra-lobular. In fact he could not recall a
case of considerable intensity in which he was able to
accurately limit the process intra lobular, or to differen-
tiate between other forms of jaundice and that which
was supposed to be strictly intra lobular. Perhaps he
might in the future, since his attention has been spe-
• daily directed to it. It was difficult to him to grasp the
two ideas at the same time, that the bile was formed in
the hepatic cells, and that jaundice was due to disorgani-
zation of those cells. We saw in yellow atrophy of the
liver, for example, very rapid destruction of the liver-
cells and substance, and yet a great degree of jaundice,
as if bile production was very active at the very moment
that it was destroyed. It seemed to him that in many
instances the question was chiefly one of nervous influ-
ence, one which a chemical formula would hardly reach.
A large amount of bile, say a pint and a half, was
secreted by the liver every twenty-four hours, and while
much of it passed out with the faeces, yet not a little
entered the circulation. Notwithstanding this, die col-
oring matter of the bile did not appear in the urine
under ordinary circumstances. There must be some
process by which the bilirubin and biliverdin were rap-
idly destroyed. It seemed to him that there was as much
opportunity for the production of jaundice, the appear-
ance of bile at the surface, from some interference with
the destruction of the bile after it had entered the circu-
lation as by some change taking place in the hepatic
structure. It was difficult to account for the sudden oc-
currence of jaundice under certain circumstances, as
mental emotion, on the theory advanced in the paper.
There was a very marked nervous impression, and this,
perhaps, caused some disturbance of the vasomotor sys-
tem of the liver, with less degree of tension in the blood-
vessels of that organ than in the bile-ducts, under which
circumstances there might be transferrence of bile from
the ducts into the capillaries. This, however, was mere
supposition, and was difficult of absolute demonstration.
If the rules offered with regard to diet and medication
were intended to apply only to cases of what we had
been accustomed to consider catarrhal jaundice lasting
some weeks, Dr. Smith had no criticisms to make, but he
thought more latitude could be allowed in jaundice of
less degree, and especially in so-called biliousness.
Heptogenous versus Hssmatagenous Jaundice. — Dr.
R. C. M. Page said jaundice was usually described as
of two forms, heptogenous and hematogenous. The
latter was claimed to be due to disintegration of blood-
corpuscles and the transformation of their coloring
matter into bile pigment. Now, bile is formed in the
liver, and as it exists there in health there is no jaundice,
but if from any cause it is retained in the liver it is ab-
sorbed by the lymphatics, passes along to the thoracic
duct and general circulation and produces jaundice of
most of the fluids and tissues of the body. This reten-
tion of bile is due to obstruction. The mode of ob-
struction in many cases is very readily understood — for
instance, in catarrh of the bile-ducts, in the presence of
gall-stones, of neoplasms. But the cause is not so ap-
parent in some other conditions, as in suppurative pyelo-
phlebitis, icterus neonatorum, acute yellow atrophy, phos-
phorus-poisoning. But even in these cases there is
probably obstruction to the escape of bile from exten-
sion of inflammation to the bile-ducts, or else the ducts
become stuffed with desquamative epithelium, or both
conditions may act, for the expulsive forces of the liver
are so very feeble that it requires but a slight amount of
resistance to produce retention. True jaundice depends
upon coloring matter of the bile which has entered the
circulation, and this entrance into the circulation is
probably due in all cases to obstruction, although the
obstruction may not be fully apparent in rare instances.
If this be so, it is manifest there is no such thing as he-
matogenous jaundice.
Some closing remarks were made by Dr. Porter.
Women in the Scotch Universities. — By a recent or-
dinance of the Scottish University Commission the uni-
versities are empowered to throw open to women such
open bursaries, scholarships, and fellowships as they may
see fit.
The Mecca Pilgrimage in 1893 was much larger than
usual, aggregating over 350,000 souls. Of this number
25,000 died, most of them from cholera.
November 24, 1894]
MEDICAL RECORD.
663
THE NEW YORK PATHOLOGICAL SOCIETY.
Stated Meeting, October 10, 1894.
George C. Freeborn, M.D., President.
Typhoid Fever with an Unusual History. — Dr. George
P. Biggs presented specimens from a case of typhoid
fever, which was chiefly interesting on account of the
peculiar clinical history. The subject of the report was
an Italian woman, aged nineteen, and married, with a
negative family history. About two weeks previous to
her admission to the hospital she had been taken with
prostration, headache, pain in the back and abdomen,
and was so ill as to be confined to bed. She felt fever*
ish and constantly hungry. Four days before admission
there was quite a profuse hemorrhage from the bowel,
and two days later she aborted at the third month. A
few days after entering the hospital the physician who
had attended her previously called at the hospital, and
said that one week before the abortion an attempt had
been made to produce abortion, under the impression
that the chill that she had had was a convulsion. It had
been so reported to him by the friends. At the time of
her admission her temperature was 104. 6° F., the res-
pirations were 28, and the pulse 128. Physical exami*
nation revealed nothing but a few riles over the lower
lobes posteriorly. The heart sounds were normal, and
the heart action, though rapid and feeble, was regular.
The spleen did not appear to be enlarged. She was ex-
cessively anaemic. The urine had a specific gravity of
1,018, and contained five per cent, of albumin, but no
casts. On the day following her admission there was a
decided chill, and a subsequent rise of temperature to
1060 F. An intrauterine douche was given, and a
number of old blood-clots removed from the uterus. On
the following day she was curetted, and a portion of tis-
sue, supposed to be the remains of the placenta, also re-
moved. The discharge from the uterus was moderate,
and was without odor ; but with the history, and with
the chills and fever, it was thought probable that her
symptoms were due to sepsis. On the third day of her
stay in the hospital there was a hemorrhage from the
bowel, similar to that which is observed in typhoid
fever, and that night she had a severe chill. She was
more than ever prostrated the next day. Hie urine
had a specific gravity of 1,009, an^ contained two per
cent, of albumin and granular casts. She died one week
after admission, and just three weeks from the onset of
the first symptoms.
The lesions at the autopsy were found to be those of a
typical case of typhoid fever. The spleen was about
three times its usual size. The intestinal glands were
greatly enlarged. The typhoid ulcers were limited to
the lower two feet of the ileum, and were particularly
prominent in the last nine inches. There were also a
few typhoid ulcers in the ascending colon, and these
were quite superficial. The mucous membrane at this
point was much congested, and there were small hemor-
rhages. Some of the ulcers in the small intestine were
quite deep. The body of the uterus was cauterized with
a hot iron, and a culture taken from the interior of the
organ. The result was a pure culture of a bacillus
which appeared to be identical with those obtained from
the spleen. The uterus was about ten centimetres in
length, and six centimetres in breadth at the middle. Its
interior surface was covered with a whitish fibrinous mate-
rial. The cavity was entirely empty. The peritoneum
was normal, as were also the ovaries and Fallopian tubes,
showing clearly that there had been no septic process
originating in the uterus. A very marked atheromatous
patch was noted in the aorta. The other organs showed
well-marked parenchymatous changes, passing into fatty
change. This was particularly noticeable in the heart
and liver. In the latter organ there were also some pe-
culiar yellowish areas, the exact nature of which had not
yet been determined. They were located in the centre
of the lobules, and from an examination of a frozen sec-
tion they appeared to be composed of a few fiat globules
and of granular detritis.
General Tuboreulosis. — Dr. Biggs then presented
specimens from a case of general tuberculosis. The
specimens were removed from a woman, forty- seven years
of age, who had been admitted to the New York Hospi-
tal on May 16, 1894. For one year previous she had
had constant pain in the left hip with a sense of numb-
ness of the left thigh. For six months the severity of the
pain had steadily increased. Examination under ether
showed a mass about the size of a duck's egg in the left
iliac fossa. It was quite tense and immovable. On ad-
mission the temperature was 98. 40 F., the respirations, 24,
and tihe pulse, 76. The urine was alkaline, had a spe-
cific gravity of 1,016, and contained a trace of albumin
and a few leucocytes. Under ether a four-inch inci-
sion was made just above and parallel to Poupart's liga-
ment on the left side. This led the way to an extra-
peritoneal collection of fluid in the left iliac fossa. On
incision six ounces of a dark-greenish fluid escaped. The
cavity was washed out and packed with gauze. No con-
nection between the cyst and the other parts could be
detected. The fluid was not examined, The pain was
relieved by the operation. On June 25th she menstru-
ated. By the time the wound had nearly closed, July
5th, she was again complaining of much pain. The
wound was re-opened, and with the finger in the rectum
another mass was felt quite low down. A similar collec-
tion* of fluid was evacuated, and the same treatment
adopted. The first cyst had apparently disappeared by
this time. The urine was then found to be free from
albumin, but it contained hyaline casts. The pain was
once more relieved by the operation. On July 30th
another accumulation of fluid was evacuated. On August
4th it was noted that the left leg was quite markedly
adducted and rotated inward, and that it was partially
flexed, with a shortening of the limb on that side of one
inch. The pain was now worse, and the discharge from
the old sinus quite profuse. On August nth this sinus
was explored, and a distinct, harsh crepitation felt on
moving the thigh. The finger could be passed into the
hip joint. The head of the femur was found to be bare,
and considerably eroded. The patient's temperature at
that time was as high as 1030 F. in the evening. On
August 19th some oedema of the right leg and foot was
noted The oedema increased, and she filially died on
October 9th.
The first specimen presented, the hip- joint, showed
that the floor of the acetabulum had been entirely des-
troyed, and that the opening so made communicated
with a large collection of pus. The lining of the acetab-
ulum was extensively infiltrated with partially necrotic
tubercular tissue. The head of the femur was also ex-
hibited, and was shown to be deeply eroded. There was
a large abscess extending up behind the peritoneum as
far as the diaphragm on the left side, and as far as the
spinal column on the right side. Another abscess ex-
tended down on the inner side of the pelvis between the
layers of the broad ligament. Then there were ab-
scesses burrowing down into the thighs. The pus was
rather thin and mixed with blood. There was another
collection of about two ounces of thick cheesy pus in
the median line in the pre- vesical space. The mucous
membrane of the bladder was considerably thickened
and congested, and there were a few points of hemor-
rhage. Its whole surface presented a more or less granu-
lar appearance. In the trigone were two perfectly dis-
tinct tubercles. The uterus was of about the normal
size, and contained three perfectly characteristic fibroids
about the size of hickory nuts. The mucous membrane
of the upper two-thirds of the body of the uterus was
covered with a yellowish- white cheesy layer characteristic
of tuberculosis of the endometrium. The posterior wall
of die vagina contained one small nodule about three
millimetres in diameter, and this, on incision, was found
to contain some material apparently tubercular, although
the presence of tubercle bacilli had not yet been demon-
664
MEDICAL RECORD.
[November 24 1894
strated. The tabes were larger and harder at a distance
from the uterus, and were filled with cheesy matter.
The ovaries were distinctly atrophied, and while the
tubes were adherent to them there was no evidence of
tubercular matter in the substance of the ovaries. There
were no symptoms referable to the condition of the gen-
ital organs. There were typical tubercular deposits
scattered through both lungs. The bronchial glands
were deeply pigmented, but contained neither cheesy
nor calcareous matter. The liver was extremely fatty.
In spite of the rather prolonged suppuration, none of
the organs gave a reaction with iodine. A nodule was
found in one of the suprarenal capsules, which was prob-
ably tubercular in its nature. It was fibrous rather than
cheesy, and was situated superficially in the suprarenal
capsule. The intestines showed no tubercular lesions.
The peritoneal cavity contained no fluid, and the peri-
cardium and pleura were perfectly normal.
Marked Atheroma of the Aorta. — Dr. Biggs also pre-
sented a specimen of marked atheroma of the aorta.
The specimen had only been removed late that afternoon
by autopsy from a man dying with uremic symptoms.
The kidneys showed rather advanced chronic diffuse
nephritis. No special lesions were found except in the
aorta, which, in the lower portion, showed a large number
of greatly softened areas, some of them measuring as
much as 2 ctm. in diameter, and apparently on the point
of rupture.
Dr. Biggs, in answer to a question from Dr. H. P.
Loomis as to what he considered the primary lesion in
the case of tuberculosis, replied that the lesions in the hip
and genital organs appeared to be of longer standing
than those in the lungs. Personally, he thought primary
tuberculosis of the genital organs was not very rare.
Da. R. H. SAYRSsaid that the lesions in the lungs and
genital organs seemed to him much more recent than
those in the hip, and certainly the clinical history seemed
to point to primary disease in the hip.
Dr. Biggs asked what would then be the explanation
of the tuberculosis in the hip.
Dr. R. H. Sayrb said he did not think anyone had
offered a satisfactory explanation of the common clinical
fact of tuberculosis of the joints without apparently any
prior tubercular lesions. There were various autopsies
on record where, so far as the gross appearances went,
there were no evidences of tubercular processes in the
lungs, vet there were quite well marked tubercular proc-
esses in the organs. Virchow had reported several
such autopsies. He saw no reason for assuming that
tuberculosis must come through the lungs.
Dr. J. S. Ely thought there was another way of ex-
plaining a primary tubercular process in the internal
organs where it occurred in relatively young persons, and
that was by direct transmission of the tubercle bacilli
from the mother to the foetus. It had been demonstrated
experimentally, and inferred from these experiments, that
the lesions might lie dormant for four or five years. It
was known that under certain circumstances, germs
might remain quiescent in the body for a long time, and
then become active. Fraenkel had reported a case sev-
eral years ago, in which a deep abscess had developed a
year after a typhoid fever, and in which the typhoid
bacillus was found by cultivations. In Vienna not long
ago a case of osteo myelitis had been reported where
careful search revealed no fresh source of infection, but
where thirty-five years after a previous osteomyelitis
there was a fresh outbreak in the same spot. On chisel-
ling away the bone a layer of fresh pus was found contain-
ing the staphylococcus pyogenes aureus. It was sur-
rounded by dense bone, which had probably encapsulated
the bacteria thirty-five years before. Now, it was pos-
sible that the hip, in the case under discussion, had
become infected many years before any real outbreak of
tuberculosis had been manifested by physical signs. It
seemed to him that the hip was the primary source, but
he also believed that the point of entrance of the tubercle
bacilli was the lungs. A strong argument to him was
the much greater frequency with which the bacilli
entered the lungs than elsewhere.
The President said that not long ago he had had
sent to him for examination a portion of tubercular tis-
sue taken from a female nurse's arm. During labor, her
arm had been gripped very strongly by the patient, and
some time afterward small nodules had developed sub-
cutaneously at this spot. On examination, he had found
the typical lesions of tuberculosis, as well as tubercle
bacilli in the lesions. Three or four specimens were
taken. More recently he had learned that there had
been a diffuse tubercular inflammation of the cellular
tissue of the arm. The patient appeared to be perfectly
healthy. It was thought that the lymph nodes in the
arm had contained some of these bacilli, and that the
gripping of the arm, by rupturing these nodes, had set
free these germs, and had enabled them to become active
as a result of this traumatism.
Dr. H. P. Loomis recalled an autopsy made about
three years ago on a prize-fighter. He had died of acute
pneumonia. The autopsy showed the lungs normal,
with the exception of the pneumonia, but there was a
large bronchial gland which contained typical tubercle
bacilli in large numbers, and also typical tubercular le-
sions, showing that these germs might be stored up in
the body for a long time without manifesting them-
selves.
Dr. W. G. Hudson presented a microscopical speci-
men for an opinion as to its nature.
Dr. H. P. Loomis expressed the opinion that the
specimen was undoubtedly one of tuberculosis.
Tumors from Dogs were presented by Dr. J. S. Ely.
The first tumor was an ecchondro-osteo-sarcoma of the
mamma of a bitch. The specimen was taken from a
thoroughbred Irish spaniel belonging to Dr. Furman.
Last March this animal had a litter of seven pups. One
of them nursed persistently on the left nipple. Shortly
afterward several lumps developed in this mamma, which
were lanced by Dr. Furman, and pus evacuated. Three
months before the tumor was removed it had become so
large as to be troublesome.
The second tumor, of which a microscopical specimen
was also presented, was a carcinoma of the skin, situated
on the lower surface of the tail of a dog, about one inch
from the root of the tail. These tumors, the speaker
said, sometimes developed from the peri-anal glands, but
in this case there was no connection with the trunk.
The tumor was dense and lobulated.
The speaker said that Bland Sutton, in his introduc-
tion to general pathology, had treated at considerable
length of tumors, yet he had not mentioned carcinoma
as common in the dog. In a recently published article on
tumors in some of the lower animals, 38 tumors were de-
scribed as having been observed in dogs, viz., 16 were
adenomata, 9 were carcinomata, 2 epithetiomata contain-
ing " pearls," and n were sarcomata.
Ovarian Tumor. — The President presented a portion
of ovarian tumor showing electro punctures. The growth
had been removed from a woman, forty-six years of age.
The history of the growth extended over a considerable
number of years. She had been under treatment in Lon-
don for a long time, and while there one hundred and
thirteen electro-punctures had been made during a period
of a year and a halt The tumor, nevertheless, continued
to grow. She entered the hospital service of Dr. Bache
Emmet, and on April 10, 1894, he removed the tumor
piecemeal. It was attached to the left horn of the ute-
rus. The woman died of shock. The tumor was a large
lobulated mass, the central portion of which was a rather
large cyst. The greater part of the cyst was composed
of fibrous tissue. There were evidences of smaller cysts
in the wall. Microscopical examination showed the tu-
mor to be a fibrosarcoma. The spots, which from their
gross appearance were at first supposed to be hemor-
rhagic spots, were really areas of necrosis. Scattered
through the tumor were calcareous masses. The clinical
record was unfortunately very incomplete.
November 24, 1894]
MEDICAL RECORD.
665
OUR LONDON LETTER.
(From our Special Correspondent)
THE MEETING OF THE COLLEGE OF SURGEONS — REFUSAL
TO THANK THE COUNCIL — CHELSEA HOSPITAL AGAIN —
COVENTRY DISPENSARY — CLINICAL SOCIETY — SUBDIA-
PHRAGMATIC ABSCESS COMMUNICATING WITH PLEURA —
CHLORAL POISONING.
London, November 3, 1894.
The annual meeting of the Fellows and members of the
Royal College of Surgeons was held on Thursday, and
gave one more occasion for a protest on behalf of the
members. This protest, however, will no doubt, as
usual, be calmly disregarded by the Council. The Pres-
ident opened the proceedings with a few remarks on the
Report for the year, which had been already circulated.
Then Mr. Joseph Smith, who had given notice of the
oft- passed resolution that members should have a voice
in the election of the Council, rose and said that he re-
gretted no hope of redress had been held out by the
President. His motion had been passed by several suc-
cessive annual meetings, but it had never been acted
upon. This year the notice was pronounced not quite
in order, but the President and Council had permitted it
to be brought forward. Mr. Smith, however, declined
to accept any grace in the matter, holding that the dig-
nity of the members demanded the right to discuss their
affairs in a manner consonant with the propriety of pub-
lic meetings. He therefore withdrew his motion. There-
upon a resolution in somewhat modified terms was moved
and seconded. After some discussion it was carried by
twenty- five votes to eight. In the course of discussion
the President said he was the son and grandson of a gen-
eral practitioner, and that every Fellow was a member,
though how that affected the claims of members who
were not Fellows he did not explain. Mr. T. Smith de-
clared it would be ungraceful for the Council to try to
deprive Fellows of their privileges. In that objection is
the gist of the matter. The Fellows claim the privilege
of electing. Of this privilege they have deprived the
members, and they refuse to restore a single vote to those
who constitute the great majority.
A resolution was proposed thanking the Council for
the Report and for their concessions as to separate meet-
ings for Fellows and members. Objection was taken to
this on the ground that whatever had been conceded was
a right, not a favor, and the motion was rejected by nine-
teen to six. The numbers show what a falling off there
has been in the attendance at these meetings. This is
caused by the apathy of despair at obtaining what once
seemed possible. The members are absorbed in their
daily duties and can hardly spare time to take part in
political movements. When, however, they next arouse
themselves to appear in their thousands they may effect-
ually assert their rights.
The Chelsea Hospital scandal seems interminable.
Lord Cadogan has now resigned the presidency and it
is reported that the next development will be the with-
drawal of the royal personages who are patrons. Still
the committee stick to their position and will not resign.
It is suggested that the newly elected staff should resign.
But what would be the result ? Others would step into
their shoes, just as on the last occasion.
An example of the want of unity and the readiness to
supplant is also furnished at Coventry. The dispensary
of that town has been figuring in a correspondence in
which it is asserted that if the staff resigned their neigh-
bors would take their places. I expect this .is a fact,
though the British Medical Journal affects to be shocked
at such a suggestion, and pretends it would not accept
advertisements of the vacancies. This is really too good
when we remember what advertisements are accepted,
and that on other occasions the Journal has actually
more than withheld support from a hospital staff which
was resigning. But I turn from these unwelcome dis-
putes to more practical subjects.
At the last meeting of the Clinical Society Dr. Hector
Mackenzie and Mr. F. C. Abbott related a case of sub-
diaphragmatic abscess communicating with the right
pleura successfully treated by resection of ribs and drain-
age, in a boy aged ten. When admitted into the hospi-
tal there was an acutely rounded and reddened swelling
centrally situated in the epigastrium. The right side of
the chest gave the physical signs of a pyopneumothorax,
and the epigastric swelling freely communicated with the
right pleura, for it became much more prominent when
the patient sat up or coughed, and then distinctly gave
evidence of fluctuation. It was decided to drain the
sub-diaphragmatic abscess and the empyema by a single
opening in the pleura. On the second day after admis-
sion a portion of the sixth rib was resected just behind
the mid-axillary line. Thirty ounces of exceedingly of-
fensive thin watery pus containing some flakes were evac-
uated. On exploring with the finger the upper surface
of the liver was felt through the opening in the fore part
of the diaphragm. The whole cavity was well irrigated
with warm boracic solution and a double drainage tube
inserted. The cavity was washed out daily, but the die-
charge continued to be offensive for several days. The
patient left the hospital on the forty seventh day cured.
The lung expanded well, and the only sign to be detected
six months later was a slight relative dulness at the base
of the affected side. The history of the illness pointed
clearly to an abdominal origin. The presence of air as
well as fluid, and the factor of the abscess pointed to
perforation of an air containing viscus, most probably of
a gastric or duodenal ulcer.
The President, Mr. Hulke, mentioned the case of a
lad aged thirteen, for whem he made an opening in the
tenth interspace, and, removing a piece of rib, gave exit
to much foul pus. It could then be made out that there
was an opening in the diaphragm leading down to an
abdominal abscess. Drainage-tubes were inserted and
the lad made an excellent recovery, the lung subsequent-
ly expanding fully.
Mr. F. C. Abbott said he had little doubt at the time
that the abscess originated on the upper surface of the
liver, thus shutting off the greater sac of the peritoneum.
He pointed out that most cases like this occurred on the
left side, and observed that a gastric ulcer which had per-
forated, would, after passing into the lesser sac, naturally
affect the pleura on the same side. Perforating ulcers on
the anterior surface of the stomach really penetrated the
corresponding pleura. He thought the best plan was to
attack such abscesses through the thoracic wall, because
the lung invariably expanded well after. The danger in
any event was certainly less than would result from an
opening made in the middle line of the abdomen.
Dr. S. West questioned the propriety of getting at
these abscesses through the chest, cutting into what
might prove to be healthy pleura, and thus introducing
fotd septic pus into the pleural cavity, the more so as the
abdomen could at present be opened with comparative
impunity. He, however, recalled a case in which Mr.
Pitts had cut down upon a hepatic abscess through the
pleura with every success. Mr. Peaice Gould observed
that many of these cases died before the abscess had ex-
tended from the region of the duodenum to the coi re-
sponding pleura. He saw one case a few days since, a
young woman said to have a sarcoma of the liver. There
was evidently a large abscess below the diaphragm, and
he opened it in the middle line, immediately below the
ensiform cartilage, giving exit to a large quantity of gas,
to several pints of fluid, and to an enormous hydatid
cyst springing from the upper surface of the liver. There
was no opening in the diaphragm.
Dr. Lee Dickinson said that duodenal ulcers were very
rare in boys of this age, and suggested perforation of the
colon, referring to a case of right subphrenic abscess de-
scribed by Dr. C. J. B. Williams, which proved to be
due to a perforation of the hepatic flexure of the colon.
666
MEDICAL RECORD.
[November 24, 1894
Mr. Bruce Clarke said that not long since he had
opened a hydatid of the liver through the pleura without
any untoward sequelae.
A case of recovery from poisoning by one ounce of
chloral hydrate was next communicated by Sir Dyce
Duckworth for Dr. R. J. Colenso. A lady aged thirty-
four, deliberately took, on December 12, 1893, one ounce
of chloral hydrate in two ounces of water at 8 a.m. At 4
p m. she was discovered in her bed unconscious. No or-
dinary rousing measures were of any avail. Medical aid
was not procured till 5 30 p.m. The patient was then
found to be comatose, with abolition of all reflexes,
breathing shallow and stertorous, pupils both small and
very sluggish, pulse 130, small and rather firm; temper-
ature 1 00.5 ° F. The nature of the poison taken was not
found till about three hours subsequently. Atropine was
given hypodermically, and the stomach washed out, but
the washings revealed nothing as to the poison taken.
Strychnine, ether, amyl and other restoratives were em-
ployed, and recovery ultimately occurred. The satisfac-
tory result was doubtless due to the robust health and
fine physique of the patient, and in no small degree to
the persistent and energetic efforts made by a staff of in-
telligent assistants, who labored for twelve hours to re-
store animation.
The president alluded to a case of a young woman who
was proved subsequently to have taken 320 grains of
chloral. The pupils were contracted almost to a pin's
point. He washed out the stomach, but they had to re-
sort to artificial respiration several times in order to
keep her going. He pumped strong coffee into the
stomach and ultimately she came round.
Dr. Churton-Leeds then read the notes of a case of
multiple neuritis, fatal on the sixth day, in a rather frag-
ile girl aged fourteen.
MR. BRYANT'S HUNTERIAN LECTURE.
REPORTED BY OUR LONDON CORRESPONDENT.
The lecture at the Hunterian Society was this year de-
livered by Mr. Thomas Bryant, ex- president of the Royal
College of Surgeons. The topic he chose for his address
was " Some subjects of Public and Professional Interest."
After some general remarks on the education of the pro-
fession, he enforced the necessity of keeping up the
standard of preliminary studies, and declared that the
Medical Council represented not only the licensing boards
but the best views of the profession in the conviction that
those young men who have enjoyed the broadest and deep-
est general education are the best fitted to undertake and
master as they ought the many difficulties with which the
student of medicine has to grapple. He hoped, therefore,
that the time was not far off when for all university men an
Arts degree, and for all others an examination of equal
standard, will be required before they are allowed to
enter the portals of the profession ; although, with the
view of giving a helping hand to the student who, af-
ter taking his arts degree, must now have five years for
special medical study — it ought to be so arranged that
in his arts curriculum the subjects of physics, chemistry,
and biology should be included. Under this new regime
the student would enter upon his purely medical work
better equipped and with every prospect of success, and
would with greater probability than now can be said to
exist, have unconsciously acquired in his university train-
ing a cultured mind, and with it something of the true
"professional spirit," so that he would not only practice
in that spirit, but when the business side had to be faced
— for there was such a side — and the question of emolu-
ment and worldly advantages must be considered — he
would recognize and remember that he could only raise
himself by raising the profession in the estimation of
those who formed his circle, and that he could never do
so either by lowering the position of his profession ever
so little, or by allowing the " spirit of trade " to master
the " professional spirit," and so becoming a " medical
tradesman." Where, then, asked the lecturer, "is the
room for the old system of apprenticeship, for the res-
toration of which we every now and then hear a feeble
cry? The reply to this could be but one, "Too late,
too late. Apprenticeship is as dead as Caesar." ^ This,
he held, need not be a source of regret, for, reviewing the
system all round, the master was the only one who, as a
rule, derived any certain benefit from its adoption, for
he pocketed the premium which went with the apprentice-
ship— often several hundreds of pounds — and at the same
time found a dispenser or useful servant in the unfortu-
nate man who was bound for five years to do whatever
was required of him. With the present heavy demand
upon the powers and time of the student, he hoped to
hear no more of this system, as it is an impossibility and
an anachronism. He thought it would be well if the
teachers during the last year of study would take some
opportunity of leading their pupils' thoughts in this di-
rection, for it was clear that in business questions, busi-
ness knowledge is essential, and good advice at this
time must bring forth good fruit. This might be done
by means of a post graduate lecture, this taking the place
with advantage of the old " introductory," which had
been nearly given up. He believed that the best step a
student could take before entering upon a practice was
to spend a year as an assistant to a good medical prac-
titioner ; by so doing he would learn the business part
of his profession as well as acquire much more if the
practitioner happened to be of a high class. Medical
schools should keep a list of high class men in good
practice who were willing to accept qualified students
for this end, and both would no doubt profit by the
plan.
The subject of professional remuneration, which was
now claiming attention, he felt was a difficult one to
handle, but it had been the cause of no little recent com-
plaining and heartburning, and there was a great deal of
reason for this feeling, since much professional work was
notoriously ill paid, and private work was no less so.
Not long since an active chairman of a provincial county
council told him in conversation he was as chairman
ashamed at the smallness of the salaries the poor-law
medical officers received, and yet he was alive to the fact
that if the present ones refused to continue for that
amount there were others who would readily accept the
place. He admitted the parish parsimony as regards
payments, but with such competition before him, what
was he to do. The same complaints might also be made
as regards clubs, and more particularly of the so-called
Medical Aid Associations. Indeed, rising higher in the
scale, and with respect to honorary appointments, men
who would wish to stand well with their confreres were
at times too ready to accept positions which others had
deemed it right to vacate. In such men the "spirit of
trade " had mastered the " professional spirit " and was
allowed to have its way. This conduct all round was bad
and sad ; but how was it to be prevented ? Some men
to put a stop to these practices and other evils called out,
" Let the Medical Council or Royal Corporations cor-
rect them ; " while others looked to defence associations,
medical associations acting as courts of ethics, to pass
judgments and enforce decisions.
He wished to point out that to look for a sound rem-
edy we must look to ourselves, for " our remedies oft in
ourselves do lie." To aid us in this direction by all
means' let medical defence unions, local societies and
medical associations be formed, if we have not enough,
and more particularly let these bring before the General
Medical Council or Royal Colleges every grave act of
professional misconduct of registered practitioners, and
in so doing support their causes with evidences which
must satisfy their judges ; for the functions of these bodies
were simply judicial. By so doing the evils of covering,
of unqualified assistants, of giving false certificates, of
undue or gross forms of advertising and touting for pa-
tients would speedily be abolished, and with these evils
many others would die. He suggested a Board of Dis-
November 24, 1894]
MEDICAL RECORD.
667
cipline to whom all medical grievances could by the
local societies or associations be submitted, the duties of
such a board being much the same as those of our own
Royal Colleges of Medicine and Surgery. Such a strong
appeal court would have the confidence of the profession
and public and would help materially to suppress doubt-
ful acts and check many evil ones before they became
grave enough to be pronounced " infamous in a profes-
sional respect " and so render the culprit liable to be
taken off the register. In practice we should never for-
get that the patients' interests are those which should be
first thought of, and that the public good was its ulti-
mate object ; but in so doing let us remember that it was
all important for the public interests, as well as for the
due exercise and dignity of our profession, that every
practitioner should hold an independent but responsible
position and that in his professional work he should be
left perfectly free from lay control, although amenable to
lay censure. It was also equally needful that he should
be adequately paid for his services by all classes accord-
ing to their means. All measures, whether under the
guise of charity or termed "provident," and all hospi-
tals which encourage the public to seek professional ad-
vice for nothing or next to nothing, were to be discour-
aged as helping to pauperize and degrade the public at
large.
The same might be said of the members of the profes-
sion who tempted the public to do the same thing by
means of private hospitals, touting clubs and associations,
or who were ready to accept at a reduced figure, over their
neighbors' heads, appointments which had been put up
by laymen, as it were, to auction or competition. Medi-
cal men by such acts adopted the surest way within their
power to lower the position of their profession in general
estimation ; and at the same time did injustice to them-
selves and the public by not giving to the latter the best
services the profession can supply, ,while they must, in ad-
dition, lose their own self-respect even if they happen to
gain cash by their own unworthy actions. For let it be
asked, How is it possible for a man who is ill-paid or
overworked, or both, to give the attention it is essential
for him to bestow on every case he has undertaken to at-
tend ; or to maintain, in the interests of the profession,
the position to which he is entitled and his own self-re-
spect. Mr. Bryant then passed on to consider the fol-
lowing questions : the working of public provident dis-
pensaries, the conditions under which private ones should
be worked and sanctioned ; the conditions under which
clubs should be worked ; the good or evil influences of
medical aid associations worked for their own profit by
laymen ; the duties of unqualified assistants ; and how
mid wives, or, what seemed a better term, " nurse mid-
wives," are to be educated and utilized for the public
good. The chief solution of these lay in the hands of
the general practitioner ; and he expressed his convic-
tion that clearly formed opinions upon each of these,
formulated after due discussion by such societies as this,
would do more to mould the professional mind for good,
and form a better basis for future corporate action than
any opinions emanating from the General Medical Coun-
cil or the two Royal Medical Corporations.
It was likewise an error to look to the General Medi-
cal Council or Royal Corporations to give, under exist-
ing circumstances, judicial opinions on these and other
complicated questions. To ask these bodies to consider
and solve ethical questions connected with professional
work and professional advancement, and, having solved
them, to seek powers to enforce their views, is too much
to expect, even if it were desirable. The General Medi-
cal Council has done good work in putting down the
serious public offence of " covering " and of giving false
certificates, more especially of death, by unqualified prac-
titioners. It did good also in expressing decided opin-
ions on gross advertisements and other delinquencies.
He assured his hearers that his own college — the Royal
College of Surgeons of England — with its present limited
disciplinary powers, had not been, and was not idle in
the same direction, for there were few meetings held of
the council before which some complaint of undue
modes of advertising, and of the employment of secret
remedies, with other illegitimate methods of carrying on
the "medical trade," was not brought. If the offence
charged was not serious enough to justify the name being
taken off the books, a serious expression of the council's
opinion upon the nature of the act complained of, and a
decision that the misdemeanor was inconsistent with the
declaration made by the delinquent when he was ad-
mitted a member " that he would demean himself honor-
ably in the practice of his profession, and do his best to
maintain the dignity and welfare of the college," were
often enough to induce him to mend his ways and adopt
more lawful means of carrying on his work. At any
rate, these expressions of opinion did great good and
tended to stop ways which lead downward ; and he be-
lieved that if the attention of the council were more
often drawn by the college members to methods which
weak men adopted from their weakness and which strong
ones know were injurious both to the profession and the
public, the action of the council for good would be more
frequently repeated, to the great advantage of the pro-
fession and the suppression of bad ways. A society
could well do what individual men might shrink from.
During the last seven years — besides all members of the
college who had been convicted of criminal offences —
six members have been removed from the list of mem-
bers for issuing advertisements or practising secret meth-
ods of cure which the council regarded as " prejudicial
to the interests " and " derogatory to the honor of the
college," as well as "disgraceful to the profession of
surgery ; " and six other members who had offended
against our by-laws in the same way had simply been let
off after they had made " declarations," that they would
not so offend again; while one other member was re-
moved for being associated with a disreputable museum.
Thus thirteen members had been brought before the coun-
cil in seven years for having seriously offended against the
by-laws of the college, besides many others who had
been satisfactorily dealt with by the President for minor
offences. But, said the lecturer, " you must not rely on
the Royal Corporations for the help which, to be effec-
tive, must come from yourselves."
Let such societies as this, and all others like it, exclude
men who do such wrongs from their list of members if
they persist in their bad ways after they have been
warned, and let the excluded members know the reason
why they are so excluded ; and when the profession as a
body has spoken, greater powers may be attained by the
corporations; for seven years ago, when the Royal Col-
lege of Surgeons applied to the Privy Council for some
enlargement of its disciplinary powers, its requests were
refused, not, however, on account of any objections
which were raised by the Privy Council to the powers
asked for, but on account of the opposition of certain
Fellows and ill-informed members of our own body who
had placed themselves in antagonistic positions. If this
opposition had not occurred, the disciplinary powers of
the college would have been enlarged.
With respect to " public provident dispensaries," such
institutions might be made valuable both to the public
and the profession. But in order to secure these desira-
ble ends it was all-important that only such members
should be admitted to the advantages of the dispensary
as were of the wage-earning and poorer classes, and that
the scale of admission charges should be calculated in
single persons as upon a percentage of their wages, and
in families upon the aggregate wages of the family or
household and not on that of the member only in whose
name the ticket was taken out. Their doors should be
opened to registered members, but their rules should be
such as to allow of any of the " well- to do poorer
classes" being able to obtain speedy help and relief
upon well-defined terms from any one of the doctors of
the district in the event of any sudden illness or accident
taking place. Every doctor of the district should, more-
668
MEDICAL RECORD.
[November 24, 1894
over, be admitted a member of the staff, should he wish
to, and be paid for the work he had done.
With parish dispensaries for the very poor, and provi-
dent dispensaries for the "well-to-do poor," the needy
classes would be well looked after, and the medical offi-
cers of both would be (airly treated. With the existence
of these public provident dispensaries, so called " pri-
vate dispensaries" would not be needed, and conse-
sequently should not be allowed ; since such dispensaries
were too often the mere speculations of needy men who
traded upon the poor for their own ends, and degraded
the medical officer to the level of a small and unscrupu-
lous tradesman. Again, town and country clubs were
institutions to be encouraged, for the same reasons as
public provident dispensaries; but it seemed that the
scale of charges now required should be somewhat higher
than that which has been asked in past years, for wages
had been much raised, and the medical club charge
should be a percentage on wages. As to what were
called " medical aid associations " the lecturer was at a
loss to know where, in most of them, good was done, for
it was clearly degrading for any qualified man to do pro-
fessional work as the paid servant of a committee of illit-
erate or even educated laymen, and consequently to
work under their control.
It was likewise a clear wrong both to the public and
profession, that members should be admitted to these as-
sociations who were not of the wage earning or allied
classes, and who were well able to pay the limited charges
of a private practitioner. The medical aid association
was a growth of a diseased nature, and it ought to be
either brought into line with public provident dispensa-
ries or club practice, as sanctioned by and based upon
the friendly societies act, or it ought to be rooted out of
professional public work. As to the duties of unquali-
fied assistants, all would agree that they should be re-
served for home duties, not far beyond those of a
dispensing assistant.
Finally Mr. Bryant said a few words about the burning
question of midwives. He admitted that in some dis-
tricts they are necessary. If necessary, it was evident
that they should be efficient, for if they were not efficient
they must be dangerous assistants and had better be
away ; and if they were to be efficient, the conclusion was
that they must not only be made so, but that their knowl-
edge should be tested by competent examiners before
they were allowed to embark on their responsible and
serious duties. He wished all " midwives," as they were
called, to be regarded as "nurse midwives" and even
to be named such — and he was pleased to add that this
suggestion had been adopted by the General Medical
Council, since the term carries with it the meaning that
they were really nothing but skilled nurses educated for
special work. He wished it to be undertaken under the
direction of the two Royal Medical Colleges of England
by means of examining boards, central or district, the
curriculum of study as well as scope of examination en-
tirely resting with the two royal colleges.
"MUST THE PARSON PAY?" AGAIN.
TO THE EOfTOK OE THE MEDICAL RbCOED.
Sir : As I am asked a question or two or more by a
gentleman (I wish he was more of a gentleman) of
Pararis, Fla., it brings me forward to trouble you a lit-
tle to answer. He asks, " Is it not a fact that laboring-
men and clerks who receive a salary of £40 per month
(some less), pay their medical bills without a murmur? "
No, sir : some of them do, many of them murmur, and
some do not pay at all. Again, " Is it not also a fact
that the vast majority of physicians do a great amount of
work for which they receive not a penny, in some in-
stances even furnishing the medicine?" Yes, sir; but
how does that tally with the first question, or do other
people better off cheat the doctors ? No man honors
the medical profession more than the writer, nor have
I said a word against them and do not propose to, as a
class. My objection to C. H. Carroll's letter is his un-
warranted inference that the minister merely recites his
sermon on Sunday, as if he preached but one, when
many of them deliver three, besides week evening work,
funeral sermons at any call, and often receives no com-
pensation. His sarcastic sneer of a minister's " repeat-
ing a prayer which he has learned by heart," is so ut-
terly unworthy of any man, let alone a professional one,
that it really places a stigma on his manhood (if he has
any) that no gentleman would have placed there. Does
the man imagine that a minister has no brains to think ?
Does he suppose that ministers have no heart for human
suffering, no sympathy for the sick, no regard for God ?
that they merely repeat parrot -like words without a
thought? expressions without a feeling? sentences with-
out a care to comfort the sick, the sorrowing, and the
mourner ? Does he have the opinion that ministers mock
God with lip service, without devotion, when they pray
in the presence of human misfortune ? Thank God, the
medical profession, as such, are nobler-hearted than the
few cavillers like this Florida agnostic. If he will read
my article he will see that the average salary of the
entire ministry is less than the $40 a month clerks.
And no minister in the United States gets as high a
salary as some medical men. I do not want the services
of a man who so undervalues a minister's self-sacrifices,
and don't expect it. Medical services have been ren-
dered me by men of large souls, not by being asked, but
because they appreciated the poorly paid services, as a
rule, of the large army of philanthropists in the Christian
ministry. Minister.
Beeun, n. h.
THE MARRIAGE OF SYPHILITICA
To the Editor or thb Medical Riookd.
Sir : In a letter appearing in your issue of November
10th, entitled " The Marriage of Syphilitics," Dr. Frank
E. Maine, of Auburn, N. Y., answers a series of questions
propounded by Dr. Burnside Foster, which, if accepta-
ble to the latter, will render any further research on his
part quite unnecessary. Unfortunately, Dr. Maine has
taken a very positive stand in this matter, and one that
is wholly unwarranted by either authorities or facts.
The opinion expressed in this letter is opposed utterly
to that held by all prominent authorities in the study of
syphilis, both at home and abroad, and differs wholly
from the teachings of men like Bumstead, Taylor, F. N.
Otis, Keyes, Sturgis, and others, who haye devoted a
large part of their lives to the careful and painstaking
study of this disease in the rich fields for research only
obtainable in great cities.
While Dr. Maine may have had sufficient practical ex-
perience in the study of syphilis, in its relations to mar-
riage, to feel justified in presenting his opinion in oppo-
sition to the gentlemen above cited, I must certainly
object to his classifying scrofula among the syphilitic
sequelae, and would respectfully refer him to any of the
more modern works on general pathology under the
heading tuberculosis. As a matter of tact, some of the
most healthy persons of my acquaintance have been born
of parents, one of whom, at least, had been a sufferer
from syphilis before marriage ; nor have I observed the
slightest trace of the disease in any form passed down to
the third generation. In conclusion, Mr. Editor, allow
me to refer to the words of Jonathan Hutchinson, F.R.S.,
the greatest English syphilographer of today, who says
in regard to the advisability of telling syphilitics that
marriage is for them ever to be avoided : " Such a course,
or anything near it, would prevent thousands of happy
marriages ; would swell the ranks of those who adopt
concubinage instead of wedlock, and while it would re-
duce the sum of human happiness, would probably not
in the least diminish the prevalence of syphilis."
Very sincerely yours, W. K. Ons, M.D.
5 West Fiftieth Strbkt, New Yoek City.
November 24, 1894]
MEDICAL RECORD.
669
NUCLEUS OF RED BLOOD - CORPUSCLE OF
MAMMALS.
To the Editor or the Mhdical Record.
Sir : I read Dr. William Moser's remarks, in the Med-
ical Record of October 20th last, relating to the caryo-
cinetic changes in the red corpuscle, with much interest,
as I there recognized various appearances of blood which
I discovered during examination under the microscope
about seven years ago, which interested me greatly at the
time.
Up to this date it appears to be a recognized fact,
taught in all text-books, that a nucleus did not exist in
the red corpuscle of mammals, except in the embyro, and
as a consequence, in certain anaemic conditions of the
blood. I was always unwilling to accept that conclusion,
on account of the admitted importance of all nuclei to
cell life, and thus, as the blood corpuscles of birds and
reptiles always contained a nucleus at all stages of their
existence, it seemed highly probable that thev really
existed in the red corpuscles of the mammalia, and,
reasoning by analogy, it seemed difficult to account for
their absence, especially as they had been seen in human
blood in the foetal stage and under certain pathological
conditions.
As I considered that the nucleus was composed of
protoplasm, it struck me that the stain used by botanists
as a reagent for this material in plants would be the
best to employ to demonstrate the nucleus of the red
corpuscle of animals, if it contained protoplasm.
Acting on this suggestion, I made a large number of
human blood preparations in the following manner.
Placing a drop of human blood on a slide, 3X1 inches,
I then took another slide and drew the sharp edge rap-
idly across it at right angles, using all the pressure pos-
sible, and allowing it to dry. This is the best method
of obtaining a single layer of blood with the corpuscles
evenly distributed. When quite dry I pour over the
preparation a strong solution of iodine, and remove after
about a minute. It will dry rapidly, and will then be
ready for microscopical examination.
I may here state that preparations of blood treated in
this manner will remain in good form for an almost in-
definite length of time, needing no glass cover or any
preservative, and can be examined dry.
This examination of preparations of blood, dry, and
without the addition of a glass cover, I consider an im-
portant feature of my work, and accounts for my seeing
so much which had escaped previous observation, be-
cause I noticed that the addition of Canada balsam and
other preservatives and a cover, caused most of the
special features to disappear.
I was surprised to find on making a microscopical ex-
amination of human blood thus prepared, that all the
red corpuscles in the field showed in each instance a
clearly defined nucleus, some in the centre of the cell,
and at the edge in others ; in many instances two nuclei
were visible in the one cell, and in rare instances they
were in a cluster of five or six. In some instances were
exhibited what a German authority calls homogeneous
cells, having merely a very fine line as an outer ring,
and in some cases such cells contained a nucleus.
At the time I made a very fine photograph of this
slide showing all these appearances above described in
the most clear and definite manner, but I failed to find
any specialist who would take the slightest interest in the
subject. I was aware that Dr. Osier, late of Canada,
and then holding a professorship at the Johns Hopkins
University, had given much attention to the microscopi-
cal appearance of blood, and I forwarded to him copies
of my original photograph and enlarged copies of the
same ; but he came to the conclusion that because they
bad foiled in their laboratory to find a nucleus in the
red corpuscle by any of their methods of staining, that a
nucleus did not exist, although he admitted that I had
stained and photographed such an object which was
optically perfect. I have still the original plate of my
photograph, and have shown copies to hundreds of phy-
sicians.
However, feeling discouraged at the want of sym-
pathy with my work, I simply let the matter drop, and
was glad to find by Dr. Moser's paper that the subject is
now claiming attention and has a prospect of being fol-
lowed up, as I consider it will be an important factor in
solving many of the most difficult medical problems of
the present day, when systematic and intelligent micro-
scopical examination of the blood is carried on.
John Michels.
315 Wsst Fourteenth Street, New York.
THE DISPENSARY QUESTION IN CLEVELAND.
To the Editor of the Medical Record.
Sir : I have noticed that your medical journal has from
time to time denounced the " dispensary abuse," but on
the other hand I have noticed the apparent apathy of the
profession in regard to this question. I would call your
attention to the fact that here in Cleveland we have got
the profession at large agitated over the question of the
dispensary abuse, partly brought about by a trial going
on between two homoeopathic physicians in regard to
this subject, the judges in the case being two trustees of
their college.
In my own case the trial was before a jury in a Justice
court. I sued the defendant for services rendered. The
defendant came to the college dispensary looking for the
surgeon who treated cripples. On being questioned
he claimed a willingness to pay* He stated that he had
a correspondence with Columbus, O.., parties who would
correct the club-feet of his boy for I500. He said that
£500 was too much, but that he could pay a reason-
able fee. I agreed to do it for a reasonable fee — less
than $500. For personal convenience I very com-
monly have private patients from in and out of town
go to the college building when a plaster of- Paris dress-
ing is required, but it is not applied in the presence
of the class. This is done at the college instead of my
office on account of having plenty of help at the college
and also that it saves my office from being plastered up.
In this case I applied plaster to the child's feet several
times at the college building. The operation was per-
formed at University Hospital. The treatment was con-
tinued at the defendant's home and my office, lasting, in
all, about four months.
The defendant reassured me over and over that he
would pay, and acknowledged indebtedness in the
presence of others. Finally when I tried to collect my
fee he denied indebtedness, claiming that I treated his
child as a clinical case before the class. My answer to
this is that there was no session of the college, and there-
fore there was no class. I sued for 2262.50. The de-
fendant had paid on account, 25. The jury granted
2143, with interest for three years.
In discussing the " dispensary abuse " there is no
chance for argument in regard to the deserving poor —
they are never turned away from dispensaries to my
knowledge. The question is : " Is it right for a dispen-
sary to treat the well-to do ? ' ' My argument on the sub-
ject is as follows :
< I hold that the services of dispensaries are maintained
solely for the poor. That in return for the services ren-
dered the poor patient may be used for clinical teaching.
That the wealthy make donations to the institution on
the representation that the money is to be used in this
way. That to obtain donations in the aforesaid manner,
and then to use the funds so obtained partly for the
benefit of the well- to do, is usually called " obtaining
money under false pretences," and is punishable by fine
and imprisonment.
But we all know that this abuse exists; and what is
the cause ? As I see it, the incentive is the inherent
selfishness of man ; it is largely brought about (especially
in the great cities of the East) by the men at the top—
670
MEDICAL RECORD.
[November 24, 1894
those in authority. The Professor says to himself, " The
larger the clinic, and the more assistants I have, the
more important is my position. Secondly, these middle-
class patients do not come from my following — I loce
no practice by it." It was from the same motive that
one of the Vanderbilts was led to say : " The rights of
the public be d — d." In this case it would read " The
rights of the profession be d—- d."
The dispensary has no rights in the handling of pa-
tients further than the treatment and clinical use of the
poor. It has no moral right to enter into competition
with the outside practitioner.
But what about the rights of the dispensary physician ?
He is in active outside practice and has educated him-
self for that purpose. He is in open competition with
all other practitioners and has a moral right to increase
his practice by any honorable means, i.e., in this case to
take what additional practice the dispensary may acci-
dentally or incidentally bring him. What right has a
dispensary to say that we as a dispensary acknowledge
that we have no right to this well-to-do patient, but we
shall not permit you (the dispensary physician) to treat
him? What right has a dispensary to discriminate
against their dispensary physicians ? Certainly the dis-
pensary would admit the right of some other doctor
(who might be physician to some other dispensary) to
have the patient as a private case.
I am willing to abide by any reasonable rule of a dis-
pensary as to the treatment of the poor, but will brook
no dictation from any such organization as to whom I
shall treat among the well-to-do.
Dr. Bishop, the defendant in the trial between the
two homoepathic .physicians, sent out a card to the
physicians of the city asking the opinion of the profes-
sion in regard to the dispensary abuse. He claims to
have over one hundred answers in which they all de-
nounce the abuse, and agree that dispensaries are solely
for the poor, with the privilege of using the patient for
teaching purposes.
William E. Wirt, M.D.
Clrvbland, O.
Hettr Instrument*.
AN ASEPTIBLE BISTOURY.
The general desire of physicians to obtain an aseptible
bistoury, that resembles in its main features the old shell-
handle double bistoury, with slide catch, has been com-
plied with by introducing a new bistoury, of which the
above is an illustration. It is the same form and size as
the old slide bistoury, its blades open and close just as
readily, and have the improvement that they lock auto-
matically, both in the open and closed position. The
advantages claimed are: 1. Its great simplicity. (It
consisting only of a plain skeleton steel handle and two
blades.) 2. Its blades are locked automatically, both in
the open and closed position, and their edges are pro-
tected in the handle when closed. 3. Its blades can be
removed for sterilization in a simple manner, by holding
them at a right angle with the handle. 4. The con-
struction of the handle admits larger blades than any
other bistoury, which is in many cases of great impor-
tance to the operator.
The accompanying cut shows the form and construc-
tion of the instrument. The small spring is pressed
outward by the thumb nail, while the middle finger
acts as a counter- pressure against the side of the handle,
at the same time the blade is opened by the fore-
finger. The same position is assumed in dosing the
knife. In this case the fore finger presses against the
back of the blade. In readjusting die blade, hold the
same at a right angle to the handle, so that the corre-
sponding numbers on the blade and handle are in view.
The instrument is manufactured by Max Wocher &
Son, surgical instrument makers, Cincinnati, O.
Contagious Diseases — Weekly Statement — Report of
cases and deaths from contagious diseases reported to the
Sanitary Bureau, Health Department, for the week end-
ing November 17, 1894.
Tuberculosis
Typhoid fever
Scarlet fever
Cerebrospinal meningitis
Measles .
Diphtheria
Small-pox
86
106
28
10
7*
3
1
z
52
2
166
27
45
2
Yellow Fever and Mosquitoes. — Dr. Carlos Finlay, of
Havana, believes that yellow fever is propagated chiefly,
if not entirely, by inoculation, the principal agent of
which is the mosquito. In a paper in the Edinburgh
Medical Journal iox October, 1894, he presents the fol-
lowing parallel, showing how closely the vital conditions
of the mosquito agree with those which are known to
favor or hinder the spread of yellow fever.
Yellow Fever. — Temperatures at which yellow fever
has been observed to cease in New Orleans and in Rio
Janeiro = 150 to 180 C.
Temperatures which have proved insufficient to pre-
vent a subsequent reappearance of the disease without a
new importation = o° C.
Temperatures which are considered to completely ex-
tinguish the infection of yellow fever = severe frosts.
Mean temperatures which admit of a free propagation
of yellow fever in Havana = 260 to 300 C.
Coincidence of unprecedented abundance of mos-
quitoes with severe yellow- fever epidemics, in Philadel-
phia, 1 797, and in the Southern States of North America,
1853. — {Laroehe^ ii.)
Artificial heat which has proved efficacious in definitely
arresting the transmissibility of yellow fever — several
stoves employed to heat the hold of the Regalia. —
(Laroehey ii., p. 440.)
Altitudes at which epidemics of yellow fever have been
exceptionally observed: Newcastle (Jamaica), 4,200
feet; and Madrid (1870), 2,000 feet.
Culex Mosquito. — Temperatures at which the mos-
quito is completely benumbed by artificial cooling of the
air=i5° to 190 C.
Lowest temperature which the mosquito will bear, in a
state of apparent death, and after which it may yet re-
vive = o° C.
Artificial cold after which the mosquito cannot revive
= from i° to 40 C. below zero.
Mean temperatures in which mosquitoes are most nu-
merous in Havana = 25° to 30° C.
Coincidence of a scarcity of mosquitoes in Havana
with an unusual diminution of yellow fever during the
November 24, 1894]
MEDICAL RECORD.
671
summer of 1886, the reverse coincidence being observed
during the autumn of the same year.
Temperatures at which the mosquito falls into a con-
dition of apparent death, but may still revive = 39 Q to
41 Q C. Temperatures after which it cannot revive = 41 Q
to 490 C.
Artificial rarefaction of air in which the mosquito is
for a while deprived of its power of flying or stinging,
but sometimes after a while recovers = equivalent to 1,000
-6,000 feet.
Influence of Bicycle Biding on the Uric- Acid Dia-
thesis.— Dr. Robin read a paper before the Academy of
Medicine of Paris on this subject, in which he stated that
moderate bicycling diminished markedly the secretion of
uric acid, and emphasized that this exercise does not re-
sult in lack of elimination of the uric acid, but really
diminishes its production.
He finds, on the other hand, that in sclerosis of the
kidneys, in which a small amount of albumin is the most
constant symptom, indulgence in this form of exercise is
apt to markedly increase the amount of albumin, and is
therefore contra- indicated.
Thyroid Feeding in Basedow's Disease.— Treating
Basedow's disease by the administration of thyroids is in
opposition to much that has recently been written con-
cerning the pathogenesis of this disease, but this is what
Dr. Voisin (Medical Society of the Hospitals, Paris)
has recently reported. A young woman affected with
exophthalmic goitre was given the thyroid gland of the
sheep to the amount of two drachms daily. At the end
of two weeks the tachycardia had reduced one third, the
goitre had considerably diminished, as had the exophthal-
mos. When the case was reported the only symptoms of
the disease were slight swelling of the neck and slight
exophthalmos. Dis. Dreyfus, Brisac, and Beclere ex-
pressed their opinion that thyroid feeding tends to ag-
gravate the disease and increase its symptoms rather than
cure it.
Hereditary Syphilis in the Hew born Associated
with Acute Nephritis. — Dr. Hock showed at a meeting
of the Medical Club (Vienna) an infant, the second child
of a syphilitic mother, who eight weeks after its birth
showed a syphilitic erythema which disappeared under
the influence of proto-iodide of mercury. Later the
extremities and penis began to swell, and an examination
of the urine showed albumin, hyaline casts, and white
and red corpuscles. Other symptoms of syphilis disap-
peared under the use of iodide of potash.
Hysterectomy for Uretero - uterine Fistula. — Dx.
Mackenrodt presented at a meeting of the Medical So-
ciety (Berlin), a woman on whom he had successfully
performed a hysterectomy for the cure of a uretero- uter-
ine fistula. An attempt was made to cure the fistula,
a result of a forceps delivery, by converting it into a ure-
tero vaginal fistula, but failing in this the operator pro-
ceeded to extirpate the entire uterus. The ureter was
first separated from the uterus and then the latter re-
moved, care having been taken to close the peritoneal
cavity, and also to arrange an opening for the ureters into
the vagina. Three weeks afterward an oblique opening
was made in the bladder, and the utero- vaginal fistula
was attached to its walls. The vaginal wound closed,
and the patient made a good recovery.
Tannigen, a Hew Intestinal Astringent. — Tannigen,
according to Professors Meyer and F. Miiller, in the
Deutsche Med, Wochenschrift, is a derivative of tan-
nin, and is a golden-gray odorless and tasteless powder.
In dilute acids and in water it is not noticed, and is
readily soluble in alcohol. As it produced no ill effect
when given to animals, Professor Meyer requested Pro-
fessor MQller to try it clinically, and the latter gentle-
man has for the last eighteen months been testing it with
a view to its employment as a remedial agent. The dose
given was from 0.2 to 0.5 grm. three times a day, and be-
ing tasteless it was readily taken. It was given, however,
in as large a quantity as would lie on the end of a knife
without producing any ill effect. It was first of all
given in chronic diarrhoea of different kinds, in dysen-
tery, and in the diarrhoea of phthisis. In far the larger
number of cases it reduced the number of stools and im-
proved their consistency. This result was not, however,
a constant one, especially in the diarrhoea of phthisis,
and when the remedy was stopped even in the other
cases the diarrhoea returned. Some patients took the
drug for weeks and experienced no diminution of its effi-
cacy. In acute diarrhoeas it acted, but not constantly,
and in the diarrhoea of infants it produced no effect.
The proper field, therefore, for tannigen is the chronic
diarrhoeas, and it possesses the great advantages over
tannin that it is tasteless and does not distuib the gastric
functions ; it does not tan the stomach, but only the in-
testines. Professor Miiller. thinks there is a decided
want of such a remedy, especially in the diarrhoea of
phthisis and in chronic intestinal catarrh, a remedy
which can be used for long periods with good effect,
which does not take away the appetite, and which can
be conveniently taken and is not disagreeable.
The Parasitic Theory of Eczema. — Dr. Malcolm
Morris asks and answers these four questions regarding
eczema :
Are internal remedies required in eczema 9
The gist of his reply is embodied in these words :
" My own view, stated broadly, is that as a general rule
the less internal medication there is in eczema the better.
If a constitutional dyscrasia underlie the skin affection it
must of course be treated on the ordinary principles of
medicine.' '
And so if neuroses, gastrointestinal complications, or
special or general debilities occur, they require due at-
tention. But without definite indications internal medi-
cation should be withheld.
The influence of diet in eczema.
The writer here says : " I may frankly state that my
own view is that diet has no influence at all except indi-
rectly." Qualifications are entered, of course, in the
case of gout and diabetes complicating eczema, and a
lowered diet is advised " if the lesions are of an acutely
inflammatory type."
What are the principles on which the local treatment of
eczema should be carried out ?
" Speaking generally, 1 treat every case as if it were of
parasitic origin. Even if micro organisms are not the
exciting agents in the causation of the process in all
cases, parasitic irritation always comes into play sooner
or later as a secondary factor, and requires to be appro-
priately dealt with. The objects which I aim at in the
local treatment of eczema are, first, to destroy micro-
organisms; secondly, to protect the inflamed surface
from the air and from further microbic invasion ; thirdly,
to sooth irritation."
How is the tendency to recurrence of eczema in those
predisposed to the disease to be overcome ?
" Change of climate is often productive of good in
this direction, especially if accompanied by complete
rest of mind as well as body."
Then, touching the efficacy of baths and medicated
waters, about which so much has been said, and which is
a matter of strong popular opinion, the following sum-
mary appears :
1. No spring known to me has any specific action on
eczema.
2. Sulphur waters have no special effect other than
that due to their anti-parasitic action.
The Rev. Cotton Mather, of Salem witchcraft epidemic
fame, was much interested in medical topics. He intro-
duced the practice of inoculation into New England at
the risk of his life, and published a popular work on
medicine which, as Dr. Oliver Wendell Holmes points
out ("Medical Essays"), proves him to have been
what to-day would be called a bacteriologist. One
of his capsulas (chapters) is devoted to the animalcular
672
MEDICAL RECORD.
[November 24, 1894
origin of diseases ; at the end of which he says, speaking
of remedies for this supposed source of our distempers :
" Mercury we know thee : But we are afraid thou wilt
kill us too, if we employ thee to kill them that kill us.
And yet for the cleansing of the small blood-vessels and
making way for the free circulation of the blood and
lymph — there is nothing like mercurial deobstruents."
The Water-supply of Jerusalem.— The Turkish Min-
istry of Public Works has determined upon the recon-
struction of the ancient water conduits of Jerusalem,
dating from the age of King Solomon. By this means it
would be possible to convey twenty-five hundred cubic
metres of water daily to the Holy City. Of this it is
proposed to give one thousand metres away free of
charge to the poor of Jerusalem, the distribution to take
place at the Mosque of Omar, the Holy Sepulchre, and
other places frequented by pilgrims. The new conduits
are to be joined to the ancient aqueducts of Arob, and
are to be carried through a tunnel 3,570 metres in
length. The total outlay in connection with these
works is estimated at 2,000,000 francs.
A Historical Case of Diphtheria. — The influence
which epidemic disease has had upon the course of his-
tory is a curious subject for speculation, but most of the
instances which have been adduced by various writers
who have occasionally touched upon the subject, have
been instances of wide-spread epidemics, such as the
plague at Athens and the "Black Death " in England;
but the effect which certain infectious diseases, more or
less constantly present in temperate climates, may have
had upon historical events is less clearly perceived. A
curious instance is afforded by the death of Napoleon
Charles, Prince Royal of Holland, the son of Louis,
brother of Napoleon Bonaparte, and of Hortense, his
stepdaughter. This child died, when not quite five
years old, of a disease, which, there can be little doubt,
was diphtheria. The boy was a favorite of his Imperial
uncle, and was generally taken to St. Cloud when Napo-
leon stayed there in the summer. Though Napoleon
never seems to have expressed himself clearly upon the
Subject, it was thought by many that he proposed to
make this child, who was his nearest male relative in the
second generation, his heir. Among those who shared
this opinion was Meneval, who, as private secretary to
Napoleon, had special opportunities of forming an opin-
ion as to the Emperor's intentions. If this child had
lived Napoleon, Meneval thinks, would not have di-
vorced Josephine, would not, therefore, have exposed
himself to be insulted by the Emperor of Russia's refusal
of the hand of a grand duchess, and in all probability
would not have gone to Moscow, and might therefore
very possibly have founded a lasting dynasty. It is cu-
rious to remember that this boy's brother — his uterine
brother at least — did actually sit on the throne of France.
Napoleon, who was very much moved by the death of
his nephew, offered a prize of 12,000 francs to the author
of the best work on the means of preventing and curing
croup. The boy died on May 5, 1807, and Meneval re-
marks that the superstitious looked upon it as a curious
coincidence that Napoleon himself died on the same day
of the same month fourteen years later. — British Medical
Journal.
The First Recorded Death in Hypnosis.— The death
of Ella Salamon, in Tuzer, Upper Hungary, at her home,
on September 17, 1894, while in an hypnotic state, has
attracted much attention abroad, owing to the fact that
it is the first recorded instance of death of this kind. —
Medical Association.
The Church Sanitary Association is the name of a
society recently founded in England. Its membership is
made up of the clergy and laity of the Established Church
who believe that personal cleanliness and the observance
of hygienic laws are Christian duties. It proposes to or-
ganize a propaganda by the establishment of lecture
courses and the wide circulation of tracts on the preser-
vation of health. It has been suggested that the work of
reform should begin with the church buildings, which are
so often poorly ventilated, draughty, and dark, and where
people are often compelled to sit, with perhaps wet feet
and damp garments, through a long service in a chilly
cavern, whose stone floor is covered with pools from
dripping umbrellas.
A Bust of the Late Br. Leidy is to be placed in the
library of the University of Pennsylvania.
A Cancer Ward in a Vienna Hospital— Baron Al-
bert de Rothschild has just given $250,000 to build and
equip a pavilion in the Empress Elizabeth Hospital at
Vienna for women suffering from cancer. The money
constitutes a " Bettina " fund, called after the baron's
late wife, who died from this disease.
Professor Koch on Cholera. — At the recent meeting
of the German Public Health Society at Magdeburg, Dr.
Koch said that it is now possible to prevent the spread
of cholera in any country, and he was certain that Ger-
many would never be visited again with an epidemic if
only the measures now adopted were carried out early
and energetically. It was a matter of indifference to
him what precautionary measures were taken in other
countries, for Germany was now able to protect herself
and keep the cholera out of her own borders.
Lepers in Iceland. — A physician was sent by the
Danish Government last summer to make a special in-
spection tour of southern Iceland to ascertain the num-
ber of lepers. The number found was fifty-three, or
twice as many as expected. A hospital is to be built to
prevent further spread of the disease.
Opium-Eaters and the Plague. — The opium dealers
of Hong-Kong have collected data and issued a special
pamphlet, in which they triumphantly point to the fact
that opium eaters or smokers were, almost without ex-
ception, exempt from attack during the recent epidemic
of the plague.
The Song of the General Practitioner.
Sung at the Annual Dinner of the Bolton and District Medical
Society, October^ 1894.
He must not walk his rounds for fear his patients think him poor,
And dearly do they love to see a carriage at their door ;
And if his horse is fat—" He must have little work to do,"
And if it's lean the reason is : " He starves the poor old screw.'*
Should he call upon his patients every day when they are ill,
His motive plainly is u to make a great big doctor's bill ; "
If he visits them less frequently— thus less'ning their expense—
The chances are he'll be accused of wilful negligence.
He must work all day and half the night, and never say he's tired ;
For the public look upon him simply as a servant hired ;
And should he take a holiday he'll find when he comes back
Some patients have resented it by giving him " the sack."
Concerning money he must seem indifferent to be,
And folks will think he practises from pure philanthropy,
When we hear about him boasting of the guineas that he earns
We wonder if they all appear in his income-tax returns.
About his own afflictions he must never say a word ;
The notion of a doctor being ill is so absurd 1
And when, perhaps from overwork, he's laid upon the shelf
His sympathizing patients say : ** Physician, heal thyself ! "
J. Johnston, M.D., in Lancet.
Cigarette makers' Cramps has attacked the operatives
in the French state tobacco factories. It is very com-
mon in Spain, but has not hitherto been noticed to any
extent in France. The cramp affects the muscles of
the thumb and first finger of each hand.
Drunkenness in St. Petersburg is reported to be
greatly on the increase, so much so that the authorities
nave become alarmed, and have instituted the most ener-
getic measures to suppress it. Any one found drunk in
the street is imprisoned for from one to three days, and
the person from whom the last drink was bought, if he
can be found, is fined from five to twenty-five rubles.
Medical Record
A Weekly Journal of Medicine and Surgery
Vol. 46, No. 22.
Whole No. 1356.
New York, December i, 1894.
$5.00 Per Annum.
Single Copies, ioc.
Gfrrijjitral Articles.
HISTORY OF AN EPIDEMIC OF ACUTE NER-
VOUS DISEASE OF UNUSUAL TYPE.1
BrC. S. CAVERLY, M.D.,
RUTLAND, 7T.
PXRSIDBNT 8XATB BOARD OP HEALTH.
During the month of June, 1894, there appeared in a
portion of the valley of the Otter Creek, in the State of
Vermont, an epidemic of nervous disease, in which the
distinctive and most common symptom was paralysis.
The great majority of the sufferers were children under
six years of age. The city of Rutland and town of Wal-
lingford were first affected, later the towns immediately
contiguous to these, and to this tier of towns, thirteen
in number, the outbreak was almost exclusively confined.
A remarkable series of cases occurring in' the city of
Rutland first attracted the attention of the physicians,
and later, popular interest. Many of these cases were
taken sick without apparent cause. In others it was
ascribed to getting over- heated, or chilled suddenly when
heated, indigestion, and occasionally to trauma. After
a few weeks deaths were heard of, and during the latter
part of July everyone was discussing the " new disease."
From my own observation, and conversation with
other physicians, it was plain to me that an epidemic of
unusual, if not of unique, type was prevailing, and I
decided that my connection with the State Board of
Health imposed a duty on me in connection therewith.
The investigation thus undertaken in an official capacity
soon showed me that the information I was acquiring,
while unusual and valuable from a public-health stand-
point, was doubly so from that of the practitioner. I am
sure, therefore, that the physicians who have so kindly
given me, as a member of the State Board of Health, the
bulk of the data on which this paper is founded, will
pardon the use to which I propose to put this material.
This epidemic has been confined, with very few excep-
tions, to the narrowest part of the Otter Creek Valley.
The territory is bounded on the east by the Green
Mountain range, and on the west by the Taconic range
of mountains. North and south it has no natural
boundaries. Its area is about fifteen miles wide, in-
cluding the sides of the bounding mountains, and thirty
miles long. Through this valley, from south to north,
flows the sluggish stream of Otter Creek, dammed at
several points. The extreme heat and drouth of the
early summer had rendered the stream unusually low.
The only reliable figures obtainable as to temperature,
humidity, and rainfall for Vermont, are furnished me by
the United States Weather Bureau Observer at North-
field, Vt. Since the opening of the station at that place,
in 1887, the average temperature, humidity, and rain-
fall per month, for the months April, May, June, July,
and August, the months in which these conditions could
have any influence on an epidemic occurring during the
summer months, was as follows :
Temper-
ature.
Humid-
ity.
Rain-
fall.
Temper-
ature.
Humid-
ity.
Rain-
fall.
1887...
1888...
1889...
1890...
•S77* F.
•"•US-
•55.3 **.
76.7
72.5
74.1
87.8
375
345
3-05
3.79
1 891.
1892.
1893.
1894.
..56.2°F.
..56.9°F.
..56.5°F.
...56.i°F.
75.8
74-8
75-6
77-3
2.98
3-76
3-51
2.25
> Read before the Vermont State Medical Society at its annual
meeting, October, 1894.
It will be noticed by these figures that the only marked
deviation from the recorded meteorological conditions
of the past eight years, which has occurred during the
past summer, has been in the average monthly rainfall.
This has been thirty per cent, less during the past spring
and summer months than the average for the past eight
years during these months. While it was a matter of fre-
quent remark that our early summer was this year unusu-
ally hot, the official figures do not bear out this statement.
The population of the towns affected in this valley ag-
gregates twenty- six thousand, of which eighteen thou-
sand dwell in the quarrying and manufacturing centres
of Rutland, West Rutland, and Proctor. The usual
sprinkling of foreign elements prevails in these centres,
while in the outlying farming towns the population is
chiefly of the regular New England type.
The first cases in this epidemic of which I find notes,
occurred in the city of Rutland and town of Walling-
ford, simultaneously, about June 17th. The characteris-
tics of the disease can be illustrated by a few cases,
among the one hundred and twenty six cases of which I
now have notes.
Case L— Boy, three years of age, American. Previ-
ous health good ; active child ; healthier than his brother
two years older. No apparent cause. Moderate fever;
coated tongue; loss of appetite; sluggish bowels. As
these symptoms improved it was observed that he could
not walk or even stand alone. The weakness was most
noticeable in the extensors of the thigh. After ten days
he began to improve, and in three weeks was quite well.
This case is an illustration of the mildest type of these
cases.
Case II.— Boy, three and a half years of age, Irish ;
sturdy child ; apparent cause playing too hard. Fever,
1020 to 1030 F. Incontinence of urine for ten days;
hyperesthesia. Fever abated on third day. Then was
noticed paralysis of both legs ; loss of patella reflex ; no
anaesthesia ; slight response in lower extremities to
faradism. Left leg improved rapidly, right slowly.
After six weeks was able to stand and take a few steps
by taking hold of chairs. After three months paralysis
confined to right glutei and lower spinal muscles, with
considerable wasting. The weakness of spinal muscles
has resulted in a spinal curvature.
Case XCHL — Boy, two years of age, American.
Had an attack of indigestion, from which he recovered,
when he was taken on a long carriage drive. Imme-
diately developed high fever, with an erythematous rash
and considerable muscular rigidity. After a few days
there was paralysis of both legs and loss of patella re-
flexes. . After a month has not improved.
Case XCIV.— Boy, six years of age ; healthy child ;
apparent cause chilling the body; fever, 1040 F. ; vom-
iting. Acute symptoms lasted six days. On the sixth
day paralysis of right arm, followed on the seventh day
with paralysis of left leg. After three months extensors
of left thigh and right deltoid wasted and weak.
These three cases illustrate a very common phase of the
disease. Some of the cases fully recovered, and many
still suffer from probably permanent impairment of some
muscles.
Case IV.— Boy, six years of age ; no apparent cause ;
taken sick with convulsions while playing in the street ;
these lasted nine hours; moderate fever; rapid pulse;
vomiting ; rigidity of neck and back muscles ; hyperes-
thesia of skin ; very restless. Death on sixth day.
674
MEDICAL RECORD.
[December i, 1894
Case XXXII. — Female! twenty-one years of age ;
married ; one child, aged sixteen months. Had been
caring for child, which was sick ; somewhat fatigued.
Complained of head and backache. Pulse, 80 ; tem-
perature, normal. Third day, temperature, 103.50 F. ;
pulse, 100. Eyeballs rolled up ; head and neck drawn
back. Bowels regular ; urine normal ; no albumin ; no
sugar. Red blotches on skin that came and went ; urti-
caria; temperature, 100.50 to 1020 F. for succeeding
three or four days. Pulse about 100 ; unable to swallow
or speak; answered questions by moving head; in no
pain ; sixth day, pulse, 60 ; temperature, 98. 6° F. On
the eleventh day had some pain in the stomach (indiges-
tion ?), neck became rigid. Pulse, 100, and temperature
98. 6° F. during next two days. Then pulse sank to 45
and became irregular. On the thirteenth day some pain
in right side of head and right eye. Heart gradually
gave out and she died.
Case XCVI. — Boy, three and a half years of age ;
Italian. Headache ; drowsiness ; fever ; on second day
strabismus. Pulse, 45, irregular. On the sixth day he
apparently recovered. Played too hard, and two days
after developed same train of symptoms and died.
Case CXXV. — Female, aged twenty- nine; American.
Married ; one child, agfed eight months. Does not nurse
child. Neurasthenic; no apparent cause. No fever;
much nausea; great head and backache; marked opis-
thotonos ; double vision ; deafness for several days and
roaring in head. Retention of urine ; catheterized eight
days. Soreness of legs and arms ; no eruption ; pupils
fully dilated ; second day, paralysis of right arm ; fourth
day, right leg ; fifth day, left leg ; and sixth day, left
arm ; also paralysis of abdominal muscles and obstinate
constipation; anaesthesia of limbs ; reflexes gone. After
three weeks has recovered slowly use of limbs except
leg muscles, which she is still unable to use.
Cask LXXXVIII. — Female, aged six ; American.
Frail child ; had a spinal curvature for four or five years.
No history except this. Fever ; nausea ; head drawn to
one side ; facial paralysis. On third day paralysis in all
extremities; hyperesthesia; soreness of joints; obsti-
nate constipation; inability to use abdominal muscles.
After two months paralysis continues, except slight move-
ments of toes and fingers ; considerable wasting. Bod-
ily functions fair ; mind and special senses normal.
Facial paralysis passed.
These five cases illustrate the severer cases of the epi-
demic, many of which were fatal. There were a certain
number of cases exhibiting odd and interesting symptoms
out of the usual line.
Case XL — Aged seven; American. Whooping-
cough followed by broncho-pneumonia. During prog-
ress of the latter disease had loss of speech for two
weeks; delirium; fever; left arm paralyzed. Recov-
ered after two weeks.
Case LXXXVII. — Boy, aged four ; American. Con-
vulsions; double vision for one week; very drowsy.
Paralysis of external rectus of one eye, which remains.
Case XC1X —Boy, aged thirteen ; French. Had a
fall injuring back, followed by fever, nausea, muscular
rigidity of neck. From this, case ran along like an aver-
age case of typhoid fever, lacking marked typhoid symp-
toms except the fever curve. Fever lasted four weeks.
Following this was paralysis of right arm and right leg.
Paralysis improving.
Of the 126 cases of which I have notes, all except six
were in the valley above described. Of these 6, 2 oc-
curred in the town of Ludlow, on the east side of the
Green Mountains, and 3 in Middletown, and 1 in Fair
Haven, in Rutland County. The epidemic died out
first in the towns first affected, and lingered latest in
those affected last.1 Of the thirteen towns in the Otter
Creek Valley which have suffered from this epidemic,
1 New cases, three in number, are reported from Proctor and Pitts-
ford since the preparation of this paper. These towns were chiefly
affected during August, and the last cases prior to these occurred
about September xst
those that show the greatest number of cases — Rutland,
55 ; Proctor, 26 ; and Pittsford, 8 — are immediately on
this stream. The towns of Wallingford and Clarendon,
also on the stream, suffered very little.1
It should be stated that there have been, among do-
mestic animals in this valley, many cases of paralytic dis-
ease during the period of this outbreak. Deaths among
horses have been found post mortem, according to at least
one veterinarian, to be due to meningitis, and there have
been also deaths among fowls and dogs described as par-
alytic.
It has been remarked by many physicians that die
usual diseases of children, during the past summer, have
been attended with exaggerated nervous symptoms. It
is a source of great regret that in none of the fatal cases
could an autopsy be procured, though extraordinary ef-
forts were several times made to secure one.
In collecting statistics of this outbreak I have sought
only those cases attended with marked nervous phenom-
ena, like muscular rigidity, special sense disturbance, or
paralysis, and no disease by name, seeking not to pre-
judge the character of the disease or anticipate a diagno-
sis. Without detailing further individual cases I have
prepared a tabulated history of the epidemic as a whole,
collecting the commonest features of the cases in my re-
ported list of cases by themselves. I presume my list
includes ninety per cent, of all the cases that have oc-
curred.
Table i. — Age and Sex.
Under 6 years Male, 33 cases.
14 " Female, 16 "
14 " Not stated, 36 '«
From 6 to 14 years Male, 10 cases.
" " Female, 2 "
41 Not stated, 9 •'
Over 14 years Male, 8 cases.
«4 •« Female, 5 "
Stated between a few months and 9 years 7 "
Of the 119 cases in which the age is given, 85 are
under 6 years, 21 between 6 and 14 years, and 13 were
over 14 years. Of the latter was one case 70 years of
age. The genuineness of this case might at first be ques-
tioned, but the train of initial symptoms was the same as
in the milder cases of childhood, with paralysis of both
lower extremities, clearing up after ten days.
Of the 74 cases in which the sex was stated, 51 were
males and 23 females.
Table 2.— Nationality.
American 35
Irish-American 17
French 6
Jewish 1
Italian 1
Swede 1
Not st ated 65
It has been noted that in the larger centres the races
affected were oftenest foreign, while among the farming
population Americans predominated. It has not been
entirely confined to any one class, but has been most
prevalent among working people and those whose
sanitary surroundings were not of the best.
Table 3. — Previous Health.
Good 41
Poor 10
Not stated 75
Table 4. — Immediate Cause.
Fatigue. 2
Whooping-cough 1
Over-heating 22
Chilling body 4
Indigestion 2
Typhoid fever 2
Trauma 2
Pneumonia 2
No apparent cause or not stated 89
1The map on p. 676 will show the geographical distribution of
the cases.
December i, 1894]
MEDICAL RECORD.
675
There has been but a single instance, so for as I can
determine, in which there has been more than one case
in a family, and since it has usually occurred in families
of several children, I think it can be safely set down as
non-contagious.
Table 5.— Initial Symptoms.
A.
T. stated as above 1030 F 27
T. •« «« between 99° and 103° F 22
Said to have had no fevtr 3
Not stated ". ... 7.7.7.7. 74
B. —Duration of Initial Fever.
Stated to be 1 day or less 4
. •■ " •' i»2 days-. 2
days •. 2
*. « .< 2- 4. 6
I* u " 3-4 " 7
4-7 " 26
« « •« 7_I4«» 4
No fever, or not stated 77
C. — Nausea.
Stated to have had nausea or vomiting 25
il *« *« •« no 11 It U " J
D. — Convulsions.
Stated to have had convulsions 12
All under 14 years.
E. — Bowels.
Stated to have been constipated 3
" " ,% had diarrhoea 3
F. — Bladder.
Stated to have had retention of urine 7
" *• " •' incontinence " 1
G.
Stated to have had muscular rigidity of neck or back or opistho-
tonos:
Fatal cases 5
Non-fatal 15
H.
Stated to have had hyperawthesia of skin or soreness of muscles
of the extremities :
Fatal cases *
Non-fatal.
«4
I.— Special Senses.
Stated to have had strabismus 2
14 4i partial blindness 1
44 u double vision 2
*' " deafness I
K. — Skin Eruptions.
Stated to have had a simple erythema 29
" " urticaria 2
Table 6. — Initial Paralysis.
No paralysis. 6 Fully recovered, 5 ; died, 1
Not determined 7 "7
Both legs 66 " '• 43 " 4
Arm and leg (same side; 9 " " 2 " 1
One arm 5 *' u 3
Oneleg 6 u " 1
Both legs and one arm 4
Tongue and throat 2 " 1
Both arms 3
All extremities 4 4* 3
Extensors one thigh I
•' Variously in arms and legs " 8 u '* 1 " 1
External rectus one eye 1
One side of face. 1
One arm and opposite leg 1
All extremities and abdominal
muscles 2
Table 7.— Paralysis Remaining at Time of Report.
Glutei and lower spinal muscles of one side 1
Both legs 17
One leg 8
Both legs and one arm 3
Both arms. 2
Arm and leg same side 6
Extensors one thigh 2
One arm 3
44 Variously in arms and legs" 6
External rectus one eye I
All extremities 2
One side of face 1
Extensors left thigh and right deltoid 1
It will be seen by these tables that 6 of these cases
had no paralysis, as stated, but all of these had distinct
rigidity of the spinal muscles, strabismus, or other symp-
toms referable to the nervous system, and are therefore
included in this report. Of the 7 cases reported as
"not known" to have had paralysis, or in which
'nothing is said of any paralysis, all died with distinct
symptoms of acute nervous disease, and may be fairly
supposed to have died in the initial stage.
Of those that died it will be noticed that, besides the 7
that succumbed early in the acute stage, 4 had paralysis
of both lower extremities, 3 of all extremities, and 1
each had . no paralysis, hemiplegia, tongue, and throat,
and variously paralyzed.
Of those who had recovered fully at the date of the
reports, which varied from two weeks to two months
after the attacks, 5 had no paralysis, 43 had paralysis of
both lower extremities, 2 of one arm and leg of same
side, 3 of one arm, 1 of one leg.
While of the cases of which I have reports, 53 have
still some paralysis at the time of the report, and it is
probable that many of these are permanently disabled.
I am unable to make any statements based on statis-
tics as to the number of cases in which there has been a
wasting of the affected muscles, for the time is yet too
short in most cases for marked wasting to have occurred.
I hope later to be able to report on these wrecks of the
epidemic. The composite picture presented by the facts I
have elicited does not readily admit of a name. It is
at once noticed that individual cases can be readily rec-
ognized as presenting a typical picture of poliomyelitis
anterior, but that the variations from the text book type
of this disease are many and marked. Opisthotonos, eye
symptoms, and hyperesthesia are out of place in the
phenomena of this disease, so that the epidemic, as a
whole, presents notable departures from the regular feat-
ures of the disease.
Again, cerebrospinal, especially spinal, meningitis, is
quickly seen in certain phases of this outbreak, but the
season of the year, the general absence of the special
sense disturbance, particularly ear disease, the low mor-
tality, the absence of purpuric eruption (stated by some
as the most important diagnostic point in this disease as
an epidemic), are strong arguments against this diagnosis.
Without further detailing the arguments that present
themselves to all of us for and against the claims of in-
dividual diseases to recognition in this connection, I am
glad to be able to quote the opinions of high authority
in regard to this point.
Dr. A. Jacobi, whose knowledge of this outbreak is
gained solely from my written description, has very
kindly permitted me to quote him on this point. He
says : " All your cases belong to the same class, cerebro-
spinal meningitis. They prove that nature does not
walk in ruts as most of our text books do, and that tran-
sitions and variations are common. Two years ago I
made two autopsies in which the main lesions were in
the lumbar portion of the spine. I have no doubt they
had a chance to become paraplegic if they had lived.
The frequency of paralysis in your cases is something
very uncommon; so is your low mortality; both prove
that your cases were more spinal than cerebral."
This opinion, coming from so high an authority in
medicine, is of course entitled to the greatest respect.
Dr. M. Allen Starr saw, in September, ten of these
cases, at that time, of course, in the chronic stage of the
disease. His conclusions in regard to the epidemic,
which I am permitted to give, are : " The cases seen, if
seen without a history, would have all impressed me as
cases of acute anterior poliomyelitis, without a doubt
The history does not appear to me to contradict this
diagnosis, and while in some respects unusual, viz., in
eye paralysis, in stiff neck and pain, there is not as
much difficulty in assigning them to anterior poliomye-
litis as there is in assigning them to cerebro-spinal men-
ingitis. Epidemics of anterior poliomyelitis are not
unknown."
676
MEDICAL RECORD.
[December i, 1894
He cites one reported by Cordier in Lyon Medical,
January and February, 1888 ; one in Switzerland in 1889
(account not found) ; one near Boston, reported by Put-
nam two years ago, and one in Stockholm, reported by
Medim, Neurohg. Centralblatt, 1891, p. 397. Dr. Starr
further says, " As to eyes, there are some cases on record
of ocular palsy with infantile paralysis. Sachs had such
a case. As to pain, in the majority of adults and young
in several of the accessorius, and in others symptoms
referable to the vagus Disturbance of the voice and
paralysis of the muscles of mastication, and vaso-motor
paralysis were seen in 2 fatal cases. In 1 ophthalmo-
plegia externa. At the time of this Stockholm epidemic
of poliomyelitis, during August and September, polineu-
ritis appeared and was thought to be due to the same
source. This neuritis was followed by considerable
Rutland County. C&ftcs indicated by black dots.
people able to state symptoms, pain was complained of.
I saw such a case yesterday."
The Stockholm epidemic, reported by Medim, an
account of which Dr. Starr furnishes me, occurred in
1887. The disease first appeared in the month of May,
and by August 9th had assumed an epidemic character.
From the latter date to September 23d, Medim saw 29
cases, and knew of 44 during the summer, from May
to November. The cases reported by him, as a whole,
resemble more nearly the typical cases of poliomyelitis
than those in the Vermont epidemic. Three of his
cases were fatal in the acute stage. "There were no-
ticed paralysis of the abducens in 5 cases, disturbance
of speech in a few; in 1 case paralysis of the tongue,
tenderness; in some cases twitching and tremor; also
there was ataxia of movement during convalescence.
These neuritis cases, however, showed no wasting.
Medim considered infantile paralysis a specific infectious
disease, in whose acute stage the entire organism is
affected. Autopsies by Rissler support this theory. He
found in the spinal cord an acute parenchymatous in-
flammation in the anterior horns, with degeneration of
the ganglion cells and secondary degeneration of nerve-
fibres in the association tracks, in the anterior columns,
and in the anterior nerve- roots; also in the nuclei of
the hypoglossus, vagus, facial, and abducens nerves. In
most of the cases the anterior horns were particularly
affected ; in other cases also the peripheral nerves and
December i, 1894]
MEDICAL RECORD,
077
brain cortex. It was possible that all the nerve nuclei
in the medulla and pons should be affected."
I have quoted freely from Medim's report because his
is the only epidemic of poliomyelitis of which I can se-
cure accurate facts. Dr. Charles L. Dana has also per-
mitted me to quote his opinion of this epidemic. His
knowledge oi the outbreak was likewise gained from my
written statements to him, and from an examination of
the cord and brain of a fowl sent him, which was suffer-
ing from paralysis of legs and wings. His statement is
as follows : "Dr. Dunham, of the Carnegie Laboratory,
very kindly made a bacteriological examination of the
cord and sciatic nerve of the fowl ; but with negative
results. Microscopic examination shows an acute
poliomyelitis of the lumbar part of the cord, and no
meningitis. Dr. Dunham's inoculating needle did not
strike the affected part.
" Apart from the results of this case, which, of course,
may have no relation to the epidemic, I feel the greatest
possible confidence that the disease is in most cases a
true anterior poliomyelitis."
Of course the epidemic and apparently infectious
character of the disease points to a microbic origin.
That epidemic poliomyelitis has such an origin is not a
new hypothesis. Dr. Dana in an early letter to me
says: "Roger, Thornot and Masselin, Bourges, and
Vincent, produced poliomyelitis in rabbits and guinea-
pigs by inoculation of the coli bacilli, streptococcus of
erysipelas modified by culture."
On this point it is to be hoped that Dr. Dana's further
examination of the cord and brain of the. fowl will throw
some light
In a recent letter Dr. Starr further says that " there
is now a tendency to revise the pathology of poliomye-
litis," the regular descriptions of which are founded on
Charcot's statements. Dr. Starr gives me the gist of an
article published by Goldschreider in the Zeitschrift fur
klin. Med., 1892, in which he says that his (Goldschreid-
er's) conclusions, founded on a review of all the cases
with autopsy, was that the disease began with a " very
intense congestion of the central arteries of the spinal
cord which come up on each side of the central canal,
and spread out in the central gray matter and into the
anterior horns. These arteries have branches passing
backward into the gray matter of the posterior horns,
but the posterior horns are chiefly supplied with blood
from the peripheral arteries, and hence are less affected
when the inflammatory condition is limited to the dis-
tribution of these central arteries. After the engorge-
ment of all the arterial twigs, diapedesis occurs and the
surrounding nervous tissue is permeated by small cells
and by serum. It is this choking of the gray matter by
the inflammatory products which leads to the suspension
of functional activity, and when, as in many cases from
impoverished nutrition, the cells of the anterior horns
are actually disintegrated by the inflammatory products,
permanent destruction of the nerve* tissue ensues.
Goldschreider believes, therefore, that the primary con-
dition is a congestion in the domain of a definite set of
arteries, quite comparable to the condition occurring in
the lung in a pneumonia, and in the intestine in a ty-
phoid fever.
Siemerling has also written a very careful article on
the " Pathology of Infantile Paralysis," in the Archiv
fur Psychiatrie for January, 1894. His conclusion is as
follows : " After a careful review of all the literature, we
reach, therefore, the following conclusion, that in the
pathogenesis of infantile spinal paralysis the inflamma-
tory lesion of the interstitial tissue in connection with a
distention of the blood-vessels, especially in the region
of the anterior spinal arteries, plays the chief rdle. A
primary inflammation of the ganglion cells, in the sense
given by Charcot, is not to be admitted."
Dr. Starr further says : " One more point. If you con-
sult the descriptions given of congestion of the cord, you
will find many of the general symptoms of pain, stiffness
of the muscles, pain on movement, and general tender-
ness, which were present in the early stage of your epi-
demic. If now we grant that this newer pathology is
correct, these symptoms are easily explained on the the-
ory that the congestion and the inflammatory processes
were in your epidemic not limited to the domain of the
anterior spinal arteries, but extended to the posterior
parts as well."
The quotations thus liberally taken from so competent
authorities leave very little to be said in regard to the
pathology or diagnosis of our disease. Admitting Dr.
Starr's reasoning in regard to the congestion of the pos-
terior as well as the anterior portions of the cord to be
correct, supported by his citations from Goldschreider,
Siemerling, and Rissler, the phenomena of this epidemic
can be reconciled with a diagnosis of poliomyelitis. The
pain, hyperesthesia, special sense disturbance, and mus-
cular rigidity, the most important departures in our epi-
demic from the established symptoms of poliomyelitis,
are rendered explainable under this newer pathology.
A diagnosis of epidemic cerebro spinal meningitis would
certainly be more strained. The disease, cerebro* spinal
meningitis, in epidemic form being more common, its
symptoms and behavior are correspondingly better un-
derstood than poliomyelitis.
Gowers states that it has usually prevailed chiefly in
winter and spring, ceasing about July. This seems to be
very uniformly agreed to. Its features are discomfort,
later pain in the head, backache, vomiting, stiffness of
neck and back muscles. Pulse not uniformly rapid;
temperature usually very high, 1040 to 1060 F. Erup-
tions, especially herpetic and purpuric, are common.
Cranial nerve symptoms, and deafness and blindness as
sequelae, are the rule in a certain number of cases. Cases,
and even epidemics, of an abortive form of this disease
are not unknown. Gowers states that the mortality var
ries from twenty to eighty per cent. Hemiplegia, and in
spinal cases paraplegia, are occasional sequelae, but they
are always attended by rigidity and contractures of the
muscles. These are the long- recognized features of epi-
demic cerebrospinal meningitis. There must be admit-
ted to be some marks of similarity between this descrip-
tion and our epidemic. The almost universal paralysis
in our cases, and its irregular and varied character, are
entirely foreign to the generally described features of
cerebrospinal meningitis. Likewise, too, the season of
the year, the general absence of eye and ear impairment,
and of herpetic and purpuric eruptions, the low mor-
tality, and the absence of contractures.
In an epidemic like this, in which there is a blending
of the symptoms of two or more diseases, the decision
must rest between the symptoms which are most uni-
formly present and which are most pathognomonic of each
disease. And while, as Dr. Jacobi, speaking — we are
always glad to admit — from a vast experience and long
study, intimates that there are important exceptions in
actual life to the stereotyped description of the books,
the exceptions in this outbreak to the long established
symptoms of cerebrospinal meningitis seem to be so
marked as to really overshadow those that would be left
to establish that diagnosis. Under the newer pathology
given of poliomyelitis, symptoms referable to the me-
ninges and cerebral ganglia can be reasonably explained.
In conclusion, let me acknowledge the uniform cour-
tesy with which the practitioners of Rutland County
have responded to my requests for statistics of this out-
break. The list includes nearly all the practising phy-
sicians of this county. Comparatively few of the cases
have fallen under my direct observation, and without
their aid it would obviously have been impossible to
make any record of this unparalleled epidemic approach-
ing completeness.
Army Medical Museum. — There are now 32,269 spe-
cimens in the Army Medical Museum in Washington.
The number of specimens received during the year end-
ing June 30, 1894, was 1,363.
678
MEDICAL RECORD.
[December i, 1894
PREMATURE DELIVERY OF A DEAD CHILD,
INDUCED BY ACUTE APPENDICITIS, WITH
REMARKS ON APPENDICITIS IN WOMEN.
By PAUL F. MUNDfi, M.D.,
MHW YOMC.
Although there is no real anatomical or pathological
reason why acute inflammation of the appendix vermi-
formis should not occur as frequently in the female sex
as it does in the male, it is only within recent years that
the reports of appendicitis in women have become so
numerous as to attract attention. One reason for this
apparent immunity of the female sex from this disease
probably was that in the ante operating days such in-
flammations in the right iliac region were looked upon
as pelvic "cellulitis," or peritonitis, the incorrectness of
this diagnosis never being exposed, either because the •
patient died of general peritonitis and no autopsy was
made, or because the abscess fortunately opened into the
bowel, the pus was evacuated per anum, and the patient
recovered without a suspicion of the true nature of the
case.
I remember perfectly seeing such a case of supposed
inflammatory exudation between the layers of the right
broad ligament, some twenty years ago, in which I or-
dered the usual blister and hot-poultice treatment. The
idea of an appendicitis, or perityphlitis as it was then
called, did not occur to me, although I had shortly be-
fore assisted at several operations for perityphlitic ab-
scess in men. Some two weeks after seeing this woman
I was called to her house, and found a fluctuating swell-
ing in the median line between umbilicus and pubes,
which I aspirated. The true nature of the case was
then revealed, for the fluid removed had a decidedly fecu-
lent odor. I incised the abscess freely, and in course of
time the sinus healed.
Since it has become the rule to open the abdomen and
remove all pus sacs, whether of ovary or tube, as soon
as the presence of suppuration is discovered, and in cases
where the pus points toward the abdominal skin to open
the abscess there freely, as in a subcutaneous abscess oc-
curring anywhere else, we have met with more and more
cases of unsuspected abscesses of appendiceal origin in
the female, the existence of which had been masked by
the great frequency of inflammatory and suppurative dis-
ease of the uterine appendages. I have seen in consul-
tation and in the hospital at least half a dozen cases of
exudate in the right ilio-ovarian region which were sup-
posed to be due to pelvic peritonitis or cellulitis, where
the high location of the exudate and the absolute free-
dom of the right appendages showed the exudate to be
caused by appendicitis, and the opening of the abscess
confirmed this diagnosis. In one case an ovarian tumor
of the size of a grape fruit occupied the right hypogastric
region ; the pain and high temperature were supposed to
be due to an inflammation of the cyst, probably from a
twisted pedicle. Vaginal examination revealed nothing
but a rigid vaginal vault. On opening the abdomen the
ovarian cyst was found not inflamed, and after its re-
moval an abscess was discovered between the layers of
the broad ligament which had worked its way down from
the right periappendiceal region. The appendix was
found to be gangrenous.
It would be well, therefore, to bear in mind in every
case of inflammatory exudate or suppuration in the right
half of the female pelvis, particularly if the exudate ex-
tends up as high as, or higher than, the crest of the ilium,
that the primary cause of the exudate may be an appen-
dicitis, whether the uterine appendages of that side be
inflamed or not. If the appendages are healthy, and the
exudate is due to inflammation of the appendix vermi-
formis, the finger per vaginam will find the right vaginal
vault empty, the uterus normally movable, and the exu-
date not reachable from below. We must not forget an-
other possibility, however, namely, if the exudate extends
much above the crest of the ilium, it and the suppuration
may be of perinephritic origin, and thus retro-peritoneal.
I have recently seen, in consultation with Dr. D. Froeh-
lich, a lady just recovering from an attack of severe pain
in the right iliac region, the seventh in three yean,
when under anaesthesia the swollen, curled appendix
could readily be felt through the abdominal wall.
I will mention, en passant, that occasionally an en-
tirely unexpected fortunate termination of the case may
be brought about by the bursting of the perityphlitic ab-
scess into the bowel, whereupon the swelling in the right
iliac fossa disappears and rapid recovery takes place. I
have seen two such cases, in one of which the diagnosis
was made and operation fixed for the following day; in
the other, the swelling was in the median line, resem-
bling the distended bladder, and exploratory aspiration
was to be performed on the next morning. In both
cases during the night a chamber- vessel full of stinking
pus was evacuated from the bowels, the swelling disap-
peared, and the patient rapidly recovered.
The above instances show how the diagnosis of an ap-
pendicitis in the female may be masked, and even ren-
dered impossible before the operation, owing to the com-
mon inflammatory diseases of the uterine appendages,
even more frequently than is the case in the nude. My
object, however, in this short paper is rather to lead up
to the occurrence of acute appendicitis at a particular
time in a woman's life, which has, to my knowledge, here-
tofore not been mentioned, than to discuss the general
subject of appendicitis in the female. I refer to the in-
fluence which inflammation of the vermiform appendix
occurring during pregnancy may have on that condition
and the welfare of the child.
So far as I am aware there is no case on record of ap-
pendicitis during pregnancy. There is, of course, no
reason why such an inflammation should not occur at that
time. But, if any such case has been reported, I have
not seen it.
The rarity of the occurrence and the practical impor-
tance of thinking of its possibility, and consequently de-
tecting its presence at an early stage, have led me to
report the following case which recently came under my
observation :
On the night of September 21st I was called by Dr.
E. Hochheimer to see, with him, Mrs. F , then at the
end of the eighth month of her first pregnancy. I saw
her at about one o'clock on the morning of September
sad, when she was in active labor, the mouth tempera-
ture being 1040 F. ; the pulse, 140 ; the face much flushed
and expression anxious. The history given me by the
doctor was, that on the 15th he was called to see the
lady for " pain and tenderness in the lower part of the ab-
domen, equally severe in the median line and on both
sides. This was accompanied by a rise of temperature
to 1010 F., and eventually to 1020 F. on the fourth day.
Rest in bed, light diet, and hot-water bag, together with
occasional ^- grain doses of morphine p.r.n., were or-
dered. The pain gradually subsided and the tempera-
ture fell till the evening of September 20th, when it was
990 F., and she was expected to sit up on the following
day. On the 21st, about 9 a.m., she was seized with
atrocious pains in the pelvic region, accompanied by
pronounced chill, and temperature 101.50 F., at the same
time labor pains began and continued until you saw her."
The foregoing account is from a letter to me written
after the patient's recovery. With a large obstetrical
experience and considerable acquaintance with appendi-
citis from personal observation, it still, very naturally,
did not occur to Dr. Hochheimer to attribute the pain
and fever in this case to so unexpected a cause as appen-
dicitis, and when I saw the patient the pains were so uni-
versal over the whole lower part of the abdomen, both
during and between the uterine contractions, that it was
impossible to localize any one particularly painful point.
About 2.30 a.m., on September 2 2d, a dead child was
born without any artificial assistance. Desquamation of
the epidermis on one leg showed that the child had been
dead at least twenty-four hours. There was no difficulty
in delivering the placenta, nor any post-partum hemor-
December i, 1894]
MEDICAL RECORD.
679
rhage, bat the patient went into a semi-delirious condi-
tion, and appeared very much prostrated, so that further
examination was postponed. I was at that time in great
doubt as to the cause of the fever and premature delivery
of a dead child, particularly as the history gave the very
decided possibility of infection from scarlatina and diph-
theria, to both of which diseases the patient had been
exposed during the two previous weeks. The abdomen,
even after delivery, was universally so tender that no re-
liance could be placed on the location of the pain as an
aid to diagnosis. On seeing the patient again, about
twelve hours later, however, decided dulness could read-
ily be made out, together with a very acute pain on press-
ure in the right iliac region, the outlines of the uterus
being clearly distinguishable. Per vaginam, the right
vault was found free. No particular pain elsewhere in
the pelvis or abdomen. Temperature now 1020 F;
pulse, 120.
The probability of general scarlatinal or diphtheritic
infection was now excluded, and the choice lay between
typhoid fever, pelvic peritonitis, and appendicitis, of
which I chose the latter as the most probable. I had
never heard of or seen a case of this kind during preg-
nancy, but could see no reason why it might not occur.
And I ascribed the severe pain on the morning of the
day preceding delivery to the perforation of the appen-
dix and the discharge of pus into the pericecal cellular
tissue, since its discharge into the general peritoneal
cavity would have been followed by general peritonitis
and speedy death. At any rate the peritoneal cavity
could safely be considered closed from the cavity of the
abscess by adhesions. As the patient's condition was
much improved, I preferred to wait until the immediate
shock of the confinement had passed away, especially as
rather intractable bilious vomiting came on, which de-
pressed the patient both morally and physically. Dr.
Hochheimer and I therefore decided to defer the in-
evitable operation for appendiceal abscess a few days, so
long as the patient's condition allowed it ; my own chief
reasons for this postponement being the absence of any
symptoms requiring immediate operation, the undoubted
sealing off of the abscess cavity from the general peri-
toneal cavity, and the possible danger of puerperal in-
fection from the abscess after it was opened. With the
understanding that I should see the patient again, three
days later, unless something unexpected occurred, I left
her on September 24th, and on the 27th I found that,
after nearly normal temperature on the 24th and 25th,
the thermometer had again shown a rise to 1020 F. on
the 26th, and was 101.80 F. when I saw her. The dul-
ness in the right iliac region was as marked as ever,
although the pain was less severe. I now advised im-
mediate operation, which was deferred until the next
day in order that Dr. Willy Meyer, at the request of the
family, could he present to examine the case and assist
at the operation. Accordingly on the 28th, Dr. Willy
Meyer concurring in the diagnosis and indication for
operation in his presence, and with the assistance of
Drs. Hochheimer and B. H. Wells, I opened the abscess,
which was found completely closed by a thick wall of
agglutinated intestines. Drainage tubes were inserted,
and the after-treatment left to the care of Dr. Hoch-
heimer. Convalescence was practically uneventful.
I need scarcely say that the death of the child was due
to the high temperature, and the premature labor to
the effort of the uterus to expel its dead contents. It
is. providential that the high temperature preceding, dur-
ing, and following labor did not produce, at least, an
acute endometritis, which would certainly have been the
case had the cause of the fever been a general septic in-
fection. As a preventive, an ice-bag was kept on the
abdomen for several days after delivery.
I am indebted to Dr. Hochheimer not only for the
opportunity of seeing the case, but also for the permis-
sion to publish it as an example to other physicians who
may happen to see pregnant women with acute pain in
the right iliac region accompanied by fever. I think
that in a future similar case I would open the abscess
at once, as soon as a reasonable probability of its existence
could be settled, without reference to the pregnancy or
the impending or completed delivery. I would rather
take the chances of puerperal infection from the abscess
than of its unexpected rupture at any moment into the
peritoneal cavity.
20 West Forrv-nrrH Steeet, November 8, 1894.
A CONTRIBUTION TO THE STUDY OF THE
LOCATION AND PHYSIOLOGY OF THE VIS-
UAL CEREBRAL CENTRE.
As Shown by a Case of Monocular Amaurosis
which Terminated in Complete and Permanent
Recovery.1
By ALFRED HINDE, M.D.,
CHICAGO, ILL.
SENIOX fUIGEON TO THE BYE AND BAR DEPARTMENT OP THE CENTRAL FEES
DISPENSARY ; INSTRUCTOR IN DISEASES OP 1HE BYE AMD BAR, AND OPHTHAL-
MOLOGIST TO THE NEUROLOGICAL CLINIC OP RUSH MEDICAL COLLEGE, CHICAGO.
The sparseness of its literature! because of infiequency of
occurrence, the apparent seriousness of the clinical pict-
ure, and a desire to aid in elucidating an interesting
brain condition, prompt me to briefly record the fol-
lowing case.
S. D. T. , female, American, single, age nineteen,
school-teacher, a florid blonde, in height, five feet six and
one half inches, and weighing 145 pounds, was referred
to me from an adjoining State, because of total blindness
of the right eye.
She detailed a good non-neurotic family history, and
had had no severe personal sickness. At the age of
seventeen she first menstruated scantily, and thereafter
repeated the function at intervals of five weeks for the
first year. During the succeeding twelve months the
intermenstrual period of time had shortened, and, when
the case presented itself, was only of three weeks' dura-
tion. The discharge continued to be of slight amount,
lasted for three days, and its commencement was asso-
ciated with pelvic distress, as well as before, during, and
after the period; there was considerable nerve- stoim,
that presented itself in an irritable temper, with anorexia
and insomnia, besides vulvar heat, and frequent mictu-
rition.
Mentally bright, industrious, and of studious bent, she
said she had lately lost only slightly in weight, but
greatly in bodily strength and endurance, so that the
least physical exercise, or mental application, resulted in
extreme exhaustion, and produced a perfect whirlwind of
unrest.
When eighteen years old, and " preparing an essay,"
for a school examination, she was under considerable
mental strain, and was seized with a condition of uncon-
trollable nervousness which lasted one week and necessi-
tated her return home. During this entire time con-
sciousness was retained, but she lost all control of herself
— would laugh and cry alternately — and though real-
izing her ludicrous behavior, she seemed utterly unable
to prevent her strange actions. With rest of brain men-
tal quiet ensued, but during the past year minor recur-
rences have happened, whenever her surroundings were
not to her liking, or when she again attempted further
studious efforts; and the attacks were most pione to
occur at the menstrual periods.
During the last week of December, 1893, she became
a subject of the grippe, and soon after its onset she
noticed that the vision of the right eye was failing, and
it became progressively worse during the following six
weeks, so that at the end of this time not only no ob-
jective vision was retained, but also perception of light
was annulled ; day and night were alike to this eye. She
observed that her recognition of colors, and that of ob-
jects, was gradually reduced; and that for light was
the latest to be perceptibly affected.
This condition of right-eye blindness had lasted for
» Read before the Chicago Medical Society, October 15, 1894.
68o
MEDICAL RECORD-
[December i, 1894
about six weeks when I first saw her on March 31, 1893.
At this time there was no apparent disease of motility, or
structure of either eye ; ophthalmoscopies^ both were
alike and normal. The pupils had a diameter of 4
mm., were circular, and the iritic reflexes— direct and
consentaneous — were actively and equally present in the
two eyes. Of the left eye there was no complaint. It
had more than average vision and read half of the *J
types of Snellen at twenty feet distance. Its color-sense
was perfect. The visual field, however, was inconstant.
At the commencement of the testing it was perfect
throughout and of full size, but before the dose of the
examination it contracted slightly in its periphery, above,
below, and nasally ; or in those portions of the retina
that are least richly supplied with nerve-elements. This
decrease in size of the visual field was solely due to ex-
haustive effort, however, for after eye rest the field was
again found to be full sized, but again contracted, as be-
fore, on continued testing. This apparent asthenopia of
the peripheral nerve-tissues is of cortical origin, because,
in cases where both visual fields are present, a corre-
sponding simultaneous contraction in the untested field
occurs, thus showing an exhaustion of function of cen-
tral location.1
Covering carefully the left eye, a concentrated beam
of the strongest gas light, cast within the pupillary area
of the right eye, was said to be totally unseen, and
surprise flashes were without conscious reflex results. The
diplopia confusion tests for simulated blindness of one eye,
together with Selling's test of colored letters on a black
ground viewed through colored glasses, were negative.
Thus was proved the presence of the claimed right
amaurosis.
The special senses of taste, smell, and hearing, and
that of ordinary cutaneous sensation, were normal and
alike in both halves of the body.
Digital pressure over the right supraorbital notch elicited
acute pain, and deep pressure over the ovarian regions,
more especially the left, produced a sickening weakness
which spread throughout the body, perspiration followed
and she appeared to be considerably disturbed and was
very restless. She stated that the symptoms present were
similar to, but less severe than those experienced at the
first nervous seizure of spontaneous outset, and almost
exactly like the minor attacks that occurred later. Here
was present an ovarian hyperesthesia, besides an in-
creased sensitiveness of the superficial branches of the
ophthalmic division of the right fifth nerve.
Galvanic testing developed photopsia in the left eye,
with one-third the current strength required to produce
the same result in the right eye. A 5-milliampdre
current was needed to arouse flashes of light in the right
eye when first applied, but before the termination of the
testing a weaker current was sufficient to start them.
When compared with the left, this indicated a markedly
decreased galvanic reaction of the right visual tissues,
together with the probability of restoration to the nor-
mal after repeated galvanization — because of the im-
provement in light perception before the close of the
sitting.
The right auditory nerve did not develop the Brenner
reaction even with 6-xnilliampgre currents; whereas,
continued hissing tinnitus was produced in the left ear on
KaCl, and slight transient hissing on AuO, the testing
pole in each instance resting in the external auditory
canal.
Here we had a patient in whom, up to puberty, there
had been no complaint, but when that time arrived, with
its disturbing nerve-storms, the cerebrospinal system
had to share with the sympathetic the existing nerve-
stream — the diversion of a portion of which resulted in a
hyperesthesia of the pelvic viscera. Along came the
grippe infection, reducing still further the already weak-
ened nerve-tone, and in some indeterminate way its
ptomaines, acting locally upon especially suitable tis
1 Schiele : Archiv f. Augenheilk., BA xvi., quoted by Gowers, Dis-
eases of the Nervous System, vol. ii., p. 147, 1893.
sues, produced the right-eye amaurosis. Thus we had
present the anomalous condition of a strictly localized
cerebral anaesthesia, together with an ovarian hyper-
esthesia, briefly, a disarrangement of forces rather than
a destructive process. The equal pupils and the absence
of ophthalmoscopic signs proved eye escape. The pres-
ence of the iritic reflexes, as first pointed out by Von
Graefe1 in 1868, excluded disease as far back as the
corpora quadrigemina. The motion of the irritant lu-
minous ray was still appreciated by the right retina and so
transferred, through rhodopsin - reduction and other
chemical processes, to the molecules of its badUary
layer, and hence backward to be switched off at the re-
flex centre and returned by the third nerve-trunk, there-
by excluding disease in this arc. The optic thalamus
and the posterior limb of the internal capsule had es-
caped, for there were no evident symptoms present im-
plicating these areas. Therefore, we had remaining only
the termination of the visual path in the left occipito-
angular cortex, and whatever normal stimula were con-
ducted to this part were without conscious perception or
effect. Here, we presumed, was the site of the patho-
logical process, and the cortical nerve-cell as the part
especially affected, and, because of the increasing ap-
preciation of galvanic irritation, we considered the con-
dition present as one of simple inhibition of function — a
rare example of suppression of visual will, or visual con-
sciousness of the left cortical centre, and that besides the
psychical condition there was also some uncertain molec-
ular change in the affected cells. Because of this in-
terpretation, a favorable prognosis was given, and it was
thought that insufficient time had elapsed for permanent
changes in nutrition to result Yet this opinion must be
regarded as very venturesome because in functional in-
activity, as in excessive use, there are physical changes,
and if the abolition is sufficiently prolonged these may
be irremovable and function remain permanently ' abro-
gated. Our hopeful opinion was, moreover, founded
upon the ready institution of returning function as shown
during the galvanic testing.
No time-limit for available eye-use was, however, haz-
arded because of the well-known persistence of many
cases of central neurasthenic, or hysterical, asthenopia,
;.*., those cases where there is present perfectly acute
vision momentarily, but in whom the sight melts rapidly
away upon attempted continued use, this being most prob-
ably due to insufficient nerve-charging of the tissues em-
ployed, or else to an impairment of visual will.
Remembering the psychical element in our case we
directed her to practise and exert her will upon all oc-
casions where self-control was endangered; to restrain
her flightiness; to avoid over-excitement and over-
fatigue, both mental and bodily, and to live the details
of a quiet daily life with clock-work regularity. The
usual medicines for the hysterical state were given.
Above all things her impressionable mind was not per-
mitted to grasp the idea that she was the subject of any
possibly irremovable physical imperfection over which
she might pore. She had no womb to be tinkered for
imaginary disease from my saying so, and her thoughts
were steered away from this end of her anatomy.
We thus avoided the institution of that aura of melan-
choly that too often surrounds such cases and engulphs
them, alas ! impenetrably, so that all our efforts to remove
their fancied and real ills are without avail.
In ordinary health the storehouse of the nerve-centre
is surcharged with nerve-power, and but a small portion
of it is in actual use at any one time, the remainder being
retained to draw from, so that continuous work without
conscious fatigue can be accomplished; but here the
storage battery was only sufficient to keep charged tem-
porarily the nerve-tissues of this brain — feeble efforts re-
sulted in rapid exhaustion, and in the elements of the
left visual centre it appeared to be entirely lacking.
To aid the restitution of a normal condition the con-
» Berliner Klinische Woch., 1868, p. aa.
* For examples see Gowers, loc. cit., p. 165.
December i, 1894]
MEDICAL RECORD,
681
stant current was applied with the anode to the closed
right eyelids, and the cathode to the left occiput, thus
trying to bring within the range of the ascending current
the entire visual path. The current strength used was
only sufficient to arouse and barely maintain the sensa-
tion of photopsia in the right eye. The seances were
daily and lasted about ten minutes. The applied current
was started at zero, steadily increased to the exciting
strength, and after continuing it at this point for the req-
uisite time, it was gradually reduced to zero again with-
out a break. The necessary current was always strongest
at the beginning of each sitting, and before its close had
to be reduced to avoid excessive photopsia with dizziness.
The first treatments needed a current-strength of 5
milliamperes, but as function became restored weaker
and still weaker currents were sufficient. General gal-
vanization and faradization were also resorted to.
Improvement was rapid, and after the fifth treatment,
and with the left eye carefully covered, a concentrated
beam of gas light suddenly flashed into the right eye,
startled the patient, and she said she " felt a flickering
sensation " in it, and a feeling of weakness diffused it-
self throughout the body. On further examination, at
this time, it was ascertained that only the central portion
of the retina was momentarily aroused by the strong
light, the remaining parts being wholly anaesthetic.
The constant current had produced irritation sufficient
in the optic tissues to start the subjective light- flash, but
in the feeble recognition of this strong light we had the
first evidence of actual light perception — the light-sense
was awakening. From this on a daily improvement in
light sensitiveness of the right eye was perceptible both
quantitatively in the centre of the retina as well as in
increase of area of sensitive tissue. The first faint flicker
of light-perception grew steadily stronger, and a weak
flicker spread nasally over an increasing surface. Pro-
gressing uninterruptedly daily, the nasal limit of the
retina " felt the flicker," and, latest of all, the temporal
periphery became sensitive to it. By this time the cen-
tral retina had advanced in sensitiveness, so that a very
much weaker light was recognized as such. Of natural
light, that of the morning was first seen on awakening,
bat after being observed for a short time it faded en-
tirely from view. Each morning it appeared stronger
and stronger, lasted longer, and finally continued all
day. Large objects then began to appear, very indis-
tinctly at first and only temporarily. In this we had
the first commencement of the returning form sense —
and eleven days after the beginning of the light-sense.
This objective vision improved rapidly, and progressively
smaller and smaller objects appeared to view, and the
larger ones, first seen, became more clean-cut in outline.
Objective vision was also only temporary at first, but
became more and more permanent with voluntary exer-
cise and time. In forty eight hours after the initiation
of objective vision, Snellen's 200 feet type could be read
at six inches ; and twenty-two days still later, the vision
of this right eye was I? — , and it could read the smallest
type of Snellen with the near point at six and one- fourth
inches. Nervous asthenopia was still a prominent symp-
tom, however, for vision for minute objects was only
transient. As the light-field had contracted on effort
from periphery to centre, and, at first, had totally dis-
appeared, so the patient said she noticed the form-field
get steadily smaller and smaller, until only the type-
letter looked at remained visible ; and during the first
days even this melted from view, all that remained was
merely perception of light.
About the return of the color sense we have no exact
data further than that it was gradually restored, but more
rapidly than either that of light, or form, and last of all,
but it finally became as acute as in the left eye.
From this observation it would seem certain that the
light-sense and form sense are separate and distinct from
each other. The rapid return of the color sense inter-
fered with our observation of it, and I regret greatly that
I failed to map out the color-fields of each eye for pur-
poses of comparison. From the fact, however, of the
frequently observed cases of simple color hemianopsia,
without any affection of the half fields for objects and for
light, leads us to believe in a separate centre for colors
also. That there are separate centres for light, form, and
colors has been recently asserted by Wilbrand,1 quoted
by Gowers, who adds that for light and form " it is not
yet certain that this is so," but, on account of the cases
of simple color hemianopsia, he appears to agree with
Wilbrand, who suggests that the color centre "is in
some part of the occipital cortex in front of the apical
region," and Swanzy2 places it in " the posterior part
of the superior and inferior occipitotemporal convolu-
tions."
The observation of cases of crossed amblyopia has been
frequently made. In these there is simply a reduction of
the normal acuity of vision of the eye opposite to the
lesion — there is still remaining a portion of the visual
function for light, form, and color. Our accompanying
case, however, is unique, from the fact that there was a
complete suspension of the function of the right eye, and,
lasting several weeks, a true amaurosis. I am not con-
versant with a strictly parallel case. Those that most
nearly approach it are the transient monocular amauroses
of purely hysterical origin.
That the area of disease was cortical there can be
no doubt. That the half vision centre of the occipital
lobe was not involved is equally patent, yet it usually
is affected in the cortical visual cases. The few autop-
sies in cases of crossed amblyopia point to the angular
region as the seat of disease, and Gowers adds that the
field of the same side as the lesion is also represented,
but to a much slighter degree than the one of the opposite
side, because there is usually a " slight restriction of the
field of the eye of the same side." This localization of
the diseased site perfectly fits this case, and we are led
to presume that the intensity of the'acting bacteriological
process in our case was greater, in order to completely
annul function, than occurs in the ordinary cases of
crossed amblyopia. If we are correct in the selection of
the seat of the disease we choose at the same time the site
of the light, form, and color centres, viz., the "occipito-
angular ' ' region. The phenomena of disappearance and
return of these senses would seem to imply either separate
centres, as Wilbrand and Gowers maintain, or that these
functions are dependent upon different degrees of physi-
ological life of a single centre.
We are here treading on purely polemical ground,
however, because though numerically observers are
agreed that the visual cortical centre in man occupies
the occipital lobe, yet it is by no means decided that it is
solely limited to this district, but that more probably it
extends anteriorly into the angular region, as Ferrier
first pointed out Therefore, with doubts as to the exact
limitation of the whole visual cortical centre we can
readily understand the greater difficulty of the exact
localization of its several parts for light, form, and color.
On this account further exact observations along this line
are greatly needed, and I reiterate Gowers's request that
bedside examination of medical cases should be careful-
ly carried out and the results recorded. This field is
particularly one for the family physician.
Before full restoration of visual acuity of the right eye,
with equal endurance for work of the two eyes, there was
a period of fifty- six days of treatment. By daily exer-
cise the time limit for comfortable use of the right eye
became steadily more and more prolonged until each eye
became alike in its working power. Distinct and easy
near vision lasted in either eye only twenty- three min-
utes, and the near point was farther off than the age of
the patient would indicate — showing an impairment of
accommodation. With + 1.25 D lenses the normal
near point (4 inches) was restored and with these glasses
1 Gowers, loc. cit., pp. 147 and 155, 156.
* Swanzy, Ed. 1892, p. 409. He also adds, p. 410 : " It is also prob-
able that the centres for the three visual perceptions of light, foim,
and color are distinct from each other, and that they are arranged, as it
were, in layers, one over the other."
682
MEDICAL RECORD.
[December i, 1894
binocular vision was comfortable for a greatly prolonged
time. The left eye that had read half of the W types on
the first testing, now read correctly every letter of this
line. This would indicate an improvement in the form-
sense of this eye and predicates a slight previous affection
of its centre also, or may be it was due, as Gowers claims,
to the influence of the diseased centre belonging to the
other eye. The hysterical state appeared to be com-
pletely overcome, and with greatly improved general
health she left for her home. Since then further im-
provement has occurred. She has resumed her occupa-
tion of teaching, and now, seventeen months since her
discharge, without any signs of eye- relapse or impair-
ment of general health, we have every reason to hope for
the further permanency of the recovery.
In conclusion, I may say that the evolution of this
case, as told by the patient, and its involution as noted
by myself, form one of the most interesting and perfect
clinical pictures that it has been my good fortune to ob-
serve.
16 Laflin Street.
THE RATIONAL TREATMENT OF DIPH-
THERIA.1
By B. VAN D. HEDGES, M.D.,
rLAiNrims n. j.
The author's warrant in presenting this subject for your
consideration lies in the realization that we are living in
an age when men and methods are judged alike by the
cold logic of practical results.
In an uninterrupted series of cases, upon which this
paper is based, we have the pleasure of reporting thirty-
five per cent recoveries in cases of croup under five years
of age demanding intubation, and a mortality of only six
per cent, in diphtheria not requiring operative interfer-
ence. These results, we believe, are directly due to meth-
ods of treatment which it shall be our pleasure to discuss
this evening.
How interesting it would be, had we the time, to turn
our gaze backward and note the different remedial meas-
ures in vogue from century to century, all of them em-
pirical, because founded upon a faulty conception of its
true pathology and etiology. But the mists have
cleared away, the darkness has had its dawn, and in the
clear, strong light of modern research we are able to
positively assert that diphtheria is due to the presence of
a definite specific micro-organism that can be isolated
and detected in the very earliest hours of the disease, and
that it is primarily and essentially a local trouble, with
secondary constitutional symptoms, due to the absorp-
tism of septic products from the local seat of lesion.
Upon the proper appreciation of these two fundamental
truths rests the modern rational treatment of diphtheria.
It was the author's privilege, during the past year,
while resident physician at the New York Foundling
Hospital, to have had under close personal observation
some sixty-seven cases of genuine diphtheria, proven to
be such in each instance by bacteriological examinations,
conducted by Dr. Wm. H. Park, of the New York Board
of Health. The assistance thus rendered us by Dr. Park
in enabling us to effect prompt isolation and early treat-
ment was most valuable. From this series as well as
from the accumulated experience of others in this same
institution during former yean, the writer begs leave to
draw the conclusions embodied in this present paper.
He is indebted to the staff of attending physicians for their
kind courtesy in allowing him full use of the histories.
If, then, diphtheria is a local trouble, with constitu-
tional symptoms dependent upon the amount and viru-
lence of the toxic ptomaines developed and absorbed
into the system from this primary source, we must first
consider the
Local Treatment — Welsh and Abbott have shown,
after long and careful investigation, that the bacilli are
1 Read before the Plainfield Medical Society, October I, 1894.
most abundant in the very outermost layers of the mem-
brane, and comparatively absent in the deeper portions;
hence the indication is to attain thorough local disinfec-
tion, and not necessarily the entire removal of the mem-
brane— a radical measure which is further contra-indi-
cated by the fact that we leave behind us a raw, bleeding
surface, a most tempting field for the reinvasion of die
hosts of germs that hover about.
As to the best means for obtaining local disinfection
it would seem as if the neutral solution of peroxide of
hydrogen was the most valuable. Williams, of Boston,
claims the best results with a strong concentrated thirty
to fifty volume solution. Squibb' s ten volume solution,
with the addition of a small amount of bicarbonate
of soda to neutralize the hydrofluoric acid which is so
often present, proved equally efficient, and has the ad-
vantage of being much less irritating. Bichloride of
mercury has many drawbacks. To do its work well, it
must be strong, yet in this strength, if swallowed, it may
give rise to serious symptoms. The writer will never
forget the sudden and violent death of a little one under
his care, due to the accidental swallowing of three large
syringefuls of a 1 to 3,000 solution. Carbolic acid and the
stronger antiseptics are all open to the same objection,
but in peroxide, with its powerful affinity for inorganic
matter, we have a remedy which thoroughly disinfects
the outer layers of the membrane, and has no bad effect
upon the stomach even when swallowed in large quanti-
ties.
If the child is tractable and will allow the tongue to
be depressed, either an atomizer or a hard- rubber syringe
can be easily used. But when the little one fights and
struggles against such interference, it is best to simply
irrigate through the nostrils, rather than incur the risk
of provoking cardiac failure ; and yet we must remember
that the very reason the child is sick, the very reason we
fear cardiac failure, is because of these highly toxic prod-
ucts of the Loeffier bacilli. The extent to which we
can safely proceed in. our efforts at local disinfection
must always be determined by the attending physician
upon the merits of each individual case.
After the throat has been irrigated and cleansed with
peroxide, we would advise the application of papoid,
either in the form of a powder — and for this purpose
Osborn's insufflator is best— or a strong solution painted
upon the parts. It is a powerful digester of membrane,
acts in any medium, and is very tenacious to any surface
with which it comes in contact. Acting also upon the
outer layers of the membrane, it forms a rational and
valuable link in our chain of treatment It is much
superior to any of the older combinations of pepsin,
trypsin, and sulphur.
The local action of the tincture of the chloride of iron
— both astringent and antiseptic — belongs to the realm
of ancient therapeutics, and yet the writer believes it to
be most beneficial and efficacious, particularly in those
cases where there is a condition of profound anaemia. A
most delightful vehicle for its administration is the syrup
of pineapple — made fresh from the fruit and not from
the worthless extracts sold in the shops. Besides making
a palatable menstruum, it has a valuable proteolytic ac-
tion upon the membrane itself, and is a powerful aid to
stomachic digestion, as ably demonstrated by ProfesBor
Chittenden, of Yale, in a recent number of the Journal
of Physiology.
Just a word in regard to the matter of prophylaxis
while making these local applications. To guard against
any bit of membrane being blown into the eye, it is well
for the doctor or nurse to wear a pair of large goggles.
A lovely woman, in perfect health, who lost her sight,
and almost her life, through an accident contracted in
this way, has made an impression upon the writer that
will never be forgotten. Indeed, it is safer to wear a
mask over the entire face. One of New York's well-
known physicians lost his only daughter, a few years ago,
through a piece of membrane coughed into his beard and
retained there despite subsequent washing.
December i, 1894]
MEDICAL RECORD.
683
In a word, then, we would advise as local treatment :
1. Thorough disinfection with peroxide solution, with
spray or syringe, either through mouth or via the nos-
trils. 2. The local application of the tincture ofr the
chloride of iron, administered in syrup of pineapple. 3.
Insufflation or painting of papoid.
Constitutional Treatment. — Next and equally im-
' portant is the constitutional treatment. We are dealing
with a disease that at any moment may strike its fetal
blow. The battle is not a long one, as in typhoid and
the protracted fevers, but short, sharp, and decisive,
hence the necessity for prompt action at the very start.
Alcohol, in the writer's opinion, pushed to the point
of tolerance, is our strongest bulwark of defence. It
dilates the superficial vessels, relieving internal conges-
tion, its carbon forms a direct food to the body tissue,
its action as a cardiac stimulant and tonic in conditions
of profound toxaemia is unsurpassed. Next to alcohol,
and almost equally valuable, is strychnine, preferably
given hypodermatically through a small needle, the
prick of which the child scarcely notices. Taken by
mouth it is too apt to derange the stomach. As a pure
heart tonic strychnine is equal, if not superior, to alcohol,
and it is surprising to what an extent it can be pushed
before we get the exaggeration of the deep reflexes, a
point beyond which it is unwise to proceed. A child
three to four years of age will often take one-thirtieth of
a grain every four hours with marked benefit.
The local action of the tincture of the chloride of iron
has already been mentioned. In cases of profound anae-
mia, a condition easily demonstrated by Gower's haema-
globinometer, the constitutional effect is also valuable.
Sometimes the stomach is intolerant of any form of iron.
In such cases it should be promptly stopped, for in nour-
ishment properly administered we have, after all our
most valuable aid — one which is too often overlooked in
our zeal to obtain local antisepsis and cardiac stimula-
tion. The soreness and pain that often accompanies
each act of deglutition, the irritability and fretfulness of
• the patient, the utter loss of appetite, are all factors that
conduce toward a starvation diet if the watchers are not
constantly on the alert. Concentrated fluid nourish-
ment — milk-punches, eggnogs, the expressed juice of
meat, Rudisch's sarcopeptones, Mosquera's beef-jelly,
panopeptone, and the different forms of nutritious broths
should be our main reliance. To avoid the introduction
into the stomach of an unnecessary amount of septic
matter it is wise to administer the nourishment imme-
diately after the local disinfection with peroxide.
The fever, as a rule, runs a low course and requires
no treatment. A temperature above 1030 F. can be
controlled by cool sponging; under no circumstances
by the exhibition of the coal tar antipyretics. Ipecac,
quinine, turpeth mineral, veratrum viride, and the long
list of drugs formerly held in high repute, it is best to
altogether discard. Preserve the integrity of the
stomach at all hazards, so that digestion and assimilation
may be as perfect as possible. See that the child gets
the proper amount of nourishment at stated intervals ;
guard the action of the heart by the judicious use of al-
cohol and strychnine, and we have the gist of our consti-
tutional treatment.
Among the complications demanding our attention
croup ranks facile princeps. In nineteen cases that fell
under the writer's observation during the past year, bac-
teriological examinations have shown in each instance the
presence of the Loeffler bacilli. They have been found
present in over eighty per cent, of all cases examined by
the New York Board of Health, so that we feel warranted
in establishing an identity between the two diseases.
At the very first suggestion of any stenosis we would
begin with calomel fumigations, burning fifteen or
twenty grains of the powder every two hours. Whether
it acts solely as a local antiseptic or constitutionally by
diminishing the plasticity of the blood, and so decreas-
ing the amount of fibrinous exudation, is a matter of
minor import. We know that it does good if begun
early in the disease and vigorously pushed. An um-
brella, covered with a sheet and raised over the little
one, makes a handy and convenient tent. A wash- bowl,
two cross pieces of iron, a tin platter, and an alcohol
lamp complete the outfit. To avoid the danger of sali-
vating the nurse, a complication of no mean moment,
the room should be thoroughly aired after each fumiga-
tion. It is surprising how often very severe cases will
yield to this treatment alone, without resort to graver
measures. The inhalation of medicated steam relieves
the condition of dryness so often present, promotes ex-
pectoration, and acts as a local antiseptic. A solution of
carbolic acid, eucalyptus, and turpentine— a favorite com-
bination of J. Lewis Smith's— is valuable for this pur-
pose. The addition of lime water is possibly of some
assistance.
If every case of croup were given the benefit of this
conservative method of treatment, thoroughly and con-
scientiously tried from the very start, there would be a
marked improvement in our mortality statistics. But
when the symptoms of stenosis grow steadily more and
more pronounced, when the air no longer enters the
lower lobes, as determined by the absence of vesicular
murmur on auscultation, when there is marked intercos-
tal and supra- and infra clavicular retraction with each in-
spiration, then we only hazard our patient's chances by
delaying operative interference. We must choose be-
tween tracheotomy and intubation.
In cases complicated by intense oedema of the epiglot-
tis and marked tonsillar enlargement, the older operation
is much to be preferred. In simple uncomplicated cases
of laryngeal stenosis it has today been almost entirely
superseded by the more modern method, thanks to the
genius and untiring industry of Dr. Joseph O'Dwyer.
I should say its main advantages were these : 1. It is
a bloodless operation and entails a minimum amount of
shock, the whole procedure taking less than a minute in
the hands of a deft operator. 2. The consent of the
parents can always be obtained when the very first indi-
cation presents itself. There is no delay until the pa-
tient's strength and vitality are both at such a low ebb
that no interference avails. 3. The air, as it enters the
lungs, is warmed by passing first through the natural
channels. 4. There is no wound for reinfection ; no scar
to mar the beauty of later life. 5 . In intubation the tube
can usually be removed within a few days. ^ In trache-
otomy it is a matter of weeks before recovery is complete.
6. The tracheotomy tube requires untiring watchfulness
day and night by trained attendants. Only the ordinary
care is required in intubation.
On the other hand it has its disadvantages. Mem-
brane may be dislodged and pushed down by the intro-
duction of the tube, closing up its lower orifice. It hap-
pened to me once in one of my earlier cases. In such
an emergency the expulsive power of the lungs is
usually sufficient to eject both tube and membrane, as in
this case, when the tube can be reinserted. To avoid any
unpleasant sequelae of such a complication, it is wise to
leave the string attached to the tube, fastening the free
end to the cheek with a small bit of adhesive plaster,
and instructing nurse or parent to pull it out if the child
suddenly chokes or becomes blue. Again, the operation
is one which requires a great deal of manual skill and
dexterity. If done in a bungling manner, extensive
harm can be committed, and tracheotomy, under such
circumstances is always to be preferred.
But the operation is no longer an experiment.
Weighed in the balance, it has not been found wanting,
and its most bitter opponents of former years are to-day
its warmest advocates.
Diphtheritic conjunctivitis, either by direct contami-
nation or extension through the lachrymal duct from the
nares, is fortunately a rare complication. It demands
most energetic and prompt treatment. Here, as in the
throat, we found the neutral solution of peroxide most val-
uable. Applications were made to the membrane every
half hour, followed by the cleansing solution of boracic
684
MEDICAL RECORD.
[December i, 1894
acid. Out of four cases three recovered. In the fourth,
where there was also a complicating malignant scarlet
fever, both corneas became involved, followed by exten-
sive sloughing, before death supervened.
Diphtheritic paralysis occurred in only one instance,
and yet it taught us a most valuable lesson, showing the
danger of sudden cardiac failure. There was first the
paralysis of soft palate, regurgitation of fluids through
the nose, and partial disability in the lower limbs. All
symptoms became markedly improved at the end of two
weeks. Some few days later, the child, a "runa-
round " of four years, grew excited while at play with
some other convalescents in the same room. An attack
of tachycardia suddenly developed, and death followed
in ten minutes from the onset. A case under my care,
here in Plainfield, while sitting upright on a vessel and
straining over a constipated movement, died in very
much the same way. Prolonged rest in the prone posi-
tion, the positive interdiction of any active exercise long
after convalescence seems established, and the faithful
use of heart tonics, would seem to be the lesson taught
us by these fatal cases.
Albuminuria was present in seventy-five per cent, of
the cases, leaving an acute nephritis that proved fatal in
only one instance, and that two months later. In all
the others the kidney symptoms entirely disappeared.
A rigorous fluid diet, giving the kidneys a minimmq
amount of work to perform, and small doses of sweet
spirits of nitre where secretion was scanty, were the only
measures used.
The treatment of broncho pneumonia, one of the most
frequent of the fatal complications of croup, hardly falls
within the province of this paper. Vigorous counter-
irritation over the entire chest, with warm mustard poul-
tice at the very outset, and the use of ammonium car-
bonate to promote expectoration, and at the same time
stimulate the heart's action, gave us best remits.
The new treatment by injections of antitoxin is as yet
only an experiment. Endorsed by Koch and many of
the most eminent men on the Continent, it is worthy of
faithful and extended trial. And yet we must remember
that the cure for tuberculosis came from the same source.
To-day it is of doubtful diagnostic value only to the
veterinary surgeon.
It may be of interest to note for a moment more, in
detail, what has been accomplished in the treatment of
our 67 cases. In the 17 cases of croup demanding intu-
bation there were 6 recoveries, or thirty-five per cent.
In two instances the children were brought to the hos-
pital in a dying condition, and the operation was simply
done for euthanasia, death following within a couple of
hours after admission. Two others recovered entirely
from their laryngeal stenosis, but died ten days later
from a malignant complicating scarlet fever. This
leaves us 13 cases where the treatment was given a thor-
ough trial, with 6 recoveries, nearly fifty per cent.
Among the other 49, not demanding operative interfer-
ence, there were only four deaths, and one of these was
due to the accidental swallowing of a poisonous dose
of bichloride, leaving us a mortality of only 3, or six
per cent. Including all the fatal croup cases there is
a total mortality of only about twenty per cent., a
most favorable ratio in comparison with that of other
institutions. At the Emperor and Empress Frederick's
Children's Hospital at Berlin, during the last three
years, the mortality in 1,081 cases was 38.9 per cent.
M. Roux, of the Children's Hospital in Paris, reports,
during the last four years, 3,971 cases, with 2,029 deaths,
a mortality of over fifty-one per cent. In this same
institution, during the past few months, 448 cases have
been treated with the antitoxin injections, with 109
deaths, or twenty- four and one-half per cent.
In conclusion, then, gentlemen, we would beg leave to
offer the following suggestions as the epitome of the
thoughts advanced in this paper.
Local Treatment. — 1. Thorough disinfection with
peroxide solution, rendered neutral with bicarbonate of
soda. 2. Administration of freshly prepared pineapple
juice, either alone or with the tincture of the chloride of
iron, if a condition of anaemia be present. 3. Applica-
tion of papoid, either by insufflation of powder or paint-
ing with strong solution.
Constitutional Treatment. — 1 . Alcohol given in heroic
doses. 2. Hypodermatic injections of strychnine pushed
until there is exaggeration of the deep reflexes. 3. Con-
centrated nutritious diet.
Realizing that our knowledge must be drawn from the
wells of experience, and that we have with us to night
those who have drunk long and deeply from this foun-
tain source, the writer hopes that there may be a full
and free expression of opinion, to the end that we may
be better able in the future to cope with this dread
disease.
THE NERVOUS SYMPTOMS OF PATIENTS SUF-
FERING FROM CHRONIC URETHRITIS.
By R. K. MACALESTER, M.D.,
MEW YOIK.
ASSISTANT VISITING PHYSICIAN TO THE COLUMBUS HOSPITAL ,' PHYSICIAN TO
THt FRENCH HOSPITAL, AND NEW YORK DISPENSARIES.
The nervous disorders that are often connected with
chronic urethritis may be classed under the acquired
functional nervous diseases, although they may some-
times attain such a degree of severity as to resemble the
psychoses, and often lead us to consider them as some-
thing more serious than mere functional disturbances.
They present certain characteristics and peculiarities,
which, in connection with the underlying disorder,
form, on the whole, quite a typical group of symptoms.
It is a well-established fact that irritation and disease
of the genito-urinary organs are frequently the cause of
manifold nervous disturbances, familiar to all practition-
ers, who, however, often fail to recognize the connection.
Beard,1 in his classical work on neurasthenia, writes:
" Disorders of the genital apparatus are continually ex-
citing disease in remote organs. In men a little prosta-
titis, or urethral or preputial irritation, not only phi-
mosis, but even elongation, with secretion of smegma, are
constantly the sole and demonstrable origin of hypo-
chondriasis, dyspepsia, and other nervous symptoms."
Furthermore, I have but to allude to the nervous dis-
orders coexisting with or following sexual excesses,
masturbation, interrupted coitus, operations, or manipu-
lations on the urethra, etc.
Therefore it is not surprising that a person, knowing
that he has a gleet, should succumb to some nervous
malady, the more so when, by allowing his mind to
constantly dwell upon this fact, it should become a
source of worry and all kinds of imaginary troubles.
Indeed, the nervous disturbances may progress to such an
extent and prominence as to become the predominant
feature of the case, and the urethral disease is overlooked
or regarded as one of the imaginary troubles. This lat-
ter is to be all the more regretted, inasmuch as when the
true nature of the disease is recognized, the sufferer may
either be completely cured by an appropriate treatment,
or at least greatly improved.
Having had occasion to observe quite a large number
of cases both here and in Europe, I think that the ner-
vous complications are more frequent in this country ; at
least they are more conspicuous, and oftener attain a higher
degree of severity. In fact it is, in my experience in
this country, rather exceptional to find a person who,
being aware of having a gleet for some length of time,
does not betray some marked nervous symptoms, while
in Europe this is very common, but by no means the
rule.
I have at my disposal the records of numerous cases
bearing upon the subject under consideration, but will
content myself with detailing the histories of three, that
1 A Practical Treatise on Nervous Exhaustion. New York, 188a
December i, 1894]
MEDICAL RECORD.
685
will suffice to illustrate the more important features of
the clinical picture.
Case I.1 — M. D , twenty-five years of age, sculptor,
of Roumanian parentage, single. His mother always suf-
fered from general nervousness. He was always strong
and healthy previous to the gonorrheal troubles. Is
temperate in the use of tobacco and alcoholics, drinks a
small amount of red wine daily ; is, on the whole, a man
of regular habits and in moderately easy circumstances.
Denies ever having practised masturbation. No history
of syphilis. Has had eight attacks of acute gonorrhoea
in all, or, as he states, several of these may have been
acute recurrences of the chronic trouble. The first he
acquired at the age of sixteen, and the last about one
year ago, the acute stage of which lasted for two months ;
then it subsided, and left him with the gleet. Had been
treated by several doctors, who passed sounds, made local
applications to the urethra, etc., without obtaining any
evident amelioration.
This state of affairs has been a source of great worry,
anxiety, and discouragement to him, and he has been
getting more and more nervous. He feels weak, des-
pondent, at times drowsy, has to frequently quit his work,
feeling exhausted, and lie down to rest in daytime ; at
night has difficulty in felling to sleep, and when asleep
is restless, starts and awakens often ; on arising in the
morning feels as if he " had been on a spree the night
before," which discomfort is not a little added to by his
being day after day confronted by his gautte militaire,
which is the first thing he thinks of, and looks for in the
morning. Patient has become irritable, very excitable,
sensitive, and depressed in spirits; lost his interest in
people and things in general. It is with reluctance and
difficulty that he can accomplish any work at all. Has
been obliged to give up two or three "jobs " on account
of his inability to concentrate his thoughts and atten-
tion on his work ; is overcome with a feeling of exhaus-
tion and uneasiness, so that he cannot force himself to
continue. Is very fond of changes. His sole desire and
ambition is to get cured of the terrible disease, as he
terms it, that robs him of his peace of mind, health, and
all enjoyment of life; and if this cannot be effected,
would rather die. He has a heavy feeling and dizziness in
the head, and frequent headaches ; complains of poor
memory; paresthesia in the form of numbness of the
extremities, and creeping sensations along the inner sur-
face of the thighs. His hands and feet often feel cool,
while he frequently experiences flashes of heat to the head,
and cold feelings in the back. He thinks the disease
"has gone to his eyes," as things often look blurred.
Complains of dyspepsia, which troubles him the most when
his nervous symptoms reach their climax. The symp-
toms referable to the genital organs are : A continuous
feeling of "weakness," a prickling sensation and some-
times numbness along and around the urethra ; has lost
his sexual desire to a great extent ; his sexual potency
is, however, fair; has involuntary and premature emis-
sions, and when he attempts a second coitus it is either
very long, or impossible. Worries greatly over loss of
semen, which he notices after an erection or defecation.
Has a feeling in the legs opposite the scrotum as if there
was a hollow place in his flesh, which sometimes feels
numb, at others over sensitive.
Status prcesens, July 27, 1893. — Well nourished, strong
and robust looking, skin and mucous membrane pale.
Organs of the special senses normal. Sways slightly
on standing with closed eyes. Fine tremor in tongue
and hands. Superficial and deep reflexes lively. No
objective sensory disturbances, with the exception that
the spines of the dorsal vertebrae are slightly hyperesthetic.
Extremities feel cool, hands clammy. The physical ex-
amination of the thoracic and abdominal organs re-
veals nothing abnormal. The urine contains no albu-
min or sugar, but many coarse fibrous, and fine mucous
1 Cases I. and III. are taken, with Dr. Ramon Guit&as* (chief of
clinic) kind permission, from my records in his clinic at the French
Hospital, of which I am in charge. Case II. was my private patient
threads; it is clear, and specific gravity 1.016. With
the test of the two glasses, both portions of the morning
urine contain threads. Sounds could be passed up to
26 (Charriere), a resistance was felt in the pars bul-
bosa. Examination of the prostate gland, per rectum,
showed this organ to be enlarged to about twice its nor-
mal size, somewhat increased in consistence, and not
painful on pressure. The microscopical examination of
the " seminal loss " showed it to be composed of secre-
tion from the prostate, mixed with a small amount of
pus ; there were no spermatozoa present, but I was able
to demonstrate gonococci.
Treatment.— Begun on July 27, 1893. Gradual dila-
tation of the stricture, local applications of solutions of
argent, nitric, with the Ultzmann syringe, cool sitz-baths,
and 0.5 natr. salicyl. t.i.d. were ordered for the gen-
ito-urinary trouble. For the nervous disorders I pre-
scribed a general dietetic hygienic regime, a moderate
amount of exercise in the fresh air, cold spongings in the
morning, abstinence from Baccho et Venere, etc., and
ordered x.o natr. bromid. to betaken in the evening.
Under this treatment patient improved rapidly. On
August 15, 1893, his stricture had been dilated up to
forty two ; a five per cent, nitrate of silver solution was
injected ; the drop in the morning had diminished in
size, and become nearly transparent; the urine contained
but very few fine threads, and the nervous symptoms
had markedly improved. The treatment was continued,
and on September 25th the patient was entirely free
from any urethral discharge; the examination of the
urine revealed no evidence of disease, the threads had
disappeared, and he told me that he could no more find
" the morning drop," and did not lose any more semen.
His nervous troubles had left him to a great extent, al-
though he was still restless, fidgety, and anxious ; but on
the whole he was greatly benefited, took more interest
in his work and people, felt encouraged, more hopeful,
and contented with his lot. Had he continued to ab-
stain from Baccho et Venere, and kept in the path of vir-
tue, I am confident that he would have made a complete
recovery in every respect. But alas ! Two months later
I learned that he had contracted a fresh gonorrhoea just
before he was about to marry, and that he was again
nearly mad with despondency and despair.
(The treatment of the chronic urethritis with strictures,
employed in all these cases, is that which is recom-
mended by Dr. E. Finger, of Vienna, for old cases, and
which I learned in his clinic. Judging from his results
and my own, I cannot speak too highly of this method
of treatment as being most reliable and efficient. In
brief it is as follows : If possible, the patient comes daily
for treatment ; if not, every two or three days. The
strictures are gradually dilated by means of the Obcr-
lander dilator, until the full dilatability of the normal
urethra is reached. The gradual dilatation consists in
increasing the calibre of the dilator by two numbers of
the scale at every consecutive seance. The dilatations
alternate with applications of argent, nitr. to the entire
length of the urethra by means of the Ultzmann syringe,
beginning with a half per cent, solution, and gradually
increasing to a five per cent., or even ten per cent., solu-
tion. If the disease gets sluggish, the argent, nitr. solu-
tion may be changed for one of cupr. sulph. , which can
be used in a ten or twenty per cent, solution if necessary.
After this has been used for a while, the argent, r.itr.
solutions are resumed, and often with a surprisingly good
result If the increasing strength of the applications and
the dilatations prove too irritable, it is advisable to either
not increase them, or discontinue them entirely, until
they [are tolerated again. The golden rule, impressed
upon us by Finger, was : Never employ any method
that will irritate the urethra, and set up acute symptoms
or complications. He prefers this plan of treatment to
the local applications through the endoscope, because
the introduction of this instrument is irritative to the
urethra. During the treatment the patient may take
some astringent or antiseptic internally, such as acid, or
686
MEDICAL RECORD.
[December i, 1894
natr. salicyl., which is also a good prophylactic against
cystitis. If the treatment fails to be efficacious in the
course of several weeks, it is advisable to discontinue it,
give the patient a rest for about a fortnight, and then re-
sume it. The advantages of the Oberlander dilator (or a
similar instrument) are obvious if we consider that the
dilatability of the urethra de norma is : In the external
orifice, 24, in the pars cavernosa, 30 to 35, and in the
pars bulbosa 40 to 45 (Charriere). The Oberlander
dilator is so constructed as to dilate these different por-
tions correspondingly to their normal relations. There-
fore the use of ordinary sounds that dilate the urethra
equally in all parts is quite irrational. By this means a
sufficient degree of dilatation of the bulbus, for instance,
cannot be effected, which, nota bene, is the most fre-
quent seat of strictures, and the patient may be treated
for any length of time without being radically cured.)
The above history gives a fair example of a patient
who is a familiar bugbear to most of us. When we have
to treat such a subject, we find him most exacting, change-
able, often irritable, taking pleasure in disconcerting and
tormenting his adviser, as if he were bent upon making
others share his misery. It is no wonder that such a
patient wanders from doctor to doctor, or from dispen-
sary to dispensary, telling everyone that nobody under-
stands his case. Beginning in a general medical depart-
ment, as a rule, he in tujn passes to the surgical and
genitourinary surgical clinic, and finally, if nobody
succeeds in curing him, he is, in despair, shoved on to
the neurologist.
Notwithstanding that such an individual is inclined
to exaggerate his ailments, and taxes our patience to
the utmost, still he is an unfortunate being, for his men-
tal sufferings are doubtless great. He is a deserving ob-
ject for our pity as well as our skill.
When such a patient presents himself for treatment, I
impress upon him the importance of energetically fol-
lowing out the prescribed plan, and the necessity of reg-
ular attendance. I emphasize the fact that the treat-
ment will last for two or three months. I exact a prom-
ise that, once begun, he will continue for that length of
time. With what success our endeavors will be crowned,
under the circumstances, depends as much upon the
patient's perseverance as upon our making a correct
diagnosis of the underlying urethral disorders, and ap-
plying the appropriate treatment.
Cask II. — H. B , forty-two years of age, single,
Custom-House employee, born in the United States;
father, German ; mother, English. The family history
is good. Patient is a man of regular habits, comfort-
ably situated ; being the only son, his mother has per-
haps spoiled him ; was always inclined to be nervous;
does not indulge in the alcohol, or tobacco habit ; no
rheumatic history. Practised masturbation, beginning
at the time of puberty, for several years. Had gonorrhoea
and chancroids at the age of seventeen, and the former
disease again about six years ago ; the acute symptoms
of which soon abated under appropriate treatment, but
ever since he notices in the morning that the meatus is
either stuck together, or that there is a drop of yellowish
or white fluid in it. After defecation, or overhearing
the conversation of his colleagues, which in their leisure
hours is wont to turn upon the fair sex, he either has an
involuntary emission, or observes a little thick, sticky,
and clear discharge from the urethra. He has nocturnal
emissions every two or three weeks. On questioning
him he gives an exquisite history of cerebro spinal neu-
rasthenia, even to the minutest details, the enumera-
tion of which, in order to avoid repetition, will be
omitted. In addition to the general symptoms he pre-
sents others which are referable to the affected parts,
such as itching, tingling sensations in the penis and
scrotum, twitchmgs, and pains that start in the genital
organs, radiate to the lower abdominal region, where
they at times become quite intense and are increased
by urinating, sexual excitement, fatigue, or micturition.
He has other paresthesia of these parts in the form of
hypersesthesia, and continuous irritability of the urethra.
He complains of numbness of the whole genito-urinary
tract, and keeps repeating: "Doctor, my privates
and bladder feel as if they were dead ; all the life has
gone out of them ; they have been weakened by self-
abuse, and I don't think there is any help for me.19
Questioned as to his sexual potency, he answers, that as
he " takes no more stock in girls," he is unable to say
how this is, but that he otherwise has only very weak erec-
tions, even when the nocturnal emissions occur ; he de-
nies experiencing any sexual desire ; penis always feels
cold.
Patient has other marked hypochondriacal ideas and
fears. Besides reproaching himself incessantly for his
past sins, he pours forth a host of new complaints and
ailments at every seance, as for instance : " Doctor, I
have to raise such a lot of thick phlegm from my stomach
that I am sure it must be diseased.' ' On his producing
this one day, I found it to be simply a minute quantity
of mucous secretion, probably from the pharynx. He
also worries over the smegma on the glans penis. Hay-
ing heard of paresis, he is sure he is developing it ; he is
sure something dreadful is going to happen to end his
unfortunate existence, etc. He is in constant fear of
catching cold ; carries a cap in his pocket which he puts
on immediately on taking off his hat ; in summer he
almost always has an overcoat at hand, and when the
weather is at all cool, he fastens his coat tight around the
chest, and the sleeves around the wrists with safety-pins,
for fear the cold air might get in. He eats little, al-
though his appetite is fair, fearing it might be injurious;
drinks only a small quantity of liquids, fearing to have to
urinate oftener and thus increase the " funny painful feel-
ings " in the genitals and abdomen. Some of his symp-
toms approach melancholia : he is extremely sensitive ;
imagines that everybody ridicules and dislikes him ; at
times secludes himself at every possible occasion, sits for
hours in the same chair, and mopes over his past sins and
sad condition ; has morbid fears of various descriptions ;
according to his mother, he has had hallucinations of
hearing several times, but this is quite uncertain.
Last spring he went to the Catskills to spend the sum-
mer, but he could not stand it longer than three weeks,
because some friends (?) there ridiculed him and his
eccentricities, and insinuated that he was fit for an asy-
lum. He is very exacting and inquisitive with his physi-
cians ; at every visit wishes to be examined from head to
foot, and when told afterward that there is no cause for
so much worry, he feels relieved for the moment. He
has been discharged by several doctors, rather abruptly,
as a hopeless "crank" and undesirable patient, after
they had tried to cure him by all manners and means.
Status prctsens.— Short, rather delicate looking, fairly
well nourished, weighs no pounds; the head looks too
large for the body, but shows no deformities ; the skin and
mucous membranes are markedly anaemic ; temporal veins
prominent; arteries normal; pulse regular, soft, sixty-eight
beats per minute. The physical examination is negative.
On standing with closed eyes, he feels dizzy, and sways
perceptibly. The deep reflexes are exaggerated. Over
the middle dorsal vertebrae there is a hypersesthetic
area. No further sensory or motor disturbances.
Eyes normal, the sense of smell is very acute, hearing
normal. The urine is clear, slightly acid, of high color,
specific gravity, 1.021 ; no albumin or sugar ; on stand-
ing a thick sediment consisting of phosphates is deposited.
Both the first and second portion of the morning urine
contain finer mucous, and coarser threads. In the latter
the gonococcus is present inconsiderable numbers. The
measurement of the urethra shows two wide strictures :
one in the middle of the pars pendula, and one in the
pars bulbosa, of 25 and 29 calibre, respectively. The
prostate gland is about the size of an English walnut, and
indurated. The palpation of this organ is extremely
disagreeable to the patient, — as is also any manipulation
upon the urethra — for it puts him in a state of excessive
nervousness and excitement.
December i, 1894]
MEDICAL RECORD.
687
Diagnosis. — Urethritis chronica anterior et posterior,
strictures; prostatitis chronica levis, prostatorrhcea,
phosphaturia ; anaemia, neurasthenia gravis (hypochon-
driasis?).
Treatment. — Mr. B was sent to me on August 28,
1893. After examining him thoroughly and detecting
the urethral disorder, I expressed the opinion that this
was probably the main seat of his troubles, and if it
could be cured the other symptoms would either disap-
pear entirely, or be greatly ameliorated. At this state-
ment he seemed to be satisfied and relieved, and con-
sented to undergo the treatment I proposed. The
treatment, directed against the genito-urinary disorders,
was the same as in the previous case. Iron, arsenic, and
strychnine were ordered as a tonic for his anaemia, and
his bowels regulated by laxatives. I tried to induce him
to drink more liquids in the forms of mineral waters,
milk, weak tea, etc., in order to dilute the urine, which
was always small in amount and concentrated ; but this .
advice, I fear, was scarcely heeded, owing to the sub-
jective discomfort he experienced when having to urinate
frequently.
As the patient had already been "saturated" with
bromides, anodynes, and narcotics by his former medi-
cal advisers, without achieving any favorable results, I re-
frained from any medicinal treatment of his nervous
symptoms, and put him on a general hygienic regime
(cool salt-water baths, a cold sponge bath mornings and
evenings, a moderate amount of out-door exercise, mas-
sage, a cold compress on his head if wakeful at night,
etc.), and general faradization. I also tried the mental
treatment, encouraging and sympathizing with him.
This plan of treatment was followed out scrupulously
and methodically by both patient and physician, and
the former improved most satisfactorily. In due time
his gonorrhoea was cured and his strictures dilated to the
full extent of the normal urethra, which, owing to his ex-
treme sensitiveness and nervousness, was no easy task. On
November 5, 1893, * had noted : No more evidence of
strictures, gleet cured, both portions of morning urine
clear, no threads, or other evidence of urethritis ; pa-
tient notices no more discharge of any description.
His nutrition, color, and general health had also
greatly improved, he gained weight and strength stead-
iiy.
In regard to his nervous symptoms, the progress was
slower, although he worried less over his genito-urinary
trouble, was more hopeful, took more interest in others
and his business, could sleep better, and felt encouraged
by the result of the treatment ; still he had a number of
parsesthesiae and morbid ideas left that he could not over-
come; he still mourned over his past sins, especially
over masturbation, "which must be the cause of all his
troubles.'1
On November 1 ith he came to my office, complaining
of rheumatic pains in the lumbar region. I suggested
giving him static electricity, and the next day directed
him to come to Dr. Dana's clinic at the Post-Graduate
foi that purpose. But, "the big machine and the
sparks " proved too formidable for him, especially as the
latter were — at one of my colleagues' suggestion — applied
rather intensely on the nape of the neck tor the purpose
of alleviating his neurasthenic symptoms. The patient
decided to discontinue treatment for a season, and has
not returned since.
This case is very similar to the preceding ; the nervous
symptome»are, however, of a severer type. They show
a decided tendency to hypochondriasis, or even melan-
cholia. It will be observed that the victim of these
afflictions had practised masturbation for several years.
A combination of the consciousness of this failing with
that of the urethral affections is most pernicious, espe-
cially in a neuropathic subject, and, as I have frequently
observed, is prone to give rise to a grave group of ner-
vous and mental symptoms. The above described men-
tal and physical wreck is the result of such a combina-
tion.
The following history is interesting, inasmuch as the
subject is a negro. He is a very intelligent, bright, and
reliable man ; the clearness and manner in which he re-
lates his history, especially in reference to his nervous
troubles, is quite remarkable and unique.
Case III. — C. W. P , thirty- five years of age,
colored ; married ; works in a marble shop. He gives
the following history: No syphilis. Acute gonorrhoea
four years ago ; has never been entirely free from the
urethral discharge since. For the last two years pains
and abnormal sensations referred to the region of the
bladder ; thinks he must have stone in the bladder, be-
cause his brother had. Itching in the back part of the
urethra. Is obliged to urinate every one or two hours
in daytime, and at night gets up two or three times for
that purpose. States that urine is sometimes cloudy and
smells bad. No discharge lately, but " the lips " are
invariably glued together after sleeping for several hours.
He has been treated for the urethral disorder off and on
for two years, the meatus was slit, and sounds passed up
to No. 30, but a radical cure was not effected.
Some of the nervous symptoms of which he complains
and details in his quaint way are : A heavy, stupid, and
empty feeling in the head ; forgetfulness ; general weari-
ness and weakness, especially in the back, so that it is
harder, and more tedious for him to get through his
work. He formerly saw the bright side of things, but is
now down-hearted and despondent, worrying continuously
over his health generally, and especially over his " blad-
der trouble," which nobody seems able to cure. Poor
sleep; in the morning gets up feeling unrefreshed and
but little fitted to begin the day's labor. "Funny,
darting feelings, starting in the neck of the bladder and
extending all over the privates and stomach." The
sexual functions are weak ; has very little desire in this
direction.
Status prasens (December 15, 1893). — Well-nourished,
strong, robust man ; color of mucous membrane good ;
no evidence of syphilis ; arteries and pulse normal.
Examination. — Deep and superficial reflexes lively;
sways considerably on standing with closed eyes ; fine
tremor in hands on extension ; otherwise no objective
signs of motor or sensory disturbances. The physical
examination is negative. The urine is neutral, cloudy,
contains threads, flakes, and a small amount of pus in
both portions, no albumin or sugar. The examination
of the urethra reveals a wide stricture in the bulbus, of
32 calibre. Prostate slightly enlarged.
Diagnosis. — Urethritis chron. ant. et post.; cystitis
chronica (?) ; stricture of pars bulbosa. Neurasthenia of
mild type.
Treatment. — The usual method described above was
employed for the chronic urethritis with an astoundingly
good result. As he also had some dyspeptic symptoms I
put him on rhubarb, soda, and tincture of nux vomica,
and gave him some general directions in regard to diet
and hygiene.
He progressed steadily and markedly; in less than
three months the genito-urinary trouble was radically
cured and the nervous symptoms had entirely disappeared.
This period might have been shorter, had the patient
been able to come for treatment oftener than twice a
week. On taking leave of me he seemed very happy,
and said : " Doctor, I feel like a new man, I feel stronger
and I can work first-rate again. That ' stretcher ' (di-
lator) you have is a wonderful instrument ; it has cured
me entirely." Probably the psychical influence of the
"wonderful instrument" aided greatly in the cure of
his nervous troubles !
Remarks. — I think that all the nervous manifestations
enumerated in the foregoing histories can unquestionably
be classified in the great symptom-complex of neurasthenia.
Morbid fears and other marked hypochondriacal symp-
toms are very common in neurasthenia ; even be they of
so severe a type as described in Case II., they fall never-
theless within its limits. The same applies to the symp-
toms of a tendency to melancholia.
688
MEDICAL RECORD
[December I, 1894
Following Dana,1 this case comes under the classifi-
cation : " The Modified Types," " Degenerative Neuras-
thenia," and Dana rightly says: "This type of neuras-
thenia is often described as 'sexual,' or as 'primary.'
It is really a manifestation of neurotic degeneracy, and
may be looked upon as an abortive form of paranoia."
Considering how many sufferers from chronic urethritis
are afflicted with nervous disorders, it would seem reason-
able to attribute to the former an important part in the
etiology of the latter. Whether the urethritis, per se, is
the causative factor, or whether it is the mental effect of
this, is difficult to determine, for there are many men suf-
fering from gleet for years who are entirely free from any
nervous disturbances until they become aware of its ex-
istence. The knowledge of this immediately brings on
nervous prostration. In my estimation the psychical
factor is the more powerful of the two.
On the other hand, there are men afflicted with chronic
urethritis and neurasthenia, notwithstanding their igno-,
ranee of the former's existence. But if we consider how
wide-spread both of these diseases are, it is not surprising
that we should find both of them coexisting indepen-
dently in the same individual. Nobody will deny that
many of our more enlightened city inhabitants are neur-
asthenic, and nobody who will take the trouble to in-
spect the urine of his male patients will fail to be con-
vinced of the frequency of chronic urethritis. Moreover,
evidence of this can be procured indirectly by other
means, such as Noeggerrath's statistics.
All authors agree in attributing to genito-urinary dis-
orders a more or less important part in the etiology of
neurasthenia. Beard considers involuntary emissions,
partial or complete impotence, and irritability of the
prostatic urethra as mere accompanying symptoms of in-
creased irritability. But one must be rather sceptical in
regard to such conditions, for, as I have observeci, they,
as well as many others, generally turn out to be the
manifestations, or consequences of chronic urethritis which
is the primary cause.
Finally, we have the question before us : Does chronic
urethritis invariably give rise to nervous manifestations?
No, I think not. I have seen men (in Europe) with
normal nervous systems, who showed no evidence of neu-
rotic disorders notwithstanding the knowledge and long
duration of a chronic urethritis. Therefore it is neces-
sary to recur to a third etiological factor, viz., a neu-
ropathic constitution or predisposition. Dana, under
neurasthenia, puts it in a very plausible way. He refers
to prostatic and urethral disorders as reflex causes of
neurasthenia, but presupposes a neuropathic constitution.
My own observations go to corroborate this view, to
which I would, however, add the psychical factor, viz.,
the patient's knowledge of the urethral disease, which
factor is, in my opinion, the most active. Thus, the im-
portant etiological factors of the cases under considera
tion are : the neuropathic constitution or predisposition
as predisposing, the chronic urethritis, and the patient's
knowledge of its existence, as exciting causes.
In the symptomatology of all cases of neurasthenia
connected with chronic urethritis, there is a great multi-
plicity and diversity of the manifestations in one sense,
but in the other a striking monotony. Common to
them all are the more localized nervous symptoms, di-
rectly referable to the genito urinary apparatus, which
clearly point to these parts as the seat of the disease,
causing the bearer no end of worry, anxiety, and discom-
fort, and giving the hypochondriacal tone so prominent
in these cases. These symptoms have been sufficiently
enumerated and described in the foregoing histories.
The symptoms of Case I. are a little above the average
degree of severity, though they are of every-day occur-
rence. The patient was a healthy, steady-going, relia-
ble, and thrifty artist previous to the onset of his gleet,
but afterward he was almost entirely incapacitated for
any mental or physical work, unreliable, changeable, and
more or less an invalid.
1 Text-book of Nervous Diseases, New York, 1893.
Case IL shows to what extent the neurotic disturb-
ances may progress. Here we have a perfect mental and
physical wreck before us, with marked hypochondriacal
symptoms and a tone of melancholia. It will be remem-
bered that this patient had a neuropathic constitution, to
begin with, and had practised masturbation for several
years, which factors must not be neglected in accounting
for the severity of the case.
Case III., presenting no neuropathic history and being
a negro— the male sex of which race, I believe, is not so
much inclined to functional nervous disorders — it is not
surprising that his symptoms should be of a milder type
and the course a more favorable one.
From these considerations it would appear that the
severity of the neuropathic manifestations depended upon
the power of resistance of the bearer's nervous system,
which is the case in all functional nervous diseases.
The chief features of the cases under consideration
may be summarized as follows : A history of gonorrhoeic
infection. Symptoms of general cerebro-spinal neuras-
thenia. Nervous disturbances directly referable to the
genito-urinary apparatus. Prominence of the hypochon-
driacal symptoms, and a tendency to melancholia.
The prognosis of the milder and average types of neu-
rasthenia is, as in neurasthenia from other causes, favor-
able ; even more so, for here the seat of the trouble can
be reached, which, if cured, and the physical factor be-
ing, also, thereby removed, the patient will generally
make a complete recovery. If the neurotic trouble is
more deeply seated and of a degenerative type, and there
are other factors concurring with the urethral disorder
(such as a neuropathic constitution, the consciousness of
masturbation, or other previous or present vices), then
their prospects of complete recovery are doubtful, al-
though the patient may greatly improve. The troubles
arising directly from the urethral affection will disappear
under appropriate treatment ; the other neurotic disturb-
ances may also improve markedly, and the patient be
benefited in every sense; but his morbid thoughts and
imagination will take a fresh direction, new fears, wor-
ries, troubles, etc., will develop, and he will probably
remain a neurasthenic subject, if nothing worse, for the
rest of his days.
The plan of treatment of the chronic urethritis has
been described in the foregoing, and some stress laid
upon it, because the favorable results observed in Dr.
Finger's clinic, and in my own experience, prompt me to
consider it a great advance in modern science.
In the milder cases of nervous disorders, nothing more
than general directions in regard to hygiene, diet, and
mode of living are required. In severer cases it is ad-
visable to resort to some sedative remedies, for the treat-
ment of the chronic urethritis, especially in the begin-
ning, often aggravates the nervous troubles for a while.
Then the bromides are very serviceable : Natr. bromid. ,
1.0 in the evening, or if necessary, 0.75 t.i.d. Static
electricity, or general faradization, applied cautiously, arfe
useful if the patient can " stand it." It is also advisable
to prescribe tonics, alone, or in combination with an/ti-
dyspeptic remedies, if in any way indicated. The fol-
lowing improvement of the patient's nutrition and color,
in connection with the progress achieved in the treatment
of the urethral disorder, will add greatly to the psyuhkal
effect of the "cure," endowing the sufferer witbJjnore
courage and hope. This latter factor is of no min«f.r im-
portance, for his perseverance in continuing t!ne treat-
ment depends to a great extent upon an appreciable
improvement. Furthermore, the mental training of the
patient is imperative ; he must follow out the prescribed
directions implicitly, and be prevailed upon to entirely
change his mode of life. An appreciation of .4br subse-
quent improvement will be more than sufficient to deter
him from falling back into his former habits.
Last, but not least, the physician must show much kind-
ness, consideration, patience, and interest for the sufferer.
This class of patients like nothing better than to be care-
fully and repeatedly examined, assured that there is no
December i, 1894]
MEDICAL RECORD.
689
grave disorder, and that they are progressing satisfacto-
rily. They always feel grateful for such attentions at the
hands of the doctor, and even if the effect be but psychi-
cal and momentary, it is, nevertheless, deserving of being
practised.
«3 Wbst Fimr-THiKD Stmit.
NOTES ON APPENDICITIS.1
By EGBERT H. GRANDIN, M.D.,
MEW YORK.
PUSIDBNT OF THB MEDICAL SOCIETY OP TH» COUNTY OP MEW YOK ; GYNECOL-
OGIST TO THB PXBNCK HOSPITAL, ETC.
When invited to read a paper before the Queens County
Medical Society, I accepted the honor with all the more
pleasure because it enabled me to introduce for discus-
sion a topic which, to judge from the number of instances I
have seen in consultation in this neighborhood, will elicit
most valuable information from your Fellows. Notwith-
standing the relatively large experience which it has fallen
to my lot to have with appendicitis in the r61e of consult-
ant, I am about as much in the dark in regard to the
symptomatology and treatment as I was when the surgery
of to-day replaced the medicine of yesterday in the man-
agement of this affection. It is to the general practi-
tioner, of which this body is largely composed, that I
look for the elucidation of a number of obscure points,
and I feel that my visit here will result in the personal
acquisition of greater information that I can give you.
The remarks I have to make are suggestive, although
founded on much experience.
I have come to the conclusion that there is no absolute
group of symptoms which points to appendicitis, and that
there is an absolute group of symptoms which calls for
surgical interference. I do not believe that every case of
appendicitis calls for the knife, even though palliative
treatment never effects cure in an anatomical sense. I
am firmly convinced that a trilogy of symptoms, which
I proceed to dwell upon, stamps a type of the disease
—called infectious appendicitis — as demanding surgery as
immediate as possible.
A constant symptom present in appendicitis is pain.
This pain at the outset may be located at any point of
the abdomen ^ it is often sub umbilical; it is frequently
diffuse abdominal. It is described as being acute and
agonizing, and sooner or later the maximum seat of inten-
sity lies over the ileo-caecal valve. This pain, however, is
not alone of diagnostic value, since it is an associate of
other intra-abdominal lesions besides appendicitis. Its
localization awakens our suspicion that the cause is near
the caecum ; its presence, however, never certifies abso-
lutely to appendicitis. A mere impaction at the caecum
may give as much pain. The decrease in pain, or its
disappearance, on the other hand, may, as I will show
later, be a bad omen.
High thermometric range, associated with great ab-
dominal pain, both factors being continuous, is rather
characteristic of instances which recover symptomatically
without operation than the reverse. Frequently these
instances terminate in local abscess, on the incision of
which the symptoms subside. It is the instances where,
• notwithstanding the temperature subsides, the pulse yet
remains rapid, which always should cause anxiety, and
which nearly uniformly demand surgical interference.
The fall in temperature, the subsidence of the pain, the
relatively high pulse rate, point to beginning septic infec-
tion, and if the focus be not removed general peritonitis
sets in of a type uniformly fatal. Decrease or absence of
pain, and flat instead of tympanitic abdomen, mean gener-
ally perforation of the septic appendix. The aim of sur-
gery ifc this region is to forestall perforation and the
resulting peritonitis. The gist of my argument, then, is
that I am more alarmed by the subacute nature of the
symptoms thirty-six hours or so after the initial attack
1 Read by invitation at the Semi-annual Meeting of the Medical So-
ciety of the County of Queens, October 30, 1894.
than I am by the maintenance of acute symptoms. In
the latter event apparent cure will often follow on purely
medical measures ; in the former instance incision, as
soon as may be, frequently offers the sole hope of saving
life.
It is above all important, in cases where the diagnosis
of appendicitis is suggested by the symptoms, to avoid
masking these latter through the administration of opium.
If the stomach be tolerant, it is desirable to secure free
catharsis in the early stage, since a loaded caecum not
alone may simulate appendicitis but intensify its symp-
tomatology. High rectal enemata of ox-gall, turpentine,
glycerin, and saturated solution of Epsom salts will fre-
quently be of service while awaiting the action of laxa-
tives given by the mouth. Hypodermatic injections of
a saturated solution of sulphate of magnesium, given deep
in the nates ( 3 j. doses half- hourly) have also repeatedly
in my hands had a purgative action. For the relief of
the pain the ice bag answers better than the poultice,
being a local anaesthetic, and at the same time lowering
the temperature without affecting the heart, as all the coal-
tar series of antipyretics may. If, notwithstanding these
remedial measures, at the end of thirty-six hours the
symptoms show no signs of abating, or else the abatement
is in the unfavorable direction I have noted above (fall
in temperature, relatively rapid pulse, flattening belly),
then, as the result of my experience, I feel that the time
has come for surgery. If we wait for the formation of a
distinct tumor, general sepsis may set in before operation
can be performed ; if we wait until there is evidence of
beginning perforation, operation will prove nugatory.
In my operative experience, which includes thirty-two
cases, I have met every form of complication — the gan-
grenous appendix, the appendix full of pus on the point
of rupture, the appendix which had perforated into the
general peritoneal cavity causing purulent peritonitis,
the appendix simply congested and denuded of its
peritoneal coating (the so-called catarrhal appendix), the
perityphlic abscess. In this neighborhood I have seen
18 cases of appendicitis; of tins number I operated
upon 10, with a loss of 3. In 1 case operation was
refused, and the patient died within forty hours. The
remaining 7 cases recovered without operation. The
3 fatal cases following operation were all instances of
general peritonitis, a type which yields an almost abso-
lute death-rate.
Through the courtesy of your colleague, Dr. R. F.
McFarlane, I am able to show you to-day three patients
on whom I have recently operated for appendicitis. The
little girl's initial attack dated back about forty hours.
The rapid pulse, the relatively low temperature, the di-
minishing pain pointed to perforation or to beginning
septic infection. Operation was advised and accepted.
On section I found a gangrenous, perforated appendix
and active peritonitis. Her recovery is due to the unre-
mitting watchfulness of Dr. McFarlane. As a rule, in-
stances of this nature die, no matter what the treatment.
In a case of the like nature, seen recently in New York
City, with Drs. Smith and Warner, operation was per-
formed in the presence of a temperature of 990 F., pulse
of 120, flat belly, and no pain. The same condition of
affairs was found ; the child lived ten days, finally suc-
cumbing to septic infection, characterized chiefly by ab-
solute intestinal paresis.
In the little boy the symptoms were more acute than
in the girl. The fades, however, had that anxious,
drawn, ashy look suggestive of septicaemia. I opened in
the usual locality ; behind the caecum I found the firmly
adherent appendix yielding fluctuation. There was no
peritonitis, and to avoid infection of the cavity I opened
behind, found a posterior rupture with pus,, and counter-
drained after asepticizing the cavity posteriorly.
This man was operated upon in the quiescent stage.
He had had repeated attacks and had grown weary of
the interference with his business. I found omentum as
thick as the thumb, which I tied off; underneath this an
adherent caecum which I separated ; below this the ad-
690
MEDICAL RECORD.
[December 1, 1894
herent, convoluted appendix, which I removed. I
drained him for thirty-six hours, and then sewed him up
carefully. Contrary to the advice of Dr. McFarlane, he
left his bed in twelve days and refused to wear a truss.
His contumacy resulted in this hernia.
Here are a half dozen appendices, which I present as
samples of the kind I have removed. You notice that
they are large and distorted, perforated at one or more
places, denuded of epithelium. All of these, and such
has been the necessity I have ever been under, have re-
quired a liberal incision in order to free and remove them
with safety to the patient and without unnecessarily in-
fecting the peritoneal cavity. In the majority of my
operations I have utilized the Trendelenburg posture,
which has enabled me to see what I was doing and to
protect to better advantage the peritoneal cavity. This
position you may improvise at any time by tying an or-
dinary hard bottom chair on a table, so as to form an in-
clined plane. I have further, in all pus cases, irrigated
freely with hot one per cent, salt solution and with full-
strength peroxide of hydrogen, neither of which act as
irritants, as bichloride does. Further still, whenever fea-
sible, I have counterdrained, and in large peri-appendi-
cital abscesses I have avoided digging up the appendix, a
procedure which can only result in breaking down nat-
ure's protecting wall of adhesions and in thus infecting
the general peritoneal cavity.
Such are the discursory thoughts I would offer for dis-
cussion. The principle which mainly guides me in se-
lecting surgery in these cases is the feeling that it is pref-
erable to perform an aseptic exploratory section and be
proved wrong in diagnosis, than to wait on nature until
an operation is forced upon me after perforation and in
the presence of peritonitis.
36 Eatp Fifty-eighth Street.
THE INDIAN WOMAN IN LABOR.
By GUY C. M. GODFREY, M.D.
LIEUTENANT IN THE MEDICAL DEPARTMENT, UNITED STATES ARMY ; POST-
fURGSOM AT rOBT WASHAKIE, WYO.
As the Indians are very reticent about their child-births
facts in the matter are hard to obtain, and my thanks are
due to Dr. F. H. Welty, the physician to the Shoshone
Agency in Wyoming, for his invaluable aid in preparing
this article.
The Indians at this agency are Arapahoes and Sho-
shones, and it is about them that I write. The Sho-
shone women are rather short and heavy set, with broad
pelves. Their temperament is lymphatic. The Arapa-
hoe women, on the contrary, are tall and slender, with
fine figures and broad pelves. They are of a bilious tem-
perament. In both tribes the women are stronger than
the men, on account of the enormous amount of work
they do. As the habits of any people have a direct bear-
ing on their health, a few words in regard to the cus-
toms of the Indians will not be inappropriate.
The women are very industrious and perform nearly
all of the manual labor done in the village, including
chopping wood, carrying water, cooking, etc. They
also do the sewing and bead work. Their recreation is
gambling. They, as well as the men, are filthy. As re-
gards virtue, conflicting reports are heard, some claim-
ing that the prairie Indians (Arapahoes, Cheyennes,
and Sioux) are virtuous, others claim that no Indians are
virtuous. Several years ago the Shoshones had a custom
of cutting off the tip of the nose of any woman caught in
adultery. After the woman's nose was clipped, she was
considered a harlot of the tribe. When a woman walks
by herself she is not considered virtuous, and is fair game
for any buck. ' Therefore two women generally keep to-
gether. A custom prevails among the Arapahoes of
eight or ten young men lying in wait for a solitary fe-
male, and when one appears in view they seise and ravish
her. The girls begin menstruating when twelve or thir-
teen years of age, and continue until they are forty or
forty-five. They are very regular. The half-breeds and
Shoshones sometimes suffer from suppression of the
menses, but the Arapahoe women are never known to
have any menstrual disorders. During menstruation a
woman retires alone to a small wickyup or tepee, and re-
mains there until the flow has ceased. Whether this cus-
tom is compulsory or voluntary is not known. The
child-bearing age is between thirteen and forty -five.
The average number of births per woman is about ten or
twelve. As a rule they marry quite young, because the
constant drudgery of their lives breaks them down, and
a squaw is often a wrinkled hag at the age of forty. The
bucks, on the contrary, often keep their age well. A
young man takes a wife and when, after a certain num-
ber of years, she loses the bloom of youth, he takes an-
other and so on. As a rule the squaws are quite healthy,
with the exception of scrofulous subjects, scrofula being
the most common disease among them. Cancer is never
found among these Indians. During pregnancy there is
no morning sickness, although at other times the Indi-
ans often have dyspepsia from their gormandizing and
monotonous diet. The pregnant woman is not consti-
pated anymore than at other times. As a rule they have
no sickness whatever while they are with child. During
labor the woman lies on her back supported in a semi-
recumbent position by a head-rest made of sticks cov-
ered with skin or cloth. This rest is wedge-shaped, about
three feet long and two feet high at the base. It is
placed on the bed usually occupied by the patient The
men are all required to leave, and the patient is only at-
tended by two or three old women who live in neighbor-
ing tepees. They have no regular midwives and rarely
apply to a white physician for any assistance daring
labor. The old women remove all of the clothing below
the waist and stay by the patient's side during delivery.
In case the latter is slow or difficult they occasionally
knead the abdomen with their hands. If the labor is
unusually difficult two of the women hold a stick be-
tween them at a height of about a foot from the ground
and across this the patient is required to lie with the ab-
domen downward. This, of course, stimulates the con-
tractions of the womb and causes increased abdominal
pressure from the patient's weight. The above consti-
tute all the resources of the old women, and if they fail,
the " tona-hay-hay," or medicine-man, is called in. He
is a very important personage in the tribe, and has the
full confidence of all. His art consists in making a big
" pow wow," calling on the Great Spirit and rattling his
"medicine-box." He, of course, does no good, but as
Indian labors nearly always terminate successfully by nat-
ural methods, he gets the credit. The delivery, as a
rule, is short and easy. It seldom lasts more than three
or four hours. The patients seem to suffer much less
than white or negro women. The vertex usually pre-
sents. Abnormal presentations, like pelvic malforma-
tions, are very rare. Only one case has been reported at
this agency during the last six years. Indians are very
unwilling to talk about such matters, but I conclude,
from the meagre scientific information obtained, that it
was a transverse presentation. This case lasted four
days. The old women kneaded the abdomen with their
hands and hung the patient across the stick. These two
methods having failed, the medicine-man was called in. •
He danced, shouted, and rattled his medicine*box for
two days, and as neither spontaneous version nor evolu-
tion occurred, the patient died from exhaustion on the
fourth day. No autopsy could be obtained, and the
mother was buried with the child undelivered. No white
physician was called, because the Indians do not know
the extent of science and art in obstetrics. The Indians
know nothing of artificial delivery, consequently it is
never attempted. Neither placenta previa no* tumors
ever occur to complicate delivery. I have never heard
of a prolapse of the cord occurring in labor, although I
believe it does rarely. Retention of the placenta is not
unusual, and for this the white physician is generally
called. When the doctor arrives he finds that the med-
December i, 1894]
MEDICAL RECORD,
691
icine man has failed, the old women make no attempts
to extract the placenta beyond tying the umbilical cord
to the patient's leg. They do this, they say, to prevent
the cord from slipping up. The doctor then explains
that if Credo's method fails he will introduce his hand
and remove the after-birth. This he does after taking
the proper antiseptic precautions. Whereupon the
women pat him on the breast and exclaim "ohoh
ohoh ! " which means " bless you." When he emerges
from the tent the bucks shake hands with him and, sol-
emnly pointing upward, say: "Heap big medicine
man! "
Multiple pregnancy is unknown among full-blooded
Indians. Only two cases have been reported at this
agency during the past six years, and in each case the
father was a negro and the mother an Arapahoe. In
each case the children consisted of a boy and a girl.
Triplets never occurred. The duration of the puerperal
period is usually only a few hours. At the end of that
time the patient is up and doing her usual work. In
scrofulous subjects the period sometimes lasts longer,
even extending to a week's duration. In one case which
recently came under Dr. Welty's observation, the patient,
being a scrofulous woman, was unable to suckle her
child.
Puerperal eclampsia is unknown. Puerperal septi-
caemia is very rare, only one case having occurred here
within the last five years. This case was also attended
by Dr. Welty, who says that it was caused by a decom-
posing retained placenta. The patient, a syphilitic, had
by that time contracted puerperal septicaemia from which
she died ten days after delivery. Mammary abscesses
are quite frequent, and are caused by exposure and the
filthy habits of the patients. The maternal mortality is
very small, only two deaths having occurred here in the
past six years — one from exhaustion and the other from
septicaemia, as reported in the two cases mentioned
above.
The foetal mortality is very small, only two children
having died during the past six years. Abortions are
rare among full blooded Indians, but are rather common
among half-breeds. An abortion is generally the result
of a fall, kick, or blow. The Indians have no special
knowledge of its etiology or treatment. The foregoing
facts were obtained with great difficulty, as very few of
the Indian women speak English. They are backward
about talking through an interpreter, because they are
very, .very much averse to giving any man any knowl-
edge of their sexual troubles. Therefore I offer this arti-
cle, not as an ultra- scientific study in obstetrics, but as
an interesting collection of facts concerning the " noble
red man's spouse."
VAGINAL HYSTERECTOMY BY ENUCLEATION
WITHOUT LIGATURE OR CLAMP.
By J. RIDDLE GOFFE, PH.B., M.D.,
MEW YORK.
peotessot or gynecology in the new yoke polyclinic ; assistant gynecol-
ogist IN THE SKIN AND CANCER HOSPITAL.
The possibility of enucleating the uterus per vaginam
without the use of a ligature or clamp, is a recorded fact
in surgical literature, dating from 1822. So that, in con-
templating this apparently new procedure, we are faced
at once with the stubborn tact that there is nothing new
under the sun,
It was accomplished for the first time, as far as we
know, by a surgeon named Sauter, of Constanz, Ger-
many, in the year 1820. The feat becomes the more
extraordinary when we consider that he did it without
the use of an anaesthetic or a speculum. The operation
was done for cancer, the woman was bound fast to the
edge of the bed, and the tissues were severed by scissors,
the points of which were guided by the fingers. The
account is extremely interesting, and is quoted in extenso
in a work entitled "A Handbook of Surgery," by
Chelius, of Heidelberg, and translated into English by
South, of London, under the title of " A System of Sur-
gery." The translation was published by Lea& Blan-
chard, Philadelphia, 1847. Although Sauter's patient
recovered without serious hemorrhage or other accident,
no one seems to have followed in his footsteps till re-
cently, when the operation was revived by Pratt, of Chi-
cago.
What the benefits or advantages of this procedure may
prove to be, I am at present not prepared to state. But
every new fact or principle established in surgery, as in
every other branch of science, may contain in itself
possibilities of far wider significance than the present mo-
ment can imply. At present, however, we know that the
tightening of ligatures on nerve-fibres produces a certain
amount of shock, and the placing of these ligatures re-
quires a certain amount of time. These are important
factors to the patient in every operation of this kind. By
this method they can both be eliminated.
The secret of avoiding hemorrhage in this procedure is
to adhere so closely to the uterine wall in the dissection,
that the anastomosis between the uterine and ovarian ar-
teries is avoided, and only the small branches are severed
as they penetrate the uterus.
The opportunity of trying this method presented itself
to me recently, and I put it to the test. The patient
was an Irish woman, forty- six years of age, who had been
suffering for the past seven years with complete proci-
dentia uteri and all its train of torture. My hope was
not only to relieve the tissues from the drag of the heavy
uterus, but to secure the end of the vagina to the broad
ligaments at a point sufficiently high to make them hold
up the vaginal wall and bladder.
The field of operation having been made aseptic, I
made a circular incision around the cervix through the
vaginal wall with a scalpel, and pushed the tissue away
from the cervix all around with the handle of the knife.
It occurred to me that Thomas's spoon saw would be a
good instrument for this dull dissection from this point
on, and I found it to work admirably, enabling me to ad-
here very closely to the uterus, and to separate the tissue
with ease and despatch. Upon reaching the peritoneum
in Douglas's pouch I snipped it with the scissors, and
tore it right and left with my finger.
To prevent the peritoneum separating from the vagina
too much at this point, also as a preliminary step in clos-
ing the upper end of the vagina, I now passed a strong
catgut suture through the wall of the vagina entering the
needle on the peritoneal side and passing it straight
through into the vagina, and then back again, thus leav-
ing the loop on the vaginal side. The two ends were
then caught in a clamp forceps and left hanging out of
the vagina. Continuing the dull dissection with the
spoon saw, I separated the bladder from the uterus, even
tearing through the peritoneum above it and enlarging
the opening to either side with my finger.
Although I had been in momentary expectation of see-
ing a spurting artery and was ready at any moment to apply
a ligature, no arterial hemorrhage occurred. I therefore
pushed on with the spoon saw, and soon had the satisfac-
tion of seeing the two horns of the uterus sustained by
nothing except the round ligaments. Before severing
these I passed through the upper part of each broad liga-
ment, high up on either side and transfixing the round
ligament, a single strand of braided silk, letting the two
ends of each hang out of the vagina without having tied
any knot. The round ligaments were then cut away
at either horn and the uterus delivered, thus demonstrat-
ing that the uterus can be enucleated without sufficient
hemorrhage to demand either ligature or clamp.
To complete the occlusion of the upper end of the
vagina, one strand of the catgut suture already placed was
rethreaded and passed through the anterior vaginal wall,
entering it on the peritoneal surface and passing it back
as formerly in the posterior wall. These two ends of the
catgut were now tied together, thus bringing peritoneal
692
MEDICAL RECORD.
[December 1, 1894
surface in contact with peritoneal surface, and turning all
raw tissue into the vagina.
The broad ligaments are now drawn well down into
the vagina by the silk sutures previously passed, and se-
curely tied together across the upper part of the vagina.
A light packing of iodoform gauze completed the opera-
tion. The entire time consumed was a few seconds less
than thirty minutes, much less time than it has ever
taken before.
The operation was done at the New York Skin and
Cancer Hospital, October 12, 1894, and I believe it is
the first time the operation has ever been done in New
York.
The patient had a slight hemorrhage three hours after
the operation! but it was found to proceed from the vagi-
nal mil and was controlled by a firm tampon of gauze.
Aside from that, recovery has been uninterrupted.
•23 East Thirty-fifth Stuit.
gxwgttess of pteflital jfctence*
Skin Diseases and Visceral Affections. — According
to the Medical Bulletin for June (see also Deutsche
Medical Zeitung), Kaposi spoke at the Vienna Medical
Club of a misapprehension that prevails concerning
Hebra and his school, to the effect that they look upon
cutaneous diseases as simply external abnormal conditions
having no relation to alteration of internal organs. This
is not true of Hebra and his followers. While opposed
to an uncritical assumption that such relationship exists,
such conceptions obscuring comprehension and exerting
a pernicious influence on prognosis and therapy, Hebra
continually recognized such connection and turned the
fact to practical account in treatment. Acne may be
taken to illustrate the case in point. It is asserted that
this disorder depends upon digestive disturbances. Yet
when a disease can be explained in its totality, in its
clinical and anatomical course, by demonstrable associa-
tions, a search for ulterior causes is unnecessary. Acne
generally occurs at the age of puberty, when an active
physiological process is going on in the follicles of the
skin,though it may originate later in life. There is usu-
ally a depressed condition of nutrition, atony of the tissues
involving the glands. The ducts of the glands are not
properly contracted, giving rise to comedones and acne.
The keratinization of the skin is also abnormal, and
often alterations occur in the functions of the sudoripa-
rous glands. There is not infrequently hyperidrosis. In
this class also belongs acne cacheticorum, which itself
depends upon lowered nutrition, though it may also be
due to psychical influence. In acne varioliformis, more
common in men than women, Kaposi spoke of excellent
results from Carlsbad water, while local, treatment is
usually of small benefit. Pure hyperidrosis* of the palms
and soles arises during youth ; in other instances it may
come on abruptly and continue for years, disabling the
patient for work. Here, again, general depression of
nutrition is a cause. There is weakened action of the
heart, reduced vascular tonicity, and the hands are gen-
erally cyanotic. As nutrition improves, there is apt to
be a change for the better in the hyperidrosis. A simi-
lar result takes place in that affection recently known
as erythromelalgia and characterized by the appearance
of a persistent patch of congestion, often on the sole of
the foot, attended with swelling and pain. Acne rosacea
is linked with nutritive disturbances, sometimes with
digestive errors, sometimes with uterine disturbances.
Urticaria has been supposed to be due to changes in the
alimentary tract; yet the mere sight of the specially
harmful food will bring it on in some persons. Acute
circumscribed oedema is nothing more than a giant
urticaria due to vascular spasm.
In eczema, especially recurrent eczema, there is a rela-
tion between the skin disease and internal organs. Fu-
runculosis, often referred by mistake to glycosuria, occurs
in persons who suffer from eczema. Boils are not com-
mon in diabetes ; but dermatitis diabetica is not unusual.
How great the caution to be exercised in the etiology of
skin diseases is illustrated by elephantiasis arabum tropica,
certainly produced by the filaria sanguinis. Yet in a
typical case observed by Kaposi, no trace of filariae could
be found. To depressed conditions, lupus erythemato-
sus may also be ascribed. But it is wrong to consider
pruritus senilis as due to digestive troubles ; there is usu-
ally atrophy of the skin, with irritation of the nerves.
Another form, developing in middle life, is accompanied
by albuminuria and glycosuria. Pruritus universalis is a
frequent accompaniment of pregnancy, of disease of the
genital tract, and may also depend exclusively upon psy-
chical causes. Impetigo herpetiformis also arises in
pregnancy. Kaposi has seen seventeen fatal cases under
such circumstances. Erythema, especially erythema
nodosum, and purpura are the result of infection. Yet
many cases exist that are dependent upon uterine or
ovarian abnormities, and disappear when these are reme-
died.
The Treatment of Ophthalmia Neonatorum. — Kalt
recommends irrigation of the eye with a 1 to 5,000 solu-
tion of potassium permanganate introduced through a
small funnel, one end of which is placed between the
eyelids, and the other connected with the bottle contain-
ing the fluid, which should be placed about a foot above
the patient's head. The irrigations should be made
twice a day, and two quarts of the fluid should be used at
each time. If the disease is attended with serious or ex-
tensive trophic changes in the cornea, the irrigations
must be used more frequently, say four times a day, and
gradually lessened as the inflammation disappears. [At
a recent meeting of the Ophthalmologics! Section of the
New York Academy of Medicine, this plan of treatment
was favorably commented on by Dr. H. Knapp, who had
seen its application by Kalt]
Toxic Effects of Thyroid Feeding. — Bedere presented
to the Medical Society of the Hospitals, Paris, a patient
illustrating the cure of myxoedema by thyroid therapy.
During the course of her treatment she accidentally took
a large quantity of thyroid gland, ninety- two grammes in
eleven days. At the end of this time she had developed
such symptoms as tachycardia, pyrexia, insomnia, tremor
of the extremities, exophthalmia, polyuria, albuminuria,
and glycosuria, in fact a complete picture of Basedow's
disease. The writer, therefore, concludes that the latter
disease is due to a hypersecretion of the thyroid gland
which may be caused in more ways than one. He thinks
that Basedow's disease should no longer be classed as
one of the neuroses, but as auto-toxic from an etiological
point of view.
Oastropexy. — Duret presented to the Paris Academy
of Medicine a woman on whom gastropexy had been per-
formed after all other measures had failed to relieve a
severe enteroptosis with dilatation and descent of the
stomach into the infra-umbilical region. He is of the
opinion that in cases of prolapse of the stomach of long
standing gastropexy is an efficient method of treatment,
both with reference to fixation of the stomach and cessa-
tion of the majority of the morbid symptoms.
Acute Pancreatitis. — Dr. Paul contributed to the Clin-
ical Society of London the history of a case of acute pan-
creatitis in which the prominent symptoms were the sud-
den onset of pain, which was colicky in its nature and of
short duration, constipation, and some vomiting. On ex-
amination, slight distention of abdomen, pulse and tem-
perature somewhat increased. After the action of a sim-
ple enema the patient suddenly collapsed, the tempera-
ture rose to 1040 F., and death followed speedily. The
urine passed just before death contained a large amount
of albumin, and granular and hyaline casts. Post-mortem
examination showed an acute hemorrhagic and paren-
chymatous pancreatitis. The remaining organs were
healthy except a cloudy swelling of the kidneys.
December i, 1894J
MEDICAL RECORD.
693
Medical Record:
A Weekly Journal of Medicine and Surgery.
GEORGE F. SHRADY, A.M., M.D., Editor.
Publishers
WM. WOOD & CO., 43, 45, & 47 East Tenth Street.
New York, December i, 1894.
CHLORIDE OF CALCIUM IN THE TREATMENT
OF ACUTE PNEUMONIA.
In 1893, Dr- A- Crombie called attention to the sup-
posed value of chloride of calcium in the treatment of
pneumonia {Indian Medical Gazette, January 18). Dr.
D. M. Moir, of the Indian Medical Service, confirms this
opinion of its value in an article in The Practitioner of
November, 1894. Dr. Crombie believed that he showed
that in lobar pneumonia (1) chloride of calcium reduces
the temperature and keeps it within safe or normal lim-
its, in spite of the continuance of physical signs ; (2) that
there is a tendency for the morbid process to be arrested
at whatever stage the drug is given in efficient doses, and
that the course of the disease is thus shortened or ren-
dered milder; (3) that there is a singular freedom from
all anxiety, distress, and danger, a freedom not usually
associated with continuous high temperatures ; (4) and
that there is a corresponding reduction in mortality.
Dr. Moir reports two cases in which the symptoms
were alleviated by the administration of this drug. He
gave it in doses of from sixty to ninety grains daily (ten
or fifteen grains every four hours).
Many drugs have a reputed value in pneumonia, but
none are yet accepted as in any sense standard remedies
in the disease.
The evidence in favor of chloride of calcium is suffi-
cient to demand for it some attention, and we can only
trust that further experience will show that the drug is
undoubtedly useful.
ACUTE ARTICULAR RHEUMATISM AS A
GERM DISEASE.
Birsch-Hirschfeld, in 1 888, reported five cases of acute
articular rheumatism in which he discovered streptococci
and staphylococci in the articulations and cardiac valves.
Bouchard and Charin, in 1891, reported that they had
found the staphylococcus albus many times in the
synovial secretions in subacute and chronic articular
rheumatism*
Triboulet, during the same year, found the articular
fluid sterile in a case of rheumatism with chorea, but on
death the pericardial fluid and the blood of the heart
and vena cava was found to contain the staphylococcus
albus.
Sahli, in 1892, in a case of acute rheumatism with
pleurisy and pericarditis, found that the synovial fluid of
the knee contained microbes resembling the staphylo-
coccus albus.
Dr. J. Sacaze {Archives Generates de Medicine, Novem-
ber, 1894) reports the results of his investigations in the
same line. Dr. Sacaze made, however, bacteriological
examinations of what he calls the " points of entry " of
the rheumatic infection. In one case, a man had a
wound on the foot followed by acute articular rheuma-
tism with relapse. In the fluids of the knee-joint he found
pure cultures of the staphylococcus albus. In three
other cases the patients had an acute tonsillitis followed
by rheumatism, there also the secretions of the tonsils
were examined with the result of finding staphylococci.
He concludes that very often in acute rheumatism
there is a local lesion which precedes the rheumatic out*
break. It is through this passage that the pathogenic
microbes enter the system and the staphylococci seem to
be often the infecting agents.
The history of gonorrheal and other septic rheuma-
tisms supports the view that acute inflammatory rheu-
matism must be classed among the microbic diseases.
THE CURSE OF KISSING.
Properly applied, both as to time and place, the partic-
ipators being mutually agreeable and fairly healthy,
there is little to be said against the kiss, practised in
moderation. When, however, one party to the transac-
tion is an infant, not yet up in self-defence, or a maiden
whose resistance is of no avail against the physically
stronger aggressor, or an inanimate body prepared for
burial, we claim the right to champion their cause
against the reckless kisser. We have little to say con-
cerning that form of disease known as kissing-fever, of
which instances are now and then reported, especially
from smaller towns. The over-affectionate man, who
lurks in lonely places and pounces with his osculations
upon unprotected women, without distinction as to size,
age, or color, belongs in the same mentally unbalanced
class as the despoiler of school girl tresses, the destroyer
of white lawn dresses, the ink- thrower, the hugger— and
when still more depraved — the ripper.
We leave him to the officers of the law and the alien-
ists, provided an outraged brother, father, or husband
has not already attended to his case "out of court."
The child-kisser by habit really does more harm than the
lady-kisser by disease, for while the latter shocks an oc-
casional belated female on a lonely road, the former is
constantly teaching the children with whom he comes in
contact that it is not wrong to kiss comparative stran-
gers, and a most dangerous, if not disgusting, habit is
fostered.
Scientists have never yet discovered why it is that
syphilitics, tuberculous subjects, persons with very bad
teeth, and tobacco chewers, are the greatest kissers of
infant and youthful humanity, and invariably implant
their token of affection directly upon the lips. Such,
however, is the fact, as any careful observer may discover
for himself.
If there were any possibility of this reaching those who
alone could answer, we would ask why the maiden aunt,
who never was very fond of the children at best, insists
upon coming into the room and kissing them as soon as
they are down with the scarlet fever, diphtheria, measles,
694
MEDICAL RECORD.
[December i, 1894
or the mumps ? Why must she, who " never kissed a
living man " and doesn't believe in kissing anyway,
press her lips to those of some cold corpse ? This death-
kiss may well be called a sanitary sin, and unless we, as
physicians, continually discountenance it, as well as put
our face against sick-bed kissing, we must hold ourselves
more than equally responsible, for we know the dangers
better than they.
Sanitarians have tried many times to introduce songs
among the people tending to offset and counteract that
very pernicious one which begins : " There is no harm
in' kissing/' but they have never become popular.
Must we, then, leave the youngsters in happy ignor-
ance of mouth hygiene? Can we keep their innocent
minds free from thoughts of the bacilli swarming beyond
the ruby lips ? Should we ever neglect an opportunity
to strike at the mouth which bears a mucous patch or
where lurks the poison of phthisis or to defend the de-
fenceless babe from the onslaughts of the male and female
kisser.
SPECIALISM AND MEDICAL PRACTICE IN
TEXAS.
Dr. R. P. Tallby gives the following list of modern
specialists {Texas Medical Journal) and makes some in-
teresting comments upon them. There are, he says :
" 1. The eye, ear, nose and throat specialist. 2. The
gynecologist specialist 3. The railway surgeon special-
ist. 4. Whiskey, opium, etc., specialist. 5. Dentist, or
oral surgeon specialist. 6. Orificial surgeon specialist.
7. The Arkansas Hot Spring specialist. 8. The self-
constituted midwives, and on down the line to the street
medicine man, the Christian science doctors, the pile
doctors, the Keeleys, etc., about whom and which I
shall have nothing to say on this occasion."
The doctor speaks kindly of what he calls real special-
ists who are masters of their work and confine them-
selves to it. But he has a grievance against the railway
specialist because (and Dr. Talley seems fond of enumera-
tion):
" i. These surgeons are backed by a powerful finan-
cial corporation.
" 2. They get a handsome salary for a fraction of their
professional time.
" 3. They are not required to give their whole time
and energies to their specialty.
" 4. Out of all they get a big 'ad.' by which they
step from the practice from the employees to their fami-
lies and friends, as well as to the practice for the em-
ployer, not allowed under the rules of the Hospital Asso-
ciation.
"This is all very nice and desirable for the railroad
doctors, but I think it is a devil of a hardship on the
' other fellows.1 "
Dr. Talley does not like the Hot Springs specialist.
His virtues, he says, " are advertised on every telegraph-
pole, hog-pen, etc., throughout the entire country.
Unless we can make people understand that water can
be made as hot in Texas as it can in Arkansas, our patients
will continue to slip out and pay ten times as much for
their troubles as if they would try in any sort of good
faith their family physicians/'
Incidentally we are given a painful picture of the over-
crowding of the medical profession of Texas. In the
town of Temper, where the doctor, who is President of
the Austin District Medical Society, resides, there are
twenty-two doctors to something less than 6,000 inhabi-
tants, and in the country around there are twenty-four
more within ten miles. "Some authority," he adds,
" has estimated that in the army, in time of war, one
physician can serve five hundred soldiers, and that in
civil life one thousand and five hundred patrons are re-
quired to support one general practitioner. According
to this estimate, in my town we have eighteen out of
twenty- two doctors to spare, and if we cannot get rid of
this excess, somebody will be hurt." " We presume this
has as much reference to the patients as to the doctors,"
" This excess in number leads to all manner of ' sharp
work ' to get practice. Such a crowded population of
doctors reminds me of a crowded population of poor
people, where we find hot-beds of all sorts of pernicious
diseases, moral as well as physical. Why, in too many
localities our doctors are crowded, as well as illy bred as
doctors, until the slime of local rivalry rises mountain
high. If some local brother steps a little aside from
what some other local brother thinks is ethical, he forth-
with gets all sorts of infamy heaped upon his professional
head. Who ever heard of two or three doctors getting
together, singing a song and praying for some profes-
sional sinner, who had perhaps even sinned without
knowing it ? There is only one occasion when doctors
may get together and sing and pray for one another, to
wit : When one dies they can sometimes meet around
his 'grave, and say amen, and then pass resolutions of
condolence with a prayerful and perfect unanimity."
We wonder why the doctors of Texas have been work-
ing so hard to establish a medical college if their coun-
try is so well supplied. The causes of the over-supply in
that State, as President Talley should know, are two-
fold : one is the cheapness of medical education ; the
other the ignorance of the people and their willingness
to accept anyone for a doctor if he can make a presenta-
ble appearance at the bedside, and shrug his broadly
expressive shoulders at the other fellow.
NOT ALL DIE YOUNG.
One hears so much depressing talk about the life of a
physician not conducing to longevity that it is cheering
to note exceptions to the rule.
The following, cut from an exchange, is doubly inter-
esting because we believe we can beat it.
" Oldest Physician in the Country. — Since the
recent death of Dr. James Kitchen, of Philadelphia, Dr.
Hiram Corson, of Montgomery County, Pa., is de
clared by Philadelphia papers to be the oldest physi-
cian in the United States who has been in continuous
practice. He will be ninety years old next October, and
has been in active practice ever since 1827. He is still
in excellent health, with astonishing preservation of his
physical and mental powers. Dr. Corson is now writ-
ing his personal recollections of the anti-slavery move-
ment, in which he took an active part, having assisted
many a fugitive slave to escape by the ' underground
railroad.' "
Our entry for the long distance championship is Dr.
Hull Allen, of Milford, Conn., born May 16, 1798, and
December i, 1894]
MEDICAL RECORD.
695
consequently in his ninety-seventh year. He was li-
censed to practise medicine at Newark, N. J., in 1821,
and began in the same year at Sparta, N. J., subse-
quently removing to Milford, Conn., where he continued
in active practice till 1870. Since then he says " he
doesn't go out much nights,19 but until recently he has
continued to give advice to those who call upon him at
his house.
Dr. Allen has always enjoyed excellent health, and is
to-day remarkably bright and active for one so near the
hundred-mile post May he be an example for many
years yet to those who grieve because ministers and law-
yers reach a riper age than we.
THE ANNUAL REPORT OF THE SURGEON-
GENERAL OF THE ARMY.
The report of the Surgeon- General of the Army for the
year ending June 30, 1894, contains much that is of
general interest, as the report of any head of a depart-
ment so progressive in his ideas as General Sternberg,
necessarily must. The question of the reduction in
numbers of the medical staff is discussed at some length,
but as we shall refer to this elsewhere it is not neces-
sary to enter upon the subject here. An examining
board had been convened to fill the ten existing vacan-
cies, but when Congress reduced the force there were no
longer any vacancies, the board was dismissed and the
candidates were notified not to appear.
The Army Medical School has been in operation about
a year, and the wisdom of its establishment has been al-
ready satisfactorily demonstrated. The principal object
of its foundation was to impart a knowledge of prevent-
ive medicine, which is not often possessed by the recent-
ly graduated medical man, and also to provide for spe-
cial instruction in military medicine and surgery. The
school is established in the building recently erected in
Washington for the Army Library and Museum, where
also there is abundant material for bacteriological and
chemical study. The course of instruction embraced
the following subjects : Duties of medical officers in war
and peace, military surgery, hygiene, and medicine, gen-
eral and sanitary chemistry, pathology, and bacteriology,
hospital corps drill, first aid to the injured, and equita-
tion. The latter was not so superfluous as might be sup-
posed, since two members of the class were entirely un-
used to riding. Nine medical officers were in attendance
at the school during the year.
The work of the hospital corps is referred to with ap-
proval, the wisdom of establishing this branch of the
service having been amply demonstrated. The number
of members of the corps in service is 790, 49 less than the
authorized quota. The number has been purposely kept
down in order to keep the expense of the corps within
the limit of the appropriation for its support.
Reference is made to the Medical Department of the
National Guard in connection with the fourth annual
meeting of the Association of Military Surgeons held in
Washington in May. The Army Medical Department
looked favorably upon the organization of the Association
as a medium by 'which it might keep en rapport with the
medical corps of the National Guard, in view of a pos-
sible contingency in which the State and National forces
might be called upon to act in concert. The Surgeon-
General of the Army was very properly chosen president
of the Association for the present year.
The health of the army was nearly as good as during
any previous year, the admission rate per thousand being
1,289.04, a great improvement on the average annual
rate for the past two years (1,424.2) and only slightly
greater than the lowest rate (1,247) ever furnished by
our troops. The death-rate was 6.91 per thousand liv-
ing, but little greater than the lowest rate ever recorded
in our army (6.33) and considerably less than the aver-
age for the past ten years, namely, 8.51. The death-
rate from disease alone, excluding accidents and injuries,-
was 4.01 per thousand.
Other questions treated of in the report are the quar-
ters, some of which appear to be in a disgracefully di-
lapidated condition, poorly ventilated, badly drained
and insufficiently supplied with water. The food sup-
plied to the men was in general of a good quality, as was
also the clothing.
The reports of medical officers regarding the habits of
the men were generally favorable. At some posts where
houses of bad repute are established in the vicinity, the
sick report often becomes burdened with the results of
dissipation, particularly after pay day. The recruits at
Columbus Barracks are in particular exposed to harmful
influences of this kind, owing to the location of the bar-
racks within the limits of a city.
Inadequate provision for bathing is reported from
several posts.
The benefit accruing from systematic work in
gymnasiums is appreciated by all army medical officers.
THE BRUTALITY OF FOOT-BALL.
The events of the past week have most thoroughly dis-
credited the game of foot-ball as at present played. The
contest at Springfield between the Yale and Harvard
teams was one of the most unwholesome performances
that ever masqueraded under the name of amateur sport.
Players slugged into unconsciousness, eyes nearly gouged
out, brains concussed, disabling sprains and bruises con-
stantly interrupted the progress of the game, which even
an ex-ball-player and friend of the sport declares to have
been characterized by "sickening brutality.91 Besides
this we hear of a student made insane through injuries
received in playing, and two fatal accidents are reported. '
The number of young men who are permanently injured
and who go through life more or less crippled in conse-
quence of foot-ball playing can never be known. We
should be sorry to see foot-ball abolished altogether from
our colleges. There is no game that equals it in many
ways when played as a manly sport and not for gate re-
ceipts. But the new rules are plainly ineffective, and un-
less some change can be made, the game really deserves
to be placed under the supervision of Boards of Health
working in co-operation with an efficient police.
Tale Medical Journal is the name of the most recent
acquisition to medical journalism. It is edited and pub-
lished by the medical students of Yale University under
the auspices of an advisory board composed of some of
the prominent alumni of the university. The first num-
ber makes a favorable impression. We wish it well.
696
MEDICAL RECORD.
[December 1, 1894
Hews of tfxz tfifteelu
Antitoxin for Diphtheria. — Dr. Walter Wyman, Sur-
geon General of the Marine Hospital Service, in his an-
nual report, says that investigations have been conducted
concerning the etiology and pathology of the eruptive
fevers, and the preventive inoculation against acute in-
fectious diseases. A bacteriologist of the service is now
in Europe familiarizing himself with the latest advances
in preventive inoculation. This officer has transmitted
to the bureau a supply of toxin from the Pasteur labora-
tory, with which animal immunization has already been
begun (a horse having been purchased for this purpose)
to obtain the antitoxin serum for the cure and preven-
tion of diphtheria. On the return of this officer it is
expected that the methods of preparing the toxin and
obtaining the antitoxin serum from the immunized ani-
mal will be demonstrated from time to time to State
health officers, in order that the benefits of this new
remedy for diphtheria may be as widely distributed as
possible.
The Samuel D. Gross Prise.— The quinquennial prize
of % 1,000 under the will of the late Samuel D. Gross,
M.D., will be awarded January 1, 1895. ^e condi-
tions annexed by the testator are that the prize " Shall
be awarded every five years to the writer of the best
original essay, not exceeding one hundred and fifty
printed pages, octavo, in length, illustrative of some sub-
ject in surgical pathology or surgical practice, founded
upon original investigations, the candidates for the prize
to be American citizens." The essays, which must be
written by a single author in the English language, should
be sent to Dr. J. Ewing Mears, 1429 Walnut Street,
Philadelphia, before January 1, 1895. Each essay must
be distinguished by a motto, and accompanied by a
sealed envelope bearing the same motto and containing
the name and address of the writer*
Death of Dr. Octavius Sturges. — We have to record
the untimely death of Dr. Octavius Sturges of London.
While still in the prime of life, Dr. Sturges was knocked
down by a cab in Cavendish Square a few days since, and
sustained a fracture of the left thigh. He appeared,
however, to be recovering from the effects of the acci-
dent, and there was apparently no special cause for
anxiety, but he died suddenly on November 3d leaving a
large circle of friends to mourn his unexpected demise.
It is a curious coincidence that, within the short space
of one year, the President and the Senior Censor of the
Royal College of Physicians should both have died in
harness.
The Leading Medical Journals in the United States,
as might have been expected, had much to say which
was sympathetic and kind upon the subject of the
death of Dr. Oliver Wendell Holmes. The memorial
notices which seemed to us to be most worthy of the
man appeared in the Medical Record and the Boston
Medical and Surgical Journal. — Medical Press.
The Woman's Medical Club of Chicago gave their first
banquet Wednesday evening, November 14th. Gertrude
G. Wellington, M.D., was Chairman of the Committee
of Arrangements.
Iowa Association of Bailroad Surgeons.— In pursu-
ance to the call published September 25th, there was a
good attendance of Railway Surgeons of the State of
Iowa, at Sioux City, on October 10th, when the Iowa
State Association was duly organized.
Middle Tennessee Medical Association. — The first
regular meeting of the Middle Tennessee Medical As-
sociation was held November 20 and 21, 1894, in the
Senate Chamber of the Capitol at Nashville. The Asso-
ciation was called to order by the President, Dr. J.
B. Cowan, Tullahoma, at twelve o'clock. A large num-
ber of physicians were present.
The Horthern Ohio District Medical Society.— The
annual meeting of the Northern Ohio District Medical
Society will be held at Fremont, O., December 6, 1894.
Mitchell District Medical Society.— The forty-sixth
semi-annual meeting of the Mitchell District Medical So-
ciety will be held at Mitchell, Ind., December 27 and
28, 1894. This society is one of the oldest and most
favorably known in the country, and this meeting prom-
ises to eclipse all previous ones.
Chicago Gynecological Society. — At the sixteenth an-
nual meeting of the Chicago Gynecological Society, held
October 19, 1894, the following officers were elected to
serve the ensuing year: President, Dr. Franklin H.
Martin ; First Vice-President, Dr. A. J. Foster ; Second
Vice-President, Dr. J. C. Hoag ; Secretary, Dr. H. P.
Newman ; Editor, Dr. T. J. Watkins.
Wabash Eailway Surgeons.— The annual meeting of
the Wabash Railway Surgeons was held at St. Louis, Mo.,
Thursday, November 1, 1894, in the parlors of the South-
ern Hotel.
Mew Tork State Association of Military Burgeons. —
At the annual meeting of the New York State Associa-
tion of Military Surgeons, which was held in the build-
ing of the Academy of Medicine on November 15th, the
following officers were elected: President, Dr. R. S.
Harnden, of Waverly ; First Vice-President, Dr. C. S.
Parkhill, of HornelLsville ; Second Vice-President, Dr.
J. A. Van Duyn, of Syracuse ; Secretary, Dr. C. E. Her-
rick, of Troy; and Treasurer, Dr. J. F. Valentine, of
Brooklyn.
Eastern Kansas Medical Society.— The Eastern Kan-
sas Medical Society met at Kansas City, Kan., October
9, 1894, and elected a number of new members.
The Mew Hampshire Hospital Association.— The
annual meeting of the New Hampshire Hospital Associ-
ation was held at Concord, N. H., November 15th, with
delegates present from Portsmouth, Manchester, Dover,
Keene, Claremont, and Concord. Dr. C. F. Towne read
an interesting paper on " The Relation of the Citizens to
the Hospitals." This was followed by a general discus-
sion of hospital needs. The next session will be held in
Portsmouth in May.
The Eastern Iowa District Medical Society met at
Keokuk, la., November 15, 1894. Dr. J. A. Scroggs,
of Keokuk, la., president, in the chair*
A Chicago Physician. — Dr. Arthur Von Luna com-
mitted suicide on November 23d. He came to this coun-
try from Germany last summer.
December i, 1894]
MEDICAL RECORD.
697
NEW YORK COUNTY MEDICAL ASSOCIATION.
Stated Meetings November 19, 1894.
Samuel B. W. McLeod, M.D., President, in the
Chair.
Habitual Constipation; IU Treatment.— Dr. Henry
Illoway read the paper. Constipation was becoming
more and more common, and was tolerated by persons
who claimed to be in good health in other respects. It
was a relative term, but was applicable, the author
thought, to all cases where there was not one free passage
in two days. Regularity might exist and the person
have but one passage a week, and he knew of a woman
who had her bowel scooped out once a month by a
midwife.
Acute and chronic forms existed, but the author con-
sidered on this occasion only the latter. These were
divided into : a, constipation depending directly upon a
well-defined morbid process, such as cicatricial narrow-
ing, cancer, etc., or secondary to disease in other organs ;
by constipation depending upon inaction of the bowel.
The paper was confined to this group. The author con-
sidered briefly the longitudinal and circular motion of
the gut, the several sources of nerve supply, and the
influence of pathological conditions in some other
organs, as the heart and spinal cord, in producing con-
stipation. He did not think catarrh a cause of chronic
constipation, and if cases of colic were excluded it was
questionable whether there was such a condition as
entero spasm.
Causation. — One frequent cause of constipation was
neglect to answer promptly the call of nature, whereby
tolerance was developed on the part of the mucous mem-
brane and terminal nerve-filaments. Want of closets for
use by the moving public was largely to blame in this
matter. A second important cause was use of foods not
containing sufficient residual matter. Our diet was com-
posed too much of starches, sugar, fats, and meat. A
third cause was the habit people were .acquiring of trying
to fill their heads (by reading) while emptying their
bowels. A fourth was relaxation of the abdominal mus-
cles brought on by absence of physiological exercise and
deficient oxidation. The author did not lay much stress
on the habit of purgative taking, although when carried
to excess this might act like too much and too coarse
residual matter, causing over-excitation.
Protracted constipation led to dilatation of the gut,
the colon having been found of a circumference even
of fifteen inches. In old people scybalae were liable to
form. The existence of fistulas led the patient to avoid
passages and thus tended to aggravate the constipation.
Fecal Intoxication. — The author thought this was
I liable to take place only where soft faeces flowed over long-
retained masses. The question was also raised as to the
manner in which the breath of the chronically consti-
pated took on a bad odor, whether from the stomach or
lungs.
Prognosis and Treatment. — Recognition of the cause
was of first importance in outlining the treatment and
pronouncing a prognosis. Each case had to be treated
upon its individuality. In some a permanent cure could
be expected; in others, only temporary relief. Where
constipation depended upon disease of the heart, lungs,
liver, or anatomical abnormalities, special measures
would be called for. To overcome an atonic condition
of the muscular structure of the intestine and to stimulate
the nerves use calabar bean ; nux vomica, arsenic, bella-
donna, hyoscyamus, and stramonium were sometimes
indicated, but otherwise would prove positively injurious.
Use belladonna for venous stasis. The author had not
had success from very small doses of podophyllum, for
% which claims had been made in France. Other measures
were mechanical, dietary, massage, and electricity.
Walking, riding, and rowing were valuable, especially
walking. Oxygen stimulated peristalsis. Riding was
best for shaking up the bowels, for congestion of the
liver, and for getting rid of and preventing the formation
of gas. Hydrotherapy was useful, including injection
of water at about 750 F. In some of the more obstinate
cases use hot water and cold water alternately. Massage
was indicated in all cases of atonicity and for the disper-
sion of residues. It was practised upon the naked belly,
with unoiled hands.
Faradic electricity was more effectual than galvanic
over the abdomen, while the latter was more effectual
within the rectum. The author did not approve of dila-
tation of the sphincter in the treatment of constipation
unless this were associated with fistula. Incontinence of
faeces which might follow was a most horrible condition.
One party had claimed good results from suggestion in
the hypnotic state.
Constipation in Childhood. — Dr. J. Lewis Smith
thought that many of the severe standing cases of con-
stipation in adults dated back to infancy. It was a won-
der the patients lived so long, but they often finally suc-
cumbed to the condition unless the cause, perhaps a
constriction of the bowel, were removed. Where an
anatomical cause was not present, the diet was most
likely to be at fault. One cause of delayed movement
of the bowels in infancy was greater length of the sig-
moid flexure than existed later. Carrying infants exclu-
sively in the horizontal position favored constipation.
Painful defecation would lead the child to suppress the
act. Medicines were not an uncommon cause, including
purgatives which were far from being so simple and
harmless as their name would indicate. He did not ap-
prove of mothers giving the baby " castoria," " syrup
of figs," etc. In institutions the best means of unloading
the bowels was by an injection of one to two teaspoon-
fuls of equal parts of glycerine, castor-oil, and sweet-oil,
added to a tablespoonful or two of water, allowing it to
remain in the bowel as long as it would. The glycerine
rendered the masses softer. Curative remedies were
dietetic rather than medicinal. He had not found cane-
sugar as efficient as had been claimed. Massage was of
some use. Maltose was efficacious. Some of it might
be given with each feeding in order to get a more regu-
lar movement of the bowels.
Permanent Cure Only in Recent Cases. — Dr. S. W.
Dana thought that by such means 98 the author had
mentioned — electricity, massage, diet, etc., recent cases
of constipation could be permanently cured, but not so
the really habitual ones. Trousseau had commended
belladonna, but it was not curative in this country;
neither were the cannon-ball, the compressed sponge, or
boracic acid. Habitual constipation was associated with
a sedentary life. There were cases, more than we knew
of, which were hereditary. In them, to seek to remove
the cause would require going back to the parents and
grandparents. As children these persons might suffer
little, but as soon us they grew up and became seam-
stresses or pursued sedentary vocations they became ob-
stinately constipated.
Camp Out. — Massage would relieve constipation. But
Dr. Dana knew a better method. There were a large
number of business men who went every October to the
Adirondacks, lived in a log hut open on one side, spent
their time hunting and leading an active life. These
men had told him that during this time their bowels,
which had been constipated the whole year, became easy
and natural. On returning to the city they soon became
constipated again and had to take laxatives until their
next outing.
Dr. Dana did not know why there should be such an
outcry against the use of purgatives. Elderly people es-
pecially had passed the time for a permanent cure of
constipation. They were in misery unless their bowels
moved. In many cases a regular passage could be
secured by a dinner-pill, the patients felt better for it,
698
MEDICAL RECORD,
[December 1, 1894
and were not more given to ills than persons who did
not take them.
Dr. J. G. Coyle said that when he entered upon the
practice of medicine he was not prepared to find con-
stipation in women exist to the extent that it did. The
cynical and sententious definition of woman by a college
professor seemed not altogether inappropriate : a consti-
pated thing with a pain in the side. The first doctor,
whoever he was, must have been employed to relieve
constipation. Massage was nothing more nor less than
exercise of muscles, and with few exceptions as good re-
sults could be obtained by active exercise, but the pas-
sive form appealed to women. For men it should only
be recommended to those who had more time than brain.
In atony of the bowel no drug was so effective as fluid
extract of cascara sagrada. In some cases strychnia and
belladonna were very useful.
Dr. F. M. Nye had once relieved himself of an attack
of obstinate constipation by green corn. He had heard
of a man who " couldn't get a hole through his patient,
sent out for a quart of yeast, squirted that up his bowel.
Blazes ! it didn't come away, and that's what made him
croak." Dr. Nye had found a small dose of calomel,
given regularly for a time, relieve constipation in infants.
Dr. Achilles Rose exhibited a cannon-ball, weighing
over three pounds, a form which had given satisfaction
to himself and others in constipation.
Dr. Illoway, in some closing remarks, said Trousseau
had recommended belladonna only in cases of constipa-
tion supposed to be due to spasm of the bowel, and in
such cases it was of value. He did not think length of
the sigmoid flexure in infants had much influence, while
milk from a constipated mother and use of soothing syr-
ups and brandies had.
" Xedioo-Chirurgieal Hotes on the Works of Hippo-
orates and Galon " was the title of a paper read by Dr.
R. Harcourt Anderson. Mention was also made of
anaesthetics in the early and middle ages.
OJPlitxicat §epuxtramL
A CASE OF TETANUS NEONATORUM — RE-
COVERY.
By EDWARD C. RUNGE, M.D.,
ST. LOUIS, MO.
INSTRUCTOR OF PHYSIOLOGY AND ASSISTANT CLINICIAN AT THE CLINIC FOR
NERVOUS DISEASES OF THB ST. LOUIS MEDICAL COLLEGE DEPARTMENT OF
WASHINGTON UNIVERSITY, ST. LOUIS, MO.
On August 7th, Mrs. H , called me to see her new-
born babe, which appeared to have been afflicted in a
peculiar way for some days. I found the premises located
in a healthful portion of the city, and bearing the stamp
of a good sanitary condition : foul air, cesspools, or any
other anti-hygienic elements did not make themselves
apparent upon close inspection. Everything in the
house indicated the order and care of a well-regulated
household. The father seemed to be in perfect health.
The mother had enjoyed good health during the entire
period of gestation, except for a certain " nervousness "
which was more pronounced during the early part of her
pregnancy. This is her fourth child, and the first one
to give any trouble. The foetal movements were almost
absent during the last month; some feeble ones were
felt just a week before birth, which took place on July
23d, about one month before full term according to the
mother's calculations. The labor lasted nine hours, the
pains not having been at any time severe. It was a head
presentation. The umbilical cord is said to have made
four turns around the child's neck, and was severed some
little time after birth. The placenta was not adherent,
and came away about ten minutes after the child. The
latter, a boy, weighing eight pounds, was profoundly
cyanosed, " almost black," but uttered a short cry very
soon after his birth. An enema was administered at
once, for some occult reason. Whether the babe had
received a bath at that time, or how the cord was man-
aged, could not be ascertained, as the attending midwife
had beaten a hasty retreat before my arrival, and the en-
tire anamnesis had to be elicited from the mother. The
latter did not notice anything unusual about the babe for
two days. The cyanotic hue erf the skin had given way
to an intense redness ; no " jaundice " was ever noticed.
The little fellow nursed well and eagerly, and cried at
times, but never lustily. The eyeballs seemed somewhat
too prominent, and an occasional cast of one eye was
observed. The intestinal and renal functions seemed
normal. On the third day the mother was surprised at
the "unusual strength" displayed by the babe; it
would grasp her gown, and only with difficulty loosen its
hold. The umbilical cord had become detached on some
day before the mother's leaving the bed, which hap-
pened on the tenth day after confinement. A daily bath
had been given since the detachment of the cord. On
the tenth day after birth there seemed to appear the first
difficulty in swallowing, the babe refusing to take the
breast Complete locking of the jaws supervened. This
condition was aggravated by any attempt at introducing
the nipple or a spoon. On the eleventh day the spasms
of the masticatory muscles continued with temporary
relaxations, during which some milk was forcibly given
by the spoon. The milk was, at times, vomited (or
probably ejected before it had reached the stomach).
This condition was soon followed by tight shutting of
the eyelids, stiffening of the extremities, and by drawing
back of the head. The midwife, nothing daunted,
was still directing her efforts toward combating this " un-
usual attack of colic " with castor- oil, rhubarb, and cas-
toria. The parents finally concluded to call in medical
aid, and on August 7 th I found myself at the bedside of
the little sufferer, on the fifteenth day of his extrauterine
existence, and on the seventh day after the onset of the
malady.
In the dim light pervading the darkened room the
babe's face showed a high degree of emaciation, the eye-
lids were closed, the countenance pinched, but otherwise
normal. A curtain was raised for better inspection.
No sooner had the bright light struck the infant's face
than the forehead was thrown into transverse wrinkles,
the eyelids, of which the superior ones appeared (Edema-
tous, shut more tightly, the mouth was puckered up as
if in an attempt at whistling. The lower jaw was im-
movably fixed, so as to render the introduction of my fin-
ger utterly impossible. This paroxysm was accompanied
by a half -suppressed, whimpering cry. I succeeded
with considerable difficulty in extricating the little pa-
tient from a mass of coverings, cotton-batting, and lard-
stained rags, and found him to be an apparently folly
developed infant. The emaciation was general and
extreme. The skin was of a dirty icteric hue, and cov-
ered with a papular miliaria, while the sclera and the
mucous membranes did not show any icteric discolora-
tion. There was a slight hernial protrusion at the um-
bilicus; the latter was perfectly healed, and did not
show any sign of inflammation, past or present. I also
made out a right scrotal hernia. The fontanellar pulsa-
tions were absent. The head was drawn backward by
the rigid cervical muscles ; a slight degree of opisthoto-
nus was noticeable; the forearms were slightly flexed
and crossed over each other ; the fingers were tightly
clasped over the thumbs in extreme flexion ; the thighs
were flexed upon the abdomen, and the legs upon the
thighs ; the toes were widely separated, and their exten-
sors in an almost rhythmical clonus. The abdominal
muscles hardened upon the lightest percussion. The
paroxysm was followed after some time by a period of
partial relaxation, the rigidity of the muscles never dis-
appearing entirely. The slightest irritation — as by a
touch, a sound, a change of light, a breath of air — did at
once cause an acute exacerbation of all the tetanic symp-
toms. The alvine discharge, removed at the time of my
first examination, was of a semi-solid consistency, dark
December i, 1894]
MEDICAL RECORD.
699
brown, and extremely offensive. The whole picture was
so characteristic of tetanus neonatorum as to preclude
any possibility of a diagnostic error.
I immersed the babe in a bath at 990 F., and kept it
under water for six minutes. This seemed to bring on
considerable relaxation, which lasted just long enough to
enable the infant to take about one ounce of dilute milk
from the bottle. A small portion of the milk was re-
jected, and the removal of the bottle ushered in another
paroxysm. I ordered chloral in 0.24 doses every four
hours by rectum, 0.03 of anti pyrin and 0.12 of potassic
bromide in solution cautiously dropped on the tongue
every two hours ; an immersion bath at blood-heat every
four to five hours, each to last ten to fifteen minutes ;
nutrient enemata, consisting of milk, egg albumin, and
sodic chloride ; egg water by the bottle or spoon when-
ever the child's condition would permit the procedure. .
I, of course, insisted upon the exclusion of all adventi-
tious sounds from the darkened sick room, and upon
keeping the patient well wrapped in simple coverings,
discarding the complex apparatus of the conventional
babe dress.
August 8th. — The pauses between the paroxysms have
grown somewhat longer ; this made more frequent feed-
ing possible. The egg-water was never vomited. Diu-
resis was more active ; the alvine discharges were more
watery and less offensive. The skin felt hot. The ther-
mometer was not used for fear of disturbance. Pepto-
nized milk was ordered, and treatment continued, ex-
cept for decreasing the dose of the chloral to 0.12, and
adding whiskey in repeated five* drop doses.
August 9th. — The egg- water and peptonized milk were
taken in greater quantity, and retained. The mother
succeeded in straightening the lower limbs during the
bath without producing an exacerbation of the tetanus.
The nutrient enemata were discontinued on account of
rectal irritability. Medication: Chloral 0.12 twice,
antipyrin and potassic bromide every three hours. Baths
the same as before.
August 10th. — The babe nursed more easily and will-
ingly. It tired readily, but as soon as the bottle was
moved the sucking was taken up, without producing a
masticatory spasm every time. The face wore an im-
proved look. Treatment continued.
August 1 ith. — The skin appeared more natural, hav-
ing lost its icteric hue. The eyelids opened slightly, and
involuntary winking was noticed for the first time. The
trismus appears very much less frequently ; the feeding
was more successful, one ounce of peptonized milk being
ingested each time. An enema brought a rather copi-
ous dark- colored discharge. The fingers could be sepa-
rated with some effort. The cervical and dorsal spasms
were still quite pronounced. Treatment continued.
August 1 2th. — The babe nursed well, taking about
one ounce of milk every two hours. It seemed to crave
the bottle, for the cry had lost its whimpering character,
and was evidently appeased by the bottle. The eyes
were opened, and remained open for some time. The
fingers were more readily unclasped. The introduction
of the thermometer into the rectum caused quite a severe
tonic spasm of the muscles of the lower limbs. At 6 p.m.,
rectal temperature 1040 F. Treatment continued, ex-
cept chloral given but once.
August 13th.— The patient nursed well. The intes-
tinal discharge showing undigested casein, the milk was
given in greater dilution. The cries were quite natural.
Relaxation was more persistent, and particularly marked
after the baths. The babe was ordered back to the
breast. Rectal temperature, at 10 a.m., 102. 20 F. ; at
5.30 p.m., 1020 F. No chloral; antipyrin and the bro-
mide every four hours ; baths.
August 14th. — The breasts began to yield more milk ;
still the bottle was given at intervals. Rectal tempera-
ture, at 10 a.m., 100.90 F. ; at 5.30 p.m., 100.40 F.
Treatment continued.
August 15th. — General relaxation very marked. Al-
vine discharges of natural color. The eyes were opened
readily and quite frequently. Rectal temperature, at
10 a.m., 100.90 F. ; at 6 p.m., 101.40 F. All medica-
tion suspended. Baths continued.
August 1 6th. — The patient appeared weak, otherwise
much improved. Relaxation continued, except that the
fingers were still flexed, but the fingers overlapped the
thumbs, and the clasp was not tight. The tetanic con-
dition has disappeared completely. Rectal tempera-
ture, at 10 a.m., 99.20 F. ; at 6.20 p.m., 101.10 F. The
number of baths reduced to one in twenty-four hours.
August 17th. — Doing well. Rectal temperature, at
10.30 A.M., 101.20 F.
August 1 8th. — The babe is entirely breast-fed ; weight,
seven and three-quarter pounds. Rectal temperature, at
4.30 p.m., 101.10 F.
August 24th. — Weight, seven and three quarter pounds.
September 1st. — Weight, eight pounds.
September 14th. — The boy seemed bright. All func-
tions were normal. He had the full use of his limbs, no
muscular impairment whatever being noticeable. Rec-
tal temperature, at 1.30 p.m., 100. i° F. Weight, ten
pounds. The patient appeared in every respect a per-
fectly normal child.
I may sum up the important features of this case as fol-
lows:
The tetanus set in on the tenth day after birth ; all of
its manifestations disappeared completely on the fifteenth
day after the onset.
The development and course of the disease in this case
place the latter in the category of so-styled chronic tet-
anus, with its less gloomy prognosis.
As to the therapeutic measures, it would be impossible
to decide how far they have contributed toward bringing
about the favorable result. To serve this purpose they
would have to run the gauntlet of much more extensive
clinical experience. In managing this — my first — case
of tetanus neonatorum, I had to overcome a strong preju-
dice against any, save physiological and hygienic, meas-
ures in dealing with the new-born. I felt that the oc-
casion did not warrant the taking of extemporizing
half-measures, or any dosing in strict accordance with
hard-and fast pharmacopoeial rules ; 0.03 of antipyrin and
0.12 of potassic bromide every two hours, and chloral in
o. 24 doses every four hours, seem a good deal of medi-
cine for a patient just entering upon the tenth day of his
earthly existence ; but the violent nature of the malady
rendered the adoption of truly heroic measures simply
imperative. The frequent and prolonged bathing was a
prominent feature in the management of the case, and
I will say that it caused more lasting relaxation than any
of the other remedial agents, produced repose more
nearly akin to natural sleep, and, at the beginning of the
treatment, stayed the trismus for a sufficient time to en-
able the patient to take some nourishment by the mouth.
Rectal alimentation, which I should never neglect to in-
stitute, is not quite as satisfactory in the new-born as in
infants at a later period of life.
Any attempt at solving the question as to the etiology
of the tetanus in the case under consideration would
lead directly into the field of con jecture and speculation.
The umbilicus having failed to show any evident patho-
logical changes, the case would most likely be classified
as one of non- traumatic or "idiopathic" tetanus. It
was not within my power to ascertain whether the baths
given before the onset of the disease were improperly
tempered. Foul air did not play any rdle in establishing
the disease. The atmospheric changes were devoid of
any startling features ; from the reports obtained at the
local weather bureau, I learned that for the three days
preceding the attack, and on the day of the attack, the
mean temperature registered 740, 8o°, 830, 82°F.; the
range between the maximum and minimum, 16, 21, 16,
21 ; the departure from the normal, — 4, + 2, + 5, +
4. These data point to an equable state of the atmos-
pheric temperature ; the same holds true for the first ten
days of the child's life. The meconium had been passed
in a normal way, and the alvine discharges had assumed
7oo
MEDICAL RECORD.
[December i, 1894
their usual character. In these and some more directions
causes of tetanus of the new-born have been sought after.
Upon perusing the literature on this subject I came to
the conclusion that the etiology of non-traumatic tetanus
is still a sealed book to us. Just to illustrate on what
extremely weak grounds the explanation of the causation
of this disease sometimes rests, I make mention of the
case reported by Hein, as quoted by Dr. J. Lewis Smith :
A citizen of Berlin lost, successively, two children with
tetanus soon after birth. When the second child fell ill
he observed that its cradle was exposed to a current of
air. At the third accouchement the position of the cradle
was changed and the infant escaped ! Our salvation
may possibly lie in the further pursuit of such experi-
mental work as has been done by Beumer and Riper ; its
final result may prove that every genuine case of tetanus
neonatorum is of microbic origin. Bearing such solu-
tion of the problem in mind, we should be ever careful of
giving our new-born the benefit of the most approved
surgical methods while we are inflicting upon them their
first, unavoidable, trauma. Clean hands, a thoroughly
cleansed cord, aseptic ligatures, sterilized scissors, a dry
protective dressing, consisting of some non-irritating
antiseptic powder {e.g., equal parts of iodol and boracic
acid) and gauze, are all essential features in the equip-
ment of the modern obstetrician possessed of truly surgi-
cal instincts.
A CASE OF FATAL HICCOUGH OF UNKNOWN
ORIGIN.
By D. B. McCARTIE, M.D.,
NftWABK, N. J.
Within the last few months a new and continuous form
of hiccough has appeared, unaccompanied by organic
disease or surgical malady. The minute history of all
these cases I cannot substantiate, but I know all were
continuous and irremediable, and in several instances
caused death. Some cases were treated in the hospitals,
others at home, with meagre results, and most were
looked upon as excessive forms of ordinary hiccough,
when probably the disease was a new manifestation of
nerve disturbance occasioned by some functional neuro-
sis.
Case L— History : J. C , bartender, aged twenty-
eight ; habits and family history good ; no special ner-
vous traits in family; an active, strong man; weight,
150 pounds; middle height. For yean previous to
present disease, on being shaved by his barber, he no-
ticed that when the razor touched a circumscribed spot
on the side of his chin, at the edge of the inferior maxil-
lary bone beneath the mental foramen, a trifling scratch
instantly brought on an attack of hiccough. This hap-
pened repeatedly, but the reflex action never continued
longer than for a few seconds. He always could check
it by the usual domestic remedies, as sipping water,
holding the breath, etc. The last and fatal attack be-
gan after he had been shaved, and lasted five or six
weeks, after which he died of exhaustion. The hic-
cough was almost continuous, except during sleep and
for some periods to which this brief sketch particularly
refers. After a day or two the case aroused much pop-
ular interest, since the patient was well known ; and as
a newspaper wonder stood out strongly in long, exciting
paragraphs. As a consequence, cure after cure was rec-
ommended and tried, with faith in each new method,
only to end in sad failure. Among thousands of popu-
lar devices nitrite of amyl was oftenest recommended,
even outside the medical world.
It would be waste of valuable space to add any of the
extraordinary remedies suggested ; puffice it to say they
all failed. The medical treatment for days was as hope-
less, and in this department few remedies were left un-
tried. The sedatives naturally were tried, but after
slight relief the hiccough was renewed. One medical
gentleman suggested the stomach- tube, which was even-
tually the only means by which a short reprieve could be
obtained. The use of food in any form, after being
swallowed about half an hour, caused the patient such
distress by augmenting the hiccough, that he anxiously
introduced the tube or artificially produced vomiting,
for when the stomach was empty the hiccough weak-
ened. I saw the case many times, and tried pressure on
the phrenics in the neck. This lessened the hiccough
very much and allayed the spasms of the chest, bat on
removal of die pressure the phenomena returned as vig-
orously as ever. I then strapped the lower ribs, which
apparently lessened the spasms, yet the patient com-
plained that they had not subsided internally. Cocaine
pills were next administered, and much relief followed ;
but this was not sufficient to cause a sudden disappear-
ance of the trouble, which the patient and everyone
thought was to be obtained by some mode of action or
drug. After this the patient continued to hiccough and
grow weaker. Rectal alimentation did little to main-
tain his strength. About one week later an operation
was performed on the irritable spot in the cheek, bat
failed to cure, having no scientific exactitude underlying
its performance. On a second visit to the unfortunate
fellow I observed that he was losing all his strength, and
was very exhausted and wasted. As a last resource I
tried massage, and to my surprise, after working gently
at the toes and lower extremities for a brief time, he
complained of an indefinite feeling about the epigastric
region ; presently be retched up some greenish watery
fluid, and the hiccough stopped immediately. The pa-
tient brightened up and took some nourishment, which
remained in his stomach without producing the hic-
cough. The interval lasted twenty-four hours, when
it began again. The man now despaired and sank
spiritless in his bed. Being called again, I tried the
same remedy with instantaneous success. The hiccough
stopped two days, then returned. In the meantime
hundreds of letters arrived daily, and continued annoy-
ance was kept up about the dying man. He also tried
every remedy guaranteed as a sure cure. I saw him
again three days later, and massaged him all over;
again instant relief followed, and he remained free from
the attacks an entire week, at the end of which time they
recurred. I saw the case no more, as now he submitted
to all kinds of treatment, plus an operation. One week
later he died of exhaustion ; no autopsy.
These cases appear to be of nervous origin, and, like
any other hysterical malady, are prolonged by attention.
They appear to be causeless, except through functional
nerve perversion. In the above case no organic cause
existed, or in any of the group lately reported. The
disease is not due to organic stomach trouble, or pressure
on the phrenic nerve ; nor does there appear any reason
as yet to ascribe it to any brain tumor or lesion which
would not be lacking in various other symptoms. It
remains at present to class this phenomenon as a neurosis
of functional character. Most works on medicine ignore
it, except as a concomitant to alcoholic excess, or ante-
cedent to death, or accidental to obvious causes, such as
pressure on the nerve trunk. The treatment, where ex-
haustion is the cause of death, would be suggested by like
cases of functional nerve depression, like that of bed-
ridden or hysterical patients. Little need be said on
this score, except that the disease be recognized as a
disease. Isolation, rest, removal from home, forced
feeding, encouragement, electricity, and, above all, in
these cases, massage, since the results above ascribed to
it were undoubtedly manifest and instantaneously suc-
cessful.
108 Bellbvillb Avenue.
Library of the Surgeon-General's Qffloe.— In the Army
Medical Library there are now, according to the recently
issued report of the Surgeon-General, 114,567 bound
volumes, and 183,778 monographs and theses on medi-
cal subjects.
December i, 1894]
MEDICAL RECORD.
701
OUR LONDON LETTER.
(From Our Special Correspondent.)
THE BRADSHAW LECTURE — INFANTILE SCURVY AND RICK-
ETS— PATHOLOGICAL SOCIETY — PERFORATION OF THE
PALATE IN SCARLET FEVER — DEATH OF DR. STURGES —
SMALL-POX — DIPHTHERIA— CHELSEA HOSPITAL AGAIN.
London, November 10, 1894.
The Bradshaw Lecture was delivered on Thursday before
the Royal College of Physicians. This year the Lecturer
was Dr. Thomas Barlow, who took for his subject " In-
fantile Scurvy and its Relation to Rickets." Dr. Barlow
has worked assiduously at this subject and made it quite
his own, and was, therefore, listened to with great inter-
est. It is now eleven years since he stated the results of
his observations on thirty -one cases. At that time the
disease had not been generally differentiated, and such
cases were spoken of as "acute rickets,1' even in the
German school, where the idea that they were scurvy was
repudiated chiefly because sponginess of the gums had not
been noticed, but this symptom has been since shown to
sometimes occur. Dr. Cheadle first reported this, and to
him we owe to a great extent the present state of our
knowledge of the clinical features of these cases. The
soundness of his conclusions was maintained by Dr. Bar-
low, who has himself contributed chiefly to our knowl-
edge of the pathology of the disease. In this Bradshaw
Lecture he reviewed the main clinical and anatomical
aspects of the disease, recalled the conclusions of his first
paper, and then showed ho* far they had been modified
by criticism and subsequent investigations. Copies of
the drawings of his original paper from the Medico- Chit-
urgical Transactions, 1883, were submitted, and speci-
mens were exhibited to illustrate the pathological condi-
tions. I must not omit to say that in giving some
account of the workers on the subject, Dr. Barlow did
ample justice to America, from which he said the most
striking evidence had come. He specially mentioned
Drs. Northrup, Starr, Roche and others. It seems that
the disease must be more common on your side the At-
lantic, and it would appear to be on the increase with us,
unless this apparent increase may be due to the increased
knowledge which makes differentiation more general.
Infantile scurvy is a disease of spoon-fed children. The
spread, prevention, and cure are summed up in this state-
ment. Still there are some fresh points in diet now and
again cropping up. Thus the danger of proprietary
foods is recognized, but it is not commonly suspected
that sterilization of milk may be dangerous. Dr. Barlow
spoke cautiously on the point, but suggested that pro-
longed high temperature might lessen the antiscorbutic
powers of milk. The treatment is simple, appropriate
diet and antiscorbutic remedies.
Antitoxin and diphtheria continue to occupy much
attention, and one frequently hears of fresh cases in
which the treatment by serum seems to have been most
successful. It is now said that the British Institute will
soon be able to supply the remedy. In the meantime
supplies from the continent are falling off, and will soon
be unobtainable. The Institute ought to have been
ready before this, as I some time since suggested.
There was a good show of specimens at the Patho-
logical Society on Tuesday, e.g., rare examples of
malignant disease, mediastinal tumor, peri- renal hemor-
rhage, carcinoma of kidney. Dr. £. W. Goodall read a
paper on perforation of the soft palate in scarlet fever,
and showed a preparation from a child of six months in
which perforation was first observed four days before
death. He had seen 14 cases, in 2 of which there were
3 perforations, in 3 cases a, and in 9 only 1. They oc-
curred at various periods, from the 9th to the 28th day.
Generally they were by the side of the anterior arch.
They might persist for weeks, and were probably the re-
sult of local sloughing. He had only seen perforation
in diphtheria twice, and agreed with Dr. Fowler that the
lesion is almost diagnostic of scarlet fever.
Dr. Octavius Sturges died this day week in conse-
quence of injuries received a few days previously. He
was knocked down by a cab in Cavendish Square, and
though at first no internal injury was manifest, collapse
set in and he died on the 3d inst. His chief writings
were on chorea and pneumonia, and in connection with
both of these his name will be familiar to many of your
readers. He was senior physician to the Westminster
Hospital, where colleagues and students alike held him
in the highest esteem. At the Children's Hospital he
held a similar position. At the Royal College of
Physicians he was Senior Censor. In all directions re-
grets are expressed at his untimely death, mingled with
admiration of his high character, unswerving loyalty to
truth, faithfulness to conviction, and kindly sympathy
with pupils and friends. As a quondam colleague, I
would add my testimony to his upright conduct, and re-
gret that so estimable a character should thus suddenly be
removed from among us. We can ill afford to lose such
examples. He was buried on Thursday, and a number of
distinguished physicians attended the funeral service.
Small-pox continues to abate in London. Only eight
new cases were reported last week. In the provinces,
however, the returns are less favorable. In Dublin the
disease continues. In Birmingham 69 fresh cases were
reported. In Edinburgh there has been a fresh outbreak,
to the extent of 50 cases in nine days, but I hear that the
type is mild.
Diphtheria, which was rapidly falling in the number
of its victims, has not declined further in the past week,
in fact, the number of deaths went back from 49 to 54.
At West Ham there were 12 deaths registered.
At last the committee of the Chelsea Hospital for
Women have yielded to the voice of reason and resigned.
There is no gracefulness in the act — it has been forced
upon them by public opinion. I hope the governors who
are to meet shortly will come in numbers and refuse to
re-elect one of the old Board. I heard the medical staff
will recommend the governors to appoint a special com-
mittee to deal with the subject of elections to the staff.
IS MALARIA A WATER-BORNE DISEASE?
To thk Editor op not Medical Record.
Sir : Anent the discussion on the sources of malarial
infection between Drs. Daly, of Pittsburg, and Dalrym-
ple, of New Rochelle — places where malaria is compaia-
tively'rare — perhaps a word from one who has spent six
years in the Mississippi Yazoo Delta, where the infection
is endemic, would be of value.
In the first place, both gentlemen are right Malarial
germs are earth- borne, water-borne, and air-borne ; in
fact are disseminated by every agency that circulates
except excessive heat. Now, I have frequently known of
a succession of cases of pernicious malaria in a family
who drank water from the same source. To illustrate :
In the summer of 1890, 1 had two cases of malarial
hematuria, one of which was fatal, one case of malarial
congestion fatal, one case of typho-malarial fever not
fatal, and one case of severe intermittent ; all occurring
in one family of six members; the one escaping being a
very old lady. Situated about three hundred yards from
this residence was another family of three members.
One of these had malarial hematuria and died. The
other two had very severe attacks of intermittent. About
fifty yards from the first-named residence was another
family, numbers not remembered, which developed two
cases of malarial hematuria, one of which was fatal, and
several cases of intermittent and remittent fevers. There
were several other families living contiguous to the first-
named house in every direction, who were exposed to all
the atmospheric and general causes, but remained
healthy. It was found that the three infected families
had used water from the same cistern, and this cistern was
702
MEDICAL RECORD.
[December i, 1894
cracked and fall of sipage water. The families who had
remained healthy had used a different water-supply.
Again, it has been observed repeatedly in that section,
that during a protracted draught, when the stagnant ponds
and bayous are all drying up, exposing their beds to the
sun, which soon converts them to dust which fills the at-
mosphere, malaria is rife in all its forms ; but let there
come a good rain sufficient to bring down all atmospheric
germs and fix them to the earth again, and there will be a
sudden cessation of all acute cases. This is so invariable
that its occurrence can be predicted with certainty. Of
course, chronic cases and those which have undergone
structural change will persist.
I have been told of severe epidemics caused by upturn-
ing the earth and by the exposure of large areas of the soil
to the rays of the sun, by " deadening " the timber, but
none have come under my personal observation.
Yours respectfully,
Isaac J. Jones, M.D.
1603 South Congress Avxmub, Austin, Tex., November 15, 1894.
To Tin Editor or thk Medical Rrcord.
Sir: Will Dr. F. W. Dalrymple, of New Rochelle,
kindly answer the following questions for the information
of the profession :
1. From what source does the Water Company of the
village of New Rochelle get its water supply for distribu-
tion to the inhabitants?
2. If from wells, what is the evidence that there was
no contamination in them from the land water ?
3. If from a stream, what is the locality and character
of the watershed drained by the stream which supplied
the village water ?
4. What was the storm-water fall amount and character
for the two months previous to the outbreak of malaria?
5. What proportion of the people who suffered from
malaria drank from wells in the village ?
6. What were the sources of supply of lettuce, rad-
ishes, celery, etc., eaten by the persons taken sick;
whether from muck lowlands or uplands?
7. What were the sources of the milk-supply of those
taken sick ?
8. What proportion of the men who worked in the
sewer and cellar excavations were taken sick with mala-
rial fever?
It is in no captious spirit that I ask the foregoing
questions ; I desire to get at all the facts for the sake of
accuracy, and I sincerely hope, in replying, that no fur-
ther epithets will be indulged in by the Doctor as to the
views I advanced being " absurd; " for the Doctor will
probably agree with me, that it is not difficult to mention
now other well-accepted views in medical science that
were previously more strange and unlikely than taking
malaria into the system in the water we drink ; and epi-
thets are neither argument nor evidence, in this or any
other discussion. Yours,
W. EL Daly, M.D.
Pittsburg, Pa.
CIRCUMCISION— DO WE NEED LEGISLATION
FOR IT?
To the Editor or thk Medical Rbcokd.
Sir : That delicate little procedure or operation, as Dr.
Henry Levien would have it (issue of November 17th),
circumcision, is again attracting the attention of our profes-
sion, and I believe there is no operation that has been so
much discussed or spoken of for centuries as this rite of the
Hebrews ; and it is not surprising that it is the bete noire
of our progresive Hebrew physicians imbued with the
spirit of Listerism.
The chief fault that Dr. Levien finds with the Mohel
(surgeon) is the ignorance of aseptic surgery, and he ac-
cordingly cites two cases, one of erysipelas and the other
of excessive hemorrhage, that occurred as the result of the
operation.
Those of our colleagues that practice among the He-
brews will admit that seldom, if ever, did they hear of
complications after circumcision so grave as to cause
death ; it is of so rare occurrence, nay, so unheard of, that
it is impossible to give any approximate data; it is infi-
nitesimally small. Let the Board of Health statistics
answer, how often do they contain reports of deaths as
the result of circumcision. We do not attack modern sur-
gery, with the great aseptic and antiseptic methods, but
we venture to say that in the best modern hospitals,
where Listerism is carried out in a most rigorous way,
sepsis occurs a hundredfold more than in that small
crowded room where the Mohel is the surgeon-in chief;
and the surgeon of every hospital in the country would
be proud should he be in position to point to as small a
record of sepsis or other complications as the Mohel is
able to. How to explain such a fact I do not undertake,
but one feature of the Mohel's work is characteristic—
his dexterity, the swiftness with which he performs the
only operation he is able to, and which he has performed
thousands of times, is so great that it only consumes
one or one and a half minute, including time of
dressing the wound, and, as I witnessed it the other day,
it took at most forty-five seconds in all. The little
time, say thirty seconds, which the wound is exposed
might explain somehow why so few cases of compli-
cations occur in the Mohel's practice.
In conclusion permit me to state that: 1. As Dr.
Levien himself admits the progressive Mohel employs an-
tiseptics, he believes only the city Mohel does. I had an
opportunity dozens of times to witness the country Mo-
hel's armamentarium not complete without a bottle of
carbolic and a strip of iodoform gauze.
2. There are licensed physicians, skilful and unskilful,
and the same with the Mohels, but even the poorest He-
brew always seeks the services of the best, die one who
is most popular as having the record of widest experience ;
for should the father be unable to pay the Mohel's fee, the
invited guests respond to the Mohel's individual blessing
of those present by voluntary contributions, thus paying
for the opportunity to be present at a God pleasing rite.
3. Circumcision, as practised by the Mohel on the in-
fant, is no more of an operation than vaccination, open-
ing an ordinary abscess, or severing a tongue tie.
4. As a custom and religious rite, circumcision cannot,
and should not, be interfered with as carried oat among
them.
Permit me further to add that none of our most promi-
ment surgeons ever attacked or ventured an adverse
opinion in regard to circumcision, for we never see any
evil results from it, and in many cases are sorry our pa-
tients have not been circumcised. As a patient of mine,
an Arabian, aged thirty, upon whom I was compelled to
perform circumcision about three months ago, for para-
phimosis with extensive sloughing, exclaimed: ''How
ungrateful must I be to my father, who neglected his
duty to me and left the work to be done by yon thirty
years afterward."
R. Hochlerner, A.B., M.D.
THE IMMUNE SERUM OF THE GOAT.
To thb Editor op thb Medical Record.
Sir: "C." in the Medical Record, November 17th,
suggests that " it may be worth while to test the natural
and artificial immune serum of the goat in future ex-
periments." He is speaking of tuberculosis. Let me
inform your correspondent, that there are past experi-
ments which he will find described in the Tribune
Mldicale of Paris. Unfortunately I cannot give the
date of the articles, having sent the files of this French 1
paper to the Tokio Medical Library ; but the year was
either '92 or '93. One article is entitled " Goat's Blood
in the Treatment of Tuberculosis," by Bertin and Picq ;
the title of the other is " Transfusion of Goat's Blood in
Pulmonary Tuberculosis," by M. Bernheim.
Yours truly,
Albert S. Ashmead.
December i, 1894]
MEDICAL RECORD.
703
SttrgicaX SttxgQtBtions.
Gall-bladder. — The tongue-shaped projection, to
which attention has been called by Riedel, is present in
many cases of hydrops of the gall-bladder ; it is not in-
frequently confounded with a floating kidney on the
right side. — Kshr.
Appendicitis. — Surgical interference is not advised dur-
ing an acute attack of appendicitis, except when grave
symptoms intervene, unless a competent surgeon is at
hand. Under these circumstances the case should be
operated upon after the so-called recovery. — Ashton.
Lacerated Cervix.— The kind of suture I use in opera-
tion for lacerated cervix is braided silk boiled in wax,
and these sutures can be withdrawn with such ease that
the patient is scarcely aware of the fact. — Nilsen.
Keep
itric-acid bottle away from your steel in-
ln-
jj your nitric
struments.
So not carry nitrate of silver in the same case with
struments.
Control of Hemorrhage in Cases in which it is neces-
sary to remove the Arm, the Scapula, and the Clavicle.—
The methods that have been employed in these cases
have been : (1) Simple compression of the subclavian
artery ; (2) compression of the artery after resection of
the clavicle ; (3) ligation of the subclavian prior to be-
ginning the amputation; (4) resection of the middle
half of the clavicle and ligation of the subclavian ; (5)
Wyeth first tied the artery, then formed his flaps, and,
when the arm, clavicle, and scapula were connected with
the trunk by only the veins and nerves, secured the veins
and cut the nerves ; (6) the artery and vein have both
been tied after resection of the middle portion of the
clavicle. — Keen.
Empyema. — No operation is justifiable unless the pres-
ence of pus is certain ; unless thorough treatment by
medicinal agents, blisters, etc., has failed ; or unless the
symptoms, dyspnoea, etc., are so urgent as to demand im-
mediate relief. (And the only way to be sure of the
presence of pus is by the use of the aspirating needle.) —
ASHHURST.
The man who intends to be a surgeon should not only
make a special study of surgical anatomy, but should do
a considerable amount of practical laboratory work in
bacteriology, pathological histology, and experimental
pathology and physiology. — Billings.
The shook of being knocked down by an anaesthetic, as
it is frequently administered, is very great indeed, ex-
tremely like that of a heavy blow on the top of the head.
— Ross.
We chloroform the patients in order to give them
ether. — Gorgas.
Excision of Oasserian Ganglion.— Hartley improved
on this operation by opening the cranium without incis-
ing the dura, raising the temporo sphenoidal lobe, expos-
ing the ganglion, and removing it as it lies beneath the
dura mater. This method seems to have the advantage
over the method of Rose, in the precision with which
the ganglion can, under favorable circumstances, be re-
moved, and in the absence of such disagreeable, and
sometimes unavoidable, accidents as wounding of the
parotid gland or the seventh nerve. — Stewart.
Impacted Stone in the Ureter.— If the calculus is
thoroughly squeezed between the thumb and fore-finger,
the wall of the ureter being stretched tightly over it, a
longitudinal incision will, after the removal of the stone,
so contract that in many cases its site cannot be after-
ward discovered, except by a very careful search. The
ureter should not be sutured. — Cottrell.
Contagions Diseases — Weekly Statement. — Report of
cases and deaths from contagious diseases reported to the
Sanitary Bureau, Health Department, for the week end-
ing November 24, 1894.
Tuberculosis
Typhoid fever
Scarlet fever
Cerebrospinal meningitis
Measles
Diphtheria
Small-pox
14a
103
14
5
88
13
0
I
47
a
167
35
7
6
Pathogenesis and Treatment of Influenza. — It is well
known how popular the quinine treatment of influenza
was when that maladie d la mode visited our shores. So
far as my knowledge goes this mode of treatment was
strictly empirical, no laboratory experiments having
been made on its action. The medical world will there-
fore be glad to know that the experiments of M. M06S6
have confirmed the good opinion entertained of the value
of this drug in combating "la grippe." Rabbits were
inoculated with the blood of influenza patients, and then
quinine was injected subcutaneously. Four out of six of
these animals remained unaffected, while test rabbits un-
protected by the drug became very ill. Again, rabbits
inoculated with pure cultures of Pfeifler's microbe (fur-
nished by M. Roux) were quite capable of supporting
this inoculation, provided subcutaneous injections of
quinine had been previously practised. Of three un-
protected rabbits, two were killed by the inoculation.
Efforts to cultivate (on gelatine) the pathogenic bacillus
from the blood of an influenza patient were always un-
successful. In one instance the pneumococcus, and in
another the staphylococcus were obtained. The blood
of animals experimentally infected with influenza yielded
the specific micro-organism only on one occasion. This
culture was endowed with but feeble vitality, and proved
to be non-virulent. M. Mossfe arrives at the conclusion
that the influenza bacillus is found only exceptionally in
the blood, and that when so found its virulence is en-
feebled. It is, moreover, unable to live in an organism
in which the drug in question circulates, viz., quinine.
It would thus appear that the exhibition of quinine as a
prophylactic is justified ; that it should be prescribed in
large doses as an abortive agent ; and that, finally, grave
secondary infections, especially if due to the pneumo-
coccus, call for hypodermic injections of quinine. — Paris
Correspondent of The Lancet.
A True Story. — A correspondent sends the following,
for the truth of which he vouches : A young doctor who
began his practice in Texas, west of Houston, was called
to a confinement case in which he, being green and ner-
vous, naturally had some trouble, the patient seeming
unable to make the supreme effort for final expulsion.
The only other occupant of the wretched quarters was an
old crone in a sun-bonnet who was silently but steadily
rocking herself near the foot of the bed. Finally the old
woman croaked out, " Doc, I wouldn't bother any longer
with that woman, I believe I'd quill her and have done
with it." The medical man not knowing what " quill-
ing " meant answered that he did not quite see the ne-
cessity for that yet. The old woman repeated this sug-
gestion several times until finally the nervous, exasperated
man turned angrily on her and said, " Madam, I'll be
d — if I will do it. If you want to quill her you can do
so, but I won't." The crone took from the wall a tur-
key-wing and drawing a feather from it proceeded to
fashion something like a long quill tooth-pick and, filling
this with snuff from her own. private stock leaned over
the patient and as the next pain came blew the snuff into
the woman's nostrils. Quick as a flash the woman re-
704
MEDICAL RECORD.
[December i, 1894
sponded with a giant sneeze and the child was born with
the sneeze. . " Thar/9 said the old woman, radiantly, " I
knowed mighty well that thar bust would make her break
her holt." And it did, to the great instruction of the
attending physician.
The Doctor in Fiction. — Another bad doctor— bad
rather through circumstances than of deliberate intent
— is pictured in a new novel. The medicus discovers
a specific for cancer (he is an Englishman, we hasten
to say, and not a resident of New York) and cures a
charming lady. Unfortunately she is soon after killed
in an accident, and her husband refuses to permit an au-
topsy. This does not down the scientific enthusiast,
however, for he goes to the cemetery after dark and digs
up his former patient But the husband of the deceased,
unfortunately for himself, appears upon the scene and
repeats his refusal to allow the autopsy to go on.
Science stops at no such trifle as that, and the unreason-
able husband is killed and buried in his wife's grave, the
body of the lady being taken home by the doctor and
dissected. The virtue of the cancer specific is trium-
phantly demonstrated in her body, which is then in-
terred in the garden of the intrepid scientist. Twenty
years now roll by in an uneventful way. The doctor
prospers and his beautiful daughter cuts her second set of
teeth and reaches womanhood. Now comes the son of
the murdered man and dissected woman, and wants to
marry the daughter of the doctor-villain. The latter re-
fuses, the young man grows angry, makes inquiries, and
discovers the crime. The wretched doctor becomes con-
science stricken when found out, and dies. Hie young
couple marry and are happy ever afterward.
The Value of Quarantine against Cholera was demon-
strated pretty clearly last summer in Germany. In Au-
gust and up to the middle of September it looked most
decidedly as if the invasion of the scourge, which threat-
ened Germany the whole length of its frontier toward
Austria and Russia, could not be stayed. Two months
ago the deaths by cholera in the thirty-one western prov-
inces of Russia taken account of had already figured up
three thousand one hundred, with more than double that
number of cases, and in Galicia and Bukowina, in Aus-
trian territory, there were one hundred and forty-six
deaths per day at that time. But the state, with its
severe precautionary measures — the latter going so far as
to hermetically close the Silesian frontier for weeks —
successfully stayed the spread of the disease in Germany.
In every instance where cases of cholera occurred, or
were only suspected as such, the sufferers were rigorously
isolated. More thorough and comprehensive methods,
too, were adopted to prevent travellers afflicted with the
disease from penetrating into the interior of Germany
than have ever before been employed. Quarantine sta-
tions were established at every point where the danger of
imparting the disease could possibly lurk. The result of
these strict quarantine regulations was that very few cases
of cholera occurred in Germany, and most of those were
along the banks of infected rivers, the source of infection
of the water being in another country, beyond the con-
trol of the German sanitary authorities.
"Thyroidism ; " its Relation to Exophthalmic Goi-
tre and to Hysteria. — The Gazette medicate de Paris
for October 20th contains a report of a recent meeting
of the Societk medicate des Htyitaux, at which M. B6clere
presented a woman, thirty-one years of age, who had re-
covered from myxoedema after treatment with the thyroid
glands of sheep. She had taken, by mistake, at the be-
ginning of the treatment, three ounces of the gland in
eleven days, and this excessive dose had given rise to
symptoms of thyroid intoxication. English authors,
said M. Blclere, have described these symptoms as
tachycardia, instability of the pulse, elevation of the
temperature, insomnia, agitation, polyuria, glycosuria,
albuminuria, and partial paraplegia, with a sensation of
heat and sweating. M. B&l&re had further observed
an acceleration of respiration, transitory trembling in
the arms, exophthalmia, and a staring expression of the
eyes. Was there not, he asked, a striking resemblance
between these symptoms and those of exophthalmic
goitre? Was not their appearance in exophthalmic
goitre allied, perhaps, to a supersecretion of the thyroid
gland? Furthermore, M. Btelere had seen that, during
the course of his treatment, the patient had had distinctly
hysterical symptoms, although there had been no pre-
vious neuropathic symptoms, such as aphasia, mono-
plegia, and anaesthesia of the right arm. Might it not
be concluded from this, asked M. Beclere, that the
thyroid juice excreted in excess was one of the exciting
agents of hysteria? Furthermore, he said, when
thyroidism appeared in an hysterical person, it roused
hysteria in her, as other intoxications did. M. Bectere
thought that the syndrome of exophthalmic goitre de-
noted supersecretion by the thyroid gland, and that it
acted like the poisonings that proved exciting causes of
hysterical outbreaks.
Boiling Abscess Cavities. — The Paris correspondent
of The Lancet describes a method employed by Jeannel,
of Toulouse, in the treatment of localized tuberculous
lesions, such as abscesses, ulcers, osseous, and joint
troubles, with boiling water as a cauterizing and bac-
tericidal agent. The method is applied as follows : After
having freely opened the seat of mischief and slit up any
sinuses that may exist, he excises if the lesion involves a
joint. All the caseous detritus is then removed by cu-
reting and thorough sponging of the parts, all bleeding
being arrested. Then salt solution, maintained at the
boiling point in a recipient (coffee-pot) is allowed to fill
the cavity through a thick rubber tube. The cavity is
then afterward filled and emptied until a sufficient de-
gree of cauterization is effected. It will be seen that this
modus operandi is only possible in the case of a funnel-
shaped cavity whose sides can be raised and kept apart by
tenacula and which is unprovided with counter-openings
— a condition frequently met with in practice. A second
and preferable procedure is also employed by M. Jean-
neL This consists in first filling the foyer with cold or
tepid salt solution, and then raising the liquid to boiling
point by introducing into it the blade of a thermo cautery
at a red heat One minute suffices to fill a cavity the
size of a pigeon's egg with boiling water in this way. The
thermo-cautery method insures a constant temperature of
ioo° C, but it is applicable only in the case of an ab-
scess cavity wide enough to allow the introduction of the
blade without touching the parietes. General anaesthesia
is, of course, necessary, except in cases of small abscesses,
when cocaine, locally applied, is adequate. When the
patient awakes considerable local pain is complained of,
but this disappears the next day. The parietes of the cav-
ity— or the abscess membrane, as this used to be desig-
nated— becomes gray, and yields a copious secretion of
serous discharge, which renders frequent renewal of
dressings a necessity. In a few days a detergent process
is evident, granulations develop, and cicatrization rap-
idly ensues. Suppuration is rare ; in certain cases, in-
deed, primary union is obtained. The boiling - water
method is superior to ordinary cauterizing procedures in
that it softens, disintegrates, and sterilizes the tissues to
a greater depth.
The Corset in France. — A petition has been presented
to the French Chamber of Deputies against wearing the
corset as injurious to the health of the female part of the
population. The Chamber solemnly received the peti-
tion, and passed it in committee. Meantime a Paris
journalist has been gathering the opinions of notable
women. A great many of them denounce the corset,
declaring'it to be unhealthy and ungraceful. They say
it turns the figures into one commonplace mould, spoil-
ing pretty ones and doing nothing to improve the ugly
ones, yet most of the fair ones interviewed, who expressed
themselves in this fashion, wore the objectionable gar-
ment.
Medical Record
A Weekly yournal of Medicine and Surgery
Vol. 46, No. 23.
Whole No. 1257.
New York, December 8, 1894.
$5.00 Per Annum.
Single Copies, zoc.
REMINISCENCES OF DR. J. MARION SIMS IN
PARIS.
By EDMOND SOUCHON, M.D.,
professor OF anatomy and clinical surgery, tulanb university, nbw
ORLEANS, LA.
I have often related to my friends the manner in which
I happened to meet our surgical genius, Dr. J. Marion
Sims, in Paris, and his first experiences in the French
capital. They all were much interested in this as they
were in everything pertaining to this great and good man,
and they repeatedly asked me to write out the little story
for the benefit of the profession at large. I, to-day, com-
ply with this wish, regretting very deeply for all con-
cerned that my pen is not more gifted, so as to do better
justice to my hero and to my readers.
In the fall of i860 I entered the old Charity Hospital
on the rue Jacob as a benevolent student, in the service
of the venerable and world-renowned Professor Velpeau.
It was my first beginning in the study of medicine. Fa-
cilities to beginners over there are not so great as they
are here, in our Southern hospitals especially, and in or-
der to have a chance to come in close contact with the
professor and the patients, a simple voluntary student of
the service had to be over zealous with all, particularly
the all powerful internes or lords of the service. After
several months of trial I had succeeded in ingratiating
myself with them all, and having been intrusted with the
registration book of the in coming and out-going pa-
tients, with the number of bed, diagnosis, and dates, I
had managed to be on as fairly good terms with Profes-
sor Velpeau as a little insignificant nobody like myself
could be with such a magnate as was the great Velpeau
in such a place as the great Paris at that period. This
may seem rather hard to American students, but it is all
true none the less.
Early one morning in the latter part of October, 1861,
the year the War of Secession broke out, I was going to
the hospital, and, as I was about to enter the gate, my
attention was attracted at once by the face and appear-
ance of a man who was coming toward the gate also, but
from the opposite direction. That the face and appear-
ance struck me at once will readily be believed by all
those who have had the happiness of knowing our great
American surgeon. Its characteristic soft and sweet ex-
pression, together with his deep-set, bright eyes and
prominent, bushy eyebrows, the half smiling expression
of his mouth, left uncovered by the absence of mustache
or beard, made a much deeper impression on me than a
glance ordinarily produces. I also at once recognized
that he was a foreigner, and no Englishman at that, but
surely and unmistakably an American, perhaps, hastily
thought my young rebel heart, a Southerner ; he must
be that, I thought immediately afterward, because he
looked so gentle and good, and yet, withal, so firm and
self reliant. All this took but a few seconds, and I con-
tinued my course toward the ward to which I was as-
signed, walking through the yards with another student
and the stranger coming up behind. When I reached
the door of my ward I went through and closed it ; it
was soon opened again and closed ; turning around I
noticed my •" American.1 " The doctor told me later
that at the foot of the stairs the other student went in
another direction than I, and he was perplexed for a
moment as to which one he would follow ; after a little
hesitation he said to himself: " Well, I think I will stick
to the little one." The little one was myself.
I walked to the bed of the patient who took care of
the white aprons the students wear over there, to protect
their clothes, and, as I was putting it on the stranger
came up to me, and after a most suave bow, said in a
very slow and deliberate manner, that the Frenchman he
thought he was addressing might have some chance of
understanding : " Will— Professor — Velpeau — be — here
— to day ? " I burst out laughing and answered him in
fluent English : " No, sir, Professor Velpeau is absent
on his vacation and will not return before two weeks."
The beautiful face brightened up at the sound of the
English language where and when he so little expected
it " Where are you from," said he, " that you speak
English ? " " I am from the South, from New Orleans,' '
said I, thinking that that would cool his enthusiasm if he
was a Yankee. But far from it, he grasped my hand and
pressed it so as to crush it. " Why," said he, "I also
am a Southerner ; I lived a long time in Montgomery,
Ala." That made us friends at once. I showed the
doctor around the hospital and finally asked him what
he had come over here for.
" Well," said he, " I am Dr. Marion Sims, now living
in New York, who has invented a method of operating
for vesico vaginal fistula with almost invariable success."
He looked at me to see if the name had made any im-
pression on me, but it fell flat ; we had never heard of
Dr. Marion Sims in Paris. Furthermore, we all knew
that nobody in the world knew anything about vesico-
vaginal fistula except Professor Jobert de Lamballe, of
the H6tel Dieu, and, even under him, vesico- vaginal fis
tula was cured only exceptionally, even when using his
precede* de glissement (sliding process), and the idea of
this new man coming to Paris to teach French surgeons
how to cure vesico-vaginal fistula almost infallibly, some-
what shook my faith in my new friend.
He said he had a letter for Professor Velpeau from Dr.
Valentine Mott, of New York ; that he was anxious to
see the professor to get a case to operate on before him
and thus to demonstrate his method. " Well," I said,
" the professor will be here in some fifteen days," soon
enough for your good, I thought to myself.
During that time the doctor was living in a little
boarding-house in rue de T University, close to the hos-
pital. He had invited me to dinner upon our very first
meeting, and I went there once or twice to give him all
the points about those men he was most likely to meet.
He was all the time sanguinely confident and looked so
sweet, so modest, so magnetic, that I began to feel a
very strong drawing toward him, and by the time Vel-
peau was to return I was wound up to a high pitch and
as eager as my friend that he should have a case soon.
Finally Professor Velpeau arrived, and I sent word to
Dr. Sims immediately ; he soon came to present his let-
ter, which Velpeau read at once and fluently, but when
it came to speaking to Dr. Sims he was at a loss to ex-
press himself and looked around for me. It was always
the case when prominent English visitors came to the
hospital. Although the Englishmen read and wrote
French as well as the Frenchmen read and wrote Eng-
lish, a good deal better than I could then, yet when it
came to talking they had the greatest difficulty in under-
stnading each other, and I was always hunted up to help
706
MEDICAL RECORD.
[December 8, 1894
them along. At that time Velpeau was nearing the end
of a most hard-worked career, and, although age and suc-
cess had softened him, yet he still bore the effects of his
lowly, rough, peasant birth, and of his hard earned vic-
tory. At times the stiff haughtiness of the former years
of struggle came over him. It did so to some extent
at that time, and he was not to Sims exactly, what he
should have been, as I thought, and his coldness to him
made my heart ache somewhat, as I took that to be of
ill omen. The truth was that the name American at
that time in Paris always evoked the name of Barnum, and
the fact that a comparatively young surgeon posed as a
successful operator on vesico vaginal fistula, when scarcely
anyone, not even Jobert de Lamballe, ever succeeded in
Paris, had rather prejudiced Velpeau against Sims.
After a few, very few words, Velpeau said to me, " Eh
bien, que veut-il?" "Well, what does he want?" I
translated the sentence to Sims, who at once modestly
but firmly answered, " I want a case to demonstrate my
operation, if the professor will be kind enough to pro-
cure one for me." " All right," said Velpeau, " I will
get him one," in a way that showed he had but little
confidence in the final result. Then he turned around
without a hand shake or a word more to Sims and went
on with his visit. I felt quite hurt, but could say, and
said, nothing. Velpeau was the idol of all young aspir-
ing surgeons, the demi god of the day. Nllaton was
just looming up then, and had not as yet had his famous
Garibaldi case which gave him world-wide fame.
For several days no case turned up. Sims was there
every morning. I would introduce him to the younger
surgeons who always swarmed around the old master,
that he might not forget them. To every one who in-
quired about his object he said, " I want a case," and I
myself would then also say, " He wants a case."
At last the case came ! And, just as luck would have
it, a case of moderate difficulty. " Thank the Lord,"
said I, with my American pride roused now to a high
pitch for fear Sims should fail ! When he told me he
was sure to succeed it was a great relief.
By this time the whole of the old Quartier Latin had
heard of the news, which had rapidly spread from hos-
pital to hospital. On the day of the operation the
famous little operating theatre in the old Charity Hos-
pital was overcrowded with students, and the arena below
crowded also with the most distinguished professors of
surgery of the French capital ; Velpeau, N61aton, Ri-
cord, Malgaigne, etc., all but Jobert de Lamballe, who
would not come.
Before beginning the operation Dr. Sims proceeded
to demonstrate it graphically, by using a piece of thick
and hard cotton batting, through which he cut a hole
representing the fistula, then he pared the edges slant-
ingly in one strip, next he passed the silk threads and
the wires, etc. The doctor called on me to translate as he
spoke. I was not expecting this, and before such an
audience, and I felt shy and scared, but he so insisted
with his sweet eyes and smile that I got up, trembling
all over, and with a quivering voice would repeat in
French each sentence as he uttered it in English. Grad-
ually, however, I found that it was not so very hard, I
became emboldened and went through the whole pro-
cedure with comparative comfort After the demonstra-
tion Dr. Sims proceeded with the operation, which he
performed with the skill and grace which characterized ,
him. It was done in comparatively no time, closely
watched and followed all the time by the French pro-
fessors. When the doctor finally said it was done, a
salvo of applause broke out from the benches ; the pro-
fessors rendered justice to the manner in which the oper-
ation had been performed, while reserving themselves
mentally until the day when the sutures would be re-
moved.
Dr. Sims attended to that case himself in the ward, and
during the following days felt all along confident that it
would be a success ; and a success, a tremendous success,
it turned out to be.
On the ninth day the same amphitheatre was again
packed to witness the removal of the sutures ; the case
was pronounced cured, and this was confirmed by the
French surgeons, who congratulated Dr. Sims.
The enthusiasm of the French students far exceeded
their former outburst, and, since they could not very well
carry Dr. Sims on their shoulders in triumph they took
hold of me in his place, and the resident students carried
me to their mess room to breakfast with them ; a great
and unprecedented honor in those days, for I was but a
vulgar, simple, insignificant first- year student ! I did
more talking than eating, and the result of the excite-
ment of mind and of heart was a very fine first-class
headache that sent me to bed and lasted twenty- four
hours.
However, some seemed to think that it might have
been a chance cure. But these were soon to be set right.
Immediately after the success of the first case, Dr.
Sims started on the warpath for another, which was soon
procured for him by a physician in private practice.
But this case came very near being a Waterloo. It was
taken to a private place, the Hdtel Voltaire, on the Quai
Voltaire. The patient was a short, fat, stumpy little
woman, and very obstinate. She, all of a sudden, ab-
solutely refused to be operated upon unless she was given
chloroform and put fast asleep. This much annoyed Dr.
Sims, because in those days it was hot thought quite safe
to place a patient on the left side, the side of the heart,
to give chloroform to the extent of keeping her perfectly
still, since nothing could be done otherwise, and for such
a long period as an hour or two. We- were far then
from the ideas of the present day. There was no over-
coming her stubbornness and her will had to be done.
It all went well for a while, a good while, but, all at
once, the breathing became stertorous, the face blue, and
the pulse flagged. The operation had to be suspended
until she recovered. The operation was then resumed,
but soon had to be stopped again, for the same reasons.
Things were looking a little blue aiso, and as though the
operator would not be able to complete the operation.
But it was not to be so ; it was to be completed, but it
took Sims's whole nerve and skill to bring it to comple-
tion. During all that time the distinguished guests pres-
ent said and did nothing, leaving Sims and his assist-
ants to do all the fighting and get all the odium in case
of failure, but all the credit in case of success. At one
time I spoke to Velpeau to ask him what he thought of
the condition of the patient, he shook his old silvery
head and I imparted to Sims what I took that to mean,
that he might make the best of it. Finally the patient
rallied and was put to bed. At the end of the usual
time this case was pronounced a success.
A couple of weeks later Professor Jarjavay secured
another case, upon which Dr. Sims operated at the H6-
pital St. Antoine. At the time of the removal of the
sutures, a week or so later, Dr. Sims was not pleased
with the appearance of the parts, and expressed his ap-
prehension of some ulceration setting in and destroying
the work done to a greater or lesser extent. Professor
Jarjavay said that even if there was a fistulette (a small
fistula) left it would not matter much. Although he
seemed to say this in a good spirit, yet it occurred to
some of us that some people would be glad to hail this as
a failure of the so-called infallible American method.
But no fistulette occurred, and that case was also placed
on record as a complete success.
From that time on cases were quite frequent, and
naturally so, since hardly any were ever cured before;
the stock of fistulae was very great, and cases were not
wanting. It was specially in private practice that they
appeared to be abundant, and Dr. Sims scored success
after success with the greatest ease. However, he again
struck another hard case, even a worse one than the one
at the Hdtel Voltaire ; it was the famous case of the
" countess " out in the country, in a chateau, a patient
of Professor N6laton. She also insisted upon taking
chloroform, and when the operation was about half
December 8, 1894]
MEDICAL RECORD.
707
through she showed all at once most alarming symptoms.
It was then that Nelaton uttered the legendary, cry
" Head down/1 which everyone conversant with these
matters must remember. After much and still more
anxiety the poor illustrious patient was revived and the
operation was safely completed. It turned out also a
complete success.
Cases followed one another wherever the doctor went;
in Paris, London, Germany, etc., he was kept busy with
fistulae and other female cases. It was he who then
sowed the first seeds of true gynecological science and
art throughout Europe, the science so eminently and
thoroughly American.
Wherever Sims went he coined money, although he
incessantly, willingly, and kindly did much charity
work. He is the only man I ever knew or heard of
who had such a vogue wherever he went. No French,
English, or German surgeon could go to the capital of
another country and have such calls and such success, no
matter how great he was considered at home.
Dr. Sims made a host of friends among the surgeons
of all countries, and it could not be otherwise, with his
gentle, kind, unpretentious ways. However, some of his
easy- going American professional ways did not suit all
of them, and some became a trifle cold and reserved
toward him. Perhaps they were glad to find some flaw,
ever so trifling, in such a beautiful gem. Surely, if they
could have read thoroughly through his pure and simple
heart and mind, they would have seen how unconven-
tional were his ways, and how little he thought he was
giving any offence or had any idea he was doing wrong.
Some time after all this the doctor brought his family
over to live in Paris. From that time on the doctor's
history is known to all Americans proud of the surgical
genius born in our great land. One day he said in a
burst of kindness: "How fortunate it was for me to
have met you that morning I went to the old Charity.
I was so thoroughly discouraged that I had about made
up my mind to go back home I " Of course it was his
goodness which made him express it that way and with
such force, for he surely would have met some one else
to play the idle I was so fortunate and so happy to per-
form. He spent his money lavishly : all the needy
Southerners and Northerners then in Paris were recipients
of his generosity.
One day in his house, in the rue de Balzac, we were
alone in his studio when he all at once asked me :
" How are you getting along here, anyhow? " " Well,"
said I, " I am starving as slowly as I can. All resources
from home have ceased since the war has begun, and but
for a little position of $20 a month, which Professor
Velpeau's influence secured for me, I would have suc-
cumbed to hunger and cold by this time.1' He replied,
" Anything you need I will be glad to give you ; I am
making plenty of money now.'1 I thanked him very
much, but gratefully declined any assistance, because, if I
borrowed, I intended to return it some day, and just
then it was rather problematical if I should last to re-
turn and pay any indebtedness. However, he would
not be contented unless I promised him to come to him
if ever I needed any help. All this was said and done
with a simplicity which was overwhelming, especially to
one accustomed by recent education and association to
the good but exuberant French people.
The following year, however, was the time for me to
prepare my competitive examination for the " Interne-
ship," i.e., to be admitted a resident student in the Paris
Hospital. That examination is, over there, the pons
asinorum. It is held as the proof that there is some-
thing in the man, and in fact very few are those who
attain any eminence in Paris who have not gone through
that ordeal. It is really a very hard competitive exam-
ination, and it requires all the time of any student from
early morning till late in the night to succeed. Very few
succeeded the first time, usually it required two trials at
one year's interval. I had to do it in one year or quit
the study ot medicine. I needed, therefore, every mo-
ment of the days of the year of preparation, and there-
fore it was necessary for me to renounce my little situa-
tion. Now if I could not get Dr. Sims to assist me as
he once proposed to do, what would become of poor
me ! Of course he had offered his assistance, but that
was nearly two years ago, and perhaps he had changed
his mind since, or could he still afford to do it, now that
he had a large family to provide for in a gay and expen-
sive capital ?
I called at his house, then in the rue de Suresnes, so
familiar to so many Americans, but he was out of town
and would not be back for some time. When ? No one
could say positively : he was in London, they said, and
very busy there ! Yet time was flying and I had to take
a decision, and no Dr. Sims I But at last he returned.
I called in the middle of the day, thinking I had then a
better chance of meeting him done. He was in fact
alone, taking his lunch ; as usual, he greeted me with his
kind look, sweet smile, and hearty shake hand. He in-
vited me to lunch with him and I sat down to the table ;
but I could not swallow a morsel, my mouth was dry,
my throat contracted, and my heart beating very fast.
After a little trivial talk I summoned up all my courage
and said to him: "Doctor, you once told me that if
ever I was in need to come to you, and that you would
help me along. Well, I am now in the greatest distress
and upon you depends my whole future." " Why, what
has happened, Souchon," said he, with concern in his
dear face. ' ' Well, sir, ' ' said I, " I have to give up my lit-
tle situation in order to prepare for my examination for the
residenceship of the hospital, and unless you give me to-
day the assistance you offered two years ago, it will be
impossible for me to do so and I must give up the study
of medicine." " Oh, no," said he, " don't do that, I
will help you certainly ; how much do you want? " It
was said with such natural kindness and simplicity that
my heart sank within me : I felt as if a thousand pounds
had been removed from my breast. " Thirty dollars per
month will suffice," said I. " What," said he, " a dol-
lar only a day. Oh no, take two." I thanked him
very gratefully but consented to accept only one dollar
and a half a day, remarking that I might never be able
to return that little even. "All right," said he, "I
will take my chances on that." He retired to his
library and soon returned with a check for the first
month in advance, and also for several hundred francs
to buy some little furniture and clothing which he said I
very likely needed. I should think I did need them !
From that time the check came every month, no matter
where he was — in France, England, Geimany, Russia,
Italy, or America. He never forgot it once, and when
it happened, very rarely, that he was a few days behind,
he would write a few words of apology.
When at last I was so fortunate as to succeed in my
examination and I telegraphed to him in London, he im-
mediately wired back that the news had sent a thrill of
joy through the whole family; this in 'its turn sent a
thrill of joy through me also.
The doctor's reputation had acquired such proportions
that the French Government presented him with the dec-
oration of Knight of the Legion of Honor, the highest am-
bition of all Frenchmen . It so happened that I was present
in the forenoon of the day when the mounted dragoon from
the State office brought the large, many sealed envelope
containing the brevet. It was the cause of great rejoic-
ing in the family and among his friends. He himself did
not believe very much in such trinkets, but he was happy
because all around him were happy. I was despatched to
go down to the Palais Royal to buy the ribbon worn in
the button-bole. I chose it as nice and neat as I
thought he would like, and brought it home, when I had
the happiness of being asked to place it myself in the
button-hole on the left side, over his noble and good
heart.
Another notable instance of his great kindness is, when
upon a visit through a London hospital, the physician in
charge told him that he had in his ward a Confederate
708
MEDICAL RECORD.
[December 8, 1894
surgeon who, heart-broken, had left the down-trodden
South to seek rest somewhere. He had worked his
passage through to London by acting as steward on board
ship, but when he reached London his little money, his
feeble health, his crushed heart, all had given way and he
had stranded in a London hospital. Sims at once went
to him, recognized a friend from the same grand State of
Alabama, cheered him, saw him well, and brought him to
his own house, and assisted him back home. All this I
was told by the man himself, who, upon his return home
became a most noted teacher of medicine in one of our
famed Southern medical colleges.
I remember Dr. Sims in only one case of sickness.
He was alone in the Grand Hotel in Paris, without any
of his family with him, when he sent me word to come
and see him. He had been suffering for some time from
a repetition of an attack of pain and swelling in the right
iliac region, and seemed concerned about his condition.
Surely if it had been some years later he would have
been appendicitized. But, thank God, he got well with-
out the knife.
Alas ! but that no human happiness is ever without a dark
cloud ! It was my distressing lot to be present at his
house when the sad news came of the death of his eldest
son, Granville. It was but a short message, quickly read,
followed by a cry and a sob : " Oh God ! Granville is
dead ! " Granville had torn himself away from Paris and
his family and had gone to Havana to find a chance of
running the blockade. He was there waiting for his
opportunity, when he was attacked with yellow fever
and succumbed very quickly.
Much more could be said of this great and good man
during his stay in Paris, but it would require some one
abler than I am to do justice to such a subject. He was
surely one of the most magnetic men I ever met, and he
made such a deep impression on me by his genius, en-
ergy, his courage, his goodness, his kindness, and his gen-
tleness, that for many years ol the early part of my life he
was the model and the guiding-star I strove to follow.
CHOLELITHIASIS.
By J. H. HOELSCHER, M.D.,
CHICAGO, ILL.
ATTENDING PHYSICIAN TO TMC ALKXIAN BROTHKBS HOSPITAL, AND MBMBEK OF
THK CHICAGO MEDICAL SOCIETY.
The history of gall-stones is imperfect Reference to
an old Latin work, known as " Lazari Riverri Praxis
Medica," of the year 1653, gives an account of calculi
which were found in the faeces and connected with symp-
toms of hepatic disease. Cullen's " Practice of Medicine,"
of 1792, contains considerable on the subject, and Wat-
son's " Practice of Physics," of 1 798, also contains state-
ments which compare favorably with some of our present
literature. This book contains the interesting statement
that animals when stalled all winter become affected with
gall stones, from which they recover when fed with green
grass; this fact led an able physician to the belief that
grass would cure gall-stones and jaundice.
It is consistent with this paper to give a synopsis of the
recent chemical analysis of bile and whatever pertains
thereto. Secreted and excreted by the liver cells, it flows
from the hepatic duct as a non viscous liquid, and when
it comes in contact with the ducts and mucous membrane
of the gall-bladder, an admixture takes place with a
secretion from the ducts and gall-bladder which gives it a
certain viscidity. This secretion contains a substance
known as mucoid nucleo albumin of bile.
Perfectly fresh human bile has a bright yellow and
slightly reddish color, a bittersweet taste, is generally
odorless, of alkaline reaction, and a specific gravity of
from 1.005 to 1.008. Chemically it consists of: 1, So-
dium salts in combination with bile acids; 2, coloring
substances known as bilirubin and biliverdin ; 3, mucoid
nucleo albumin. Other constituents are cholesterine,
neutral fats, soaps, lecithin, mineral matters, traces of
iron and gases, of which CO, is the most abundant.
The bile acids and coloring matters are secreted by the
liver cells. Cholesterine is excreted by the liver, and
exists in the bile in a proportion of from ^ to 3 per
1,000. It is held in solution by a combination of bile
salts and acids. Among the mineral constituents sodium
salts are most abundant, and especially sodium chloride in
the proportion of 5 to 1,000.
The quantity of bile secreted in twenty-four hours
varies from a pint to a pint and a half; diminished dur-
ing abstinence it increases immediately after meals,
which increase is maintained about one hour. From
three to four hours after meals it again increases.
This brings us to the consideration of the chemical
composition, physical characters, and formation of gall-
stones. They vary in size from a seed-like concretion to
stones as large and larger than nutmegs ; they may be
irregularly rounded, smooth, faceted, polyhedral, and
very rough and irregular. They vary in color from a
light yellow to dark brown or black. A cross-section
reveals either a series of layers, or a homogeneous structure
and a nucleus. The layers consist of cholesterine; the
nucleus may consist of biliary pigments combined with
calcium compounds, mucus, shrivelled epithelial cells,
and sometimes foreign bodies ; thus a case is on record
where an ascaris lumbricoides formed a nucleus ; Naunyn
reports a case where a needle formed a nucleus, and cases
of gall-stones in animals are on record where the disto-
ma hepaticum formed the nucleus.
Chemically, gall-stones consist of: 1, Pure cholester-
ine; 2, cholesterine and bilirubin-calcium ; 3, calcium
almost entirely ; 4, bilirubin thirty per cent, and cal-
cium ; 5, a combination of all the ingredients.
This brings us to the study of the theories that have
been advanced in explanation of gall-stone formation, and
I shall adopt the following classification : 1, Causes lo-
cated in the common duct ; 2, those located in the gall-
bladder; 3, those located in the bile; 4, those located
in the liver.
The first class implies obstruction of the common duct
and retention of bile ; this latter condition has been
cited as a cause. That this is inconsistent can be under-
stood when we consider : 1, That the lymphatics absorb
the biliary constituents ; 2, chemical analysis of the fluid
in a distended gall-bladder shows an absence of biliary
constituents ; 3, absence of bile ingredients precludes
gall-stone formations; 4, practical observations have
demonstrated the absence of gall stones in hydrops of the
gall bladder, where the duct is obstructed by tumors, etc
Gall stones may cause retention and are to be regarded
as a cause. Under the second class, of causes located in
the gall- bladder, we have the presence of foreign bodies,
such as ascaris lumbricoides, needles, distoma hepaticum,
casts of intrahepatic ducts, and epithelial debris.
Naunyn has advanced the theory that gall-stone forma-
tion is due to the entrance into the gall-bladder of the
bacillus communis coli, which in connection with a re-
tarded bile- flow causes a calculus forming catarrh ; a con-
dition wherein the mucous membrane of the gall-bladder
secretes calcium carbonate. This theory is rather nulli-
fied by the fact that ligation of the common duct, followed
by an injection of the bacillus communis coli into the
gall-bladder, causes death rapidly on account of general
infection ; when, on the other hand, the duct is not ob-
structed, a similar injection causes neither local nor gen-
eral changes ; possibly because bile is sterile and aseptic,
and thus assists in preventing pathological changes. It
cannot be denied that the bacillus does enter the gall-
bladder, because Naunyn and others have found it in cases
of acute cholecystitis and suppurative lesions of the gall-
tracts. These facts lead me to believe that it is not to
be regarded as a cause of cholelithiasis, but rather as an
agent in the production of complications ; indeed, the
presence of calculi may be looked upon as indirectly favor-
ing the entrance of the bacillus communis coli. It is of
great interest and importance to note the observations of
Naunyn on individuals affected with gall-stones who dkd
December 8, 1894]
MEDICAL RECORD.
709
suddenly. He found the epithelium of the gall- bladder
to contain fat drops and a myelin-like substance. From
some of these myelin-laden cells little masses protruded,
which, becoming detached, were found to consist of cho-
lesterine crystals. These he regarded as rudimentary
gall-stones ; other harder masses of similar composition
had already developed into small calculi. Whenever this
development of calculi from cholesterine masses was
observed he always found minute stones containing a
nucleus which consisted of bilirubin and calcium ; these
latter, it appears, are also associated with swollen epithe-
lial cells, which break down into small granular masses
and finally become surrounded by a deposit of cholester-
ine.
Of the causes located in the bile, Frerichs looked
upon bile stasis as a cause, and believed that it resulted in
decomposition of the bile salts and an acid reaction, with
a precipitation of the cholesterine and bilirubin ; these
remaining in the gall-bladder caused a cystitis, a condi-
tion wherein the mucous membrane of the gall-bladder
secretes calcium carbonate, which combines with the in-
gredients already mentioned and thus forms gall-stones.
This theory is rather disproved by the fact : first, that
bile is sterile ; second, no such chemical change is possi-
ble in the bile as it exists in the gall-bladder ; and third,
decomposition of bile and an acid reaction in conse-
quence of exposure to atmospheric germs has not resulted
in a precipitation of the ingredients already mentioned.
Of the causes located in the liver tissue nothing is
known. In fact the lesions found in connection with
gall-stones are to be regarded as effects.
If we will now consider the various causes of gall-
stone formation, which necessarily involves more or less
repetition, we are tempted to look upon Naunyn's obser-
vations as conclusively proving that the direct cause of
gall-stone formation is located in the gall-bladder. I
cannot assume this view as consistent with pathological
processes, because there can be no change in the gall-
bladder without an irritating substance, and it is only
reasonable to suppose that the exciting cause is to be
found in the bile itself. In order to support this opin-
ion I will call attention to calculi formed in the pelvis
of the kidney. From all that is known up to the present
time, renal calculus is always due to an excess of some
urinary constituent, such as urates, cystin, oxalate of
lime, phosphates, etc. In excess these undoubtedly
cause the so-called " calculus- forming catarrh" in the
pelvis of the kidney; moreover, experience has demon-
strated the existence of a certain diathesis which precedes
or comes hand in hand with renal calculus ; this tends
to support the belief that there is an excess of some
urinary ingredient.
I make this comparison in order to advance the theory
that the primary cause of gall-stone formation, barring
foreign bodies, is due to an excess of bilirubin and cho-
lesterine, or to a diminished quantity of sodium salts
and bile acids. I also believe that the excess or defi-
ciency may be confined to any one of the essential con-
stituents of bile, and just as an excess of urates or oxalates
may cause a pyelitis, so an excess of cholesterine may
cause a calculus forming catarrh in the gall-bladder, and
give rise to the condition so well described by Naunyn,
which undoubtedly plays the most important part in gall-
stone formation.
It is impossible to say what changes in the human
economy underlie an excess of essential bile constituents,
and this is rendered more difficult when we consider that
it affects individuals under all circumstances— the seden-
tary as well as the active, the glutton as well as the ab-
stemious liver.
This brings me to the symptomatology of cholelithiasis ;
and since it is so varied and different in a series of cases
I will place some stress on the symptoms as they are ob-
served in connection with certain shapes of calculi.
The most common and readily diagnosed cases are those
where the gall-bladder contains the small, smooth,
faceted calculi, which consist of bilirubin- calcium and a
large proportion of cholesterine, etc. These may, as has
been observed in autopsies, lie dormant in the gall-
bladder and never give rise to symptoms. This is gen-
erally observed in old people, and may be accounted for
by the fact that the gall-bladder's contractility is con-
siderably lessened by certain pathological changes that
accompany old age.
The symptoms of this class of cases ordinarily manifest
themselves after a heavy meal, jolting in a buggy, or in
consequence of sudden physical exertion, and begin with
a violent, sudden, paroxysmal, and colicky pain in the
epigastric or right hypochondriac regions, which radi-
ates to the lumbar regions, right shoulder-blade, cardiac
region, and sometimes to the opposite side. Owing to
the intensity of the pain the pulse becomes weak, the
skin is covered by a cold perspiration, there is a feeling
of oppression across the chest, there may be nausea, and
sometimes vomiting, which generally becomes biliary ;
this condition of shock may be accompanied by epilepti-
form seizures and syncope ; the latter has proven fatal.
Within twenty-four hours after the onset of the attack
jaundice develops, which first appears in the sclerotic
of the eye and rapidly involves the skin of the whole
body. Coincident with this jaundice the urine contains
bile pigments, it usually deposits an abundance of lithates,
and the feces are acholic. Palpation of the gall-bladder
always reveals tenderness, which persists for two or three
days, and sometimes longer. Owing to the tenderness
it is generally impossible to feel the gall-bladder. The
pain ceases suddenly, which signifies that a calculus has
passed through the common duct and entered the duo-
denum, or has fallen back into the gall-bladder.
Examination of the faeces during a number of consecu-
tive days will bring to light the presence of one or more
faceted calculi. I wish to emphasize the importance of
properly examining the faeces a number of days after the
attack; the reason for this precaution becomes apparent
when we consider that foreign bodies may remain in the
intestines two or three weeks, and I do not see why gall-
stones should be an exception to this fact. The gastric
disturbance gradually diminishes in the course of a few
days ; with the cessation of jaundice and returning appe-
tite the patient resumes his daily duties. Generally
more or less gastric disturbance, always manifested by a
tendency to gaseous distention, eructations, anorexia,
and often constipation, remain to remind the victim of
his illness ; in fact, this latter condition may be so per-
sistent that the patient gradually becomes exhausted,
loses in weight, and is rendered unfit to fulfil ordinary
mental and physical exertions ; this condition I look upon
as a strong indication for operation.
The colics may be of daily occurrence, or months
and years may elapse before anymore make their appear-
ance. In typical cases calculi will be passed with the
colics. The number that may be passed varies from one
to several hundred.
The diagnostic features of these cases are : 1. Colicky,
sudden, and violent pain, beginning in the epigastric or
the right hypochondriac regions, and radiating to the
lumbar, cardiac, and hypochondriac regions. 2. Ten-
derness on pressure over the dividing line of the epigas-
tric and right hypochondriac regions. 3. Jaundice fol-
lowing the colic 4. Bile in the urine. 5. Acholic
faeces. 6. Calculi in the faeces. 7. History of previous
attacks. 8. Palpation of gall-bladder may reveal the
presence of calculi. All except tenderness and tumor
may be absent.
These are the typical cases where a diagnosis is readily
made. I shall give a few histories :
Case I — Mrs. A , aged twenty-nine ; two children ;
history good ; was suddenly seized with hepatic colic,
with all the symptoms already given. The colics appeared
every three or four days, each one accompanied by the
passage of small faceted calculi. This condition existed
six weeks, during which she passed twenty-four calculi,
and then recovered fully. It is now five years since her
illness, and there has been no return up to date.
7io
MEDICAL RECORD
[December 8, 1894
Case II. — Merchant, of temperate habits and well
nourished, had attacks of colic during a period of five
years; not oftener than every two or three months.
Calculi were passed each time, with typical concomitant
symptoms. He refused an operation, and during one at-
tack the duct ruptured. An operation performed by Dr.
J. B. Murphy verified the diagnosis ; the patient died.
Case III. — Colics had existed for a period of eight
years. They occurred after long intervals at first, but
finally became so frequent that the patient was forced to
a life of invalidism. All the concomitant symptoms
were present The patient passed over two hundred cal-
culi, one of which finally became impacted in the com-
mon duct, intensifying all the symptoms, with complete
jaundice and a severe degree of cholaemia. There was
no distention of the gall-bladder in this case. Dr.
Parkes (deceased) performed the operation of cholecys-
totomy and found the duct thickened and obstructed by
a calculus. The patient died on the third day after op-
eration.
I wish also to call attention to cases where the symptoms
persist two or three months. They are accompanied by
a decided tenderness and increased resistance in the right
hypochondriac region, increase in temperature of from
two to three degrees, complete anorexia, intense jaundice,
and daily colics.
Case IV. — In this case this condition was notice-
able. She recovered after three months' illness and then
had attacks of hepatic colic only four or five times in
three years. I attended her and witnessed three attacks
of hepatic colic which were accompanied by all the con-
comitant symptoms. Seven calculi were passed. Exam-
ination revealed the presence of a resistant, illy-defined,
and tender mass in the region of the gall-bladder. I
advised operation, to which she consented. Dr. J. B.
Murphy operated, assisted by Dr. Lee and myself. The
gall-bladder was found to be contracted, and surrounded
by a mass of connective tissue with firm adhesions.
Thirty-two calculi were removed, and the long button
was introduced and removed on the seventh day. She
mide an uninterrupted recovery.
Case V. — The history corresponded to that of the
fourth case. She had hepatic colics for ten years. Two
years ago, in 1892, she was confined to bed for a pe-
riod of four months with daily attacks of hepatic colic,
and a constant pain and tenderness in the right hypo-
chondriac region ; she also had chills and fever, with de-
cided gastric disturbances, such as nausea, vomiting, con-
stipation, and anorexia; these, together with decided
jaundice and cholaemia, made the case a serious one.
She always passed calculi after one or more hepatic
colics. When I saw her, in 1894, she had had colics ten
days, and passed only three faceted calculi. The gall-
bladder could be distinctly felt and was tender on press-
ure. Operation by Dr. J. B. Murphy. Found a purple,
congested, and moderately distended gall-bladder ; find-
ing that it remained in the incision without support, a
tampon was introduced and removed on the eighth day.
I then incised the gall-bladder, and in the course of a
week removed three hundred and eighty-five calculi of
the bilirubin-calcium variety. No bile escaped through
the incision, leading me to believe that the cystic duct
was obstructed by calculi. She is recovering at the pres-
ent time.
I cite these two cases because both give a history of
prolonged disturbance covering a period of three months,
during which time the pathological changes already men-
tioned must have taken place. To recognize this condi-
tion would assist in arriving at a conclusion when the
question of an operation presents itself.
Differential Diagnosis. — In renal colic the pain begins
in the lumbar region and radiates down into the thigh,
testicle, and hypogastric region. After an attack the
urine contains blood and pus. Concretions may also be
passed. In the absence of urinary changes the history
of the case will reveal the occurrence after active and
passive motion, and there will also be vesical tenesmus.
Tenderness over the kidney will invariably be present ;
finally, the absence of jaundice, bile in the urine, and
acholic faeces will make the diagnosis positive. Here I
will interpose the possibility of a renal and hepatic colic
being present at the same time ; and can best illustrate
this occurrence, by citing the history of a case which I
witnessed in my own practice :
A lady, aged thirty four, married, gave a history of
four weeks' illness with symptoms of nausea, vomiting,
chills and fever, vesical tenesmus more or less constant,
and violent colics every three or four days, followed by
a moderate jaundice. Physical examination revealed the
presence of a movable kidney, which was tender on press-
ure ; the gallbladder was tender, but could not be felt;
faeces were acholic. The urine contained bile, lithates,
and pus-cells; no albumin nor sugar, and was dimin-
ished in quantity to about twenty-two ounces in twenty-
four hours. I observed several colics, and found the first
to be an hepatic colic which gradually terminated in a
nephritic colic, or a violent boring pain in the right
lumbar region, accompanied by vesical tenesmus. After
such an attack the urine contained bile, pus, blood, in-
dican, and was diminished in quantity. The final out-
come of this case was favorable, recovery being com-
plete after the passage of two cholesterine calculi.
Intestinal colic may be differentiated from hepatic colic
by the following symptoms: 1, Pain begins in the um-
bilical region ; 2, pressure relieves the pain ; 3, pain is
distinctly intermittent ; 4, there may be tympanites, or
contraction of the abdominal muscles ; finally, the seat
of the pain is an important differential symptom ; and
the absence of hepatic disturbance will establish the diag-
nosis.
Carcinoma of the pancreas should be considered, be-
cause there are cases where the common duct has been
obstructed and given rise to decided jaundice, bile in the
urine, and dropsy of the gall bladder. The symptoms
are : 1 , Rapid emaciation and cachexia ; 2, occasionally the
nodules can be felt ; 3, there may be fatty stools ; 4, the
jaundice is persistent, and there is no history of hepatic
colics, which fact would materially aid in removing the
diagnosis of gall-stone occlusion of the common duct.
Absolute differential signs are : 1 , The presence of a fixed
tumor in the umbilical region ; and, 2, the concomitant
symptoms which always accompany carcinoma.
Catarrhal jaundice is readily diagnosticated from chole-
lithiasis by gastric disturbances followed by a jaundice,
which remains more or less constant from two to six
weeks ; it is accompanied by temperature and sometimes
chills ; finally, it is never accompanied by hepatic colics
and the passage of calculi The history is important.
Acute appendicitis begins suddenly with a sharp pain
in the epigastric region, nausea, chills, and temperature,
sometimes diarrhoea. Finally, in a short time pain be-
comes localized in the right iliac region, with decided
tenderness, local tympanites, increased resistance, and
an indurated mass makes its appearance in the right iliac
region. Appendicitis can be diagnosticated from hepatic
colic : 1, By the previous history of the case ; 2, by the
absence of jaundice, acholic faeces, and bile in the urine ;
3, the tenderness in hepatic colic is generally (though not
always) most marked in the region of the gall-bladder.
It is oftentimes difficult to make a differential diagnosis.
I had a case recently, where the patient was seized sud-
denly with acute and violent pains in the right hypo-
chondriac and iliac regions, with nausea, vomiting, and
a temperature ranging from ioo° F. to 102 50 F. There
was obstinate constipation. I saw the case about four
days after the onset, and found the following condition :
A large, fixed, indurated, extremely tender mass in the
right iliac region, extending upward toward the liver ;
there was decided tenderness over McBurney's point;
the bowels had resisted all efforts at evacuation, which,
together with the persistent vomiting, indicated bowel
obstruction. Here, then, the symptoms of appendicitis
were well marked. She gave a history of having had
periodical attacks of gastralgia for ten years or more, not
December 8, 1894]
MEDICAL RECORD.
711
accompanied by jaundice or any conclusive sign of chole-
lithiasis. A closer examination disclosed that the tumor
in the right iliac region had a round shape, and extended
upward toward the liver ; it was resistant and fluctuating.
From the shape, size, and apparent origin of the tumor,
as well as the bodily temperature and chills, together
with the previous history, I diagnosed impaction of cal-
culi and suppuration in the gall-bladder. With the
assistance of Dr. Lee I performed a cceliotomy, and
found the tumor already described to be the gall-bladder
intensely distended. Suspecting its contents to be
purulent, I adopted the procedure of placing an iodo-
form tampon in the incision, taking care to properly
place the peritoneum in contact with the gall-bladder.
Ten days later I incised the gall-bladder, evacuating
twenty five large biliary calculi, and about ten ounces of
pus; I introduced a large drainage-tube. About two
weeks later ten large calculi were removed, which, I be-
lieve, had been encysted somewhere in the gall bladder.
Bile flowed through the tube immediately after the opera-
tion, and all symptoms of bowel obstruction disappeared.
The obstruction was undoubtedly due to the large size of
the gall bladder and pressure on the intestines. The
progress of the case was favorable up to the eleventh
week, when she became comatose and died in four days,
with symptoms of cerebral abscess.
This brings me to the consideration of gastralgia.
The importance of properly understanding what we mean
by gastralgia becomes very apparent when we recall the
similarity between it and hepatic colic ; indeed, it ap-
pears to me that it is oftentimes a decided symptom of
cholelithiasis. Gastralgia, pure and simple, is typical
neuralgia, and generally makes its appearance after pro-
dromal symptoms, such as gastric disturbance, neuralgic
pain in other parts of the body, and general lassitude.
The pain comes on suddenly, is intensely acute and par-
oxysmal, of a boring, lancinating, and burning charac-
ter; it always begins in the epigastric region and radiates
to the shoulder blades, hypochondriac, and umbilical re-
gions. The pulse is weak and sometimes irregular ; the
skin is covered by a cold perspiration, the abdominal
muscles are generally contracted, and pressure relieves the
pain. There may be concomitant pains in other parts of
the body. This condition may last from a few minutes
to several hours or days. The urine may be diminished
in quantity, or be very abundant when hysteria is a
causative agent. There may be nausea, and sometimes
vomiting terminates the attack. The symptoms of gas-
tralgia will vary with the cause or causes. It occurs in
conjunction with menstruation, gouty diathesis, ulcer of
the stomach, carcinoma, malaria, nervous lesions, dis-
placed kidney, etc. Since gastralgia is a symptom of so
many lesions it becomes apparent that a process of diag-
nosis by exclusion must be adopted, and this applies with
special force to cholelithiasis.
I shall have to base the description of gastralgia as it
occurs in cholelithiasis on cases in my own practice.
The attacks were extremely irregular, and rarely appeared
oftener than once every two or three months ; or a series
of attacks covering a period of three or four years were
noted, when they disappeared and did not return for
several months.
I have noticed that they become more frequent when
the pathological changes in the gall-bladder, such as
thickening and contraction, are far advanced. Gastral-
gia occurs most frequently where the calculi are too large
to enter the common duct ; naturally the symptoms of
bile obstruction, such as jaundice, bile in the urine, and
acholic faeces, are always lacking in this class of cases.
Here gastralgia and a very persistent gastric catarrh,
which usually resists treatment, are the prominent symp-
toms.
In every case of cholelithiasis where this symptom was
present, I observed that the pain commenced in the epi-
gastric region ; it was intensely acute and always accom-
panied by signs of shock. Local examination showed
marked tenderness in the region of the gall-bladder,
most acute during and immediately after the attack ; it
generally subsided and almost disappeared in three or four
days. This symptom I have never found in these cases.
I believe the pain is due to irritation of the opening at
the cystic duct. Recently I introduced a blunt sound
into the gall-bladder where cholecystotomy had been
performed. The moment the sound entered the cystic
duct the patient complained of acute pain in the epigas-
tric region, which immediately ceased when the instru-
ment was withdrawn. The injection of sterilized water
into the gall-bladder, with slight force, elicited the same
pain, or reflex gastralgia.
I will now cite a few cases wherein gastralgia was a
prominent symptom :
Case I. — Married lady, has several children, and no
history of lesions, except chronic gastric catarrh and gas-
tralgia. These attacks had appeared about five or six
times a year, but more frequently in the last year, and
led her to consult Leube, of Germany, who made the di-
agnosis of gastralgia. In 1888 I was called to relieve an
attack. She had a violent pain in the epigastric region
and marked tenderness over the gall-bladder. The at-
tack lasted four days, and was accompanied by a very
slight jaundice, most noticeable in the sclerotic coat of
the eye. There was no bile in the urine, and the faeces,
which were thoroughly examined, were normal. There
was an apparent enlargement in the region of the gall-
bladder. Dr. Parkes (deceased) operated and removed
two large calculi from the contracted and thickened gall-
bladder. She made an uninterrupted recovery.
Case II. — A well- nourished, married lady was sud-
denly seized with a violent attack of gastralgia accompa-
nied by vomiting and obstinate constipation. The history
revealed chronic gastric disturbance and attacks of chronic
gastralgia every three or four months; she never had
jaundice, bile in the urine, or acholic faeces. Local ex-
amination revealed the presence of a tumor which ex-
tended downward from the liver into the right iliac
region, and backward into the right lumbar region. It
was tender, fixed, rounded, fluctuating, and very resist-
ant. Urine was diminished in quantity and deposited
lithates in abundance. There was no bile in the urine,
no jaundice, and no acholic faeces. Constipation was
obstinate. The tumor was immobile, and apparently
separated from the liver by a distinct depression. On
account of its apparent origin in the right lumbar region
I suspected a nephritic tumor, though the history did
not justify this belief. Dr. J. B. Murphy made an ex-
ploratory incision and found a distended gall-bladder of
a dark-red color, which was apparently (Edematous.
Calculi were felt, and a large sized Murphy button was
used to make an anastomosis with the duodenum. Seven
or eight days after the operation two calculi were passed
per rectum ; the largest measured one inch in its longest
diameter, its shortest seven-eighths of an inch. The
smallest measured seven-eighths of an inch longest diam-
eter, and three-fourths of an inch short diameter. The
button was passed on the eighteenth day. The operation
was performed October 7, 1892. The patient has been
perfectly well and free from all physical ailment up to
date.
Case III. — Mrs. C , married, illy-nourished ; has
had three children. History gives the following symp-
toms : Chronic gastric catarrh for twelve years ; attacks
of violent gastralgia about every three months ; each at-
tack lasted about four days. One physician advanced
the opinion that she would not survive another attack.
This state of affairs, coupled with a severe degree of atonic
dyspepsia, brought about an extreme degree of anae-
mia, emaciation, and inability to perform ordinary house-
work. She had never had jaundice, bile in the urine,
acholic faeces, and no calculi were passed. I observed
her in two attacks of gastralgia. The pain was intense
and distinctly located in the epigastric region, and radi-
ated to both hypochondriac and lumbar regions, with
syncope, a very small and weak pulse, and cold extremi-
ties. Morphine always gave relief. Local examination
712
MEDICAL RECORD
[December 8, 1894
revealed acute tenderness in the region of the gall- blad-
der, which could not be felt on account of tenderness.
In four days the pain had ceased, no concomitant signs
of gall-stones were noticed. At a second examination I
found both kidneys movable and displaced. 'She had
never had renal colics, and the urine presented no evi-
dence of kidney lesion.
(It is said that gastralgia is often due to a movable
kidney. This I have not observed in a series of nineteen
cases. To be sure, there are reflex gastric disturbances
of a neurotic type, but I have yet to see gastralgia due
to movable or displaced kidney.) Pushing the right
kidney back I felt a small, resistant tumor in the region
of the gall bladder, which moved with respiration. Re-
peated examinations always resulted in finding this tumor.
After the exclusion of other abdominal lesions, I made
the diagnosis of cholelithiasis. Dr. Murphy examined
the patient and agreed to the diagnosis. Dr. Murphy
removed two calculi — as large as nutmegs — from the
gall-bladder, which was thickened and had contracted
down around the calculi, thereby forming a distinct sac
for each calculus — giving it the appearance of an hour-
glass. Anastomosis was made with the duodenum by
means of the Murphy button. The progress of the case
was interrupted by an attack of acute dry pleuritis on the
tenth day, which subsided rapidly and terminated in
acute bronchitis. The button was passed on the twenti-
eth day. The patient has been well since the operation.
Her appetite has returned and the gastric catarrh under-
went rapid improvement.
This completes a synopsis of three cases, wherein the
gall-stones were as large as nutmegs, and gave rise to at-
tacks of gastralgia, cholecystitis, constant gastric disturb-
ances peculiar to chronic gastric catarrh, constipation,
and general physical debility in consequence of defective
digestion. The indigestion was not limited to any par-
ticular kind of food ; indeed all foods, either liquid or
solid, caused distress. Therapeutic remedies gave only
slight relief.
The indications for operation in these cases were : 1.
Gastralgia. 2. Persistent gastric disturbance. 3. Ema-
ciation and physical exhaustion. 4. The possibility of
complications, such as carcinoma and suppurative lesions.
5. The safety of operative procedure, and the improve-
ment of health that invariably follows.
I also wish to report two other cases of cholelithiasis
wherein the calculi were large, polyhedral and tetrahe-
dral in shape, with large, smooth, faceted sides.
Case I. — Had been ill for a period of twelve years,
with the following symptoms : Constant gastric disturb-
ance, anorexia, general debility, exhaustions, and emacia-
tion. She gave a history of having had one distinct
hepatic colic, and claimed that she passed some small sand-
like concretions. She never had jaundice, and according
to her own statement no bile in the urine or acholic
faeces. She also gave a history of slight chills followed
by fever. The most constant symptom was pain in the
right hypochondriac region whenever she worked in a
stooping posture, or simply stooped. During all this
time there was habitual constipation.
Local examination revealed the presence of a pear-
shaped, smooth, and painful tumor in the region of the
gall bladder. It moved synchronously with respiration,
and could not be fixed by holding it between the two
hands, something that always can be done with a mova-
ble kidney. It could be moved slightly from side to
side, and since it appeared to be distinctly connected
with the liver, and located in the region of the gall-
bladder, as well as its smooth, globular shape, I made
the diagnosis of gallstone impaction. Dr. Murphy op-
erated. Upon incising the gall-bladder a puriform
fluid made its appearance and several calculi of the shape
already described made an escape through the opening.
Anastomosis with the duodenum was made by means of
the Murphy button. Owing to the carelessness of the
nurse I was handicapped in making thorough examina-
tions of the stool after the operation ; at all events the
patient made a good recovery, gained in weight, regained
her appetite, and was able to attend to her household du-
ties when I last saw her. It is now over a year and a
half since the button operation was performed.
Case II., which I mentioned in connection with ap-
pendicitis, gave a history of attacks of gastralgia every
four or five weeks, but sometimes months elapsed before
an attack made its appearance. Every attack was in-
stantly relieved by vomiting. She had never had jaun-
dice, bile in the urine, or acholic faeces. Here the cal-
culi were unusually large; there were thirty-five, three
of them were rounded and almost as large as nutmegs, the
rest were of the same shape already described.
The details of this case have already been mentioned.
Among the cases of interest, I have in mind two where
the calculi consisted of cholesterine entirely. One I
have already mentioned in connection with renal colic,
and therefore will not repeat it. The second case occurred
in a lady, aged fifty-five years. She gave a history of
having had colics five or six years, not oftener than once
every three or four months. All the concomitant symp-
toms, such as bile in the urine, acholic faeces, and jaun-
dice, followed the colics. When I saw her she had been
sick two weeks. There was moderate jaundice, a large
quantity of bile in the urine, acholic faeces, and colicky
pains bad persisted steadily, the constant use of morphine
being necessary to subdue the violence of the pain. Be-
yond tenderness localized in the region of the gall-blad-
der, nothing abnormal was found in the abdominal cav-
ity. Considering the history, the occurrence of jaundice
within twenty-four hours after a decided hepatic colic,
the constant presence of bile in the urine, and acholic
faeces, together with the persistent colics, I diagnosed
obstruction of the common duct, and recommended op-
eration. Dr. Murphy operated, assisted by Drs. Lee and
Hartmann and myself. The gall bladder was normal and
contained no calculi. The cystic and common ducts
were so obstructed by calculi that they felt like a string
of beads. Dr. Murphy made an anastomosis with the
duodenum, using his button for this purpose.
The colics ceased immediately after the operation. On
the sixth day three round, semi-transparent cholesterine
calculi were passed, each one about three-sixteenths of
an inch in diameter. These were passed without pain
or colics, which substantiated Dr. Murphy's opinion,
" that the calculi would fall back into the gall-bladder
after the anastomosis was made."
On the seventh, eighth, and ninth days more calculi
were passed, making a total of thirteen pure cholesterine
calculi which had obstructed the bile ducts. The pa-
tient passed the button on the twentieth day after the
operation, and never had an unpleasant symptom since.
It is nearly a year since the operation. Here the Mur-
phy button operation was certainly superior to the more
difficult and dangerous procedure of cholecystotomy.
Owing to the rarity of pure calcium calculi in the
gall-bladder, I shall give the history of one of two cases
which I observed.
Mrs. X , aged thirty-six, married, had never been
sick and gave no history of hepatic colics. In 1888 she
was suddenly seized with a distinct hepatic colic, followed
within twenty-four hours by all the concomitant symp-
toms of cholelithiasis, such as jaundice, bile in the urine
and acholic faeces. Local examination revealed tender-
ness in the region of the gall-bladder, which organ could
not be felt. The hepatic colics were intense and con-
tinuous for a period of three weeks. During this time
there was nausea and vomiting, and rather decided chol-
aemia. Finally, at the end of three weeks, I found an
irregular, rather hard, white calculus in the faeces, which
consisted almost entirely of calcium. Following its ap-
pearance the patient made a rapid recovery, and has
had no recurrence up to the present time.
The other case resembled this in all respects.
It will be observed, from the histories given, that the
classical symptoms of cholelithiasis, such as jaundice,
bile in the urine, acholic faeces, and the passage of cal-
December 8, 1894]
MEDICAL RECORD.
7i3
culi, were lacking entirely in five cases, and one case gave
a history of twelve years' illness with only one distinct
colic. These facts render a diagnosis extremely difficult,
and sometimes impossible. The symptomatology there-
fore deserves special attention. In these five cases the
most constant symptoms were gastric disturbance, such
as gaseous distention, nausea, fermentation of foods dur-
ing digestion, a constant sensation of pressure and slight
pains in the epigastric region, and constipation. This
condition may be so marked that the patient becomes
emaciated, exhausted, and unable to perform ordinary
physical exertions. This, together with attacks of gas-
tralgia every two or three months, in conjunction with
decided tenderness in the region of the gall-bladder dur-
ing the attacks, completes the picture of subjective symp-
toms in these cases. A diagnosis by exclusion must be
adopted and all other causes of the symptoms mentioned
eliminated. Local examination is of the utmost impor-
tance, and must be practised in a suspected case. Where
the calculi are large and patience is used, one can often
feel a distinct rounded enlargement in the region of the
gall-bladder, which is slightly tender and moves syn-
chronously with respiration. A tumor in this region
must be differentiated from carcinoma of the pancreas,
echinococcus cysts, fecal accumulations in the_ colon,
renal tumors, movable and displaced kidney.
In carcinoma of the pancreas we have cachexia, rapid
emaciation, and sometimes fatty stools, an irregular
tumor deeply seated in the epigastric region, and some-
times metastatic deposit in other organs. The tumor is
generally fixed, and on auscultation one may hear a bruit
due to transmitted pulsations from the underlying
vessels.
When the common duct is obstructed in carcinoma of
the pancreas, there will be intense and constant jaundice,
bile in the urine, and acholic faeces, coincident with a dis-
tended gall-bladder, which can be distinctly felt as a
rounded, smooth, fluctuating, and pear- shaped tumor, en-
croaching on the anterior margin of the liver; sometimes
atrophy of liver tissue takes place at the point of contact.
This tumor moves with the respiratory movements and is
distinctly connected with the liver. In order to deter-
mine the cause of hydrops of the gall-bladder in these
cases the history is of importance, and in connection
with it the symptoms mentioned will make a diagnosis
possible. It should not be forgotten that cholelithiasis
may also be present.
Echinococcus cysts rarely originate in the region of
the gall-bladder. When by reason of extreme size or
central origin in the liver they occlude the bile- ducts, we
will observe that, first, the jaundice developed without
pain; second, it is persistent; third, the gastric func-
tions are generally undisturbed; and fourth, other physical
signs of echinococcus cyst would exclude cholelithiasis.
Fecal accumulations in the transverse colon present the
following symptoms : An irregular mass, superficial, non-
fluctuating, and freely movable, coupled with a history of
bowel obstruction, intestinal colics, and constipation.
Cases have been observed where diarrhoea was present.
The treatment with purgatives will remove all doubts.
Renal tumors, when smooth and symmetrical, may sim-
ulate a largely distended gall-bladder to such an extent
that a diagnosis is made with difficulty. Renal tumors
are of slow development and are always accompanied by
changes in the quantity and quality of the urine, which
may contain albumin, blood, pus, casts, and be dimin-
ished in quantity. There may also be a history of renal
colics and vesical irritability. In a large hydrops of the
gall-bladder the onset is generally sudden and painful, and
by reason of its size gives rise to symptoms of bowel ob-
struction. This I observed in two cases. The distended
gall-bladder is generally fixed, smooth, rounded, fluctu-
ating, and pear-shaped, and very tender on pressure when
the distention is acute.
Renal tumors when large are more resistant, have an
irregular surface, and generally the colon overlies the
tumor. In hydronephrosis the enlargement is smooth
globular, and fluctuating, and bears a striking resemblance
to hydrops of the gall-bladder.
Especial attention must be directed toward ascertain-
ing: 1, A history of sudden increase in the quantity of
urine voided and a corresponding diminution in the size
of the tumor ; a, diminution in normal quantity of urine ;
3, the presence of renal colics and lumbar pains ; lastly,
it may depend on pelvic enlargements which have oc-
cluded the ureter on the right side.
Movable kidney diners from distention of the gall-
bladder as follows: 1, It is bean- shaped; 2, it is freely
movable and can be replaced to its normal location ; 3,
it does not move with the respiratory movements ; 4, it
can be fixed between the hands in spite of the respira-
tory movements; 5, there may be a history of renal
colics; and lastly, there is no history of jaundice, bile in
the urine, and acholic faeces. It should not be forgotten
that movable kidney and cholelithiasis may exist to-
gether. I have given the history of two cases. In case
the kidney is displaced and fixed under the liver, the
diagnosis is more difficult. Careful analysis of the symp-
toms and history will always render diagnosis possible.
It is important to mention the physical characteristics
of gall-bladders which have become elongated and di-
vided in two or more sacculi, each one containing a cal-
culus. A local examination reveals the presence of a
rounded elongated tumor which admits of being freely
moved from side to side. It can be traced to the region
of the gall- bladder and is attached to the liver. In con-
nection with the history of the case a diagnosis can be
made.
This brings us to the complications of cholelithiasis.
They are: 1, Obstruction of the common duct; 2, impac-
tion of gall- stones and suppuration in the gall- bladder;
3, hydrops of the gall-bladder ; 4, contraction and al-
most entire obliteration of the gall- bladder, and a deposit
of connective tissue with adhesions to the surrounding
organs; 5, carcinoma of the gall- tracts; 6, obstruction
of the cystic duct ; 7, cholecystitis with thickening of the
gall-bladder and its division into several diverticular ; 8,
hepatic abscess; 9, rupture of abscess in the colon, kid-
ney, stomach, duodenum, and through the abdominal
wall; 10, rupture of the gall-bladder or bile-ducts; n,
obliteration of the common and cystic ducts.
It is not out of place to say a few words about the
symptomatology of the complications. Rupture of the
gall-bladder or its ducts generally occurs suddenly during
an attack of hepatic colic. I can best describe the symp-
toms of this accident by citing one of two cases which I
treated. A merchant, whose case has been mentioned in
this paper, was seized with an ordinary hepatic colic ;
feeling a desire to evacuate his bowels he went to the
closet, and while straining felt something give way sud-
denly. Thereupon the hepatic colic immediately ceased
and was replaced by syncope, cold sweats, and a feeling
of extreme weakness. Two hours later I saw the patient
and found his condition to be as follows : Rapid, weak,
and thread-like pulse, cold extremities, dyspnoea, and de-
cided abdominal tympanites ; in fact the patient was ap-
parently dying. Dr. Murphy performed coeliotomy in
the hope that drainage would save life. The abdominal
cavity was full of biliary fluid; the intestines floated on
the latter. Death occurred on the third day and an
autopsy was refused. The second case was almost iden-
tical with the first. An operation by Dr. Murphy sub-
stantiated the diagnosis.
When carcinoma of the gall-tracts develops in the
course of cholelithiasis the patient rapidly loses in weight,
and ordinarily the jaundice becomes intense and per-
sistent, with all the concomitant symptoms of bile ob-
struction. Local examination reveals uniform tender-
ness over the gall-bladder and along the liver-margin.
Sometimes it is possible to feel carcinomatous nodules
which completely obstruct the bile-ducts. The follow-
ing case will be of interest and serve as an illustration :
Dr. Allaben, of Rockford, 111., to whom I am indebted
for the history, and who referred the patient to me, had
7H
MEDICAL RECORD.
[December 8, 1894
made the diagnosis of cholelithiasis. The case was a
typical one, and accompanied by jaundice, bile in the
urine, and the passage of calculi after every hepatic
colic. Suddenly jaundice developed without a preceding
colic, it was persistent and accompanied by rapid emaci-
ation, occasional vomiting of mucus and undigested
food. There was no recurrence of hepatic colic. He
also had chills and a temperature rising from one to three
degrees. This, together with decided tenderness in the
region of the gall-bladder and along the liver margin, as
well as the presence of a nodular mass in the region of
the gall-bladder, completed the picture of this case.
Owing to the intense jaundice and its time of occur-
rence, as well as the concomitant symptoms, the diagno-
sis of gall-stones with carcinoma and probably suppura-
tion was made. Operation by Dr. Lee found the gall-
bladder contracted and shaped like an hour- glass. The
outer portion contained a large calculus firmly fixed, and
consequently it could not be removed. The inner por- '
tion contained a greenish puriform fluid. A nodule
was also felt. Death followed in twelve hours. Autopsy
brought to light what has already been mentioned. The
common duct was completely obliterated and surrounded
by a carcinoma as large as a hickory-nut Metastatic
deposits were found in the liver and elsewhere.
It is not possible to predict the pathological changes
in many cases of cholelithiasis. Sometimes those where
the symptoms have been comparatively mild present the
most decided pathological changes, and vice versa.
We now come to the treatment of gall-stones, which
can properly be divided into two classes, viz. : Thera-
peutic and surgical. It would not be consistent with
the present medical knowledge to give the details of
every remedy which has been used. Among those
which have claimed the greatest attention are such as
olive oil, arsenic, iron succinate, the mineral acids, and
saline laxatives. It cannot be claimed that any of these,
and others not mentioned, act as solvents of gall stones.
Moreover, were it possible to dissolve them as contained
in the gall-bladder, we would not cure but merely re-
move the effect of a cause which is yet a mystery. No
doubt the medicines are of value in relieving concomi-
tant conditions, such as constipation, gastric disturbance,
etc.; thereby temporary improvement is procured. Laxa-
tives probably encourage the elimination of calculi by
reason of their action on the intestines and bile secretion.
Diet and the regulation of living have a good effect, as
they do in other diseases.
Since it would be useless to say more about the thera-
peusis of cholelithiasis, I will discuss the surgical proced-
ures and the indications for interference. When we
would operate, is a question that admits of much argu-
ment, particularly so when the patient has been made to
believe that this, that, or the other medicine will dis-
solve the stones. I recall a case where olive oil had been
administered ; the patient passed a number of soft green-
ish masses consisting of fatty substances. And lo ! the
people and others declared that they were gall-stones
which were partially softened by olive oil ; that mistake
is sometimes encouraged by the attending physician.
The indications for operation are: 1. Hepatic colics,
coming on every four or five days for a period of several
months, with passage of calculi. 2. Obstruction of the
common duct by a calculus, with cholaemia and gall-
bladder dropsy. 3. Hydrops of the gall-bladder, of
acute development, with obstruction of the cystic duct.
4. Persistent gastric disturbances with occasional at-
tacks of gastralgia, physical exhaustion and anaemia, and
the presence of tumor in the region of the gallbladder.
5. Suppurative cholecystitis, due to gall stones. 6. Con-
tinuous daily hepatic colics, with signs of bile-duct ob-
struction, and the absence of calculi in the faeces. 7. The
possibility of dangerous complications, such as rupture
of the gall-tract, carcinoma, adhesions, etc 8. Hepatic
abscess, due to gall-stones. 9. Impaction of gall-stones
in the gall-bladder. 10. The comparative safety ^of
operative procedures.
Among the operations ordinary cholecystotomy is
most generally practised, and with the present methods
has given good results. The ideal operation consists in
making an anastomosis between the gall-bladder and the
duodenum, called cholecyst-duodenostomy. By this
method we imitate to an extent the normal physiologi-
cal conditions, and meet the usual indications of choleli-
thiasis. The gall-bladder is drained thereby, and the
bile flows into the intestine when the cystic duct is not
obstructed. There is no fistula left. In my own prac-
tice that useful and ingenious contrivance, the Murphy
button, has been used four times in making an anasto-
mosis. These cases have been under my observation over
a year and a half, and are in the best of health to-day.
I believe that sufficient time has elapsed to demon-
strate the safety of the operation as it is done with the
Murphy button, and recommend it wherever the condi-
tion of the organs will admit of its use.
I wish also to add that the four cases under my obser-
vation were of a widely different type. In Case L, the
gall-bladder was enormously distended and cedematous;
in Case II., the gall-bladder was normal in size, its walls
thickened, and contained a purulent fluid; in Case HI.,
normal gall-bladder with calculi obstructing the common
and cystic ducts, which subsequently fell back into the
gall-bladder; Case IV., thickened and sacculated gall-
bladder.
Another point in favor of this operation is the impos-
sibility of a return of gall- stones, and the certainty that
all the calculi will escape from the gall-bladder.
In cholecystotomy it is possible to leave calculi in the
gall-bladder which may occasion considerable trouble.
Someone made the statement that the operation of
cholecyst-duodencstomy with the Murphy button favored
infection of the gall-tracts; this is not possible; first,
because bile being aseptic and sterile, would to an extent
overcome this danger ; second, infection with the bacillus
communis coli (which is generally found in suppurating
lesions of the gall tracts) is harmless when not confined,
as has been amply demonstrated by Naunyn.
In any of the cases under my own observation, where
the Murphy button was used, no infection occurred.
I wish to add that, up to the present date, I have the
reports of thirty-four cases of cholecyst-duodenostomy
done with the Murphy button for gall-stones ; of this
number one died, making thirty three recoveries and
one death.
LANDMARKS OF VISCERAL DISEASE, WITH
A NEW THEORY.
By BYRON ROBINSON. M.D.,
CHICAGO, ILL.
Useful works on applied anatomy and pathology of the
abdominal viscera are very scarce. I do not know any
subject in medicine of which the general student and
practitioner is so lightly supplied. It must be acknowl-
edged that the abdominal cavity is filled with a compli-
cated mechanism which holds body and soul together ; it
is the assimilating laboratory of life, the location where
food is worked into blood, bone, and tissue. This cavity
is less generally known than the cerebro spinal cavity.
In this article I wish to speak of what one sees in open-
ing the abdomen in dead bodies. One has not the right
to attempt to study very much on the viscera while lapa-
rotomy proceeds. I also think that by disseminating some
real, practical knowledge of the abdominal viscera unnec-
cessary laparotomies may be spared. To-day there are
too many laparotomies done by unskilled physicians
without proper facilities. In speaking of the landmarks
of visceral disease I mean the points of the viscera when
disease is apt to arise. Probability is the rule of life, and
when we find in autopsies that certain viscera and certain
localities are liable to show pathological conditions it is
wise to look after these same points during life. The
comparison of the pathology found in the dead abdomen
December 8, 1894]
MEDICAL RECORD.
7i5
with that of the living gives ample rewards to the thought-
ful surgeon and physician. The great phenomenon in
the dead abdomen which leads one to the origin of dis-
ease is peritonitis. Inflammation of the serous sac may
refer one back a quarter of a century to events long for-
gotten, but the " blaze " on the peritoneum, like that of
the surveyor on the tree, remains to tell the story of in-
vasion. If one will carefully examine at least twenty-
five adult bodies as regards the abdominal viscera he will
be liable to observe the main common visceral disease.
It will require at least twenty-five autopsies to be im-
pressed with the idea that, after all, visceral disease has a
peculiar similarity, a liability to be alike in each body.
Visceral disease has common grounds to start on and
common organs to attack. It persists in definite locali-
ties and has many common symptoms. Visceral disease
is much like meals, which are generally composed of a
few common articles. Meat, bread, and potatoes are the
common articles found in most meals. So, for example,
one can find with a similar commonness that autopsies
reveal peritonitis in the pelvic, appendicular, and gall-
bladder region. On first opening the abdomen one will
soon generally observe whether peritonitis has existed
by the position of the omentum — the surgeon's friend,
the patient's man-of-war. If peritonitis has existed the
omentum, or a part of it, will generally be found trying
to quell the fire by covering it up with adhesions. The
omentum has covered up the infectious invader and
buried the slain of the battle. It has guarded the parts
where infection is liable to enter. In seventy-five per
cent, of bodies the omentum tends to the left and readies
to the pelvis. In some it is rolled up around or behind
the transverse colon. Sometimes we find the omentum
so thick and large that scarcely a viscus is in sight. Now,
there are greater and lesser districts of peritonitis in the
abdomen. All peritonize districts depend on certain
weak points of viscera. These peritonitic regions are
places where disease arises in viscera, for peritonitis is a
secondary matter. The great peritonitic districts are —
a, the pelvis ; 3, the appendix ; and c, the gall-bladder.
These are the three great regions of peritonitis in man.
I have scarcely posted an adult body which has not
some trace of peritonitis in one of these three major
regions. In these peritonitic districts is where abdom-
inal surgery has made progress and where life has been
many a time and oft saved or snuffed out. These three
regions have tolerated infectious invasion so long that
they resist it and almost always save life by producing a
peritonitis which buries the invaders in exudate forever.
It must be remembered that peritonitis is a life saving
process, while it is infection that kills. Peritonitis is
nature's method of repair. If it were not for perito-
nitis the people would soon be swept from the earth.
Peritonitis produces exudates which bury and starve
the invading deadly germs. Now, there are other regions
of peritonitis which I call minor districts. We have in-
flammation around the sphincters (pylorus and ileo-cae-
cal valve and anus), which is common in adults, though
limited in extent. Again the flexures of the colon suffer
(hepatic, splenic, sigmoid) from inflammation. Perito-
nitis is common around the colonic flexures. The
reason is that as the solid faeces, containing sharp, rough,
foreign bodies pass around the acute angles of the flex-
ures the mucous membrane becomes abraded and torn so
that the way lies open for germs and infection to pass
into the gut- wall and peritoneum. At these sphincters
and flexures malignancy as well as cicatricial strictures
are apt to arise. The hernial orifices are very apt to
catch some portion of the gut and inflame it, starting up
peritonitis. Also we have what I designate as accidental
peritonitis, i.e., from some perforation or trauma in some
portion of a viscus outside of what has been designated
as a distinct peritonitis district (major or minor).
What I wish to present in this paper as original, as I
have never seen it in a book nor heard it from anyone,
is the peculiar inflammation or peritonitis which occurs
around the caecum and under the sigmoid, as it crosses
the psoas muscle. For a long time in autopsies I have
been carefully observing local peritonitis, and particular-
ly my attention has been called to two points whose
explanation did not seem satisfactory. The peculiar,
apparently benign inflammation which one can so fre-
quently see around the caecum, and just under the sig-
moid as it crosses the psoas muscle, cannot be wholly due
to appendicitis nor to the acute angle of the sigmoid.
First, the pericecal adhesions are entirely out of reach
of the appendix. In fact, it is the most distant from it.
I admit that the appendix is often movable and may cre-
ate inflammation in a locality and then leave it to lie in
another region. But physical circumstances were such
in many cases that it appeared unreasonable that the ap-
pendix could produce such old adhesions. Really there
is a kind of pericaecal adhesion and a kind of appendicu-
lar adhesion. These kinds of adhesions may be totally
separate and distinct by physical spaces. Now, how do
I account for the inflammation around the caecum which
is not appendicular? The answer is that it is due to
the relaxation and contraction of the psoas and iliac mus-
cles. The majority of caeca lie partly on the psoas mus-
cle and partly on the iliac muscle, and in walking these
two muscles are continually contracting and relaxing.
Should the caecum be congested or even inflamed the ir-
ritation produced in these muscles would cause an exudate
which would organize and result in bands. Again, as
the sigmoid crosses the psoas on the left side, I have
seen the peritoneum or its mesentery inflamed so often
that I looked a long time for a cause. The cause, in my
opinion, is due to the contraction and relaxation of the
psoas and iliac muscles. This is a clearer case than the
caecal region, for the old peritoneal inflammations are so
frequent and entirely isolated from all other fields and
sources of inflammation. The old bands, dense adhe-
sions, and thick, new cicatricial tissue so frequently found
just under the sigmoid as it crosses the psoas muscle can
be accounted for, so far as I can see, only by an irritation
arising out of the psoas and iliac muscles. It must be
chemical or mechanical peritonitis due to irritation.
This explanation will give a new view to all the isolated
adhesions around the caecum as not being due to rupture
of the appendix.
In nineteen autopsies made by me in special reference
to the abdominal viscera, where every point was observed
in regard to peritonitis and an attempt made to measure
almost every viscus, I found over seventy-five per cent, of
old adhesions resulting from peritonitis existing around
the caecum. I can say that many of the adhesions were
entirely isolated from the appendix. In the same autopsies
we found thirteen cases out of nineteen with distinct old
peritonitic adhesions under the sigmoid as it crosses the
psoas muscle. In many cases the peritonitic adhesions
under the sigmoid were entirely isolated from all other
fields, and many were in men, so that the tubal end could
not empty its infection there, just exactly on the psoas,
immediately under the sigmoid bend.
It cannot be explained by the flexure in the sigmoid,
for it is not sharp enough. In these very cases the
sigmoid was almost straight over the adhesions, and
therefore could not become angular. When Albers, of
Bonn, said, over two generations ago, that the caecum
was the disturbing element in man's trouble in the right
iliac fossa, he had a grain of truth on his side, for there
do exist old adhesions around the caecum separated
from the appendix which do not appear connected with
the appendix. It must not be forgotten that about all
fatal pathology lies in the appendix. I am mathemati-
cally investigating one hundred cases of autopsies on the
abdominal viscera. So far I have done with as much care
as possible nineteen autopsies of this proposed one hun-
dred, and many interesting revelations have arisen. Fur-
ther investigation will either confirm or deny this theory.
The Death-rate of Montreal has fallen from 37 per
1,000 in 1872 to 24 per 1,000 in 1892.
7i6
MEDICAL RECORD.
[December 8, 1894
ELECTRIC LIGHT AS A DIAGNOSTIC AND
THERAPEUTIC AGENT.1
By MARGARET A. CLEAVES, M.D.,
INSTRUCTOR IN ELECTRO-THERAPEUTICS, MEW YORK POST GRADUATE MEDI
CAL SCHOOL.
The attempt to illuminate the less accessible cavities of
the human body had its origin as long ago as the be-
ginning of the present century. Bozzoni, in 1805, first
conceived the possibility of throwing light into the blad-
der, but without much success. In 1853 Desormeaux
exhibited the first endoscope before the Paris Academy
of Medicine. Julius Brack, of Breslau, is said to have
first employed the platinum loop as a source of illumina-
tion for medical work. In 1867 he exhibited a stomato-
scope designed to assist in examining the rectum and
bladder. These old instruments were cumbersome and
inefficient, but Nitze and Leiter have constructed a cy-
toscope which has achieved remarkable success.
The use of the electric light in medicine now covers a
much larger field and has become an important aid in
diagnosis. By it the dentist can detect spots of de-
cay in the tooth which without it would escape his ob-
servation. The nose and throat specialists are able to
search the minutest recesses, while the physician who is
in doubt regarding certain diseased conditions of the
stomach and abdomen, may literally study his obscure
cases in a new light.
In 1885 Dr. Louis J. Lauterbach, of Philadelphia, pub-
lished an account of the use of the incandescent electric
light in examinations of the eye, ear, and throat. He
recommended for illumination of the ear the use of a
tiny lamp placed close to the speculum and enclosed in a
shield having a small circular opening in it.
In 1890, Theodor Heryng was able to illuminate the
antrum of Highmore by using a five-volt incandescent
lamp attached to a tongue' depressor. He was able in
more than thirty cases to diagnosticate latent empyema
without exploratory puncture, and this diagnosis was
corroborated by the subsequent removal of the pus.
About two years ago Davidsohn called attention to
the value of illuminating the eyeball by an incandescent
lamp in the mouth. Quite recently Burger has claimed
that luminous sensations in the eyeball were far more
distinctive tests than illumination, as a very feeble light
was sufficient to excite the subjective sensations.
On November 1, 1893, the writer had the pleasure of
demonstrating this point to a number of medical persons
by introducing an incandescent lamp into the mouth.
On the lamp being illuminated the pupils of the eyes were
seen as blood red apertures, and it was also shown that if
the person so illuminated cast his eyes upward at an
angle of 45 ° he could discover the same phenomenon.
Mr. N. Stevenson has called attention to the curious
fact that when light is thus introduced the pupils do not
contract.
Dr. D. Braden Kyle, of Philadelphia, has recently in-
troduced some improvements for examining the nasal
cavity. The essential feature of his method is the placing
of the lamp within the post-nasal space so that the parts
are seen by direct instead of by reflected light. He also
recommends that the lamp be protected with a cap of
aluminum, by the aid of which it can be used continu-
ously for thirty seconds without inconvenience from
heat. This lamp was furnished by Charles Leutz, of
Philadelphia.
Within the past few months Dr. Charles W. Caldwell
has published an article in which he has considered the
subject of transillumination of the mastoid cells as a
means of diagnosis of mastoiditis interna suppurativa.
The examination must be made in a perfectly dark room.
When the lamp is inserted well into the external audi-
tory meatus and the current turned on, the healthy mas-
toid is illuminated with a red glow, extending from the
apex to the lateral sinus and to the limits of the cells
1 Read before the American Electro-therapeutic Association, Sep-
tember 27, 1894.
above. By placing the lamp on different parts of the
mastoid the limitation of the cells and the position of
the lateral sinuses may be accurately mapped out, and
pathological conditions demonstrated if present. If
there is a purulent condition in the cells this portion will
appear dark. Comparison with the opposite healthy
side renders the diagnosis of pus in the mastoid cells
complete, whether or not the usual symptoms are
present.
The same observer has also described a method of
transilluminating the accessory sinuses of the nose, by
which he was able to detect a large mucous polypus by
its translucency, higher refraction, and globular form,
which concentrated the light, and increased the brill-
iancy of the illuminated area.
Dr. Chevalier Jackson, of Pittsburgh, has also practised
transillumination of the nose successfully for some time
past. His method differs somewhat from that previously
described, as he uses a fifty-candle-power lamp and a
hollow silvered glass rod.
As an instance of the great clinical value of electric
illumination in diseases of the nose and throat a case of
tubercular laryngitis has been reported in which no
tubercle bacilli could be found in the expectoration, but
on passing an applicator deeply down into the passages
under the guidance of a brilliant electric light, some
secretion was found, which on removal proved to contain
innumerable tubercle bacilli.
The work of Dr. Max Einhorn in connection with the
transillumination of the stomach is well known. His
"gastrodiaphane," first described in November, 1889,
consists of a soft rubber stomach tube containing wire
conductors and having a small Edison incandescent lamp
mounted at the gastric end of the tube. By its aid the
examination is performed so quickly that there is no
danger of the lamp becoming too hot, especially as the
water in the stomach (swallowed by the patient just
previously) exerts a cooling action upon it. Dr. D. D.
Stewart, in the Medical News for February 18, 1893,
speaks of the value of gastrodiaphany as follows : " The
actual utility of gastrodiaphany over other methods of
outlining the stomach lies especially in the application of
the diaphanoscope to the differentiation of gastroptosis
and gastrectasia, as by it the determination of the site of
the lesser curvature is far more readily made than by in-
flation."
Theodor Heryng has succeeded in transilluminating
the anterior walls of the vagina. With the help of a
Ferguson speculum he was also able to insert an electric
apparatus into the rectum and so transilluminate the pos-
terior wall of the vagina as far as the posterior fornix.
With reference to apparatus, it is a matter for regret
that much of the intended experimental work has not
been done on account of the great difficulty experienced
in securing suitable lamps.
The W. F. Ford Surgical Instrument Company have
furnished a lamp for transillumination of the frontal si-
nuses, also one for the transillumination of the antrum of
Highmore, and a head lamp. The Galvano Faradic
Manufacturing Company have furnished a small mouth
lamp for general use. The use of a lamp bps also been
secured for the transillumination of the bowel, known as
Hertyng's lamp, and a lamp for the transillumination of
the pelvic tissues devised by myself. These lamps have
all been personally tested, with the following results :
Ford's head lamp requires 10^ volts and 1 ampere,
and gives 3 candle power. For use with a street current,
it should be placed in circuit with one 16 and one 24-
candle-power lamp. Ford's lamp for the transillumina-
tion of the frontal sinuses requires 8 volts and .8 ampere
and gives about 2-candle power. For use with street
current two 16 candle-power lamps should be placed in
circuit. Ford's antrum lamp requires 8 volts and .8
ampere and gives a little over 2 candle power. For use
with the street current, one 16 and one 24 candle-power
lamps are needed. The lamp supplied by the Galvano-
Faradic Company, requires s}4 volts and .8 ampere and
December 8, 1894]
MEDICAL RECORD.
717
gives a little over 1* candle power. For use with street
current it requires two 16 candle-power lamps in circuit.
Hertyng's lamp for transillumination of the bowels has a
shield or cap over it with an attachment to a fountain
syringe so that water is allowed to flow about the lamp
and also through the terminal opening into the bowel it-
self. It requires 9 volts and . 7 amp&re and gives a little
over 2 candle power.
The lamp for the transillumination of the pelvic tis-
sues, devised by myself, requires 32 volts and .8 ampere,
giving about 8-candle power. It was intended to be a
20-candle power lamp, but as it passed through a chapter
of accidents, it is at present only an 8 candle power, but
will be replaced shortly by one of 20 candle power.
The lamps variously used and the results obtained from
them have already been indicated in the report. The
Edison lamp or condenser for direct illumination of the
different cavities of the body has also been tested. It is
best suited to positions in which the direct rays of light
may be used and is also satisfactory where the light has
to be reflected.
So far as the transillumination of the bowel is con-
cerned, nothing has as yet been done. A number of
observations have been made in transillumination of the
pelvic tissues. As a result of these it is found that wher-
ever there is morbid material, either in the form of
exudative matter or abnormal growths, as fibroid tumors,
sarcoma, etc., the tissues of the anterior pelvic and ab-
dominal walls are not transilluminated but remain abso-
lutely black. In the abnormal conditions which have
been examined the pelvic cavity has been pretty well
filled, so that there has been no transillumination. Of
course with the morbid material on one side only, the
other side should be transilluminated. In so far as the
writer has done any work in this direction, she regards
transillumination of rather doubtful utility. The condi-
tions can be much more accurately determined by means
of the educated finger than by any candle power of elec-
tric light that has yet been used.
I have been able to obtain translucency of the tissues
within two inches of the umbilicus, but have demon-
strated nothing save the course of blood-vessels.
The foregoing statements give a fair idea of the use of
electric light in diagnosis, but they by no means compass
all the methods by means of which electric light is help-
ful in therapeutics. One of the recent adaptations is
known as the electric-light bath, and is based on the
proposition that the properties of electric light are simi-
lar to those of sunlight. By means of a suitably con-
structed cabinet, patients are subjected to the rays of a
number of incandescent lamps. The temperature can be
regulated by passing the current through a resistance coil
and may vary between 900 and 1500 F., with a result
equivalent to a combined light and vapor bath. The
skin is browned as if by sun-burn and the effect is claimed
to be most salutary.
The writer has had placed in her hands for use an
apparatus furnished by a manufacturer of Newark,
which is worthy of attention as a means of experimental
work. It is a cabinet with an arc light arranged in front
of a large tin reflector which can be raised or lowered at
will. This and a lamp with a very strong lens and re-
flector for localization of the rays of light are the only
apparatus which have been placed at my disposal. It is
impossible, therefore, to say which form of apparatus is
best. No observations have yet been made as to the
efficacy of the light used through glass or similar sub-
stances, nor have investigations been attempted which
would enable me to arrive at any conclusion as to pos-
sible difference in therapeutic effect between electric light
and solar light.
Turning now to a consideration of the effect of light on
living organisms we find that plants have been forced
into rapid growth by exposure to the rays of the electric
light. M. D'Arsonval has made many investigations on
the effect of both sunlight and electric light on various
bacterial growths. He found that cultures exposed to
the white rays were not colored while those exposed to
the red rays had developed pigment. He also expressed
the opinion that light exerted a more powerful influence
over bacteria than ozone or even oxygen.
Dr. H. Marshall Ward in a paper read before the
Royal Society showed the effect of light on bacilli from
the Thames, and found that in all cases both solar and
electric spectra exerted no perceptible action whatever in
the infra red, red, orange, or yellow region, while all the
bacteria were injured or destroyed by the rays from the
blue or violet spectrum. The intervention of a thin
piece of glass resulted in cutting off a large proportion of
the effective rays. The most distinctive rays, /.*., those
at the end of the blue and beginning of the violet, were
to some extent effective even after reflection from the
inner faces of a quartz plate covering the film, and the
glass on which it was supported. This investigator goes
on to say that these results evidently suggest that the
naked arc light may prove to be a very efficient disin-
fecting agent for use in hospital wards, railway carriages,
and other places where the rays could be projected di-
rectly on the organisms.
Theodor Geisler in 1892 found no qualitative differ-
ence between sunlight and electric light, only a quantita-
tive difference. In the course of some experiments on the
typhoid bacillus, he found the most decided effect was
produced by the rays from the violet end of the spectrum.
P. A. Khmelevsky, of St. Petersburg, after prolonged
experiments, concluded that both solar and electric light
have an undoubted inhibitory influence on the growth of
microbes.
Klebs-Loeffler has discovered that diffused light does
not prevent the development of cultures of diphtheria at
ordinary temperatures or at a temperature as high as 95 °
F., but that sunlight arrests this development, and after
an exposure of several days sterilizes bouillon. This
bactericidal power of light toward the bacillus of diph-
theria is due almost exclusively to the rays of greatest
refraction, those at the other end of the spectrum having
little or no action of this kind.
Some years ago experiments were made with Jabloch-
koff candles in the Paris sewers, with the result that con-
siderable purifying action was noted.
In i88i(?) Mr. Harold P. Brown, E.E., of New York,
while using Brush arc lamps for lighting the basement of
a store in Chicago, noted that within an hour after turn-
ing on the current, the odor from the closets, which at
first was very offensive, became entirely neutralized.
The writer, who has an arc-light apparatus in her office
such as has been described, made the following observa-
tion on a recent excessively hot day. The refuse barrels
which had accumulated over Sunday in the basement and
had not yet been removed Monday morning, emitted a
very unpleasant odor, which filled the office. The arc
light was turned on and the writer left the room for half
on hour. On her return she found that every evidence
of odor had disappeared and that the air seemed perfectly
pure, while in another part of the house which was not
near enough to be affected by the light, the odor still
persisted as before. This action was undoubtedly due to
the ozone.
In an article in The Medical Week for August 17,
1894, Dr. R. L. Boqles gives some interesting facts re-
garding the influence of solar rays on the skin and con-
cludes that some other principle must be at work beside
heat. Some observations of M. Charcot tend in the same
direction. The phenomenon appears to be due to the
action of the chemical rays in the ultra violet end of the
spectrum. Mr. H. B. Hewetson, in the British Medical
Journal ion 1893, c*tes ^ve cases m which eyes became
inflamed after watching the operation of electric wiring
by the arc light, unless the observer was protected by a
shield of thick ruby glass. It was found that the skin
of the face and neck would become tanned and would
peel off just as if it had been exposed to the rays of the
sun. This was evidently not due to heat but to the
chemical rays.
7i8
MEDICAL RECORD.
[December 8, 1894
M. Gautier has recently investigated a curious phe-
nomenon, namely, that substances which have been sub-
mitted to the action of electricity or which have been
exposed to the direct rays of the sun, are in a peculiar
state of excitement which renders them much more active
as regards one another than are the same substances pre-
pared by the ordinary methods of the laboratory.
Such being the admitted facts, one is prepared for the
assertion that electric light may be made a potent thera-
peutic agent. Dr. Gatchkowski, St. Petersburg, 1892,
reports twenty-seven cases, chiefly of rheumatic and
neuralgic pain, which he had quickly cured by the
electric light, and Stanislaus von Stein also reports good
results.
Few observations have yet been made by the writer as
to the therapeutic value of electric light. Something,
however, has been done, as the following particulars will
show. In one case of cervico-occipital neuralgia of great
severity, coupled with supra-orbital neuralgia, the appli-
cation of the electric light was found to be exceedingly
grateful to the patient and resulted in relief from pain for
several hours. In a case of intense pain in the roots of
the cervical cord, an extension of neuritis, the only way
the patient was able to get sleep, without hypnotics, was
by having an electric lamp placed directly over the cer-
vical cord. In this instance, however, it is believed that
the heat only produced this grateful result.
The following experimental observation is reported
somewhat at length :
J. C , twenty-one years of age ; suffering from
anaemia and enuresis. The electric arc-light bath was
given for twenty minutes. The patient was placed upon
a stool with the entire body exposed to the rays of light,
special attention being paid to localizing it at the lumbar
and sacral plexuses. The treatment was entirely experi-
mental, but with the expectation of, at least, improving
the nutrition. The writer felt willing to undertake it, as
she was confident of being able, later on, to cure the
enuresis by long percussive static sparks. Hie patient
had suffered from nocturnal enuresis as far back as she
could remember. Menstruation was established at seven-
teen and was perfectly regular. All the conditions were
normal save that the patient was decidedly anaemic, and
suffered from facial acne. The pupils were always di-
lated, and there was a tendency to constipation, the
bowels often moving but once in two days — rarely two
or three days consecutively. The wet nights were slight-
ly variable ; she would sometimes go in summer two or
three nights without trouble, but rarely for this time in
winter. In all, sixteen treatments were given, extend-
ing over a period of one and a half months, three times
weekly. Careful examinations of the urine were made
at first, and the pulse, temperature, and skin were care-
fully watched. Thirteen observations were taken of the
temperature and pulse. In eleven instances the pulse
dropped, and it was always of better volume after the
bath. In two instances the pulse remained unchanged
but its volume improved ; while in every instance (thir-
teen times) there was a rise in the temperature of from
one to eight degrees. The skin always became moist
under the applications, and during the last treatments
was very profuse. There was a general sense of well-
being expressed by the patient after each application.
Soon after coming under treatment the bowels became
regular, and there was no trouble during the time she
was under care, nor since then, a matter of nearly six
months, excepting for a few days at one time after dis-
continuance of treatment, when very much hurried mak-
ing preparations for leaving the city. The urine was
analyzed from time to time, and showed a steady increase
in the amount of urea eliminated The patient gained
a pound and a half during the first two weeks, and since
that time has gained seven pounds more, and is in better
health than for several years. The temperature of the
bath varied on different days, being affected by the out-
side temperature, but it ranged from 900 to ioo° F., and
the patient left the office feeling much better. No drug
of any sort was given or allowed the patient during the
time she was under observation.
Arrangements have just been made with a dermatolo-
gist to have observations made as to the value of arc light
in parasitic skin disease, and, in fact, to carry out a sys-
tematic series of scientific experiments bearing upon
these points. The writer is well aware that the value of
one or two experimental cases is open to question, bat
under the special circumstances already referred to has
thought well to mention the few cases quoted, wishing it
to be distinctly understood that she considers the inves-
tigation very incomplete in its present stage.
It is interesting to note that Dr. Dawson Tyner, of
London, commenting upon the well-known treatment of
goitre by smearing the part with red iodide of mercury
ointment and then exposing the surface to direct sun-
light, suggests that the effect is due to the power of iodine
to cut off the visible rays of the spectrum. The fact that
red iodide is the more efficacious points in this direction,
for it would serve to transmit the heat rays only. In
this way the part is subjected to the full blaze of the
calorific rays without the vibrations of its molecules being
altered by the visible rays. If this theory be correct we
could expose diseased parts to sunlight or to a fire after
the application of iodine. May not this suggestion give
us a valuable hint in connection with the use of the elec-
tric-light bath.
And now, after studying this novel and interesting
subject until we have begun to form some adequate con-
ception of the potency of light, we are confronted with
the rather startling announcement, from no less a physi-
cist than Professor Dolbear, that there is no such thing
as light — that there are no peculiar waves which can be
called light. In proof of this assertion he describes a
method of taking a photograph of an object in absolute
darkness by means of the ether waves set up by working
an electrical machine. We have already seen how similar
are the effects of sunlight and the electric light, but lest
there should still be a lingering doubt in the minds of
some individuals regarding this point, that distinguished
experimenter, Nikola Tesla, comes forward and produces
a faint glow of light in a dark room with alternating cur-
rents of 800,000 voltage, by means of atmospheric vibra-
tions to such an extent that the phenomenon would no
longer be electricity, but light !
68 Madison Avenue, Nkw York, October 30, 1894,
Who Fed Fevers ? — The story of the physician who
wished to have as his epitaph, " He fed fevers,91 has been
told, the saying being usually attributed to Stokes. Dr.
Julius Althaus writes to the British Medical Journal that
it was Graves who said this. In the biographical notice
of Graves which precedes his edition of the latter's
" Studies in Physiology and Medicine," Stokes says :
"Graves was going round the hospital, when, on enter-
ing the convalescent ward, he began to expatiate on the
healthy appearance of some who had recovered from se-
vere typhus. ' This is all the effect of our good feeding/
he exclaimed ; 'and lest, when I am gone, you may be at
a loss for an epitaph for me, let me give you one in three
words :
" « He fed Fevers.' "
Trousseau has alluded to this point in his introduction
to the French translation of "Graves's Clinical Lect-
ures," where he says : " Graves's maxims relating to the
regimen of fever have become the guide of practitioners of
all countries ; yet when he inculcated the necessity of
giving nourishment in long-continued pyrexias, the Dub*
lin physician assailed single-handed an opinion which
appeared to be justified by the practice of all ages. Had
he rendered no other service than completely reversing
medical practice upon this point, Graves would, by that
act alone, have acquired an indefeasible claim to our
gratitude."
December 8, 1894]
MEDICAL RECORD.
719
MAY THE SHOCK OF A RAILROAD ACCI-
DENT EVER BE BENEFICIAL TO THE RE-
CIPIENT ? 1
By RICHARD C. NEWTON, M.D.,
MONTCLAIR, N. J.,
SUBGEON TO THI NEW YORK AND GREENWOOD LAKE RAILROAD ; ATTENDING
SURGEON TO THE MOUNTAINSIDE HOSPITAL ; PHYSICIAN TO THE ESSEX COUNTY
PENITENTIARY ; LATE CAPTAIN AND ASSISTANT SURGEON UNITED STATES ARMY.
My excuse, if one be needed, for selecting the above sub-
ject for a paper before this learned body is that a brief
consideration of the possible benefits of a railroad acci-
dent may prove of interest and profit, if for no other rea-
son, simply because we have been made so familiar with
the injuries, both immediate and remote, which a railroad
accident may inflict upon its unfortunate victims, that it
may be worth our while to consider the other side of the
question, and to dwell for a few moments upon the bene-
fits, if any there be, which may follow such an accident.
The great variety and extent of railroad injuries afford
to this branch of surgery an interest peculiarly its own.
The railroad surgeon is called upon to treat lesions more
variable and complex than those that usually come under
the care of the military surgeon. In war it is true that
men are horribly wounded by missiles and explosives of
different kinds, are cut by sabres, trampled by horses,
stabbed by bayonets, etc. They are, however, seldom or
never scalded by escaping steam, burned or drowned in
wrecked cars, or crushed under heavy bodies. Moreover,
soldiers are picked men in the prime of life, and are, by
their training and surroundings, inured to danger. They
look upon wounds, sickness, and even death, as some of
the contingencies of their profession. In battle, espe-
cially, they are nerved up to a high pitch, and often suf-
fer willingly for the cause in which they are enlisted.
It is not so with the victims of a railroad accident.
These unfortunates are of all ages and stations, of both
sexes, and of every degree of bodily strength and mental
calibre. Furthermore they are injured when totally un-
prepared for an accident. They are taken entirely by
surprise, and the shock and fright complicate and increase
their injuries, and bear a considerable relation to the ul-
timate result. The nervous and psychic lesions following
railroad injuries have for years engaged the attention of
the alienist and neurologist, as well as the surgeon, and
various and far-reaching have been the results of their
studies. In these respects I think that you will agree
with me that railroad surgery covers a wider field than
military surgery.
Who, indeed, ever heard of a military spine ? Perhaps
this is one of the discoveries now in the womb of the
future which only awaits some bold accoucheur for its de-
livery and addition to that already numerous family of
disabilities for which enterprising patriots may draw pen-
sions from a grateful country.
A surgeon of this city has described typhoid spine, and
it seems probable that, following in the steps of Erichsson,
other writers will, from time to time, increase the present
stock of spines indefinitely.
So far as the scope of this brief paper is concerned, it
will simplify matters to consider our subject under two
heads, as follows : 1. May a person suffering from some
bodily ailment be benefited by the shock of a railroad
accident? and 2, May a person suffering from some ner-
vous or mental disorder receive benefit in a similar man-
ner?
The literature relating to railroad injuries does not
provide as many cases illustrating these questions as
could be wished. Yet some quite striking ones may be
found, and doubtless the number would be largely in-
creased if railroad surgeons generally would report cases
of which they may be cognizant. Probably nearly every
one in this room can recall cases in which disease has
been checked or even cured by the shock and excitement
of a railroad or other serious accident.
Hack Tuke, in the preface of his book, " Influence of
1 Read before the Erie Railway Surgeons' Association, at the Acad-
emy of Medicine, New York City, January 5, 1894.
the Mind upon the Body," relates the following case
which he had found in a newspaper under the heading
" Curative Effects of a Railroad Collision." I quote
verbatim; "Allow me to confirm all that your two
correspondents have related with respect to the alarm-
ing collision on the 17th inst. on the Midland line.
Nothing needs to be added either to their description
of the circumstance or to their just condemnation of
the reckless negligence which brought us so near to
death ; but the shock produced so curious an effect on
myself— an effect perhaps unparalleled in the history of
railway accidents — that you will perhaps excuse my
troubling you with the details.
" At my hotel in Manchester I was seized with all the
symptoms of a violent attack of rheumatic fever, in fact,
my condition so alarmed me and my dread of a sojourn
in a Manchester hotel bed for two or three months was
so great that I resolved to make a bold sortie and, well
wrapped up, start for London by the 3.30 p.m. Midland
fast train from the London Road terminus. From the
time of leaving that station to the time of the collision
my heart was going at an express speed ; my weak body
was in a profuse perspiration ; flashes of pain announced
that the muscular fibres were under the tyrannical control
of rheumatism, and I was almost beside myself with
toothache. Crash ! smash ! bump ! and bang ! and
from side to side of the carriage I went like a billiard-
ball under a hard cushion hit. The compartment was
soon seen to be sprinkled with the blood of a hapless
victim whose face had come into crushing contact with
it" Dr. Tuke continues — " The rest of this paper was
unfortunately wanting, but I learnt from other sources
that, as the heading intimated the patient was cured of
his rheumatism."
I can relate a somewhat similar case of serious ac-
cident on shipboard which undoubtedly prolonged for
years the life of the young man who received the injury.
L. M , aged about twenty, came of a highly phthis-
ical family. His father and mother, and all of their
children, were consumptive. The latter all died, soon
after reaching maturity, of this disease. When L. M
was approaching his majority, similar symptoms began
to manifest themselves in him to those that had appeared
in the older members of his family. He was sent to Cali-
fornia in a sailing vessel in the hope that the voyage
might be of benefit to him. When the ship was return-
ing to New York, the young gentleman, having climbed
into the rigging, lost his hold and fell from a great
height on to the deck, striking the keel of an upturned
boat. He sustained fractures of both legs and other
serious injuries. In one leg at least he had a compound
comminuted fracture. He was laid up for months, and
it was supposed that this accident to one in his delicate
condition would surely prove fatal. For a long period
one or more open sinuses in his leg discharged freely pus
and bony detritus. Contrary to the general expecta-
tion, however, the young man finally recovered from his
injuries, although he walked with a limp from shortening
of one leg. As he began to get about it was observed
that his pulmonary symptoms had disappeared. He grew
stouter and stronger. He was able to engage in business
and married and had a family. Whether his death,
which occurred a number of years afterward, was due to
tuberculosis or not, I have not been able to ascertain. It
seems fair to assume, however, that his life was prolonged
by the accident.
A case of gout suddenly cured by fright is given in
Tuke's work already cited. I quote verbatim : " Peter
Fether, the person cured, is now alive, a householder in
Reading, seventy-three years of age, a native of Germany,
and a very hearty man. The first fit of gout he ever had
was about the year 1773, and from that time until 1785
he had a regular attack in the spring of every year. His
feet, hands, and elbows were much swollen and inflamed.
The fits lasted long and were excruciating. In particu-
lar the last fit in 1 785 was so severe as to induce an ap-
prehension that it would inevitably carry him off, when
720
MEDICAL RECORD.
[December 8, 1894
he was suddenly relieved by the following accident:
As he lay in a small back room adjoining the yard, it
happened that one of his sons in turning a wagon and
horses drove the tongue of the wagon with such force
against the window, near which the old man lay stretched
on a bed, as to beat in the sash of the window and to
scatter the pieces of glass all about him. To such a
degree was he alarmed by the noise and violence that he
instantly leaped out of bed, forgot that he had ever used
crutches and eagerly inquired what was the matter. His
wife, hearing the uproar, ran into the room, where to her
astonishment she found her husband on his feet bawling
against the author of the mischief with the most passionate
vehemence. From that moment he has been entirely ex-
empt from the gout, has never had the slightest touch of
it, and now enjoys perfect health, has a good appetite and
says he was never heartier in his life. ' ' The reporter of this
case, who was no less a person than Judge Rush, brother
of the famous surgeon, goes on to say, "To you, who
have long been accustomed to explore diseases, I leave
the task of developing the principles on which this mys-
terious restoration from the lowest decrepitude and
bodily wretchedness to a state of perfect health has been
accomplished. I well know that toothaches, headaches,
hiccoughs, etc., are often removed by the sudden im-
pression of fear and that they return again. But to see
a debilitated, gouty frame instantly restored to vigor, to
see the whole system in a moment, as it were, undergo
a perfect and entire change, and the most inveterate and
incurable disease radically expelled, is surely a different
thing, and must be acknowledged a very singular and
marvellous event. If an old man, languishing under
disease and infirmity had died of mere fright nobody
would have been surprised at it, but that he should be
absolutely cured and his constitution renovated by it, is
a most extraordinary fact, which while I am compelled
to believe by unexceptionable evidence I am totally at a
loss to account for.'1
A case of the relief of ascites due to an accident is
recorded by Dr. John Pennington, who says: " A sailor
in an ascites fell off the end of the yard into the sea ;
the weather being calm he was taken up unhurt, but
to use the sailor's words who told me the story, he
was frightened half to death and as soon as he was
taken out of the water he discharged a gallon of urine
or more." Dr. Pennington observes, "the sedative
operation of fear was no doubt the cause of the cure."
I cannot forbear to give one other case which was re-
lated to me in my boyhood. An Irish peasant had suf-
fered for a considerable time with fever and ague and the
ordinary remedies having failed to arrest the disease, an
extraordinary one was employed, some human ordure
was concealed in a bowl of milk, which the patient was
made to drink to the bottom. The intense disgust and
horror which the dregs of this dose caused, it was alleged,
entirely < broke the chills/ "
I have given these cases at some length because they
appear to me remarkable, and because their recital an-
swers the first of the two questions that were asked in
the beginning of this paper, viz. : " May a person suffer-
ing from some bodily ailment, be benefited by the
shock of a railroad accident ? " There is no doubt that
a favorable result may follow in certain cases. Naturally
we should hear of such results far oftener, were it not
for the fact that the proportion of people injured in rail-
road accidents to the whole number of travellers is ex-
ceedingly small ; and of the injured a very small per-
centage are suffering from illness at the time of the
accident.
As to the second division of our subject, I find that
the time allotted me is already about exhausted, and
that the field for discussion upon the effects of shock
upon the nervous system in health and disease is almost
without limit. I could multiply cases almost without
end, to show that the emotions — fear, anger, and excite-
ment— can, and frequently have benefited or even cured
the most severe nervous maladies. From the nature of
such complaints such a result seems reasonable enough.
It is well known that such grave nervous lesions as
chorea, paralysis agitans, asthma, epilepsy etc., are fre-
quently brought on by fright or other strong emotion
and are also cured by similar means.
I will not take up your time by citing cases of which a
number are given in Tuke's work already referred to.
Professor Goodell, of Philadelphia, in a recent lecture,
has related some remarkable cases of coccyodynia and
other nervous affections of which the cause was mental
or emotional, and which were apparently cured by anger,
fright, or excitement.
I cannot forbear to quote one case, which is given
in Professor Norton's " Life and Letters of James Rus-
sell Lowell," recently published. It seems that while
Mr. Lowell was minister to Spain, his wife's health was
apparently in quite a precarious condition. He received
a letter from the State Department at Washington,
offering him the mission to England, which he was de-
sirous of accepting, but felt obliged to decline, as it did
not seem possible that his wife could be moved. In
fact she was confined to her bed and seemed perfectly
helpless. After Mr. Lowell had despatched his letter de-
clining the English mission, his wife's bedclothes took
fire ; whereupon she jumped up with the greatest alacri-
ty and for the time being at least found herself quite
well. Mr. Lowell then sent a telegraphic message to
Washington, in time to anticipate his letter of declina-
tion, and accepted the mission.
That intractable and discouraging disease epilepsy has
occasionally been cured by a fall or blow, or by fright
It would seem that the nervous elements that have been
disarranged by one shock might be shaken back into
place by another. I would explain the beneficial re-
sults that have followed most of the surgical operations
for epilepsy by saying that they are caused by the fright
or excitement of the operation.
I believe that enough has been said to prove that a
railroad accident, horrible as it is apt to be, may be of ben-
efit to those concerned in it. As a therapeutic measure
fright or shock, produced by such a means is of course
entirely out of the question.
How far a physician may be justified in shocking or
frightening a recalcitrant or hysterical patient is a prob-
lem requiring the nicest discrimination and the highest
diagnostic acumen. Such a course has sometimes suc-
ceeded in doing good. It has often done harm. Of
practical results our discussion may have been barren,
but I venture to hope that it has not been entirely unin-
teresting.
A Strange Disease in Dublin. — A number of the in-
mates of the Richmond Insane Asylum at Dublin have
been attacked with a disease resembling beriberi in many
of its features. The symptoms are a general oedema, be-
ginning in the legs and spreading thence to the whole
body, followed by peripheral neuritis and paralysis.
There is no fever, and albumin has been found in the
urine in a few cases only. The heart is weak and dyspnoea
is complained of. After a while the oedema diminishes
and signs of neuritis appear ; then atoxic symptoms set
in with loss of the patellar reflex and muscular atrophy of
the extremities. Post-mortem examination has shown
hydropericardium, oedema of the lungs, ascites, and
fatty degeneration of the heart and kidneys. Over a
hundred inmates of the asylum have been attacked with
the malady.
Porous Glass for Windows. — The latest hygienic
craze in Paris is the use of porous glass for windows.
This is declared to possess all the advantages of the or-
dinary window-framing, and, while light is as freely ad-
mitted as through the medium of common glass, the
" porous " further admits air too, the minute holes with
which this is intersected being too fine to permit of any
draught, while they provide a healthy continuous venti-
lation through the apartment. — The Hospital.
December 8, 1894]
MEDICAL RECORD.
721
TUBERCULOSIS—ITS ETIOLOGY AND PROPH-
YLAXIS.1
By F. A. BOTTOME, M.D.,
NEW YORK.
Before the discovery of the tubercle bacillus by Koch
in 1 88 1 there existed a great difference of opinion as to
the etiology of pulmonary tuberculosis ; since then all
the study expended upon the subject has but strengthened
the position of Koch, and in this present year our Health
Board expresses the universal belief when it states : " Tu-
berculosis is a communicable disease and is distinctly
preventable, and acquired by the direct transmission of
the tubercle bacillus from the sick to the well."
Indeed, we are all so familiar with this view of the
etiology of tuberculosis that it would be presumptuous on
my part to go over this well-beaten ground. Our Health
Board has distributed among the physicians of this city a
circular from which I have just quoted, and which ex-
presses the latest views on the subject in a clear, concise
way, and moreover gives the most practical methods for
destroying the tubercle bacillus and thus preventing the
spread of the disease.
As you are all doubtless familiar with this circular I
shall not take up your time to read it, but call your atten-
tion simply to one paragraph, which reads as follows :
" It is a well-known fact that some persons, and espe-
cially the members of some families, are particularly lia-
ble to tuberculosis. So marked and frequent is the de-
velopment of the disease in certain families that the af-
fection has long been considered hereditary. We now
know that the disease itself is very rarely hereditary, but
that there is inherited a liability to the disease which
renders the individual a more easy prey to the living
germs when once they have gained an entrance. "
This " liability to the disease" is a phase of the sub-
ject which, it seems to me, is often lost sight of in the
consideration of tuberculosis. We think of the disease
as being caused by a specific micro-organism, the tubercle
bacillus; but we forget that this germ is powerless un-
less there is a coincident peculiar state of the system —
" a liability to the disease.''
Without depreciating in the least all that the Health
Board is doing to eradicate this disease by the destruc-
tion of the tubercle bacillus, I would emphasize the fact
that there is another way of accomplishing this end, which
should go pari passu with the former, and which is the
peculiar province of the practising physician, i.e., remov-
ing the peculiar state of the system which constitutes a
liability to the disease. Indeed until the great work
which the Health Board has undertaken in this line has
succeeded in lessening to a very great extent the count-
less numbers and universal distribution of this dread
germ, it would seem as if the removal of the liability to
the disease was easier than the eradication of the germ.
And yet there should be no relaxation on our part in
carrying out the former while we endeavor to accomplish
the latter, since carelessness in so doing may result in
the occurrence of the disease in the individual before we
have succeeded in removing the " liability."
It will not be 'amiss, then, if we spend some little time
in considering what constitutes this liability and the
means for its removal.
This peculiar state of the system is variously designated
tubercular habit, tubercular predisposition, tubercular
diathesis. That it is this diathesis which is inherited
and not the disease itself has been quoted above; but
not only may it be inherited, it may also be acquired,
and this will account for the cases of tuberculosis occur-
ring in those whose family histories show no trace of the
disease for generations back ; in other words, this diathesis
may be inherent in the constitution of an individual.
Children of tuberculous parents are frequently, during
the early period of their lives, to all appearance per-
fectly healthy and may remain so till the first symptoms
of the disease appear in the cough, hectic flush, and ma-
1 Read before the Harlem Medical Society, November 7, 1894.
laise ; while in others we recognize at an early period cer-
tain physical conditions which warrant us in predicting
the advent of tuberculosis at a later period. Thus they
may exhibit the slight build, contracted chest, and deli-
cate complexion. But if it is true that in both these
classes of cases the diathesis exists, we must look for this
diathesis in some defect deeper than in a gross physical
malformation visible to the eye.
S. Solis Cohn, in speaking of this condition, says :
" It is a negative, not a positive, state ; an absence, not
a presence. . . . That which is wanting in individ-
uals who become tuberculous is the life force, the vital
energy, an energy which we know to exist because of its
manifestations as fully as we know electric energy to ex-
ist."
Vital energy we know is an inherent quality of the in-
dividual cell, so that, if Cohn's view is correct, this de-
ficiency in vital energy must be inherent in the individ-
ual cell, and whether this be absolutely true or not it
at least serves as a working hypothesis and is consistent
with many of the peculiar phenomena of this condition.
For instance, we know the cell contains not only suffi-
cient energy to meet the ordinary demands made upon
it, but is continually storing up surplus energy (potential
energy) to be used in time of extraordinary demand, and
this would explain those cases of tuberculosis developing
in persons apparently healthy, the fact being that in
these the individual cells possess sufficient energy for or-
dinary circumstances but succumb under an unusual,
though, perhaps, slight demand, and, sinking below a
certain point, are in the proper condition to constitute a
suitable nidus for the development of the tubercle bacillus.
At the present time this germ is so widely distributed
and exists in such numbers that it would seem as if there
must be a constant warfare between the germ and the
cell, the former laying siege to the latter, and waiting
patiently till the cell shall be sufficiently reduced in
strength to warrant an easy victory.
This comparison is not a bad one, for it indicates the
proper line of treatment. The vital point with a be-
sieged army is to keep up the supply of food, and the
same is true of the cell in its warfare against the tubercle
bacillus. If the cell is sufficiently fed, so that its vital
energy remains above par, it can defy the tubercle bacil-
lus and hold it at bay till the bacillus itself dies, for the
tubercle bacillus cannot multiply unless it feed upon the
animal cell, and also its period of vitality and virulence
outside the animal body has a limit.
In the use of this term, vital energy, it must be re-
membered that it includes that energy which is expended
in nutrition, heat-production, growth, development, re-
pair, etc., and also the stored-up or potential energy
which is held in reserve for some unusual demand which
may be made upon the system.
There is one objection, it seems to me, in this theory
of the deficiency of vital energy in the individual cell as
the distinguishing characteristic of this diathesis, and that
is the fact that if lowered vitality were all that is neces-
sary to make the cell a suitable nidus for the growth of
the tubercle bacillus, then we should expect to find tu-
berculosis developing in all individuals whose vitality
had been greatly reduced by some outside cause, as by
some one of the wasting diseases. This, however, is not
the case.
It would seem as if there were some deeper defect in
these cells, to which, if there is added a deficiency of po-
tential energy, the cells are vulnerable to the tubercle
bacillus ; while in a cell not subject to this diathesis such
a lack of potential energy would not make it more vul-
nerable. In other words our theory is that it is this, at
present, undefined defect of the cells, to which if there
is added a lack of potential energy, they become vulnera-
ble to the tubercle bacillus. This view does not conflict
with the recognized methods or results of treatment, for
it recognizes the fact that the safeguard of the cell, sub-
ject to this diathesis, is the maintenance of potential
energy, while in cells not subject to this diathesis such a
722
MEDICAL RECORD.
[December 8, 1894
safeguard is not necessary, since they are not vulnerable
to the tubercle bacillus under any conditions.
Treatment — In the treatment of this condition or dia-
thesis it must be remembered that we are dealing not
with patients who have already developed tuberculosis,
but with those who simply have the diathesis, usually in-
herited; since with our present knowledge we are
hardly able to diagnose the inherent cases before tuber-
culosis itself has developed, and then only by inference in
the absence of family history.
To put it in a more practical way, what can we do for
those cases which give a strong family history of tuber-
culosis, and whose friends, if not themselves, ask our ad-
vice as to the means of preventing the development in
them of this dread disease ?t Such a question is a very
common one, which the practitioner is asked to answer.
If it is true that the safeguard in these individuals
against the disease is the maintenance of potential en-
ergy, then the problem of treatment resolves itself into
the consideration of the best methods of supplying this
potential energy to the cells. The more we study the
subject, the more shall we be impressed with the fact
that the treatment of this condition embraces the whole
subject of hygiene, and doubtless it is owing to the vast-
ness of the subject that the above question is so often
answered by the busy practitioner in the few words,
" Keep the patient strong and well.11
So for as it goes the answer is correct, but its accom-
plishment will not be attained unless we go into explicit
detail, and treat each case individually, for we shall find
a great difference in individual cases, and in the same
case at different times, and each of these indicate special
treatment.
Of course it will be impossible for me to do more than
indicate the line of treatment, with perhaps special em-
phasis placed on certain points, but we shall be greatly
aided if we keep well in mind the object of our treat-
ment, the increasing of potential energy. In supplying
this energy three means naturally suggest themselves, in
food, air, exercise, and by regulating these we can ac-
complish a great deal even among those who must of ne-
cessity remain in the city, where these cannot be so eas-
ily regulated as in the country, and in special climates.
Food. — In the classification of food we find that dif-
ferent classes serve different purposes in the animal
economy. Thus the nitrogenous elements serve princi-
pally the purpose of tissue-building, and the storing up
of potential energy, while the hydrocarbons and carbo-
hydrates are concerned principally in heat production,
and from this fact it is evident that the food- supply in
these subjects should contain a large proportion of nitro-
gen. Unfortunately it is in this very class of patients
that we find a marked perversion of appetite, a liking
for sweets, a distaste for meat, and it will require all our
powers of tact and persuasion to regulate properly the
diet of these cases. Some experimenters claim excellent
results from an exclusive meat diet, but aside from the
difficulty of carrying this out, among private patients at
least, the general consensus of opinion is in favor of a
mixed diet composed largely of nitrogenous foods.
If we are fortunate enough to have the patient under
observation from the time of birth, the problem is less
difficult, providing we can enlist the co-operation of the
parents. The fact that the child of a tuberculous mother
should not be fed from the mother's breast, on account of
both mother and child, is universally conceded, but in
addition to this, would it not be wiser that a mother who
inherits merely this diathesis, although she may not
have developed tuberculosis, should not suckle her off-
spring ?
At the present time when the subject of bottle feeding
has been placed on a scientific basis, so that cow's milk
can be made almost identical with human milk, the re-
moval of the child from the breast is no longer such a se-
rious question, nor is there the unpleasant alternative of
a wet-nurse.
It is possible in this city to order a milk containing
the albuminoids, sugars, and fats in whatever proportion
the physician may desire, and by taking advantage of this
fact we can increase the albuminoids or nitrogenous por-
tion in these cases and watch the effect.
I do not know whether this has been done by anyone
as yet ; but is there not here a field for investigation to
find out the effects of a larger proportion than is usually
given, of the nitrogenous elements in the diet of an infant
of tuberculous parents ?
As the diet of the child increases in variety it should
still consist of only plain wholesome food, largely of a
nitrogenous character. The child should not be per-
mitted to develop an appetite for sweets and pastry. The
custom of giving a child candy as a reward or bribe is a
bad one, aside from the questionable moral effect, and es-
pecially is it true in the cases under consideration, for
perfect digestion is a sine qua non in their successful
treatment, and in these subjects (the) sugars are very apt
to cause digestive disturbances.
As the child grows older the diet, of course, varies
somewhat ; but the same principle holds good. And in
the selection of articles of diet, with the aim of giving a
large proportion of nitrogen, we shall find a large num-
ber from which to choose, for aside from meat we find
other articles containing a large proportion of nitrogen ;
thus eggs contain about thirteen per cent, of proteids,
fish, eighteen per cent., oatmeal twelve per cent., peas
twenty two per cent., cheese thirty-one per cent. I
mention these simply to emphasize the fact that meat is
not the only nitrogenous food, and that in regulating the
diet, to prevent sameness, we can select food-stuffs
which will still aid in accomplishing our aim.
Air. — The necessity for fresh air is as important as the
necessity for proper food. The r61e which oxygen plays
in the metabolism of the body is a well-known physiolog-
ical fact, but is more often disregarded in practice than
remembered in theory.
It would, of course, be better for persons subject to
this diathesis to live in some region where the air is ab-
solutely pure, and where the tubercle bacillus is not pres-
ent, but this is not often practicable nor is it necessary.
If we breathed nothing less pure than the out- door air of
this city we should have little cause for complaint. It is
the air in our dwellings that is impure, and the fault is
our own.
When the patient is old enough to look out for him-
self we can advise him, as far as possible, to lead an out-of-
door life, and in the case of a young man to select a bus-
iness or profession where this will be possible; but if the
patient is an infant or young child we must be explicit
in our directions to those in charge of the child, and
teach them a few lessons on the subject of ventilation.
We must show them how perfectly possible it is to
ventilate a room without the presence of draughts. That
it is only necessary to have a communication between
the outer and inside air, and by the law of diffusion of
gases, and the law which relates to the difference in
weight of masses of air of unequal temperature, the warm,
impure air of the room will pass out, and the cool, pure,
outer air will come in and take its place, and that the
process can be made to take place so gradually that the
temperature of the room remains stationary.
We can tell them that the simplest, and yet one of
the most delicate means of testing the purity of the air in
a room, is that by the sense of smell ; that on entering a
room to be tested we should notice no difference in point
of freshness between the out and inside air, remembering
that warm air is not necessarily impure, and that in this
test the question of temperature is not to be taken into
account
These are homely truths and it would hardly seem nec-
essary to mention them, and yet is it not true that the
majority of sleeping- rooms have a disagreeable, stuffy
odor before they are aired in the morning ? This odor
is due to the organic matter exhaled from the lungs and
skin, and if not removed from the air of the room is
taken into the lungs with each respiration and constitutes
December 8, 1894]
MEDICAL RECORD.
723
a positive poison. Such a condition is bad enough for
healthy subjects, but for the cases under discussion, in
whom the amount of vitality is below par, is a serious
drawback to our efforts in overcoming this diathesis.
Exercise. — As the child grows older, and especially
during the period of youth, exercise is important as a
prophylactic measure. In considering the subject of
food we pointed out the necessity of increasing the nitro-
genous elements ; but this is only possible as it is com-
bined with active physical exercise. The nitrogen as-
similated is stored up, principally in the muscular tissue,
and as this is increased and developed a correspondingly
large amount of nitrogen is stored up.
£1 considering the different forms of exercise it will be
well to select, as far as possible, those which, of neces-
sity, must be performed in the open air, as fresh air is
thus obtained at the same time. Bicycle riding is an
excellent form of exercise, providing a faulty position is
not adopted ; also brisk walking, especially when taken
with some definite purpose other than for its own sake.
Swimming, horseback-riding, and, in short, all recog-
nized forms of healthy out-door exercise will accomplish
the desired end.
Besides these there are special forms of exercise which
apply particularly to these subjects in whom there are
frequently found a poor chest development and deficient
long expansion. Perhaps one of the best means for over-
coming these defects is the exercise of swimming, in
which there is, of necessity, a forced inspiration and a
special development of some, if not all, of the muscles of
respiration.
In addition to these there is the exercise with the so-
called chest-weights, and how much can be accomplished
by these and other forms of gymnasium apparatus has
been recently shown in a paper read before this Society
by Dr. Gardner Smith. The only objection to exercise
in the gymnasium is the poor ventilation frequently
found there, but this is a fault easily remedied. A sim-
ple yet practicable means of increasing the lung expan-
sion, including the apices, which, in these cases, are so
apt to be partially collapsed, is that in which the subject,
when walking in the open air, inhales slowly and deeply,
and then retains the air in his lungs for a few steps, when
he gradually exhales. In this way I have seen the lung
capacity markedly increased. To some of these patients,
on account of business, daily open-air exercise or that in
the gymnasium is an impossibility. In these cases I
advise the purchasing of a chest weight apparatus, which
is placed in the bath-room and used every morning for a
short time, followed by a cool plunge-bath and brisk
rubbing. The latter serves the purposes of cleanliness,
an active tonic, and a means of hardening the skin,
thereby lessening the liability to " catch cold." The in-
terest of the patient in his increasing muscular develop-
ment removes the sense of irksomeness from the exercise,
and the after effects of the cool bath are such that it soon
becomes a great pleasure, and not to be foregone by one
who has become accustomed to its use.
These are a few of the salient points in the hygienic
treatment of this condition. I have made no mention
of drugs because, in the majority of cases, they are not
called for, though often their treatment is dismissed with
a prescription for cod-liver oil. Any intercurrent disease
must be treated on its own merits, and this includes the
surgical measures indicated in diseases of the respiratory
tract, to which we should pay special attention.
In closing, let me again emphasize the fact that the
etiology of tuberculosis is twofold, and that in the proph-
ylactic treatment we should pay as much attention to
the diathesis as to the tubercle bacillus.
My excuse, if one is needed, for confining myself in
this paper to the consideration of the diathesis, is that I
feel that this side of the question is too often neglected
in practice, and that while the exact nature of this dia-
thesis is theoretical, the treatment based on this theory
is highly satisfactory.
41 Wot 136th Stubs t.
The Surgery of the Gall-bladder and Bile -ducts,
with Brief Notes of Seventy Eight Oases.— Dr. Rob-
son speaks of the most prominent symptoms and com-
plications of cases of cholelithiasis which have come
under his observation: 1. Spasms or biliary colic with-
out jaundice, the attacks being repeated at longer or
shorter intervals, a. Collapse due to the intensity of
the pain. 3. Spasms followed by evanescent jaundice.
4. Pain followed by persistent jaundice and enlargement
of the liver. 5. Hydrops of the gall-bladder without
jaundice. 6. Ileus due to atony of the bowel. 7. Acute
intestinal obstruction due to paralysis of the gut from
local peritonitis, volvulus of the small intestine, or im-
paction of a large gallstone in some part of the intes-
tine.
In the majority of these cases, where medical treat-
ment has failed, surgical procedures hold out very good
hope of success in nearly every complication, if the pa-
tient be not too much exhausted. Cases complicated
with malignant diseases are very unfavorable for opera-
tion. First, because the subjects of cancer are, as a rule,
cachectic and worn down by disease before the surgeon
is called in; and, secondly, because such patients are
prone to hemorrhage at the time of the operation or
subsequently. The author claims that there is consider-
able risk in operating on patients that are markedly
jaundiced, on account of hemorrhage, but more espe-
cially as the jaundice is frequently associated with malig-
nant disease. In order to avert the danger of hemor-
rhage in jaundiced patients the author has found that
the administration of chloride of calcium for a few days
before the operation makes the blood more plastic and
lessens the tendency to bleeding both at the time of
operation and subsequently. In jaundiced cases he pre-
fers ligating all bleeding points rather than trust press-
ure forceps. In all of the cases operated upon by the
author, in which there was malignant disease with jaun-
dice, the gall- bladder formed a perceptible tumor,
whereas, when the jaundice was dependent upon gall-
stones, no marked tumor was present. A valuable diag-
nostic point, the author claims, is tenderness on pressure
over some point between the eighth or ninth costal car-
tilage and the umbilicus. The so-called diagnostic opera-
tion of sounding for gall-stones and aspiration of a dis-
tended gall-bladder the author believes to be futile and
dangerous, and is much better replaced by a small ex-
ploratory incision, when treatment can at the same time
be carried out, if required. The indications for operat-
ing in these cases the author gives as follows : 1. Fre-
quently recurring biliary colic, without jaundice, with or
without enlargement of the gall-bladder. 2. Persistent
jaundice ushered in by pain. 3. Empyema of the gall-
bladder. 4. Peritonitis starting in the region of the
liver. 5. Purulent collections about the gall- bladder.
If the bladder and ducts can be cleared without much
difficulty, the opening in the gall- bladder can be sutured
to the aponeurosis and drained. If the ducts cannot be
cleared, one of the following procedures may be carried
out: 1. Cholelithotrity, the stone being crushed be-
tween the finger and thumb or by padded forceps, a.
Choledodectomy, opening the duct, removing the stone,
and suturing the duct afterward. A drainage-tube should
always be inserted in the right kidney pouch in these
cases. 3. Cholecystenterostomy. This operation may
be easily performed if the gall-bladder be dilated. The
author prefers the decalcified bone bobbin, as only two
sutures must be applied. 4. The daily injection of fluids
after an interval of some days, through the cholecystot-
omy opening, which will either soften or dissolve the
concretion. For this, hot water, or a solution of
taurochlorate of soda, may be used, or, as the author
prefers, injections of olive oil or a five per cent, solution
of oleic acid. 5. Cholecystectomy may be required as
724
MEDICAL RECORD.
[December 8, 1894
a secondary operation in cases of stricture of the cystic
duct, the common duct being free. With but very few
exceptions a vertical incision along the upper part of the
right similunar line gives ample room. — The British
Medical Journal.
The Treatment of Obstructive Jaundice.— Dr. Dujar-
din-Beaumetz divides this condition into three classes
with reference to its causation: 1. Obliteration from a
calculus. 2. Obliteration from inflammation. 3. Ob-
literation from compression by tumors — the last belong-
ing exclusively to the domain of surgery.
Hepatic calculi are more frequent in women, and it is
probable that the corset is an important factor in their
causation, which is further aided by the usual costo-
superior type of respiration. In these cases systematic
massage can do much in relieving the causative factor.
Of the cholagogues, the watery alcoholic extracts, as
podophyllin, cascarUlin, and euonymin, and even so-
dium salicylate, can be of service. To these should be
added alkalies, as the waters of Vichy or Vals. For the
treatment of hepatic colic two agents have recently been
introduced — oil and glycerine. The oil has been the
subject of numerous papers, and has achieved consider-
able success, but it possesses the marked inconvenience
of being repugnant to the patients, and they swallow
with considerable difficulty, at one time, the large
amount (seven ounces) which is required. Glycerine in
much smaller quantity, two and one-half to five drachms,
appears to be equally effective, either given clear or
mixed with water. If the latter fails, then it is necessary
to resort to anodyne suppositories, ether sprays over the
hepatic region, hypodermatic injection of morphine and
atropine, or even of chloroform if the pain is acute. The
obliteration from inflammatory action, which is usually
the consequence of a duodenitis, requires different treat-
ment. The duodenitis may be the result Qf an excessive
alimentation in quality and quantity, or an incomplete
mastication. It is necessary to regulate and increase
the number of meals — for each meal, by giving rise to
reflex phenomena, produces an increased flow of bile.
Irritant foods must be avoided — those which increase
the gastric acidity, especially alcohol and liquids con-
taining it. In the advanced stages it is necessary to re-
sort to intestinal antiseptics, of which the most in use
are salol, benzonaphthol, and the salicylates. Salol,
usually the best of all, is here unavailing, because the
bile being arrested, the contents of the duodenum are
acid, and no decomposition of the drug occurs. To ob-
tain antiseptic effects from benzonaphthol one drachm
or more each day is required. Of the salicylates, bis-
muth salicylate is the best. Since this colors the faeces
it is difficult to arrive at a true understanding of the
patient's condition ; to avoid this inconvenience asaprol *
has been substituted with advantage. Calomel is useful
because it is at the same time a purgative and an antisep-
tic ; but it should be used with caution if the treatment
is to be prolonged. Constipation is always an impor-
tant symptom, and the use of Rubinat, Carabana, Vil-
lacabras, and even Carlsbad is advisable. Pancreatin
may be useful in some cases. — American Journal of the
Medical Sciences.
Stomach-reefing. — This operation has been performed
by Dr. Brandt for dilatation of the stomach. It is well
known that the stomach becomes enlarged in cases of py-
loric stenosis due to new growth, cicatricial contraction,
or bands of adhesions. The rational treatment of this
stomach trouble is the removal of the cause. This is
accomplished by pylorus resection and excision of pylo-
ric cicatrices, which have been so successfully done during
the past few years. It sometimes happens, however, that
after opening the abdomen no such a cause is found for the
dilatation. If the wound is closed, the laparotomy has
been nothing more than an explorative operation, and
the patient continues to suffer from the disease, the case
being then regarded as a medical one and a subject for
medical treatment. It has occurred to Brandt to treat
these idiopathic cases by diminishing the size of the
stomach by folding in its wall and suturing it through
the serosa and muscularis. The patient upon whom he
operated was a woman, twenty-six years of age. The
gastric sound could be introduced till it struck thepubes
and left Poupart's ligament. Palpation revealed no tu-
mor of the pyloric or other region, nor even an abnor-
mal resistance. The patient was poorly nourished and
greatly reduced in strength. She was treated medici-
nally by faradization and lavage of the stomach, with little
improvement. After this treatment had been carried on
for two months, Brandt made an opening into the abdo-
men parallel with the left costal arch, and explored the
stomach and other abdominal contents. The pylorus
was especially examined, and nothing found. The or-
gan was found enormously enlarged. He then proceeded
to fold in the anterior wall and suture it by two rows of
transverse sutures. The same was done on the posterior
wall through holes torn through the great omentum.
More than two hundred sutures were applied. The pa-
tient made an excellent recovery, without any disturb-
ance of digestion, and was able to leave her bed on the
tenth day. Brandt has published this case as preliminary
to a more exhaustive communication upon the subject.
The same operation has been described under the head
of " gastrorapie " in the same periodical. — Annals of
Surgery.
A New Method of Resecting the Rectum.— Dr. Rou-
tier described (Chirurgical Society, Paris) a method of
resecting the rectum as devised by Moulonguet, a modi-
fication of Kraske's operation. The first step is the same
as in Kraske's operation ; the sphincter is then dissected
out, and even though the lower portion of the rectum is
found healthy, it is cut away instead of being preserved,
as in Kraske's operation. The sphincter, after having
been dissected out, is lined by the upper portion of the
rectum, which is pulled down for this purpose and sutured
to the edges of the wound at the anus. The perineo-
sacral wound is then sewn up, with a drain in the lower
portion. In Dr. Routier's estimation the usefulness of
the operation is rather limited, especially to cases in which
the cancer is not situated high up, and in cases in which
the sphincter is intact.
The Lnoculability of Cancer. — Dr. Gratia reported,
at the Academy of Medicine, Brussels, a series of experi-
ments, in which he had employed grafting and inocula-
tion, with the object of proving or disproving the
inoculability of cancer. The result of his experiments
led him to conclude that cancer does not seem to be
inoculable even between individuals of the same species.
He likewise feels justified in making the following state-
ments: 1. The parasitic nature of cancer has not been
satisfactorily proved. 2. The direct or indirect conta-
giousness of this neoplasm has not been proved ; the
most that can be admitted, in the present state of our
knowledge on this subject, being the possibility of ingraft-
ing, that is to say, transplanting cancer, and that only in
individuals exhibiting exceptional predisposition such as
cancerous patients themselves. 3. The etiology and
pathogenesis of cancer are still undetermined.
Myxcedema and Thyroid Therapy. — Ewald presented
to the Medical Society of Berlin a woman, aged fifty-two,
who had been treated for myxoedema by the use of the thy-
roid gland in tabloid form. The three points to which
he called attention in the report of the case were : 1.
The complete failure of all other forms of treatment.
It was also peculiar that the hypodermatic use of the
thyroid extract had been fruitless. 2. Investigation of
the products of retrograde and constructive metamor-
phosis showed, in contradiction to what has been re-
ported by English and Danish observers, that the urinary
constituents were not increased. 3. The presence of a
considerable quantity of sugar in the urine. He was
unable to decide whether this was due to the method of
treatment or an intercurrent complication.
December 8, 1894]
MEDICAL RECORD.
725
Medical Record: .
A Weekly Journal of Medicine and Surgery.
GEORGE F. SHRADY, A.M., M.D., Editor.
Publishers
WM. WOOD & CO., 43, 45, & 47 East Tenth Street.
New York, December 8, 1894.
A NATIONAL BOARD OF HEALTH.
The President of the United States, in his recent mes-
sage to Congress, formally and forcibly recommends the
establishment of a National Board of Health, or Na-
tional Officer, having under his control or advice matters
pertaining to the 'protection of the country against pes-
tilence and disease.
It can be easily seen, by the wording of his recommen-
dation, that the establishment of a new Department of
Government is not intended or considered at present
necessary. This is the view which has been taken by
leading sanitarians all over the country, and is the one
that has been voiced by the Academy of Medicine in its
carefully prepared bill.
There is little doubt that, with the generous and united
support of the profession, the Academy bill, or one of
similar tenor, could soon be made a law. It is equally
certain to all acquainted with the feeling at Washington,
that the attempt to establish at once a new department
and a new cabinet officer would fail. No such thing has
ever yet been done since the foundation of the Govern-
ment. The Department of Agriculture, for example, for
many years was simply a Bureau, and had its usefulness
tested in this way.
If medical opinion cordially supports the project
for a Bureau, it will get it ; the rest will come in good
time.
THE ORAL EDUCATION OF THE DEAF.
The Churchman for December 1st contains an illustrated
article by S. Millington Miller, M.D., on the above
topic. The writer defends, with a considerable array of
facts, the superiority of the new oral system of educating
those congenitally, or otherwise, afflicted with dumb-
ness.
The particular facts which he employs with most tell-
ing effect are, first, that the intermarriage of deaf men
and deaf women, necessarily thrown together by the
manual sign-alphabet system, produces children a large
proportion of whom are congenitally deaf; and, second,
that orally educated deaf persons can mingle without dis-
ability with the world at large, while the manually edu-
cated cannot. He also points out that all Europe is oral,
and that America is lagging instead of leading.
It seems that some eleven years ago that very distin-
guished physicist and inventor, Dr. A. Graham Bell, an-
nounced that a series of investigations pushed in all di-
rections, and as exhaustive as he could make them at that
time, showed that one-third of the total number of chil-
dren of deaf and dumb parents were congenitally deaf.
This means that they are also dumb, so far as articulate
speech is concerned. In other words, he had been
forced to the conclusion that the method of instructing
the deaf then mainly in vogue (by the manual alphabet-
sign system), isolated deaf men and deaf women from
society in general, facilitated their intermarriage, and
was therefore developing a deaf and dumb species of the
human race.
Since that paper appeared, statistics bearing on this
subject multipled exceedingly, and they have all been
sent to a gentleman who is an instructor in a manual in-
stitution, Dr. Fay, of the Gallaudet College, in Washing-
ton.
Those interested in such matters have been long ex-
pecting the publication of these reports, but their appear-
ance has been most persistently delayed.
Within the past few weeks, however, Dr. Fay has writ-
ten to the Philadelphia Press, stating that he is now
busily engaged in sorting out and arranging this interest-
ing matter, and will publish it at the earliest possible mo-
ment. It was decided by those who advised the placing
of it in Dr. Fay's hands, that he was the person most
competent to handle the subject.
According to conservative authorities there is one deaf
person in the United States to every fifteen hundred
units of population. Others place the proportion as high
as one in every twelve hundred. We take it for granted,
therefore, that there are some fifty thousand deaf persons
in round numbers, in a total population of sixty- five
million people. As there are at least ten persons more
or less directly interested in the welfare of each deal
person, we have a total of half a million people to whom
the method employed in educating a person so afflicted
is a matter of vital interest Two-thirds of these fifty
thousand deaf persons were either born deaf or have be-
come so under the age of two years. They are, therefore,
dumb as regards articulate speech.
There have been various systems invented for the edu-
cation of the deaf. One of the earliest references to
the treatment of the deaf occurs in Bede's History,
where Bishop John is spoken of as curing " a dummy
man by blessing of him." The earliest schools for the
instruction of the deaf were those of Pedro Ponce de
Leon, in Spain, and of Jerem Garden, in Italy. Both
of these men flourished in the sixteenth century, and
their method of instruction in both cases was oral.
The cure of the deaf was universally regarded at that
time as a miracle, and its instances were sedulously fos-
tered as such by the Roman Catholic Church.
Jean Paul Bonet introduced and taught the single-hand
alphabet in Spain in the first half of the seventeenth cen-
tury. In the latter part of the eighteenth century three
great schools were started : that of the Braidwoods, in
Edinburgh; that of Samuel Heinecke, in Germany;
and that of the Abbfe de l'£p6e, in France. The Braid-
wood system was a mixed sign and oral education, and
was carried on by the family of that name for years as a
sort of trade monopoly. Samuel Heinecke taught pure
oral speech. The system of the Abb6 de r£p£e consisted
entirely in a series of conventional and pantomimic signs.
Among the latter were included the drawing together of
726
MEDICAL RECORD.
[December 8, 1894
the shoulders and shivering to indicate " feeling cold ; "
nodding the head to express assent! and shaking it as a
sign of dissent. Besides such natural signs as these, the
benevolent Abb6 invented a number of conventional or
arbitrary signs to express certain ideas. The most primi-
tive races of mankind conversed in signs, and some of
these earliest pantomimic signs still survive among civil-
ized people, and are likely to last forever by reason of
their terse expressiveness.
So it occurs that some of the most natural and forcible
of the Abb£ signs are still taught in connection with
the one-hand alphabet. The letters of this alphabet are
formed by the rapid juxtaposition of the fingers of one
hand. They are arbitrary letters, not at all like the
stately and rounded capitals of the copy-book, but still
the child learns by their combination to spell out words
and form sentences, and so to converse with other deaf
children similarly instructed, and with its teachers. In a
manual-sign school, speech is regarded as an accomplish-
ment. The graduate of a manual school can only com-
municate with those unacquainted with his language —
signs — by means of a writing pad.
But revenons d nos mautons. It was the general belief
of continental Europe at the time when these great
schools began their career, that mentality, or thought,
could not be successfully carried on by any other me-
dium than that of articulate speech. The system of
r£pee was therefore a startling innovation, as he had
taught the oral system previous to his elaboration of the
sign method.
The first American mover in this same benevolent
purpose to remedy a prevalent affliction of humanity was
Francis Green, who flourished in the latter part of the
last century in Boston. He secured statistics showing
the existence at that period of at least seventy deaf folk
in Massachusetts. And he made strenuous efforts to start
a school for them in Boston, but unsuccessfully.
Early in the present century Col. Boiling, of Virginia,
two of whose children were deaf, made arrangements
with the Braidwoods to send one of their number to this
country who should found a school in America, and thus
allow two continents the privilege of their monopoly.
In 181 7, Dr. Thomas Gallaudet was sent abroad from
Boston to study the Braidwood system, but its founders
were so economical of their monopolistic right that the
Doctor wended his way to France, visited the manual
school of the Abb6 de l'£pee, then conducted by his suc-
cessor, the Abb6 Sicard, spent several years in Paris, and
brought back with him the deaf-mute Laurent Clerc as
an assistant in the school then opened in Hartford, Conn.
The oral method was never introduced into America
until 1887. In the following year the president of the
National Gallaudet College in Washington called together
in that city a meeting of the American manualists to
take action against the new heresy. But the seed had
been planted in a good soil and grew.
In 1880, a great convention was held in Milan, Italy,
to settle forever in Europe the question of how the deaf
should be taught ; to arbitrate between Purist (oralists)
and Non Purists (manualists). Dr. E. M. Gallaudet was
present at that convention. Since that day every child
in Continental Europe who is deaf has been taught by
the pure oral system. The very school of de L'^pee has
become an oral school.
But matters were by no means so easily cut and dried
in England, until some five years ago, when a Royal Com-
mission was appointed by the Crown and experts sum-
moned to London at the expense of the English Govern-
ment Dr. Bell and Dr. Gallaudet went from America.
The decision of this Commission was that every child who
was thus afflicted in Great Britain should be taught for one
year by the pure oral method. And only then be turned
back into the manual-sign system if it was clear that the
oral system was not suited to its individual requirements.
This country is therefore now going through the same
scientific birth-pangs as did Continental Europe before
the 1880 convention of Milan. " Verbum sapientibus"
would seem to be the only criticism needed.
There are practically only two methods in vogue at
the present day for teaching the deaf— the oral method
(teaching by and through articulate speech), and the
manual-sign alphabet method. Under both methods the
child is taught writing, composition, arithmetic, spelling,
geography, and all the English branches. The methods
differ distinctly in that the oral system endows its grad-
uate with articulate speech, and that the manual- sign
system does not.
THE MODERN TREND OF GERMAN MEDI-
CINE.
It used to be the reproach of medical science in Ger-
many that it was not practical, that its students con-
cerned themselves little with what should be the end and
aim of the physician, namely the cure of disease, the re-
lief of suffering, and the saving of life. Once the diag-
nosis made, all interest in the patient ceased, unless in-
deed he chanced to die, when he again became an
object of interest for pathological purposes. The re-
proach was not undeserved, although it was somewhat
exaggerated. But now things have changed, and a ques-
tion of therapeutics arouses as great interest as did
formerly one of pathology. This change is 'well illus-
trated by the comparative sale of two subscription works
now being issued in the German language. One, edited
by Penzoldt and Stintzing, devoted chiefly to the treat-
ment of disease, is having, so we are informed, a very
large sale, while the work edited by Nothnagel, the ten-
dency of which is chiefly pathological, is meeting with
but indifferent success. The cause for this change is
doubtless the hope of cure that has been aroused by dis-
coveries in bacteriology. Formerly it was nearly all
guess-work and empiricism, but now there is a basis upon
which to build a science of therapeutics, and inspired
with the hope of success, the German shows that he is
just as willing to save his patients as is anyone else, pro-
vided he has an incentive for trying.
Garbage Cremation. — According to the Inventive Age
there are now fifty-five towns and cities in England
which destroy their garbage and solid refuse by burning,
using an average of about ten furnaces each for that pur-
pose. The combustion of the material is used for the
generation of steam, by which the streets are electrically
illuminated, and other cities are reported to be consider-
ing the propriety of reducing their municipal expenses
by this means.
December 8, 1894]
MEDICAL RECORD.
727
gtexxxs tit tfie $S8teefL
President Cleveland's Recommendation ef a National
Board of Health.— President Cleveland, in his message to
Congress, makes the following recommendation : " I am
entirely convinced that we ought not to be longer with-
out a national board of health or national health officer
charged with no other duties than such as pertain to the
protection of our country from the invasion of pestilence
and disease. This would involve the establishment, by
such board or officer, of proper quarantine precautions,
or the necessary aid and counsel to local authorities on
the subject, prompt advice and assistance to local boards
of health or health officers in the suppression of con-
tagious disease, and in cases where there are no such
local boards or officers, the immediate direction by the
national board or officer of measures of suppression, con-
stant and authentic information concerning the health of
foreign countries and all parts of our own country as re-
lated to contagious diseases ; and consideration of regu-
lations to be enforced in foreign ports to prevent the in-
troduction of contagion into our cities, and the measures
which should be adopted to secure their enforcement.
There seems to be at this time a decided inclination to
discuss measures of protection against contagious diseases
in international conference, with a view of adopting means
of mutual assistance. The creation of such a national
health establishment would greatly aid our standing in
such conferences, and improve our opportunities to avail
ourselves of their benefits. I earnestly recommend the
inauguration of a national board of health or similar na-
tional instrumentality, believing the same to be a needed
precaution against contagious disease and in the interest
of the safety and health of our people."
The Causa of the Czar's Death.— We have received a
copy of the official notice giving forth the nature of the
malady to which the Czar succumbed. The diagnosis
made by the physicians in attendance, Dxs. Leyden,
Zakharin, Girsh, P. Popoff, and Weliaminoff, was con-
firmed in the main by the results of the autopsy per-
formed the following day. This diagnosis was " chronic
interstitial nephritis with secondary disease of the heart
and vessels, and hemorrhagic infarction of the left lung
with secondary pneumonia." The following is a trans-
lation of the report of the autopsy: On October 22,
1S94, at 7.30 o'clock in the evening, we, the undersigned,
upon the occasion of embalming the body of the Em-
peror Alexander Alexandrovich, asleep in God, found
the lesions described below. There was considerable
oedema of the subcutaneous connective tissue of the lower
extremities, with a punctate redness over the left leg. In
the left pleural cavity was 200 c.c. of serous effusion of
a reddish color; in the right cavity 50 c.c. of a similar
fluid. There was an old fibrous cicatrix at the apex of
the right lung, and this lung was somewhat oedematous ;
in the left lung there was oedema of the upper lobe and
a hemorrhagic infarct in the lower lobe, and this lobe
was also congested and contained very little air. The
infarct was situated at the upper edge of the lower lobe
and presented a triangular form on section, measuring
ij4 ctm. in length by 1 ctm. on cross section. In
the pericardium there was 50 c.c. of a blood-stained
serous effusion. The heart was considerably increased in
size, measuring 17 ctm. in length and 18 ctm. in width.
In the subserous cellular tissue there was a large amount
of fat (lipomatosis cordis). The left heart was dilated
and the wall of the left ventricle was hypertrophied
(2 j£ ctm.) ; the muscular tissue was pale, flabby, and of
a yellowish color (degeneratio adiposa myocardii). The
muscular wall of the right ventricle was thinned (6 mm.),
and of the same yellowish color. The valvular apparatus
was perfectly normal. In the abdominal cavity was about
200 c.c. of serous fluid. There was a large collection of
gas in the stomach and intestines. The liver was slightly
enlarged and greatly congested. The kidneys presented
the following measurements: left, 16 ctm. in length,
7 ctm. in width, and 4 ctm. in thickness; right, 15 ctm.
in length, 6]/2 ctm. in width, and 4 eta- in thickness.
The capsules were of ordinary thickness and not adher-
ent. The surface of the kidneys was finely granular and
of a dark-red color. The organs were not noticeably
hardened. The cortical substance was reduced in thick-
ness (6 to 7 mm.) and yellowish, the medullary portion
was dark* red in color (nephritis interstitialis'cum atrophia
substantiva corticitis venum granulosa). In addition
there was a serous cyst 3 mm. in diameter in the left kid-
ney. Upon a basis of what has been above described,
we conclude that the Emperor Alexander Alexandrovich
died from paralysis of the heart due to degeneration of
the muscle of the hypertrophied heart, and interstitial
nephritis (granular atrophy of the kidneys). The report
is signed by Drs. Klein, Zernoff, M. A. Popoff, Altuk-
hoff, and Bielousoff.
Professor Baginsky and Antitoxin. — Professor Bagin-
sky, of Berlin, writes concerning his article in October
6th issue, and desires the following correction :
Instead of: "It was difficult to ascertain the cause of
the disease : Twenty-five cases which had been exposed
to diphtheria were carefully examined a number of days,
and all developed diphtheria. As they were examined
daily, they were attended when the first symptom ap-
peared. Not one of these developed nephritis nor car-
diac trouble. Their sisters and brothers, who had been
previously admitted to the hospital, some as severe cases,
died. All twenty-five cases were discharged cured."
The above should read thus : " It was extremely diffi-
cult to ascertain the real cause of the disease from the
relatives. We have had a number of children, twenty five
in all, brought to us on the same day that their brothers
and sisters were admitted as diphtheria patients, care-
fully examined them, and found these children perfectly
healthy. These children were brought to us for in-
spection daily, and took sick some on one, two, or
several days afterward. So that in these twenty-five
cases we are really depending on proper statistics in the
beginning of the disease. All of these latter patients
got well and were discharged cured. In not a single
case did any symptom of cardiac or nephritic complica-
tion manifest itself. Whereas, the brothers and sisters
that were first brought to us developed not only severe
types of diphtheria, and some proved fatal."
Statistics in the Medical Department of the Navy.
— The new form of statistical report recently issued by
Surgeon-General Tryon will not only be appreciated by
the medical corps of the navy, but by the profession at
728
MEDICAL RECORD.
[December 8, 1894
large. The nomenclature of diseases (adopted by the
Royal College of Physicians and Surgeons, England) in
use in the navy for many years has been abolished, and
a classification substituted on the basis of modern require-
ments. The new system, commencing January, 1895,
will enforce interesting statistics rendered valuable on
account of their accuracy.
Charles T. Chase, M.D., of Brooklyn, died on No-
vember 5 th, aged sixty- three, the cause of his death hav-
ing been chronic interstitial nephritis. He was a well-
known practitioner of forty years' standing in Brooklyn,
and the son of Dr. Charles Chase, of the United States
Navy.
Dr. Hedges's Paper on Diphtheria.— By an oversight
of the printer the article of Dr. Hedges, on page 682, was
not indexed.
Football at Springfield.— We must confess to a dis-
tinct disappointment at the way in which the Harvard-
Yale game of football at Springfield was conducted this
year. The promise of reform in rules and discipline has
not been kept. The number of disabled men was un-
usually great, and there were several serious injuries;
that these were in every case the result of " accidents "
it seems to be difficult to admit. The rules may be
amended to any extent, but it profits nothing if they are
not or cannot be enforced. The penalty for slugging,
or for purposely attempting in any way to injure an an-
tagonist cannot be too severe or too severely enforced,
if this game is to be continued as a competitive sport
among college men. That a player may with impunity
jump on an antagonist prostrate on the ground with the
ball, after the whistle has been blown, and dislocate his
victim's clavicle, should be an impossibility. What the
umpire does not see, however, is supposed not to occur.
In so far as the umpire is blind he may, at least, in that
particular, be said to be a representative of justice; the
best pair of eyes may really miss some of the incidents
of the gridiron. Had the penalty of disqualification,
however, been rigidly enforced from the beginning of
the first half of this game, there would, we are convinced,
have been fewer subsequent "accidents." — Boston Medi-
cal and Surgical Journal.
Dr. William Gay Brockway died November 28th, at
181 West 134th Street, New York, aged thirty-four. He
was graduated from the University Medical College in
1887, and practised in Harlem until December last, when
he went to Florida for his health.
Dr. George R. Brash, of Sayville, L. I., died of dia-
betes on November 29th, at Colorado Springs, aged fifty-
nine. Dr. Brush was born at Smithtown, L. I. After
his graduation from the College of Physicians and Sur-
geons in 1858, he practised in this city and Sayville un-
til September, 1861, when he entered the navy as assist-
ant surgeon. He passed through the successive grades
until he became Medical Inspector in 1889, which rank
he held at the time of his death. He was detailed to the
Brooklyn Navy Yard in 1892.
A New Woman's Hospital. — The authorities of the
Woman's Hospital, at Park Avenue and Forty-ninth
Street, New York, are to erect a new hospital in Central
Park West, having acquired the block between Ninety-sec-
ond and Ninety-third Street, the plot extending back two
hundred and fifty-nine feet in Ninety- second Street and
two hundred and fifty in Ninety-third Street, with the
exception of one parcel of twenty-five feet in the latter
street Most of this property has been actually pur-
chased and the remainder is under contract. The cost
of the plot is 1331,000.
St. Mark's Hospital, New York.— Dr. H. J. Setoff has
been appointed attending surgeon to St. Mark's Hospi-
tal.
The New Surgeon-General of Hew Tork State V. Ck
is Dr. M. C. Terry, of Utica. He is a graduate of the
Cleveland, O. Homoeopathic Hospital College in 1872.
The Monteflore Home for Chronic Invalids. — The
new wing of the Montefiore Home was formally opened
on November 29th. The occasion was also the tenth
anniversary of the founding of the institution.
Bequests to Hospitals.— The late Henry Keney has
left 150,000 for the Hartford Hospital.
The Manhattan Dispensary, of this city, is the fortu-
nate recipient of a bequest of over one hundred thousand
dollars.
There seems to be Considerable Trouble in the Na-
tional Association of Railway Surgeons. The association
issues a special proclamation warning its members
against the proposed American Academy of Railway
Surgeons. Certain members of the N. A. R. S., in their
efforts to establish a rival society, says the resolution,
" have used fee- similes of letterheads of the railway sur-
geons for the purpose of producing a false impression as
to their standing with the members of this (N. A. R. S.)
association and its official organ and with railway sur-
geons, etc." Gentlemen, this is a N. A. R. S ty
trick, and, in the words of another, " You shouldn't ort
to have done it." We believe in fair play if you are
going to fight. — Medical Examiner.
A Tear's Immigration. — The annual report of Her-
man Stump, United States Superintendent of Immigra-
tion, shows that during the fiscal year ended June 30,
1894, 288,020 immigrants arrived in this country, of
whom 285,631 were landed and 2,389 debarred from
landing because of being under contract to perform labor
made previous to their arrival. Of the immigrants
landed, 96,000 were destined for New York State,
42,000 for Pennsylvania, 25,000 for Massachusetts, and
22,000 for Illinois, the others being scattered throughout
the United States, no other State receiving a greater
number than 10,000. Immigrants destined for southern
States, all told, did not exceed 12,000. Of the immi-
grants over sixteen years of age, 41,000 could not read
or write.
A German Temperance Society. — The German Soci-
ety Against the Abuse of Alcohol held its annual meet-
ing on September 18th and 19th, at Cassel. Among the
subjects discussed were Sunday afternoon closing and the
influence of women in the temperance movement.
Dartmouth Medical College held its annual com-
mencement November 20th, graduating a class of twenty-
seven.
An Epidemic of Diphtheria prevails in Yonkers, N. Y.
On November 23d there were fifty-six cases in the city.
December 8, 1894J
MEDICAL RECORD.
729
Jfacfcefeg imports*
NEW YORK ACADEMY OF MEDICINE.
SECTION ON GENERAL MEDICINE.
Stated Meeting, November 20, 1894.
W. H. Porter, M.D., Chairman.
Specimens illustrating varieties of biliary calculi were
presented by Drs. George P. Biggs and Morris Manges.
A B6sum6 of the Subject of Biliary Calculi. — Dr.
Thomas Southworth read a paper on the above sub-
ject, and in opening the discussion, Dr. Kinnicutt said
that the chemistry and symptomatology of biliary calculi
had been described very thoroughly in Dr. Southworth's
interesting paper. He had little or nothing new to say,
yet it might be useful to refer to some of the difficulties
of differentiation between certain lesions of the larger
ducts and gall bladder, produced by impacted calculi.
He would first refer to the differentiation between hy-
drops in the sense of a dilatation of the gall-bladder
through obstruction in the cystic duct, and empyema of
the gall-bladder on the one hand, and a catarrhal cho-
langitis produced by impacted biliary calculi in the com-
mon duct, also causing enlargement of the gall-bladder.
A differential diagnosis was very desirable, as in the
case of empyema, at least, prompt surgical interference
was indicated, while in dilatation with catarrhal cholan-
gitis, complete recovery frequently occurred without
operation. Although both hydrops and empyema of the
gall-bladder, as a rule, were produced by impacted cal-
culi in the cystic, rather than in the common, duct, and
hence were unattended with jaundice, nevertheless im-
pacted calculi in both cystic and common ducts were
not of uncommon occurrence.
In both empyema and catarrhal cholangitis, paroxysms
of chill, fever, and sweating of an irregular, or quotidian,
or tertian, or quartan type might be present. It was im-
portant to bear in mind that such symptoms occurred, as
a rule, in catarrhal cholangitis from impacted stones.
The fever often rose to a very considerable height. In
a case which was recently under his observation, a
severe chill was immediately followed by a rapid rise of
temperature to 1050 F., and again succeeded by profuse
sweating. Similar paroxysms of a quotidian type oc-
curred over a period of three weeks, and on operation
several large stones were found impacted in both the
cystic and common ducts, without either a trace of sup-
puration or the evidence, on the closest scrutiny, of any
lesion of the mucous membrane. The autopsy, the pa-
tient dying of uraemia, rendered a very careful study of
the ducts possible.
The true nature of hepatic fever associated with ca-
tarrhal cholangitis yet remains unsettled. It very cer-
tainly is not of a septic character. On the other hand,
an empyema of the gallbladder may exist with an entire
absence of chill, fever, and sweating. An interesting
case of this kind recently has been reported by Dr. Os-
ier, in which 150 c.c. of pus were removed from the
gall- bladder. A possible sign of differentiation between
hydrops and empyema of the gall-bladder, on the one
hand, and dilatation from an impacted calculus produc-
ing catarrhal cholangitis and hepatic fever, on the other,
may be looked for in the much greater enlargement of
the gall-bladder in the former instances. It is a clinical
fact, moreover, that in obstruction of the common duct,
even when the dilatation of the gall-bladder is found to
be very great, the physical signs of its enlargement are fre-
quently unappreciable. The explanation I am not prepared
to give, unless it be that through the distention of the
smaller ducts with bile in these cases, and the consequent
enlargement of the liver, the relations of liver and gall-
bladder are somewhat altered. A second point of differ-
entiation in favor of a catarrhal cholangitis with dilatation,
is in the persistence of the ague-like paroxysms over a
very considerable period of time ; cases are not uncom-
mon where such symptoms extend over an interval of
weeks, and even months.
In conclusion, Dr. Kinnicutt expressed his views in
regard to the indications for surgical interference in the
different conditions he had referred to. In simple hy-
drops from obstruction in the cystic duct or neck of the
gall-bladder, the indications were not very apparent,
although the passage of a large stone through ulceration
into the duodenum, and possible intestinal obstruction,
should be borne in mind. In empyema of the gall-blad-
der, speedy surgical interference was demanded. In
impaction of a calculus in the common duct, the pres-
ence of hepatic fever, even extending over a long period,
did not indicate operation in his judgment and from his
experience, unless the health seriously suffered thereby.
Complete recovery was entirely possible in such cases,
even after many months of persistence of these symptoms.
A number of cases with this outcome had passed under
his personal observation.
Dr. W. Gilman Thompson said that he was pleased to
see the specimens presented, for in addition to their
general interest some of them, by their great size, showed
that it was possible to exist in health without the use of
a gall-bladder, as they entirely occupied its cavity — a
fact that had also been demonstrated by the removal of
the gall-bladder without serious results. In the treatment
oi gall-stones it was possible that glycerine and ether
might dissolve the stone to a slight extent, but he had
not secured favorable results from the use of olive oil;
and as the oil is not taken up by the blood-vessels, but
by the lymphatics, one must conclude that the oil never
reaches the gall-bladder. Most of the "gall-stones"
found in the stools after giving oil, have turned out to be
nothing but inspissated oil. The subject of dietetic
treatment was one worthy of careful investigation, but
one on which little had been written. It is a matter of
interest to find whether cholesterin is a force-producer
that can be used in the system, or is only a waste prod-
uct. It seemed to him that it is not essentially a waste
product, for it exists in substances where we would not
look for waste matter. It is found in eggs, in pulses, and
other vegetables, in red blood-corpuscles, and in the
brain, and because it is present in these substances it
could reasonably be claimed that it is not a waste prod-
uct. The fact that it is found in the faeces and rarely
in the urine, might be cited to prove that it is waste ma-
terial, but the probability is that it never appears there
in any greater quantity than is taken into the system
with the food. As cholesterin is the substance from
which gall-stones are chiefly formed, it seems desirable
to avoid foods containing it, in the ordering of dietetic
treatment.
Dr. Thompson further said that in explanation of the
formation of gall-stones he did not see any need of a
bacterium, for we look to the precipitation of certain in- .
gredients of the bile as the true factor, and lime salts in
excess will do this. A large quantity of water should be
drunk, as it dilutes the bile and prevents further precipi-
tation.
Dr. Beverley Robinson said he thought that many
cases were diagnosed as gall stones that were not such ;
that there might be a distention of the gall-bladder and
severe colic without the presence of stone in the gall-
bladder or the ducts, and that such distention was often
wrongly attributed to gall-stones. He further said that
he did not believe gall stones occurred in young people,
unless in exceptional cases; also that there could be
spasms of the gall-bladder and hepatic duct, producing
pains similar to those of biliary colic.
Dr. Robert Abbe said he believed that the surgeons
were as conservative as the physicians, though they were
often looked upon as less conservative. He was confi-
dent that patients were sometimes operated upon for the
removal of gall stones who would recover without the
operation, yet there were cases in which an operation
730
MEDICAL RECORD.
[December 8, 1894
was a necessity. He had operated on about fifteen very
bad cases, and cited others in which an operation seemed
demanded, but the patients got well by passing the
stones. The operation was a comparatively simple one,
for there was no danger of a hernia, and drainage could
be secured without trouble. Dr. Abbe emphasized the
point that, opening the abdomen and examination of the
gall bladder was not enough for a sure diagnosis of stone,
for the gall-bladder was always found to contain consider-
able bile, and this would interfere with the discovery of
the stones. The operator could not be certain until he
had opened the gall-bladder itself. He had seen a case
that had been operated upon and no stones found, but
on a second operation and opening the gallbladder seven
stones were found. He said that he would hesitate most
in operating on the aged who had suffered from pains for
a number of years, and also in operating upon the young.
He cited a case of an expert cook who was accustomed to
serve in wealthy families, but biliary colic became so bad
every few weeks that it was impossible to retain a posi-
tion. He thought that in such a case it was very advis-
able] to perform an operation. Dr. Abbe also thought
that dietetic treatment was very important. Manipula-
tion was often of service, and in one case, that of a man
sixty years of age, the use of an ice enema and manipu-
lation caused the patient to pass a number of stones, and
thus gave relief.
Dr. Leonard Weber gave the history of several in-
teresting cases, and said that he had used an enema of
cold water with very good results, but had never used
ice for that purpose. One patient had passed four or
five hundred stones ; in another patient he had found a
stone surrounded by cancer, and in another there was a
cicatrix encircling the cystic duct.
Dr. Southworth, in closing, said that glycerine was
supposed to act by increasing the action of the hepatic
cells; that olive-oil probably reduced the size of the
formed stone ; that it was believed the cholesterin stone
was formed from the mucus of the bile-duct and gall-
bladder ; and that a stone could grow to large size in a
duct in a few days.
Clinical J^artment
A CASE OF CYSTIC DEGENERATION OF THE
CHORION.1
By L. W. ZWISOHN, M.D.,
NEW YORK.
ho
On January 3d, I was called to see Mrs. R. S ,
gave the following history: aged twenty-three ; mar-
ried three years ; has one child living, aged nineteen
months ; is greatly emaciated, has headache, sleeplessness,
and great debility. She was suffering from severe vom-
iting and thought she felt life ; on bimanual examination
I found the uterus very much enlarged and the os closed
— to all appearances a normal pregnancy. I advised per-
fect rest, and prescribed an anti-emetic. On January 10th
I was summoned in haste to see the patient. A hemor-
rhage had occurred and I deemed it necessary to tampon
the vagina ; I made cold applications and the hemor-
rhage was controlled ; the vomiting still continued and
I ordered moderate diet with cold drinks, which afforded
the patient some relief. On January 25th a second
hemorrhage occurred. I tamponed again, and six hours
later the os was well dilated. On introducing the finger
to examine the condition of the uterus a sudden and
rather severe hemorrhage occurred. I had no time
to prepare a proper tampon, but seized the nearest piece
of cotton at hand, and packed it into the vagina. Two
hours later an hydatidiform mole was removed piece-
meal, with the fingers of one hand in the uterus, and the
other hand making pressure from above externally. The
1 Read before the Harlem Medical Association.
friends would not allow the use of instruments, and as
there was no elevation of temperature I left the case to
nature, merely watching developments. Two days later
the mother of the patient presented to me the placenta,
which was expelled during the night. Since then the
patient has been doing well. Now the main points of
interest are :
x. Is vomiting one of the main symptoms of hydatid
cyst ? Thomas, Schroeder, and Tait do not mention it
Play fair says there is constant vomiting, and Polk has re-
ported a case which is similar to the case under consid-
eration.
2. Do we have positive signs to help in the diagnosis
of hydatidiform mole ? and what are they ?
3. Do they reappear in the same individual, and if so,
how frequently ? for how long a period is the mole re-
tained in the uterus ? Tait reported a case in which five
moles were removed from the same individual at differ-
ent periods. He says a mole is rarely retained more
than five months.
4. Is curetting advisable in cases of hydatid mole?
Thomas, Schroeder, and Tait do not mention this
operation ; Polk performed it in the case he reported, but
in that case he says the mass had a decided odor of de-
composition.
5. Is it possible that hydatidiform mole should occur
independently of co nception ?
To answer these important questions, I believe we
have to consider the etiology of the hydatid mole. The
chorion remaining attached to the uterine walls after the
expulsion or death of the embryo sometimes undergoes a
peculiar metamorphosis ; it differs, however, from the
true hydatids in absence of the acephlocysts and is also
unlike it in appearance and form ; the uterine hydatids
consist of little sacs in a series as if strung together,
hence their grape-like appearance; the true hydatids
are closed sacs, one within another. Giers and Graily
Hewitt say it always follows death of the foetus. The fact
that the morbid growth may owe its inception to foetal
disease seems demonstrated by the cases1 where a
healthy foetus may be developed at the moment with the
hydatid mole. Virchow thinks it originates in a morbid
state of the decidua, while others attribute it to some blood
dyscrasia on the part of the mother, such as syphilis. The
latter believes that it may occur more than once in the
same person, and that the exciting cause of the hydatid
mole is a morbid maternal condition. The probability
is that both views may be right, the disease sometimes
following the death of the embryo and at others being
the result of obscure maternal causes.
McCHntock says that hydatids may be retained in the
uterus for many months or years, or a portion only may
be expelled and the residue may throw out a fresh crop
of vesicles to be discharged on a future occasion. This
may be important from a legal point of view, for instance,
in the case of a widow or a woman living apart from her
husband. It is possible, as Playfair points out, that
true entozoa may form in the substance of the uterus,
which being expelled per vaginum might be taken for
the result of cystic disease. Hewitt also relates a case
of an unmarried woman in whom true hydatids from the
liver, had extended to the peritoneum and burst through
the vagina.
In such cases the woman's reputation may demand
that a careful examination of the cyst and its contents
should be made.
Symptoms. — The first physical sign is the rapid in-
crease of the uterine tumor, which does not correspond
in size to the supposed period of pregnancy. Leishman
attributed much importance to the unusual hardness or
density of the uterus. The uterine tumor is often irreg-
ular, and constant vomiting may be present. None of
these are, however, positive signs except the presence of
cysts in the watery and bloody discharge.
Dr. Holperin related to me two cases that came under
his observation in which there was hemorrhage in both,
» Spiegelberg, Lehrbtich, p. 33a.
December 8, 1894]
MEDICAL RECORD.
73*
and vomiting in one. In the second case he was unable
to tell, as he was called to deliver the mole and could
not obtain the history of the case.
Treatment — The uterus should be cleared of its con-
tents as soon as possible, and on account of the occa-
sional firm adhesions of the cystic mass to the uterus too
energetic attempts gat complete separation should be
avoided. . ... ;_^r" i-
Summary. — From the different opinions above quoted
we are justified in coming to the following conclusions:
1. Persistent vomiting is one of the principal symptoms,
but not a certain sign. 2. The only positive sign we
have is the presence of the cysts in the watery dis-
charge. 3. They frequently reappear in the same indi-
vidual, but for what period they are retained in the uterus
it is impossible to say. Although Tait says it is rarely
retained more than five months, it is quite possible, as
McClintock points out, that a portion may be expelled
and the residue may bring out a new crop. Thus the
five different periods in the same person of Tait may all
be from the first mole. 4. Curetting is advisable only
where the hemorrhage continues, and then with a dull
curette, as the parenchyma of the uterus may be affected
and its walls very thin. 5. Hydatidiform mole is essen-
tially connected with pregnancy.
ja6 East Seventy-eighth Street.
MENSTRUATION AND PREGNANCY — IMPAC-
TION OF A FOREIGN BODY IN THE OESOPH-
AGUS.
By R. H. PHILLIMORE, M.D.,
COOKSHIES, CANADA.
The following two cases are perhaps deserving of record :
Case I. — On October 5, 1893, I was hastily sum-
moned, at 2 a.m., to attend Mrs. C , an anaemic,
hard-working woman, aged thirty nine, and the mother
of eight children. She was suffering from severe pains,
with uterine hemorrhage. Examination showed the or-
gan to be considerably enlarged, with tenderness on
pressure. Naturally the first question to present itself
was, was the patient pregnant, and were the symptoms
those of threatened abortion ? She emphatically declared
that she was not pregnant, notwithstanding that the sa-
pient matrons in attendance were unanimous in their
belief that she was. Suitable agents were administered,
and the vagina was tamponed. I continued treating her
almost daily, up to the end of January, 1894, when the
severe hemorrhages, which had returned periodically,
ceased; and, though the menstrual epochs continued
regular, they were always attended with pain and con-
siderable constitutional disturbance.
From this time until the end of September, 1894, I
saw Mrs. C only on a few occasions, when she in-
formed me that the condition of the uterus remained
practically unchanged — it was still enlarged and tender,
and menstruation was regular. Toward the latter part
of this month she consulted me in regard to swelling of
the extremities, with puffiness of the eyelids. Examina-
tion of the urine exhibited only a trace of albumin.
On October 6, 1894, I was again hastily summoned.
" Mrs. C was flooding again." Upon examination
I found the uterus apparently in the same condition, and
the patient considerably "bloated." Menstruation, as
I have previously observed, had been perfectly regular,
and not so painful as on previous occasions. She com-
plained, as before, of pains in the back and legs. Ex-
ternal examination showed no change in the size of the
• uterus, but an internal examination revealed an os
slightly dilated, with a tumor presenting. I informed
the friends of the condition of the patient, but they,
being well acquainted with the previous history of the
case, ridiculed the idea of pregnancy, as also did the pa-
tient herself. On the morning of the 7th she was de-
livered of a female foetus, measuring S}4 inches in
length.
The following points in this case are interesting: 1,
Signs suggestive of pregnancy on first visit, eventually
proving erroneous ; 2, pregnancy present when not sus-
pected; 3, uninterrupted menstruation during preg-
nancy.
Case II. — On September 18, 1894, 1 was summoned
to attend a child, aged eighteen months, who at 11 a.m.
had swallowed an English farthing. Having placed the
patient under an anaesthetic, an examination of the throat
was made, but no obstacle was discovered, though a
horse-hair probang was employed. The following day
persistent vomiting ensued.
Patient was ordered milk with raw egg beaten up, solid
food being persistently rejected. On this diet the child
thrived. The parents having refused to allow another
examination — although I repeatedly expressed the opin-
ion that the coin was lodged in the throat — liquid diet
was daily administered. On October 7th, nineteen
days after the accident, the patient ate a quantity of
grapes in addition to its liquid diet. This was followed
by emesis, and the coin, considerably worn, was suddenly
expelled. The patient at once partook of a hearty re-
past, consisting of solid food, and has now entirely re-
covered from the effects of its financial embarrassment.
That the coin was impacted in the oesophagus there
can be no reasonable doubt, and the case is instructive
as indicating the difficulty of detecting foreign bodies in
this situation, and also the length of time which may
elapse without injury to the tube in which they are
lodged.
THE TREATMENT OF CARBUNCLE, WITH
REPORT OF A CASE.
By J. MORTON HOWELL, M.D.,
WASHINGTON COUKT HOUSE, O.
In the month of May of the present year, I was called to
see Mr. R. S. S , a man little past three score of years.
I had been treating him for some months previous, for a
severe prostatitis and functional albuminuria. There
had been but little loss of flesh as a result of the diseases
named, but the patient complained of weakness, and
was noticeably void of that vitality which was so charac-
teristic of him in former days. When I arrived, he told
me that he was suffering much pain in the small of his
back, and described it as a dull, heavy ache with intense
burning.
Upon examination, I found a circumscribed, oval, and
highly inflamed induration, situated immediately to
the left of the spinal column, at the juncture of the dor-
sal with the lumbar vertebra. It measured 5.75 inches
in its longer diameter, and was discharging pus from a
half dozen different openings. The sieve-like appearance
presented by the skin surface, together with the form of
the neoplasm and the character of the pain, made the
diagnosis one of ease.
Owing to the age and debility of my patient, together
with kidney and prostate trouble alluded to, the prog-
nosis could be but grave. To adopt a form of treatment
which would be most sure to land my patient upon the
side of recovery, was my desire.
An examination of authorities shows that comparatively
little is written upon this subject, which furnishes the
mortality that it does.
The modes of local treatment, as suggested by the va-
rious writers, differ widely. For instance, Ashhurst and
the "Reference Handbook of the Medical Sciences,"
recommend, among other remedies, poultices, while they
are condemned by the "American Text- book of Sur-
gery."
Without noticing further the treatment as found m
our medical works, we will give our treatment of this
case, which we believe may be made applicable to any
732
MEDICAL RECORD.
[December 8, 1894
case. If it proves to be an instrument in the saving of
a life, or an assistance to our brother practitioner in his
mission to do good, it will have served its purpose.
After freezing the parts, two incisions were made,
crossing each other at right angles, being carried suffi-
ciently deep to include the healthy tissue beyond the lim-
its of the disease. Bleeding was tolerably free, and
after sponging the parts well with hot water (previously
boiled) a dressing was made by application of dry bo-
racic acid (Wyeth's impalpable powder) over which was
placed a thick layer of antiseptic gauze, previously satu-
rated with hot carbolized water. Over this gauze oiled
silk was placed, which retained the moisture almost to
perfection. The burning at once ceased, the pain dis-
appeared, and the patient was made so comfortable, that
in forty-eight hours he was doing his regular choring
about house and barn. The dressing was changed once
in every twenty- four hours. He was given a ferruginous
tonic, and placed upon a light but nutritious diet
I discharged my patient in eight days from my first
visit.
A CASE OF NEPHRECTOMY ON ACCOUNT
OF NEPHROLITHIASIS AND PYONEPHROSIS.
By HERMAN MYNTER, M.D.,
PROFESSOR OP SURGERY, NIAGARA UNIVERSITY, BUFFALO, N.Y.
John S , aged twenty- two, entered the Sisters' Hos-
pital on August 2, 1894, with the following history:
He had complained for the last seventeen years of
periodical attacks of pain in the back and left lumbar
region. Up to five months ago the attacks occurred
about once in six or eight weeks, with free intervals, ex-
tended downward in left scrotum and thigh and could
only be relieved by hypodermics of morphia. They
would suddenly cease and hours afterward he would pass,
with great pain, a whitish soft mass, which did not have
the appearance of a stone, and then a profuse flow of
scalding urine. During the last five months the above
symptoms had increased in severity and become continu-
ous. The patient had lost greatly in weight, suffered
from profuse night-sweats, loss of appetite, occasionally
a dry cough. The parents were healthy, but one brother
had died of consumption. At the examination the patient
appeared extremely emaciated and cachectic, with protrud-
ing cheekbones and hectic flush. Weight, 101 pounds.
There was great tenderness from pressure in left lumbar
region, but neither anteriorly nor posteriorly, standing or
lying, could any swelling or enlargement of the kidney be
discovered. He was also somewhat tender to pressure
over the right lumbar region. He passed about one quart
of urine in the first twenty-four hours, half of which was
pus. The urine had a color like chocolate, specific grav-
ity 1,030, acid reaction, and was loaded with albumin.
Microscopically nothing was seen but pus corpuscles.
By cystoscopic examination under cocaine anaesthesia
and after preliminary irrigation of the bladder, an excel-
lent view was immediately obtained of the fundus of the
bladder. The mucous membrane appeared perfectly
normal. The orifice of the right ureter was seen as a
small oblique slit, through which a swirl of healthy urine
passed every four or five seconds. Turning the cystoscope
toward the orifice of the left ureter I saw what appeared
to be a deep crater-formed ulcer, about two centimetres
in diameter. Nothing appeared for two or three min-
utes, when suddenly a cohesive, thick, yellowish mass
commenced to protrude through the crater, as thick ap-
parently as a little finger. When about two inches of-
this mass had entered the bladder, it disappeared from
view and was followed by a profuse discharge of yellow-
ish pus, which quickly obscured the field. As it was evi-
dent from this examination that the patient suffered
from a pyonephrosis of the left kidney and that the right
kidney was healthy, nephrectomy was advised, although
his condition was so miserable that it seemed impossible
he could survive such an operation. The operation was
performed on August 8th, under chloroform narcosis,
the patient having been stimulated for a couple of
days with hypodermics of strychnia, nitrorglycerine,
whiskey, and rectal alimentation. The pulse was then
130, weak; temperature had ranged between 1010 and
103 ° F. The incision was made along the erectus
spinas muscle ending near the crest of the ileum, combined
with an oblique incision along the whole lower border of
the twelfth rib. The kidney was almost wholly covered
by the ribs, strongly attached to the colon and the sur-
rounding tissue. During the process of enucleation,
which was extremely difficult on account of the strong
adhesions and its high' position, my whole arm almost
disappearing up to the elbow in the wound, a large ab-
scess in the kidney itself was ruptured, from which a large
amount of ill-smelling pus, estimated at one pint, escaped.
The hilus was at last reached, the kidney brought out
through the wound, two clamps attached on the hilus in
order to finish the operation quickly, and the kidney re-
moved. The ureter was as large as a finger. The
wound was disinfected with corrosive sublimate, loosely
packed with iodoform gauze and partly sutured. The
patient left the table in a state of profound shock, pulse-
less and with clammy perspiration, but by active stimu-
lation, he revived in a short time. The operation lasted
about three quarters of an hour.
The kidney preserved its general contour, but was
enormously enlarged, its volume being about six times
that of the normal. It measured seven inches in length,
four in width, and three in thickness. Its weight was
twenty-eight ounces ; but as at least one pint of pus es-
caped, its weight must have been about forty four
ounces — two and three quarter pounds. The capsule
was adherent and blended with the renal structure. The
color in no place was that of a normal kidney, but that
of fat and fibrous tissue.
The surface presented numerous large circumscribed
swellings which on palpation were soft and fluctuating,
and on incision were found to contain a thick, greenish,
tenacious pus. On the posterior surface was a large ab-
scess cavity, ruptured during the operation. On section
no normal kidney structure appeared. The upper third
was a mass of multilocular abscesses which intercom-
municated and contained pus of the same character pre-
viously described. The middle third was a mass of rat
and fibrous tissue ; lying in the latter was a large trian-
gular shaped stone, i^x^ inch, of a greenish-brown
color, irregular in shape, and with rough surface. The
lower third showed two abscesses, the larger being three-
fourths of an inch in diameter. In one of the abscesses in
the upper part a rough irregular stone was found. The
pelvis was greatly enlarged, full of pus, and contained
several cohesive, yellowish masses of necrotic tissue im-
pregnated with pus, like the one which was seen to pass
with the cystoscope. Scarcely any traces of kidney tis-
sue could be seen, and its function as a secreting gland
had probably long ceased.
August 9th.— Temperature, 102$ ° F. ; pulse, 130. He
has passed 19 ounces of urine since the operation, the
last of which is perfectly clear and normal. He is ex-
tremely weak and is given -fa gr. strychnia and yfo gr.
nitroglycerine every three hours hypodermatically. He
has taken one quart of milk during the night.
August roth. — Temperature, ror° F. ; pulse, 120 ; 28$
ounces of clear ^normal urine. Patient takes lots of
nourishment and rests well.
August nth. — Temperature, 99$° F. ; pulse, 126; 3r
ounces of urine. Clamps removed and cavity irrigated
and loosely packed with iodoform gauze.
August 1 2th. — Temperature, 990 F. ; pulse, ro8 ; 27
ounces of urine. Patient takes solid food.
August r3th. — Temperature, roo° F. ; pulse, no; 32
ounces of urine.
He gradually improved, passed from 35 to 45 ounces
of urine daily ; pulse and temperature became normal.
August 23d. — The dressing was found saturated with
December 8, 1894]
MEDICAL RECORD.
73$
fecal matter, a fistula evidently having formed into the
colon, but it healed in a couple of weeks.
August 25th. — The patient was sitting up ; the large
cavity had contracted so that only a small granulating
fistula was left. His weight had increased to 105
pounds, he felt perfectly well and was discharged to his
home.
September 22d. — Weight 137 pounds, a gain of 36
pounds : patient a picture of perfect robust health, urine
normal, fistula closed.
October 1st. — Weight 140 pounds.
October 12th. — Weight 147 pounds, patient has gone
to work in a machine shop.
The interest in this case is the ease with which the
diagnosis was made by aid of the electrical cystoscope,
and particularly the demonstration that the right kidney
was healthy, and therefore an operation advisable.
Only by operative means in two other ways— an explora-
tive laparotomy or an explorative suprapubic cystotomy
with catheterizing of ureters, could the diagnosis have
been cleared up, and there is no comparison between
these methods and the simple cystoscopic examination,
done without any danger to the exhausted patient. Cys-
toscopy necessitates, of course, that the bladder shall be
able to contain five ounces of clear fluid and that the
cystoscope shall be able to enter the bladder ; luckily
both indications were fulfilled in this case.
A second point of interest was the impossibility of
feeling and palpating the enormous kidney before opera-
tion. I can only explain this by the strong adhesions
of the lower segment of the kidney to the colon and
surrounding tissue, by which the kidney was forced to
enlarge upward and forward below the diaphragm. A
third point of interest was the long time, seventeen
years, in which the patient had suffered from nephrolith-
iasis without a distinct diagnosis having been made, and
the rapid and perfect recovery that followed the removal
of the diseased organ, the patient in seven weeks gaining
46 pounds in weight. I have during the last three years
performed nephrectomy four times. Two operations
were done on account of tuberculous kidneys. One of
these died on the fourth day of suppression of urine, and
the post-mortem examination showed the remaining
kidney to be tuberculous. A cystoscopic examination
would in this case probably have shown that the opera-
tion was contra-indicated. The second case recovered,
but died half a year later of general tuberculosis of the
urinary organs. The third operation was performed in
October, 1892, on account of a large sarcoma of the left
kidney in a lady fifty years of age. The patient re-
covered, and so far, two years after the operation, no
relapse has occurred and she is in perfect health.
Longevity among Physicians. — One of the most curious
statistical records that has been compiled this century is
that by Dr. Salzmann, of Essling, Wurtemburg, on the
average duration of life among physicians. He found in
going over the ancient records of the kingdom, that in
the sixteenth century, the average duration of life among
that class was but 36 5 years — in the seventeenth century
45 8 — in the eighteenth, 49 8, and at the present time
they reach the favorable average of 56.7. It appears
from the footnotes to the above that this very great in-
crease in longevity is due to the disappearance of the
"black pest," the introduction of vaccination, and the
great diminution in the number of typhus epidemics,
three classes of diseases which formerly decimated the
medical practitioners. — College and Clinical Record.
The Gift of a Hospital. — M. Henri Schneider, of
Creuzot, France, has built and presented to the town a
new hospital, with accommodation for one hundred and
fifty patients. The hospital was opened on September
1 8 th, with religious ceremonies conducted by Monsignor
Perraud, Bishop of Autun.
VERSION THREE WEEKS BEFORE DELIV-
ERY.
By G. STARKE, M.D.,
NEW YORK.
I beg to report the following case as of probable interest
to the medical profession :
Mrs. J. T. S , age at present twenty- four; height
about five feet four inches ; weight about one hundred
and twenty five pounds. Four years ago she was deliv-
ered of a child at seven months, the baby living but
twenty-four hours. Though a breech presentation, de-
livery at that age of foetus was easy. Two years ago I
delivered her at full term of a boy, also a breech presen-
tation, with forceps, after a rather severe labor, the child
being in a state of asphyxiation and only resuscitated
after half an hour's work, after the method recom-
mended by Dr. W. E. Forest in the Medical Record
of April 9, 1892. The boy at this date is hale and
hearty.
Mrs. S again became pregnant, and having had
her last menses December 5, 1893, expected to be con-
fined about September 12, 1894. I saw her on Septem-
ber 8th, and examining her, found another breech pre-
sentation, of which fact I informed her, and it had a
decided depressing effect upon her. I informed her that,
in view of her having had a hard time with the boy, and
his life at the time almost despaired of, if she consented
I would endeavor to perform version and make an al-
most certainty of the child being born alive, knowing
that she was very anxious for it, particularly if it should
be a girl. She consented, and I performed version, by
external manipulation alone, inside of ten minutes. Be-
fore leaving her, I assured myself by vaginal examina-
tion that the head was well placed in the pelvis, and the
occiput anterior by external palpation.
On September 14th she sent for me again, fearing that
the child had turned again to its former position during
sleep, but upon examination found it to occupy the same
position I had previously placed it in. She progressed
without ill consequences till September 28th, when I
was sent for at 8.30 p.m. Arriving at her house about
nine o'clock, I was informed that the waters had broken
half an hour before, as she was about to go out for a drive.
Upon examination found the os dilating, the head pre-
senting in the L. O. A. position. Though good pains
did not set in till eleven o'clock, she was delivered of a
girl baby at 12.30 a.m. on September 29th, and her
progress since then has been uneventful.
The interesting circumstance in this case to me is that
version, being intended to be performed only a day or
two previous to the expected time of expiration of her
pregnancy, was accidentally performed three weeks be-
fore delivery, a very unusual procedure. However, in
this case with most gratifying result, saving the mother
much pain and insuring a shorter labor, and saving me
very much anxiety.
The lesson to be drawn from this case is that version
can be performed much easier some time before labor
sets in, than after the uterine expelling forces have be-
gun to exert themselves, when the uterus usually resents
any severe interference or manipulation by grasping the
foetus tighter, often necessitating anaesthetics, besides
running grave risks of lacerating the uterine and foetal
tissues, and requiring at least two for the operation. I
had a similar case of a transverse presentation some two
years ago, where fortunately I was called in a day be-
fore the confinement and corrected the presentation, re-
sulting in an easy labor.
. I would recommend to all medical men having the
advancement of their profession at heart, in all doubtful
cases, and when possible, to examine their pregnant pa-
tients a week or two before their expected confinement,
for the ascertaining and correction of presentations ; the
same as we are recommended to examine their urine for
albumin to prevent complications.
x393 Frank us Avkkue.
734
MEDICAL RECORD.
[December 8, 1894
(fovreBvon&mcz.
BERIBERI AND BEANS.
To th* Editok or thb Medical Rkcokd.
Sir : In an editorial notice, Medical Record, Novem
ber 17, 1894, of "beriberi in New Jersey/1 you speak
of the " ill favored human cargo of a vessel from Navassa,
which has entered port at Perth Amboy. There seems
to be no doubt that faulty hygiene and lack of suitable
food were the factors determining the outbreak. Beans
furnished the principal food, it appears, during the two
weeks' voyage, and, strange as it may seem, this is just
the article of diet which Dr. Simmons recommended in
a monograph on the subject in 1880."
As I had the pleasure of assisting the late Dr. Sim-
mons in some of the details of that work, and as the
above reference may give a wrong impression, please
allow me the space to say that " there are beans and
beans," and that in his monograph Dr. Simmons lays
stress upon the peculiar kind of bean — a small red
variety — that has long found popular favor in the man-
agement and treatment of beriberi, once so prevalent in
Japan. The large common starchy bean has no value,
and I think he so states it, though I have not the paper
by me for reference.
In more recent years an unlooked-for confirmation of
the value of this bean as a food in cases of beriberi is
found in the fact of its large relative amount of albumi-
noid nitrogen composition. It has been ascertained that
the chief element in the production and prevalence of the
disease is the lack of the nitrogenous foodstuffs — particu-
larly of the fresh flesh sorts — in the habitual dietaries of
the natives. The multiple neuritis is in all probability
(as believed by some distinguished investigators in the
East Indies and Brazil) the result of the presence of a
specific micro-organism, only to be found in low lying,
moist countries, among races long deprived of albumi-
nous food. Navassa is notoriously an unwholesome guano
and phosphate island in the Caribbean Sea, occupied
mainly by contract laborers, often convicts, living under
great hardship for long periods. In the past few years
the isolated rock has been unpleasantly heard from, with
trials for murder under the jurisdiction of the criminal
courts of Baltimore. Under the circumstances the oc-
currence of beriberi can cause no surprise, and scurvy
cannot be unknown there.
At the last International Medical Congress at Rome,
a paper on beriberi was read by a Japanese naval medi-
cal officer — a delegate from the marine department of
his government— giving statistics and results of the pres-
ent management of the disease in their navy. With a
rearrangement of the dietary, the introduction of a large
increase of nitrogenous food elements, and a correspond-
ing diminution of the carbohydrates, the disease has been
gradually eliminated, and for 1893 few, if any, cases are
reported. It was formerly very prevalent.
Following a common rule, beriberi requires for its
evolution a soil and a specific micro-organism, in this in-
stance the lesion being fundamentally in the white nerve*
tissue of the peripheral nervous system. Want and mis-
ery, with deprivation of proper food— albumins of animal
origin mainly — will soon produce the disease in countries
of its endemic prevalence.
As an example of how beans will vary (coming back
to our subject) in relative composition, I append some
trustworthy analyses, made by Professor Atwater, of
Wesleyan University, at the Agricultural Experiment Sta-
tion, Storrs, Conn. If such differences occur under
equal conditions, what may be looked for with widely
varying quality of seeds, soil, and climate, in the relative
amounts of legumin, sulphur, phosphorus, and albumi-
nous nitrogen substances upon which the peculiarly nutri-
tive value of some kinds of beans depends ? Changes due
to parasites, fungi, bad keep, age, etc., are not consid-
ered, yet have a share in rendering unfit for consumption
foodstuffs, especially the leguminosae so much given to
ships.
Per cent.
Percent.
Water ; 1 1.46
Protein *9-92
Fat 1.81
Nitrogenous free extract 60.26
Fibre. .
Ash
Albuminoid nitrogen
Non-albuminoid nitrogen. .
3-*5
3-3©
2.78
0.41
8.32
35-*4
2048
25.86
4.84
5.26
5-40
a 24
Common, as
Purchased
Percent.
13.70
2 32
2.0I
6a 26
Very respectfully yours,
C. A. Siegfried, M.D.,
U. S. Navy.
U. S. Steamship Cincinnati, November 26, 1894.
PERMANGANATE OF POTASSIUM IN OPIUM
POISONING.
TO TMK KDITOB OF THB MXUCAL RjtCORD.
Sir: Having been unprofessionally criticised in your
journal on October 6th, by Dr. War field, in regard to
my article on the same subject as this brief reply, and
being again made the subject of ridicule from the pen of
the original discoverer of permanganate of potassium as
an antidote to morphine poisoning, Dr. Moor, please
allow me to reply. I would suggest to the two doctors
that they read the articles of Dr. Glenn Anderson, of
Montgomery, Dr. Joseph M. Rector, and Dr. Harding.
Dr. Warfield says that Dr. Moor pointed out plainly to
his medical brethren that the administration of potassium
permanganate would chemically render inert the amount
of morphine remaining in the stomach at the time of
administration. If Dr. Warfield has the correct version
of the discoverer's ideas of this new antidote, it will only
save the use of the stomach-pump in morphine poisoning
— nothing more. I will ask Dr. Warfield to read Dr.
Moor's original article, and then his reply to my article,
and I think he will be led to believe that Dr. Moor even
claims the permanganate to be more than a chemical
oxidizer in morphine poisoning. In his original article
Dr. Moor says that he considers the permanganate to be
the antidote, par excellence, for morphine poisoning, and
further : " I have strong reason to believe that the ad-
ministration of permanganate will be of service even after
absorption has taken place." After my patient was in a
fair way to recovery, Dr. Earnest suggested the perman-
ganate upon physiological grounds of its alleged effects.
I did not want to use it, as I had no faith in it, but know-
ing the patient to be in a fair condition, I yielded reluc-
tantly to the administration of the drug. I do not claim
that the permanganate did my patient any harm — it
merely deprived him for the time being of remedies that
would have been of positive benefit. I do not consider
permanganate of potassium to be a drug of any value in
opium poisoning.
C. Monroe McGuire, M.D.
Walsbnbuxg, Col.
Aloohol and the Bible. — Dr. Harnack, of Halle, has
published a brochure to show that the teachings of the
Bible are against the doctrines of the prohibitionists.
He cites a number of passages from both the Old and the
New Testaments in which wine is mentioned as a per-
missible, if not necessary, article of diet To " look not
upon the wine when it is red in the cup," he opposes
" take a little wine for thy stomach's sake.'9
Dr. M. Bessbach died a short time ago in Munich, at
the age of fifty-two years. He was author of the well-
known " Lehrbuch der physikalischen Heilmethoden,"
and joint author with Nothnagel of a treatise on thera-
peutics.
December 8, 1894J
MEDICAL RECORD.
735
Hero %xxstvnmmts.
AN ASEPTIC AND REALLY SURGICAL POCKET-
CASE.
By ROBERT H. M. DAWBARN, M.D.,
PROFESSOR OF OPERATIVE SURGERY, NEW YORK POLYCLINIC.
In the New York Medical Journal of October 19, 1889,
I described, and showed by illustration, a pocket case
for minor surgery, which at that time seemed to me
worthy of mention.. To-day the accompanying woodcut
gives some idea of an improvement upon that case, based
upon further experiment in the matter of compactness
and also of lightness. It seems to the writer that this
case, as now completed, combines a number of desiderata :
1. It is so shaped as to be able to fit into an upper
vest-pocket, and not to spoil the fit of a coat, being quite
thin.
2. The instruments are very compactly arranged, there
being no waste space. Indeed, the only criticism on the
case which occurs to the writer is that a little practice is
needed in order to replace instruments speedily after use.
3. The case itself is of aluminum, nickel- plated, as
also are the handles of the instruments. Consequently
a great gain is made in lightness. Indeed, this case, with
about double the number of instruments contained in any
other pocket- case, nevertheless is not at all heavy.
It was necessary to nickel the aluminum because of the
next point, namely,
4. If either case or instruments become soiled, they
may be sterilized in the usual way, by boiling, and to
avoid rust we always add an alkali, e.g., some washing-
soda. Now, it is known that alkali attacks aluminum,
hence the necessity for plating the case and the instru-
ment handles.
Contrast this ease of sterilizing with the condition
found in the ordinary leather, velvet lined pocket-case,
which is still the favorite with instrument dealers. In
course of time the latter becomes grimy with dust, and
malodorous from perspiration, and is impossible of
cleansing in a surgical sense.
5 . The selection of instruments is based upon common-
sense and the needs of practical surgery, and no one can
claim as much for the ordinary pocket-case. This latter,
for instance, rejoices in a single pair of artery-forceps.
Indeed, I have seen no other pocket case with more than
one, or at least two, pairs of haemostatic forceps, whereas
every surgeon knows that if one pair be needed, half a
dozen are likely to be. This new case contains six, and
the needle-holder may, if required, make a seventh.
Again, almost all cases which I have examined still
display that abomination, a jointed metallic catheter.
This instrument of torture never fits properly when it has
been screwed together a few times, and thereafter scrapes
the urethra viciously.
The knives are a weak point in most cases and show
amateur selection. For instance, there is always the
curved, sharp pointed bistoury — a thing which surgeons
do not use, because they never stab and cut out. It is
not even necessary to do so in opening a boil, in these
days of cocaine anaesthesia.
The knives are too numerous, as a rule, and the scalpels
have little, baby-blades. By shortening their handles it
is easy to make room for blades of adult size, with which
a thigh could be amputated if need be.
We may fairly criticise, too, the needles and needle-
holder ordinarily found ; both being still of the old-fash-
ioned type ; whereas surgeons use almost exclusively the
Hagedorn needles, and these cannot properly be grasped
by the ordinary holder. The advantage of the Hagedorn
needles is, that they cut in such a way as to aid haemos-
tasia when the suture is tied ; and also to diminish the
size of the scar left by the needle. The cut runs like the
buttonholes along the edge of a coat ; i.e., at right an
gles with the wound edge. And this is just the reverse
of the direction of the wound made by the old-fashioned
needle.
I beg to apologize to all surgeons for these trite re-
marks upon needles ; but inquiry of dealers shows that
the great bulk of the profession still buy and use the kind
which should be obsolete ; apparently not yet knowing
these points.
For a good many years, now, the writer has preferred
to all others the " patent eye " or "self- threading"
modification of Hagedorn. The Germans used them for
a long time before they were much noticed here. They
call them "Nahnadeln mit federndem Ohr." If prop-
erly made, the needle does not cut the thread at the eye,
and it can be threaded in a moment, with bloody or
otherwise sticky fingers, and in the dimmest light.
To continue this little critique : We commonly find in
pocket-cases some more or less sterile silk, by way of su-
ture and ligature material, lying in one of the dusty pock-
ets aforesaid. Of course suppuration follows its use;
otherwise it would disappoint us.
In the aluminum case, instead, will be found two little
bottles with rubber corks. Each contains a small glass
reel, and one is full of sterile silk, the other of sterile cat-
gut, medium sizes, each in absolute alcohol. Enough
surgically pure material is here to supply ligatures and
sutures for even a large operation.
The same little aluminum compartment which contains
our needles, finds room for a silver porte caustique ; and
also for a few bichloride of mercury tablets, wrapped in
rubber tissue ; enough for some quarts of antiseptic solu-
tion.
In conclusion, the list of contents is appended in full. As
to the catheter mentioned, it is a soft rubber Nfelaton cathe-
ter, of medium size ; and besides its obvious function, it
acts as an elastic buffer, preventing any rattling of instru-
ments within the case. It may also serve to constrict
some small member, as a finger, during operation. It
will supply, if sterile, drainage-tubing in emergency. A
two-inch section, with the aid of a large safety-pin, makes
a very fair tracheotomy tube for infants. It enables one,
with ease, to pass twine tied to it, through the nose into
the pharynx, and so out of the mouth, thereby permitting
instant control of nose-bleed by tamponing both anterior
and posterior nares.
Contents of Aluminum Case.
1 Scalpel, full-sized blade.
1 Long, narrow, straight, sharp-pointed bistoury (this
may be used as a tenotome).
1 Metacarpal saw.
1 Peaslee needle, curved (eye in point with handle;
for passing retention sutures).
1 Grooved director and aneurism- needle combined.
1 Pair dissecting forceps.
1 Pair mouse tooth forceps.
1 Volkmann sharp spoon (an instrument often needed).
1 Pair scissors, with French lock, for ease of cleansing.
1 Needle holder, with French lock ; which is also a
dressing-forceps and an artery forceps.
1 Silver parte- caustique.
1 Nelaton catheter.
1 Small package Hg. bichloride tablets, in rubber tissue.
2 Silver probes, one-eyed.
736
MEDICAL RECORD.
[December 8, 1894
2 Bottles, one containing silk, one catgut, in absolute al-
cohol.
6 Haemostatic clamps.
Assorted sizes of Hagedorn's "self-threading " needles.
The pocket-case thus described is made by Messrs.
Reynders & Co., of this city; and is sold at about the
cost of other pocket-cases.
Contagious Diseases — Weekly Statement— Report of
cases and deaths from contagious diseases reported to the
Sanitary Bureau, Health Department, for the week end-
ing December 1, 1894.
Tuberculosis
. Typhoid fever
Scarlet fever
Cerebrospinal meningitis,
Measles
Diphtheria
Small-pox
zoo
xxo
96
90
I
a
a
47
a
aoa
59
13
z
The Physical Strain Involved in High Speeds. — The
exaction that modern railroad speed makes on the phy-
sical stamina of railroad men is demonstrated in the fact
that seven engineers are required to take the Chicago
flyer out and seven back, says the Boston Transcript
The running time between New York and Chicago is
twenty-four hours, and the average speed is forty-eight
miles an hour. Each engineer and engine runs three
hours. Machine and man return with a slow train to
their starting-point to relieve the strain on both. Then
the engineer is given forty hours' rest before he goes on
the flyer again. This rest is absolute, no work of any
kind being required of the engineer. Though the
average speed is forty- eight miles an hour, the locomo-
tive must at some points be driven at sixty or more.
The physical strain on the men in the cab at those bursts
of speed is something terrible. The engineer has fifty
things to look out for, and is being shaken and swayed
all the time. The fireman is constantly feeding the in-
satiate furnace. On the run of the Empire State express
three tons of coal are shovelled from the tender into the
furnace between New York and Albany. It is not won*
derful that the engineers of this train are given alternate
days for rest and recuperation. Fast travel not only
wears out rails and machines, but human creatures' lives.
— Scientific American.
Origin of the Term Anaesthetic— Mr. Edgar Willett,
in a communication to the British Medical Journal, re-
cords a conversation he had with Oliver Wendell Holmes
when the latter was in England in 1886. The discus
sion had turned on the subject of anaesthetics, when he
said : " Do you know the origin of the term ? " On re-
ceiving a negative answer he replied, "Then I will tell
you. I believe it was I who invented it, and this is how
it occurred. Many years ago, when ether and chloroform
were only just coming into use, Morton, the dentist at
Boston, who was largely responsible for the introduction
of ether, came to me and asked me if I could suggest for
him a word which could be used for both drugs, and also
a word which would describe the effect produced by their
inhalation. After trying two or three words, aesthetic oc-
curred to me as meaning sensitive, and in consequence
anaesthetic as being insensitive easily followed, with
anaesthesia for the condition produced. That," he con-
cluded, "was, I believe, the origin of the term."
The Middle Tennessee Medical Association, a recently
organized society, held its first meeting in Nashville on
November 20 and 21, 1894. A number of interesting
papers were read and discussed, and the meeting was re-
garded as a success.
Contagiousness of Phthisis. — It has been decided in
Toronto that phthisis is a contagious disease, and ac-
cordingly the board of education has decided to forbid
children suffering from it to attend the public schools.
Count Leo Tolstoi is, as might have been expected
from a consideration of his other eccentricities, a pro-
nounced anti- vaccinationist. He holds that " the obfiga-*
tion of parents to let their children be subjected to opera-
tions deemed necessary by doctors seems to me as great
an outrage as the obligation of parents to subject their
children to school teaching imposed upon them by the
government."
Individual Communion Cups. — The Homoeopathic
Medical Society of the County of Philadelphia, at a re-
cent monthly meeting recommended the abolition, by
all churches, of the common communion cup, or chalice,
and the substitution of individual cups.
Against Christian Scienee. — The Humane Associa-
tion, at the closing session of its annual meeting, held
in Evansville, Ind., on October nth, adopted a resolu-
tion condemning, in strong terms, the practice of Chris-
tian Scientists, and urging all societies to investigate
any suspicious deaths, and prosecute, if they are found
to result from the ministrations of this doctrine.
Trusses. — Dr. A. Landerer, of Stuttgart, recommends
the use of rubber pads filled with glycerine for trusses.
He finds them durable as well as comfortable, and says
that they never cause atrophy of the tissues against which
they press.
The Czar's Death has been attributed by some imag-
inative newspaper correspondents to the effect of poison
secretly administered by Nihilist members of his house-
hold. This report is characterized by Dr. Leyden as pure
fiction. The post-mortem examination, as detailed else-
where, established the correctness of the diagnosis of
chronic nephritis, with commencing atrophy of the kid-
ney, secondary enlargement of the heart, and inflamma-
tion of the left lung. The stomach was intact.
BOOKS RECEIVED.
A Text- Book of Volumetric Analysis. By Henry W.
Schimps. 8vo, 400 pages. Price, $2.50. Publishers, John Wiley
& Sons, East Tenth Street, New York.
A Compend ok the Practice of Medicine. By Daniel E.
Hughes, M.D. 5th Physicians* Edition. 8vo, |>68 pages. Price,
$2.50. Publishers, P. Blakiston, Son & Co., Philadelphia, Pa.
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ON THE NEW USE OF SOME OLDER SCIENCES.
Being a Discourse on Degeneration and Its
Stigmata.1
By CHARLES L. DANA, A.M., M.D.,
NIW YOBK.
Gentlemen and Ladies : As I survey the medical activ-
ities of the present time they seem to be working in
three distinct streams of fruitful and progressive effort.
The first, and just now greatest, takes in all that may be
meant by bacteriology or the science of minute organisms.
Through this we are learning the secrets of disease and
health ; through it we shall some day, I hope, reach a
germ-free millennium, or at least learn to live unscathed
among our little enemies teeming in the air and dust.
Next, one finds that while medical men are abandon-
ing faith in old-time Homeric drugs and drugging, they
are working with an intenser energy than ever to perfect
the technical details of their art. In every branch exact-
ness of observation, precision in examination, and re
sourcefulness and ingenuity of treatment are increasing,
until the reproach that medicine is not a science is
slowly losing its force.
Finally, I see a new and extraordinary energy put forth
in the study of the physical characters of man, and the
significance of the lines along which each individual is
built. We are trying to read in man's general conforma-
tion the story of bos character, his weakness, his ca
parity, his power of resistance to disease and temptation
— in fine, his moral and intellectual endowments. It is
because this movement, though it has reached great pro-
portions in Europe, has made little impression here that
I propose to make one phase of it the subject of my re-
marks to-night.
It is a doctrine as old as Hippocrates that different
people have a special tendency to different diseases, and
that they react in different ways to the influences about
them ; that one will have catarrhs, another gout, another
rheumatism, and another consumption; that one is
lethargic, another nervous, and another melancholic. It
is not of these kinds of investigation that I shall speak ;
though this new science does in a certain measure what
the quasi-sciences of physiognomy and of phrenology, of
diathesis and temperament, once claimed to do. It does
not seek to accomplish its object, however, by feeling
the bumps on the head, or noting the lines on the palm,
or studying the hand-writing, or by mystic rites per-
formed over a lock of hair. It is a science quite differ-
ent from so-called phrenology, or physiognomy, or chiro-
mancy— arts which are merely incongruous collections
of fatuous guesswork. This coming science has no name
that yet specifically indicates its work. It is approached
on the one hand by anthropologists, and on the other by
students of nervous diseases, of insanity, and of crime,
and it receives accessions from the learned savants of the
universities and the modest instructors in the gymnasia.
It is a study of the human body in its largest signifi-
cance, a measurement of the capacity and fruitfulness of
the soil. By and by all the harmful microbes of the
earth will be subdued, and we will hear no more of them
except as curiosities in germs ; but the human soil, on
1 Delivered at the Anniversary Meeting of the New York Academy
of Medicine, November 28, 1894.
which they used to grow, will remain, with all its ever-
increasing complexity, and physicians will then have
only the functions of interpreting its values and patching
up its injuries or inherited defects.
A sort of dim foreshadowing of this science is found in
the history of physiognomy and its allied arts. I use the
word and touch upon the subject with some hesitation.
Five hundred years ago Petrus de Abano, of Italy, dis- •
coursed upon it and was subsequently burned for heresy,
secundum art cm } in the flames at Padua. Not longer ago
than the times of George II. all persons " fayning to have
knowledge of Phissiognomie or like Fantastical Ymagina-
cions " were deemed rogues and vagabonds, and liable to
be publicly whipped or sent to the house of correction.
The attempt to meastfi* a man by his looks, however, has
always been made, and its professional votaries have
crystallized their knowledge into many a scientific treat-
ise of admirable length and erudition. In those days
there were onychiologists, who read character from
the nails; podoscopists, who studied the signs in the
feet; metapo6copists, who read the face, and many
other subdivisions of the general art of fooling peo-
ple by examining certain fractions of their body.
The ancients, however, did not build their science up
securely; they could not resist the desire to mingle
prophecy with their imperfect divination, and as time
passed and knowledge grew, both prophecy and the
various arts of physiognomy declined.
A little over a hundred years ago a devout clergyman
of Switzerland, Louis Lavater, gave the last impulse to
this line of work in a most learned, pious, and industri-
ously written treatise on physiognomy, which he dedi-
cated to the promotion of religion and right thinking.
Lavater called attention to the striking way in which
physiognomy sometimes indicates the character and in-
telligence of the individual. Perhaps he overdid the
thing a little. His pictures of bad men were so fright-
ful that die reader's vanity was almost compelled to feel
that he must be good, while his virtuous faces were so
insipid as to excite self respecting men to a distinct de-
sire for vice.
The soul and intelligence, said Lavater, show them-
selves in the head and brow, and their centre is the eye ;
the moral life is indicated in the face, and its expression
centred in the nose and cheeks ; the animal and physi-
cal life are centred in the stomach. They showed their
predominance also in the mouth and chin.
One day Lavater made the mistake of thinking that
an executed assassin was an eminent philosopher and
preacher, Herder. Worse mistakes have been made,
but still such things impaired the dignity and secu-
rity of his already decadent system. Lavater's teach-
ings were too simple in theory for a science and too
complicated in practice for an art. His illustrations
remain, and his head of Satan in particular repre-
sents a character which no one can see without desiring
to resemble it. His physiognomy died in the arms of
a more successful form of philosophy.
It was only a few years later that an Austrian physician,
Dr. Gall, began his lectures on what is still known as phre-
nology. The story of how he noticed the bulging eyes of
his school fellows who surpassed him in their memory,
and of how he found big bumps over the ears of murder-
ers and over the temples of thieves is probably familiar
to many. It was at least part of the learning of my
school-days. Dr. Gall was an industrious enthusiast,
738
MEDICAL RECORD.
[December 15, 1894
and there is little in the phrenology of to day which is
not due to his labors, though he had able helpers and
successors in Spurzheim and Combe. Practical phrenol-
ogy now is really but a shrewd empiricism based on
physiognomy, and not upon the classical bumps at all.
Taking a standard phrenological bust as sold by the
professors of the art, I have drawn over the various
faculties, as indicated by Gall, lines by which I could
map out the functions of the different parts of the
brain, so far as they have been absolutely determined by
modern investigations. These show some curious juxta-
positions. Thus the bumps of murder or destructiveness,
and secretiveness which lie just above the ears, correspond
with the centre for hearing; the bump of thieving, which
is a little in front of the ear, lies over the centre for the
movements of the mouth ; while self-esteem and reverence
correspond with the more measured activities of the legs;
I find also that parental love is identical on the bust
' with the sense of sight, and hope with the motions of
the shoulders and arms. Perhaps some philosopher of
the future will reconcile these differences and construct
upon them an esoteric metaphysics; but at present it
seems to me that physiology has quite extinguished the
science of bumps. While the actual contributions of Dr.
Gall to science were small, his work called attention to
the importance of studying th^conformation of the
head and the function of the brain, and gave an impetus
to more serious and fruitful studies.
It is since Dr. Gall's time that the word " degenerate "
has become one of common usage in French literature,
running through works on heredity, social economy, art,
morality, crime, insanity, and disease in all its forms.
We find French literature full of articles upon degen-
eracy and civilization, degeneracy and crime, degen-
eracy and disease. There is in France a whole school
of the Decadents, as they more euphemistically are
called. The term has been adopted by the Germans,
and runs through the work of Lombroso and his fol-
lowers in Italy. In England and this country its use
and significance seem to me to be much less appreciated.
Yet since the first applications of the new science have
been toward helping us recognize those who belong to
the class known as degenerate and unstable, I shall de-
vote a little time to explaining what is meant by the
word.
The term has an unpleasant sound, and nobody likes
to hear dry expositions of depressing phenomena. The
New Yorker of to day will hardly tolerate a tragedy ; he
wants his drama farcical, his art sensuous, and his novels
with a pleasant hymeneal ending. I cannot believe it
possible for me to make a discourse on degeneracy at
once lucid and attractive. But if one will pass the tip
of the tongue over the roof of the mouth, five or six out
of every one hundred adults will feel a curious ridge along
the middle of the hard palate. This is called the torus
palatinus, and whoever has it possesses one very inter-
esting mark of degeneracy. The finding of this will, I
am sure, give a certain percentage of people a personal
interest in the subject, and will make them listen with
some quietude in order to learn if it has any painful sig-
nificance.
I do not need at this day to refute that shibboleth of
the Reign of Terror that all men are born equal. We all
know very well that babies start in life with very unlike
endowments. For the purposes of my explanations, how-
ever, I shall only say that some are born like and some are
born unlike their parents. Those who have more or less
fully the mental and physical characters of their family
are considered technically normal, while those unlike it
are degenerate. The degenerate are those who differ
from the average standard as set up by the family from
which they spring ; 'they are variations from the health-
fulness of mediocrity; they are the peculiar people.
Here, for example, is an illustration familiar to all. An
honest, healthy, and respectable couple have a number
of children ; most of them take after their parents more
or less closely and grow up honest, healthy, sturdy, per-
haps mediocre or somewhat more than mediocre men
and women. But one of the children is different : he is
wilful, perverse, impulsive, deceitful ; perhaps, however,
talented in music or art, in business or literature. He is
looked up to as the genius or the doubtful character of
the family, and all the friends wonder where he got his
endowments. He is one of the degenerate. If his tal-
ent overrides his moral imperfections he makes, perhaps,
a success of life, and he is called technically simply an
unstable, or popularly an erratic man. If his talents
and bad tendencies are pretty evenly balanced he is
called a degenerate of the superior type, while if he dis-
closes decided mental weakness or develops an epilepsy,
or hysteria, or some curious form of hypochondriasis, he
is called an inferior degenerate.
From this last class are fed also the insane and many
criminals. The weak-minded, imbecile, and the idiot
stand at the lowest level of the degenerate class. The
common characteristic of all is that they are variations
from the family average, they have mental faculties ard
physical powers not evenly balanced, and if they marry
they may accentuate the degeneracy, while eventually
their family becomes sterile and runs out This ten-
dency to sterility is the final and uniform criterion.
The histories of prominent families of Europe, aristo-
cratic and royal, are often cited as illustrations of this
phenomenon. But it is not confined to them, and we
see it in the country as often as in the cities.
There is, however, a brighter side to this picture.
The human race possesses a conservative force which
constantly tends to bring individuals back to the avenge
and healthy type. Giants do not breed giants, or dwarfs
dwarfs ; neither do idiots breed idiots, despite the reitera-
tion* of controversial journalism, nor do criminals breed
criminals. These classes have no children, or their chil-
dren are better than the parents. Men and women of gen-
ius, and even those of extraordinary talent, follow the same
rule. Their children tend to drop to the level. There
is a centripetal force that brings the generations back to
the type of the average man. No amount of acquired
aptitude or special skill is transmitted to the children,
though some of that with which one is naturally en-
dowed may be passed on. The degenerate class in all
its grades is a very large one, embracing five to ten per
cent, of adults ; few successful men can be said to be
free from the taint. And since perfect stability of the
organism is only found in the average, or some would say
commonplace man, it may be said that degeneracy is a
condition not altogether undesirable. Such a view is
quite justifiable. I am flying in the face of the old
adage, that the best possession in life is mens sana in cor-
pare sano ; but I do not think that perfect health and
perfect sanity are things that any individual should de-
sire. It is good for society as a whole, but not so for
the individual, or, I might parenthetically and profes-
sionally add, for the doctor.
I have often noticed that families with a streak of in-
sanity, or inebriety, in their membership number the
brilliant and successful men. Only the insanity, like
the boil, should affect the other man. No man of genius
had ever perfect physical proportions or perfectly stable
organizations. On the other hand, the portraits of beau-
tiful women are not the portraits of women who have
had great intellectual attainments, and the beauty of
women has only affected the world's history indirectly
through lower channels. Perfect beauty means medioc-
rity, and man's desire for the one is the force which
brings back the degenerate to the other.1 There is a
scientific justification for the fun which one of our daily
papers so often pokes at pulchritude. I do not mean
that one must be ugly in order to be brilliant, but only
that in women and men of talent or wickedness there is
» The well-known artist, Mr. A. B. Frost, is quoted by Robert
Bridges (The Bookbuyer.) as saying, referring to artists models:
14 1 might mention that there is a singular peculiarity about the wo-
men. All the handsome ones are stupid and can't put an idea into a
pose, and all the bright ones who can and will pose and help yon
work are decidedly plain both as to face and figure.'*
December 15, 1894]
MEDICAL RECORD.
739
some deviation from the standard type which the modern
sanitarian would call the normal.
Bat here I must make some important modifications
in my text. I have spoken as though there were but two
classes of people ; 1, the normal, which includes the great
majority ; 2, the degenerate. All writers have so far cho-
sen to make only these distinctions and have established
the signs by which to divide all humanity into the sheep
and the goats.
But in this, as it seems to me, one important element
is left out, or not sufficiently considered. While most
people may be what the modern aesthete or green carna-
tion critics call " middle-class," the remnant are not all
below the average, as their name " degenerate" would
imply. Assuming at least that the human race is slowly
progressing, it must be that the average man and woman
is also becoming of a slightly higher type ; and this in
turn must be because many of the variations from the
healthy average are distinctly above it. Some of the
people who have the peculiarities of instability and ten-
dency to die out, do nevertheless give birth to a more
vigorous stock than they themselves possess. In other
words, unless the world is growing worse there must be a
class of greater than average vigor, who may be called the
progressives or " regenerates.'1 There are, however, as
yet no anatomical marks known which distinguish these
as a type.
I hope I have made measurably clear the idea of de-
generacy as it has been developed and taught by latter-
day writers. It forms a class of which the members are
as far apart morally and intellectually as the possibilities
of human nature allow. Yet it has common characters
in the reproductive weakness, in the defects of physique,
and in the instability of their mental faculties. They
are all wanderers from the normal lines. Furthermore,
and this is die point to which I have all along been, very
slowly I fear, tending, they have about them certain
marks or stigmata which indicate their divergence, and
are badges of their servitude or of their freedom. The
study of these marks forms the application of modern-
ized physiognomy and anthropometry to the determina-
tion of the degenerate classes. This is the new use of
the older sciences.
In France, Moreau, Magnan, F6r6, and others have
followed up the work of Morel, who may be called the
father of the study of degeneracy. But undoubtedly the
greatest impulse has been given to these studies by Pro-
fessor Lombroso and his pupils. This eminent scientist
believes that criminals are unlike their own race, but re-
semble each other and are a family among themselves,
with a family likeness and common bodily peculiarities.
This conclusion is one to which I cannot at all agree,
and which I feel sure is not yet subscribed to by men of
science. The exact position in which Lombroso's work
stands, I shall refer to later. Meanwhile one cannot
overestimate the value of the impulse which he has given
to investigations of the human body. If there is ever to
be a complete and exact science by which we can in a
measure infer character from figure it will be very largely
due to the work of the great Italian criminologist.
I propose now, however, to go into some of the de-
tails of the curious discoveries that have been made by
investigators, not in Italy alone, but in all parts of the
world. I do it with the hope that my descriptions will
not lead to any unpleasant habits of self examination or
to surprises that act disagreeably upon one's vanity. I
shall take up the points somewhat at random, for I have
not time to present the subject in any systematic and
complete manner.
Of all the various systems of which the body is com-
posed, the bones have been thought to be allied most
completely with the development of the nervous system.
Sir William Gull once suggested that the Socratic ad-
vice yvtaOl <t€ovtcv should be interpreted in these days
" examine your urine ; " but the modern physiogno-
mist would rather say, " examine your bones."
A perfect bony system is a rather good index of vital-
ity at least, and its variations and anomalies make up a
large part of the stigmata of degeneracy. The presence
of excessively long arms, for example, is a phenomenon
greedily seized upon by the Italian school as indicating a
return to man's ape- like state, before he fell from grace
and his arborial gambols in primeval forests.1 But long
legs and a small chest are also found to be evidence of
degeneracy; and whatever may be said of the marks
written on the bones, none of them prove that their
anomalies aie signs of a return to savagery. Degeneracy
is not a form of atavism.
Naturally the conformation of the head and face has
been studied with much earnestness and much practical
success. The skull of man is never quite symmetrical,
but it tends to become so ; on the other hand, the brain
tends to become asymmetrical, i.e., the left side to be a
little larger than the right. When things go a little
wrong in the human make-up, the skull shows it quickly
by getting out of shape. The size does not count very
much, for we know that men of genius, like Gambetta,
have had skulls that would barely be large enough for a
boy. But odd shapes do signify. In olden times the
physiognomists thought that men of evil character
had a sugar-loaf (oxycephalic) skull, while Gall found his
murderer's bump over the ears. And modern criminol-
ogists lay much stress on the size of the jaws.
There are, at least, thirty ways in which the head va-
ries from the normal type. Many of these are most
trivial, and it is only on the principle that a dozen small
things make an object of respectable size that one is
justified in giving attention to the facts that are collected.
Ordinarily we look in a man's face to see whether it is
in general attractive, intelligent, interesting, beautiful,
or the reverse. But the anthropologist looks more
closely and hunts for his stigmata. One-third of all
thoroughly bad men, for example, according to Dr.
Penta, have a plagiocephalic or twisted-shaped skull.8
A still larger proportion,8 forty-five per cent., have pro-
jecting jaws, or prognathism, wide jaws (twenty- nine per
cent.), and wide orbits (thirty per cent.)
The nose in the criminal is often rectangular, short,
large, and upturned ; the face shows early wrinkles and
a peculiar pallor. The criminal jaw weighs 94 gm.
(3 ounces), the normal jaw but 80 gm. (2% ounces)
(Manouvries). The cheek-bones are prominent, the or-
bits are large, the frontal sinuses and brows protrude,
and the teeth are defective and badly placed. The shape
of the palate stands in close relation to that of the skull,
and the neat and workman like way in which nature
joins the parts in the middle shows that she has done
well elsewhere. When the palate has a ridge along its
centre, torus palatinusf or is high and narrow, or uneven
and badly shaped, we count it among the signs of degen-
eracy, though it weighs lightly in the scale. Criminals
have three or more of these various anomalies.
The size of the head, as already stated, counts perhaps
less than anything else, unless the deformity be greatly
exaggerated. The good and the bad, the sane and the
insane, have heads of about the same size, and even
prehistoric skulls do not show much inferiority. Civili-
zation began and completed its work with almost pre-
cisely the same amount of brain tissue.
The anomalies above described have a rather forbid-
ding and perhaps alarming sound, and it is pleasant to
know that individually they are not very significant. A
homely face can be quite free from the stigmata of sin,
while one of a fascinating and even beautiful type may
have much that suggests degeneracy.
» When the arms hang straight down by the side, the tip of the
middle finger is 14 ctm. , or about six inches from the knee-cap. In
negroes it is only five to eight ctm., or two to three inches (Krause).
■ Arch, de Psych., vol. xv. , p. 327.
•Ibid.
* Among 71 patients in the general wards at Bellevue Hospital I
iound a distinct torus in 4, and in a of these cases the patients had
nervous disease, in 57 patients examined in the alcoholic pavilion, I
found the torus in 11 cases, or twenty per cent. The torus is more
marked in inebriates than in the insane, though palates otherwise de-
ormed are more frequent in the latter class.
740
MEDICAL RECORD.
[December 15, 1894
There are, as artists and anatomists know, certain defi-
nite proportions between the circumferences of the neck,
shoulders, chest, waist, and hips. These proportions
differ for infants, men, and for women.1 Among the
unstable there are often found misfits in these propor-
tions, so that a man, for example, has approximately a
child's or woman's proportions. This condition is
known as feminism or infantilism, and many striking
illustrations of it have been shown by Dr. Charles F6r6,
of Paris. I have, I am sure, seen it in some classical stat-
ues, and I believe it will be found that the Greeks had a
certain unholy admiration for some of these beautiful
but perverted types of the human figure.
We everyday people have rather agreed to ignore the
ears, yet it is remarkable to what uses they lend them-
selves at the hand of science. Laycock thtiught that the
circulation in the ear was an accurate indication of that
in the brain, and that its development coincided with
that of the brain and skull. The ear to him was, to the
brain, as accurate an indicator as the tongue is to the
stomach. Mr. Ellis speaks of an observant schoolmistress
who could tell when her pupils were tired by the state of
the circulation in their ears. Professor Grandino, of
Turin, however, may be said to have done the ear the
most illustrious service. He has examined these organs
in twenty five thousand healthy men and women, besides
eight hundred insane and four hundred and sixty-seven
criminals. I have before me the typical%ear as it should
be, or at least as the Professor depicts it from the results
of his laborious studies. I must confess that after having
mastered its admirable symmetries I have gained a new
experience in aesthetics. For now it gives me a distinct
delight when I come across a perfect aural organ, such
as one experiences in seeing a beautiful picture or listen-
ing to the harmonies of an up-to-date sonata.
It is surprising how many shapes the ear may take
when one comes to look at it seriously in the light of a
newly growing science which is thirsty for morphologi-
cal data. There are at least seven distinct ways in which
the ear can be wrong ; each corresponding perhaps to a
deadly sin, for each is more prominent in the sinner than
in the saint. I am not going to enumerate these points,
for I cannot do it except in the most technical language,
and besides, I do not like to give people who are kind
enough to listen to my discourse any opportunity to form
a poor opinion of themselves. The long lobes and a
peculiar wrinkle in the cavity of the ear are the things
which have most significance.
One of the most curious things discovered by the pa-
tience of the neurologist has been the prehensile foot
(pied prihensile). Drs. Ottolenghi and Carrara examined
the toes of one hundred and sixty-two normal people,
thirty-one epileptics, fifty-six idiots, and three hundred
and fourteen criminals.3 Among normal people the
distance between the first and second toe at the base
rarely exceeds 3 mm. (£ inch) in men, while in the
abnormal classes such excess is three times as frequent.
The idiot classes seem to be especially marked with this
stigma, so that it would be inferred that the activity of
the intelligence is indicated in a measure by the distance
between the toes. This would seem absurd, were it not
that the peculiarity suggests a return to the prehensile
toe of the ape, and is therefore classed as a mark of ata-
vism.
I said some time ago that chiromancy had not been
taken up seriously by scientists. The lines and furrows
which have been studied as a parlor game, and about
which prophetic and pseudo scientific works have been
written, is mainly but guesswork. Yet the lines so deli-
JThe average circumferences in men and women are given by
Krause as follows, in centimetres :
Men. Women.
Circumference of neck. 34 3a
" at level of iliac region 70 73
" level of hip bone joints 81 84
" breadth between trochanters 34 35
• « shoulder breadth 39.1 35.2
" hip breadth 30.5 31.4
a Giorn. della R. Acad, di Med., 1892.
eatery arranged on the finger-tips are beginning to assume
some significance. Mr. Galton, in his work on finger-
marks, established the fact that they never change in the
same individual, and that they may be to a certain extent
classified. His investigations were confined to normal
people. Alix did the same for the finger tips of apes,
and now Forgeot, of Lyons, says that in young thieves
of Boulogne are traces of the same arrangements seen in
apes, and F6r6 finds them among sixteen per cent, of
epileptics.1
Much has been written about the hand ; artists have
depicted its perfections, physiognomists have interpreted
its shape and expression, cheirologists and the gypsy
queens have tried to prophecv from its markings. But
a study of its peculiarities by the inductive method takes
one into entirely new fields, and shows that to interpret
the significance of the hand one must start on quite new
lines. There is something perhaps in the fact that the
artistic hand has somewhat tapering fingers, but beyond
this one deals with uncertainties. And I recollect an
idiot youth whose extremities had the contour of a genius
or a Trilby.
If one examines the hands of a large number of per-
sons with a nervous endowment, he will find curious de-
fects in the length and relative proportions of the fingers.
The length of the finger is determined by that of the
middle one. If the index and medius are closed upon
the palm, the ring and little finger being left extended,
the middle finger will reach close to the place where the
so-called life-line runs down, between the ball of the
thumb and that of the little finger. It will touch the
palm just below the highest part of the ball of the
thumb.9 The middle finger is taken as the standard of
length by which to gauge that of the others. In a nor-
mal hand the forefinger reaches just to the root of the
nail of the middle finger, the ring finger is longer and
should reach nearly to the middle of the nail of the me-
dius, while the little finger should reach to the last joint
of the third finger. Now in inebriates, epileptics, neu-
rotics, and the degenerate generally, these proportions are
often not observed. The most common defect is short-
ness, especially of the third and little fingers, though
sometimes a disproportionate length occurs. Sometimes
these fingers are unnaturally slender or the little finger is
slightly bent. The most common abnormality of the
thumb is excessive shortness, with a defective mobility.
These peculiarities well accentuated form what we may
call the "decadent hand" — the hand that writes our
sensuous novels, the Hauptmann drama, paints sym-
bolic pictures, and exploits pure sestheticism. Such
hands may be well- formed to the ordinary eye, and may
be attached to slender and graceful limbs. But this
kind of beautiful hand and arm is found quite as often
among the children of alcoholics and among those
highly cultivated families which have become degenerated
by vices and vicious crossing.
The hair adds a little to our knowledge of the individ-
ual, but not very much. Light hair and blue eyes seem
to be dangerous endowments in the Italian race, but
this is not the case with the Anglo-Saxon. It may be a
comfort to know that hair grows plentifully on the heads
of criminals, and that prematurely bald men are rarely
bad, through any hereditary defect at least. The degen-
erate has often a thick head of hair and a thin beard,
while in modern society the normal man seems to be
equipped in just the opposite way. That twist of the
hair known as the crown of the head, should be in the
middle line, or very close to it, and no one is entitled
to more than one crown. When it is found shifted
off well to one side, or is doubled, the twist becomes
a stigma. Art and fashion permit one to tip the hat
slightly to the side, but nature orders that we wear
our crown in no jaunty or frolicsome mode. It is often
thought that an abundance of hair signified a vigorous
vitality, but this is not strictly the case. The excessive
1 Les Empreintes dfgitales, Lyon, 1891.
3 Fer6 : La Famille neuropathique, p. 281.
December 15, 1894]
MEDICAL RECORD.
741
development of hair on the body, particularly in women,
is regarded as one of die minor stigmata of degeneration.
My remarks would be both incomplete and misunder
stood if I left it to be inferred that degeneracy, in its
various forms, is determined by bodily marks alone.
There are two other classes of stigmata, the physiologi-
cal and the mental. Under the former, we include
peculiar defects in the function and practical working of
the body ; under the other we include certain mental
characteristics. The degenerate are apt to have an
unstable circulation and a deficient vitality that responds
abnomally to stimulants of various kinds. Mentally a
peculiar characteristic is a tendency to morbid fears, in-
trospection, idiosyncracies in taste, and impulsive acts.
These and many other of the stigmata occur in the
normal, however, and I do not propose to enter a branch
of the subject which is much less definitely worked out
and less susceptible of demonstration.
I have now described to you the gradual development
of a science of human measurement out of the cruder
sciences of physiognomy, temperament, and phrenol-
ogy.
The metaposcopist of the Greek school viewed the
body and detected in it signs of some dominant quality.
The man was quick and irascible like the dog, or slow
and sensuous like the pig, brave and forceful like the
lion, everyone resembling in feature or character some
lower animal. The medueval artist added to this the
science of divination and prophecy. In the times of
Lavater the physiognomist tried to interpret from the atti-
tude, the complexion, and features, the various complex
elements of the individual's disposition.
The phrenologist of the Gall school went still further,
and described all the intellectual and moral faculties,
mapping out for the man the total sum of his capacities,
his aptitudes, and his prospects in life.
The modern student of the human frame is much more
modest He asserts only that he can by the presence of
certain stigmata say whether the individual is of stable and
normal organization, or if he belongs to that class which I
have described as the degenerate. Nor does he pretend
to do this in all, but only in those whose defects are well-
defined and reasonably numerous. Perhaps every one
has some stigma of degeneration ; but at least five out of a
hundred adults have many and striking ones. The degree
of their degeneracy may be in a measure decided, but
cannot be determined by anatomical marks alone. And
it is on this point that I must differ from the Italian crimi-
nologists, who claim that there is a criminal, an insane, a
neuropathic type.
In conclusion, let me say that the final work of modern-
ized physiognomy will not be to fix upon human beings any
stigma which marks them as necessarily useless, defective,
or dangerous. We have not discovered a type of criminal
man, or of the insane man, or epileptic or neurotic man.
All these have common marks which show simply that
they belong to the same somewhat handicapped family.
Their presence in an individual will show that he must
be especially careful in educating and using his natural
power. The discovery of degeneracy throws an additional
responsibility upon him, for there are few so bad but that
with a proper environment they can get along successfully
in life.
There may be some born criminals, but they are very
few ; most are simply persons of degenerate type who fail
to husband properly the endowments they possess. We
do not excuse the cripple who attempts to become a
sprinter, nor should we excuse the morally defective who
indulges in debasing habits and low temptations.
All modern studies in the lines I am exploiting seem to
show that man must be more than ever careful of his edu-
cation, his training, and his surroundings, and of using
all possible moral and spiritual agencies to strengthen his
defects and make more stable his powers. The future of
the degenerate depends enormously upon these factors,
and his responsibility lies in his following that line of
life which is right for him. By this means one can ren-
der many defects harmless, and make the unstable almost
as firm in judgment and healthful in body as the happy
possessors of perfectly balanced organizations.
If I have succeeded in showing that this is to be the
end and teaching of modernized physiognomy, and shall
have aroused your interest in its progress, my object will
be accomplished to-night.
THE PRESENT STATUS OF THE SPECIFIC
TREATMENT OF DIPHTHERIA.
Bv PROFESSOR EDWIN KLEBS. M.D.,
ASHEVILLV, N. C.
FOBMEftLY OF THE UNIVERSITY CF ZURICH.
Upon my recent arrival in this country I found the great-
est interest manifested, both in professional circles and
by the laity, on the subject of diphtheria, and the greatest
expectations seemed to prevail on all sides from Behr-
ing's diphtheria antitoxin as a practically unfailing rem-
edy for the rapid cure of that disease.
The reliable information which has reached the pro-
fession in this country from Germany being compara-
tively meagre, and coming, as I did, directly from there,
and having through previous and more recent labors been
intimately connected and interested in the subject, I was
naturally interrogated on all sides as to my views, and
especially so by Dr. Shrady, the editor of this journal,
upon whose request I am pleased to state them herewith
for publication.
The use of pathogenic bacteria for the production of
curative remedies may be in two directions, and for two
purposes, first, by using their own secretion products
against them and for their destruction (the possibility of
which is apparent in the dying out of artificial cultures
long before the nutrient material is exhausted), and
secondly, by using these organisms for the production of
immunity by their direct introduction into the blood of
the animal.
In the first place, we will have to produce the curative
remedy from the culture fluids ; in the second, from the
fluids of animals in whom artificial immunity has been
produced. The question arises, "Which is the surest
and easiest method ? " The degree of immunity differs
materially in the various diseases due to specific disease-
germs ; it is, for instance, very great and long lasting in
variola, very small and of short duration in diphtheria,
and entirely wanting in pneumonia.
The second method adopted by Behring, to use the
serum of animals in which immunity has beea. produced,
can therefore only be followed for the cure of diseases
which secure at least a moderate degree of immunity to
persons having recovered from them, and if we accept
the results of experiments upon guinea-pigs as applying
also to man, diphtheria belongs to this class.
In this connection the clinical experience must not be
overlooked, that man may acquire diphtheria again,
after a short period from the time at winch all evidence
of the previous disease had entirely disappeared. I have
lately been able to report several such cases,1 while the
presence, for some time, of virulent diphtheria bacilli,
especially in the nose, after recovery from the disease,
and without the production of membranes, or of gen-
eral symptoms, speaks, nevertheless, for the production
of at least temporary immunity in man also. However
this may be, Behring certainly is entitled to credit for
having shown that a great degree of immunity from
diphtheria can be obtained in animals by the injections
of increasing large quantities of virulent diphtheria cult-
ures into their blood.
According to the results obtained in Europe, the
serum from such animals has certainly a high degree of
curative property, since by its subcutaneous injections all
fresh and light cases have been uniformly cured, and the
best series of reports of all cases (severe and light, in-
> Wiener Med. Wochenschrift, Nos. 31-53, 1894.
742
MEDICAL RECORD.
[December 15, 1894
eluding tracheotomy cases) have reached as high as
eighty- eight per cent, of recoveries.
Some observers, as for instance, Hahn, of the Fried-
richshain Hospital in Berlin, have expressed themselves
more doubtful as to their experience, and it is probable
that the variability in degree of individual cases caused
the difference in the results obtained. However, upon
these less favorable reports the injected quantities were
increased to 100 c.c. (a little over three fluid ounces),
especially by Ehrlich, and apparently with good re-
sults.
To come to an understanding, two questions will have
to be answered: 1st. Are there no dangers connected
with the use of Behring's serum ? 2d. Cannot the same
results be obtained in an easier and safer way?
As to the first question, the exponents of the serum
treatment accept it as a settled fact that no harm can
come from its use ; and so far as their experiments upon
animals show, they are entitled to this belief But that
it is also true as to man can by no means be accepted as
proven, if we will only remember that the very small
quantities of organic matter which we inoculate in vac-
cinating against small-pox have undoubtedly been the
means of transmission of human diseases, especially syph-
ilis and tuberculosis. Without, in the remotest sense,
affiliating with the opponents to vaccination, who, on ac-
count of occasional harm, would throw away the valuable
and life-saving discovery of Jenner, I recognize never-
theless the danger which experience shows to exist, and
believe that by abandoning human vaccine matter for
animal lymph the profession took an important step for
the prevention of incidental infection. But even bovine
vaccine matter is not absolutely safe, since we have no
guarantee of the absolutely perfect health of the animal.
For instance, calves are frequently found to suffer from
tuberculosis, without recognizable symptoms, and noth-
ing short of the killing of the calves and painstaking au-
topsies, as I inaugurated in Austria, before the vaccine
matter derived from them is used, can be considered as
having met all the precautions necessary, and to which
persons, espscially under compulsory vaccination, would
seem to be entitled. If, however, such precautions be-
come a duty in vaccination, where only the minutest
quantity of organic matter is inoculated, how much more
is it necessary to look to the absolutely perfect health of
animals from which we derive serum for the treatment of
disease, and of which it is proposed to inject 100 c.c. for
the cure of diphtheria ?
It is, indeed, well known that in the horse, which is
especially made use of for obtaining the serum, there
may exist latent diseases of infectious character, for in-
stance a chronic form of glanders may be confined for a
long time to the cavities of the head and nose, without
occasioning any discharge whatever, and with but little
or no glandular swelling, but which, nevertheless, may be
a source for fatal infection. Only the most careful post-
mortem examinations can guard us against the occasional
use of apparently healthy but nevertheless diseased ani-
mals, and the killing and examination of these animals is
necessary before their serum previously obtained is used
for therapeutic purposes. Nothing has as yet been said
or published on this aspect of the serum treatment, but
it should not be ignored because of the value of the ani-
mals and the long time necessary before they have been
brought to a state of sufficient immunity ; and since it is
only a question of money the State should step in and
take the matter under its supervision and control.
The exponents and followers of the serum treatment will
naturally reply that so far no harm has followed its appli-
cation. It is, however, not at ail shown that this dan-
ger has been sufficiently appreciated. Of the severer
cases twenty to thirty per cent, have terminated fatally
after applying the treatment, and who can maintain that
all the fetal cases were really due to the disease?
I willingly admit that the dangers spoken of may be
diminished to a small degree by the painstaking selection
of animals, but under all circumstances the obtaining of
serum for therapeutic purposes will ever be a very costly
method.
This leads me to the second question. Can we obtain
a bacterial curative substance for diphtheria in an easier
manner, which is safer and cheaper while equally effec-
tive ? I have for a long time followed the thought that
pathogenic bacteria, the same as all other living organ-
isms, secrete substances which are poisonous to them-
selves, of which the retention of excrementitious sab-
stances from the kidney and liver of man is a familiar
instance. In the case of pathogenic bacteria this is also
manifest from the fact that artificial cultures die out long
before they have exhausted the nutrient substances in their
culture media. This principle governed me in the use
of tuberculocidin and antiphthuan for the cure of tuber-
culosis, and also of antidiphtherine, which latter I have
proposed for the cure of diphtheria. That this principle
is correct becomes further evident from a number of
quantitative experiments made by me with tubercle
bacilli.
In the beginning of July of this year I prepared three
litre cultures, containing 500 c.c. each, of old and new
culture fluids (of sterilized glycerine, pepton, and meat
extract), and on July 14th I inoculated each with equal
quantities of tubercle bacilli, from the same source. The
results on August a ad were as follows :
No. 1 contained only old culture fluids ; in this culture
the tubercle bacilli had grown but little, did not cover
the surface, and their weight, after having been dried at
280 to 300 C, was only 0.046 gm.
No. 2 contained 300 c.c. old, and 200 c.c new culture
fluid ; the tubercle bacilli had grown better, covered the
surface more, but only in a very thin layer, without at-
tachment to the side of the flask ; their weight, determined
in the same manner, was 0.443 &&-
No. 3 contained 200 c.c. old, and 300 c.c. new cult-
ure fluid ; the culture approached more to a normal one,
covered the entire surface, and in a few points attached
itself to the side of the flask; the weight of tubercle ba-
cilli, determined in the same manner, was 2.586 gm.
The latter is about half, or slightly over, the weight of
the tubercle bacilli from a normal culture of equal size
and kind.
These experiments show that considerable quantities
of toxines must be formed before the growth of the
pathogenic germs is entirely prevented ; only upon en-
tirely ripe cultures is their growth impossible. But these
experiments show further that the growths in my ex-
periments have by no means reached the weight which
would correspond with the new culture fluid which was
added to the old.
If we take round figures, 500 c.c. of new culture
should furnish in a certain time 5 gm. dried tubercle
bacilli; 300 c.c. 3 gm. and 200 cc. 2 gm. The ex-
periment shows, however, that the weight fell short in
all. In No. 1, of exclusively old culture fluid, only the
one hundredth part was obtained ; in No. 2, instead of
3 gm. I obtained only 0.45 gm.; in No. 3, instead of 3
gm. only 2.5, showing that the presence of toxines in
the old culture fluids exert a damaging influence upon
growing tubercle bacilli.
Quite similar have been experiments with cultures of
other pathogenic germs, and we can accept as a law
that the diminished growth and the dying out of bacteria
depend upon accumulation of their secretions. The lat-
ter substances, which belong partly to the albuminoid
group, are partially toxic, and I distinguish therefore soz-
albumin and toxalbumin, which must be separated from
each other.
The soz-albumin from tubercle bacilli cultures is repre-
sented in antiphthisin, and of diphtheria bacilli cultures
in antidiphtherine. The cost of production of the latter
depends entirely upon the facilities for large or smaller
quantities, and it will be my endeavor to produce it so
cheaply that it will be within the reach of the poorest
family in the land, as soon as I shall have demonstrated
its clinical value. To this end I expect the arrival of a
December 15, 1894]
MEDICAL RECORD.
743
large shipment from my laboratory in Strassburg about
the first of the year, and it is my purpose to then furnish
the remedy free of all cost for the purpose of making
comparative trials of its value with that of the serum of
Bearing. For present comparison I have at my disposal
a series of fifty- one cases treated by various physicians in
Germany with antidiphtherine. Of these fifty-one cases
seven, or 13.7 per cent., died, and forty-four, or 86.27 per
cent., recovered. They include both light and severe
cases and such where tracheotomy was required.
A similar series of cases under serum treatment, re-
ported by Ehrlich, shows 13 3 per cent, of mortality and
86.7 per cent, of recoveries. The small difference may
depend upon the greater number of tracheotomies in my
cases. As to the results in the latter alone, I have five
deaths in eighteen cases, or a mortality of 27. 7 per cent.,
which is as favorable as under the serum treatment.
I have thus far applied the antidiphtherine only lo-
cally, believing that the process is a local one in the be-
ginning ; my investigations have shown me that the diph-
theria bacillus is chiefly found in the superficial layers of
diphtheritic membranes, and, as the latter become older,
in the advancing edges of its formation the bacillus may
be demonstrated, when none will be found in the central
portions. The application of antidiphtherine has been
free from all unfavorable effects whatever, and upon its
early, thorough, local use depend its prompt and curative
effects. Upon a suitable cotton-wrapped probe the rem-
edy is applied upon the diphtheritic patch, the latter
having first been cleansed with dry cotton — gently press-
ing and rubbing the soaked cotton upon the diphtheritic
and suspected patches, and leaving it in contact as long
as the patient can comfortably hold it. We repeat this
two or three times, and then swab the entire pharynx
and fauces; great gentleness, and at the same time thor-
oughness, are essential, especially with very young chil-
dren. In the latter we may, however, touch the greater
part of the fauces and pharynx with the cotton, at one
time holding the latter in a forceps with which we may
also pass upward behind the velum and naso pharynx if
we suspect trouble there. If none of the patches have
been omitted, the temperature fells in the course of three
to five hours, and a sense of well-being returns. If the
fever does not subside the application must be repeated,
and new patches be looked for. In their absence the
application mast be made in the nose and naso-pharynx
also, where patches may be hidden from recognition.
A new rise of temperature indicates a new develop-
ment either upon the old or a new focus, and the appli-
cations must thus be repeated more or less frequently ac-
cording to the course the cases pursue. Under the most
favorable course two or three applications should be made
daily until all evidence of disease in the throat has disap-
peared. The membrane soon loosens and is cast off,
leaving a smooth, shining surface, covered with epithe-
lium, a very important result, as thus streptococcus in-
fection is prevented.
The remedy may also be used subcutaneously or per
rectum, especially in severe and older cases. Beginning
with -^ c.c, and increasing by -^ c.c. every hour, we
reach 1 c.c. in nine hours, after which the same quantity
is repeated two or three times a day, or still increased, if
necessary. Animals bear the subcutaneous use without
any unfavorable effect. For the present in the human
subject I recommend that the action of the heart be
carefully observed during the subcutaneous use of this
preparation.
A Bew Medical Fraud.— An ingenious swindler is
going about the city, collecting money from poor people
under the pretence that he is an agent of the Board of
Health. He gives it out that a new law compels the
payment of $2 a year to the Board, of which he is the
collector, in return for which the physicians of the Board
will attend the family free of charge.
THE " OYSTER EPIDEMIC " OF TYPHOID FE-
VER AT WESLEYAN UNIVERSITY.
By H. W. CONN, Ph.D.,
nOFBSSOR OF BIOLOGY, WE SLR Y AN UNIVKBS1TY, M1DDLBTOWN, CONN.
While it has been for some time suspected that raw oys-
ters may be a possible means of the distribution of geim
diseases, there have been no cases where the theory has
been positively demonstrated. The recent outbreak of
typhoid at Wesleyan University is, in this respect, there-
fore, so unique as to be of especial interest, and for this
reason the results of the investigation as to the cause of
this outbreak are given below in some detail.
The history of the epidemic was as follows : About
October 20th there began to appear among the students a
number of cases of mild fever, which were for several days
not regarded as serious. After about a week, however,
one or two of them developed into typical typhoid fever,
and several others were suspected of being of the same
nature. For a week and a half following October 20th,
new cases appeared somewhat rapidly, and by November
1st there had appeared among the members of the col-
lege about twenty-three cases of fever of more or less
prominent typhoid character. After November 1st the
number of new cases diminished, although two appeared
on November ad, one on November 5th, and one as
late as November 9th. Subsequent to that period no
new cases have developed. There have been among the
students about twenty six cases of fever which have been,
with more or less reason, regarded as typhoid. Of these
twenty- three have been pronounced typhoid by the phy-
sicians in charge, while the others are of such a slight
nature and have so few typhoid symptoms, as to make it
at least doubtful whether they were really typhoid fever.
Of the cases of undoubted typhoid, thirteen have been
very serious, and the others not very serious. Four deaths
have occurred, and at the time of writing there are one
or two other patients in a critical condition. It will be
noticed from these facts that the outbreak of typhoid
fever in college began about October 20th, and the last
case appeared about November 9th.
As soon as the serious nature of the disease was recog-
nized, an investigation as to its cause was begun. Of
course, at that time it was not known that the disease
would be limited to the dates above mentioned, and it
was regarded as possible that there was in college a con-
stant source of infection. The students that were sick
were found to room in all of the college buildings, and
also in several houses in town. Moreover, it was
seen that they did not board at the same boarding-place,
and there appeared at first, therefore, to be no connec-
tion between them except the college campus. The first
object of suspicion was the water from two wells at the
back of the college buildings, which was used occasion-
ally by the students of the college for drinking purposes.
On this suspicion the use of the water was immediately
stopped, and an examination of the wells was made.
Chemical examination showed in one of the wells an ex-
ceptionally large amount of albuminoid ammonia. The
examination was made immediately after a heavy rain
following a long drought, which might possibly have ac-
counted for this. A bacteriological examination was set
on foot according to the method of Professor Vaughn.
Bouillon cultures from the water of each well were
made and cultivated for two days in a culture oven.
Then 20 c.c. of the culture was inoculated into the
abdominal cavity of white rats. The white rats, how-
ever, were entirely unaffected by the treatment, indi-
cating plainly that pathogenic germs of a typhoid nat-
ure could not have been present. Moreover, a little
inquiry soon showed that the wells could not have been
the cause of the trouble. In the first place several of the
students who were sick had certainly not drank from either
of the wells. Secondly, the wells were used almost as
much by certain young people from the town as by the
students themselves, and there was no corresponding out-
break of typhoid in the city. In fact, Middletown, at
744
MEDICAL RECORD.
[December 15, 1894
the time, proved exceptionally free from all kinds of
fevers. These facts taken together, made it necessary to
exclude the wells from the possible sources of infection.
It was noticed at the outset that the ladies of the college,
about fifty in number, were exempted from the disease.
This, of course, indicated that the cause of the infec-
tion could not have been in any unsanitary condition con-
nected with the public college buildings in general, but
must have been some source of infection to which the
young men were exposed, and not the young ladies.
After carefully looking over the facts it was further found,
that all of the cases of sickness, with three exceptions, oc-
curred in three of the college fraternities. The men did
not all room in the fraternity buildings, though most of
them did board at the fraternity club houses. This lo-
calizing of the disease to three fraternities proved the first
usable point of departure in the investigation.
In the college there are seven fraternities, and most of
the college students board at the fraternity clubs. In the
three fraternities afflicted there were about one hundred
students, and among the one hundred students, as above
stated, about twenty- five cases of typhoid developed.
This is seen at once to be an extremely large proportion.
It is usually supposed that some ten to fifteen per cent,
of those exposed to typhoid take the disease, and here
was a percentage at least twice that proportion. This
large percentage indicated at once that there must have
been some extremely virulent source of infection to which
probably every member of the fraternities was subjected.
In no other way could the large percentage of cases
among the students be accounted for.
In the attempt to locate the source of the trouble in
connection with the three fraternities, however, every
source of possible contagion was investigated. The
plumbing was examined, and though found to be de-
fective in at least one case, in the other houses it was in
first-class condition. It was hardly possible to accuse
the plumbing, however, inasmuch as the three dubs af-
flicted were situated at a distance of half a mile from
each other and were connected with different sewers.
The probability that these three houses should have been
defective in their plumbing at the same time was very re-
mote, and their connection with different sewers, together
with the absence of typhoid in the city, made it impos-
sible to accuse the plumbing. The possibility of trans-
ference of the disease from house to house was also con-
sidered, an attempt being made to find some early case
which could possibly have been a source of infection to
the other houses. But this proved futile. There were
no early cases, for almost at once, upon October 20th,
two or three cases developed simultaneously, and, of
course, this made it impossible to explain the epidemic
by personal contagion. It was found, moreover, that
the students who were taken with the disease in many
cases had no connection whatsoever with the other fra-
ternity houses, either through their room mates or other-
wise. Another source of possible infection was suggested
in a lot of new football suits which had recently been
purchased, and which had been thought to have given
rise to one or two cases of blood-poisoning. Inquiry,
however, soon showed that most of the students who
were sick had nothing to do with the football suits, and
they were of necessity ruled out.
Naturally, one of the first objects of suspicion, after the
disease had been located among the members of the
three fraternities, was the table of the clubs. An exam-
ination was immediately made into the sources of sup-
ply of these three fraternities. All of them used the city
water, which, of course, made it impossible to accuse
the water as a source of the typhoid, there being no corre-
sponding typhoid fever in town. The milk- supply of
the three fraternities was also ruled out by several facts.
The three fraternities were supplied by two different
milkmen, and each of these milkmen supplied one or
more of the other fraternities in college, as well as a
large number of customers in town. Moreover, upon in-
quiry it was learned that these milkmen had not ex-
changed milk with each other, and that they lived at a dis-
tance of several miles from each other outside of the city.
No cases of typhoid fever could be located in or near
either of the milk-farms, as having occurred within the
last six months. It was, therefore, impossible to accuse
the milk. In the same way all the other articles of food
used by the fraternities were investigated, without success.
The three fraternities did not have the same grocer, nor
the same butcher, nor the same butter supply, nor did
they obtain fruits from the same sources ; and whenever,
in regard to any article of food, it was found that there
was a point of likeness between the three fraternities, it
was found at once that the other fraternities in college
shared with them in having the same source of supply.
After carefully inquiring into every article of diet used
on the ordinary table, it was found necessary to exclude
the table as a source of infection. The attempt was
then made to find some special, unusual article of food
that had been used during the fall by the three fraterni-
ties, but it was impossible to do so.
When the dates of the outbreak above given are con-
sidered, it will be seen that they have themselves almost
conclusively pointed to one single source of infection
that had occurred in these three fraternities at a date
something like two weeks earlier than October 20th.
The period of incubation of typhoid fever is known to be
from about eight days to about twenty eight days, and all
of the cases came in such close connection with each other
as to indicate almost beyond question that they were due
to one single source of infection, that occurred within two
weeks prior to October 20th. On October 12th all of
the fraternities in college held their annual initiation,
followed by an initiation supper, and suspicion was soon
thrown upon these suppers. The date of the suppers
was exactly such as would be needed to explain the out-
break, and as soon as it appeared that new cases dimin-
ished after November 1st, these suppers became the most
probable source of infection. When the initiation sup-
pers were taken into consideration, one of the three ex-
ceptions above noticed disappeared, because one of the
men who did not belong to the college fraternities had at-
tended one of the three initiation suppers. An examina-
tion of the bills of fere at the suppers in question was
therefore instituted. It was found that nearly every
article of food must be excluded, on the same grounds u&
the articles of food at their ordinary table. Their milk,
their water, their ice, their ice-cream, their fruits, their
celery, and in fact, nearly all other articles of diet, they
either did not obtain from the same source, or obtained
them from a source which supplied every other one of the
seven college fraternities as well as the people in town.
There was found, indeed, to be but four points of union
between the three fraternities. One was the celery used
in the salad, a second a small amount of fruit, a third some
ham, and the fourth the oysters which were eaten. The
celery, the ham, and fruit, however, were from sources
which supplied other clubs and a large part of the towns-
people, and could, therefore, not have been the cause of
the special infection confined to these three fraternities.
As soon, however, as it was found that the three frater-
nities each ate raw oysters from the same oyster dealer,
the problems began, one after the other, to be solved. It
was found that none of the other four fraternities ate these
raw oysters. Two of them ate no oysters, a third ate
oysters which, however, had been cooked, and the fourth
obtained oysters from an entirely different source. Nor
could it be learned that the lot of oysters had been used
raw to any extent among the people in town, most peo-
ple cooking their oysters. Another one of the above-
mentioned exceptions was also explained at once, because
the student, upon being questioned, stated that about the
time of the initiation suppers he had eaten of the raw oys-
ters in the store of the oyster dealer. The oysters in ques-
tion were served at each fraternity on the half shell, at the
beginning of the supper, and it was, therefore, almost cer-
tain that nearly every person who attended the banquet
ate of them. Correspondence and questioning, however,
December 15, 1894]
MEDICAL RECORD.
745
were immediately instituted, which resulted in tracing in
this way a connection between every student who was
suffering from typhoid and these oysters, with one doubt-
ful exception of a student who has not yet been personally
questioned. It was learned also that there were in at-
tendance upon these three suppers, in addition to the
students in the college, a considerable number of alumni
from out of town, and five students from Yale College.
Letters were immediately written, therefore, to all of
these persons to learn if they had eaten of the raw
oysters, and whether they had suffered from any febrile
disturbances. - It must be remembered that the alumni
were, as a rule, considerably older than the students, and
it was, therefore, to be expected that the alumni would
be more likely to be exempt from the disease than the
students themselves. From twenty responses received
from the alumni it was found, however, that there were
two cases of genuine typhoid fever, which had developed
simultaneously with those in the college, and that there
were three other cases of sickness which had not been re-
garded as serious. These might or might not have had
some connection with the banquet in question, though it
is quite doubtful. Of the five students in Yale College,
two were taken with typhoid symptoms at just four
weeks after the banquet. Both of them developed into
severe cases of typhoid fever. In regard to these two
cases at Yale, it should, however, be noted that they
appeared quite late, indeed four weeks after the sup-
per had been held; and although four weeks is not
too long a period of incubation to be possible, still it
is unusual. They developed, however, at exactly the
period that the last case in Wesleyan made its appear-
ance. It is also a fact that there were two other cases of
typhoid fever in Yale College that certainly had no con-
nection with these banquets or these oysters, and it is there-
fore not certain that these two cases are to be attributed
to these banquets. It is, however, a remarkable coinci-
dence that of four cases of typhoid at Yale two should
have been those who attended the banquet at Middle-
town and ate of the oysters in question, and that these
two should have developed within the four weeks follow-
ing the banquet. It is therefore at least probable that
these cases were due to the same cause.
It will be seen that, as soon as the oysters were accused
of the trouble two of the three cases above mentioned of
typhoid occurring outside the fraternities, were at once
explained. The fourth case remained isolated. This
case was a member of the faculty, who had not attended
either of the banquets. He was taken with a slight fever,
and inasmuch as it appeared at about the same time with
the students, it was regarded as identical with the other
cases. It proved, however, a very slight fever, lasting
only a few days, and it is therefore at least doubtful
whether it was typhoid. Whether this person ate of the
raw oysters cannot be positively determined. It is a
fact that raw oysters were eaten at the table where he
boarded at about the time of the banquet, but as yet no
positive connection between the person and these oysters
has been made out. Whether, therefore, this case is to
be regarded as an isolated case of fever having no con-
nection with the others and not strictly typhoid fever, or
whether it is a fact that it is also explained by some con*
nection with the infected oysters, has not been deter-
mined.
Inquiry was made at once as to the source of the
oysters, and it was learned that while they had grown in
the deep water of Long Island Sound, they had been de-
posited in the mouth of a fresh-water creek for a day or
more to freshen. This freshening, as is well known,
consists of the absorption by the oysters of fresh water
which causes them to swell up and become plump.
These oysters had thus been "fattened" before being
sent to Middletown. Further inquiry showed that, with-
in about three hundred feet of the place where they had
been deposited, was the outlet of a private sewer coming
from a house wherein were two cases of typhoid fever.
The persons in question were a lady and her daughter.
They were taken sick at such a period as to call in a
physician for the first time October nth, which, of
course, means that the disease had been in its period of
incubation for probably considerably over a week earlier.
The oysters were sent to Middletown on October ioth,
and therefore they were deposited at this place in ex-
actly the time to receive contamination during the early
days of these two cases of typhoid. Of those two cases
one proved extremely severe, and the lady died on
October 21st. In the other case, the fever, after running
about five weeks, disappeared and convalescence set in.
It is, of course, very easy to understand that the typhoid
germs could have found entrance into the oysters from
this source of contamination. Now, it has been known
for some time, having been shown by Foster and Frey tag,
that the typhoid germs will live for a long time in sea-
water, or indeed, in a concentrated salt solution. Speci-
mens of the oysters from the creek, however, were put into
the hands of Dr. Foote, of Yale College, who soon showed
that if the typhoid germs were forced in between the two
valves of the shell they would remain alive in the oyster
for a time sufficient to enable the oyster to be carried to
Middletown and to be used at the initiation banquets.
Whether or not they will grow and multiply in oysters,
has not yet been positively determined.
Shortly after the oysters had been placed under sus-
picion, it was learned that there were at Amherst College
several cases of typhoid fever. Correspondence was in-
stituted, which resulted in showing that at Amherst there
had been held an initiation supper on the night of Oc-
tober 1 2 th. Most of the cases of typhoid at Amherst
occurred among the members of one fraternity, who, as
at Wesleyan, neither roomed nor boarded together.
They, however, had attended the initiation supper on
October 12th, had eaten of raw oysters at the supper,
and inquiry showed that these raw oysters also came from
the same place as the Wesleyan oysters, and had been
fattened in the mouth of the same creek. As at Wes-
leyan, certain wells were first placed under suspicion, but
examination showed them to be good. While, of course,
this did not conclusively demonstrate that the cases at
Amherst were due to the same source of infection as that
at Wesleyan, it rendered it at least probable.
The facts above related, it will be seen, point with
conclusive force to the oysters as the cause of the typhoid
outbreak. The dates of the outbreak, October 20th to
November 8th, plainly point to one source of infection
about October 12th. The fact that two cases of genuine
typhoid developed at the same time among the alumni,
and that two others appeared also among Yale students,
none of whom have had connection with the three fraterni-
ties later than the initiation supper, or before that time,
plainly demonstrates the initiation supper on October
1 2th as the time of the infection. At these initiation
suppers only one article of food or drink was used which
was not used by the other fraternities in college and by
the people in town in general. That one article of food,
the raw oysters (not eaten raw by people in town in
general), was learned to come from a place where it was
certainly subjected to a probable contamination of
typhoid fever from two severe cases of the disease. The
use of raw oysters from the same locality elsewhere, has
been found, at least in one case, to have been followed
by a similar outbreak as occurred in Wesleyan. These
facts taken together, leave no possible doubt that the
Wesleyan typhoid fever was caused by the oysters in
question.
It must not, however, be inferred that because the lot
of oysters supplied at these initiation suppers was in-
fected, therefore, that all the oysters from the same lo-
cality would be thus infected. The public press has cer-
tainly exaggerated the condition of affairs. The oysters
from the same locality were widely used in Connecticut,
and doubtless in many cases have been eaten uncooked.
There has been, it is true, quite a little typhoid fever
in Connecticut during the past month, but it has not
been possible thus far to trace very much of it to the
746
MEDICAL RECORD-
[December 15, 1894
eating of raw oysters. The probability is that the oysters
fattening in the locality in question would not, as a rule,
be contaminated, but that it would only be an exceptional
condition that would produce the result. It would be
necessary that they should be lying in this place at just
the period when the typhoid germs were swept by the
currents or eddies from the sewer over the oyster-bed;
and such a condition, even though there might be con-
tinued cases of typhoid in the course of the sewer, would
doubtless not by any means be a constant one. Oysters,
as a rule, are said to open their shells on flood-tide rather
than ebb-tide, and this would, of course, make it more
difficult for them to be contaminated by sewage from
sewers above them on the creek. While this would by
no means make the chance of contamination impossible,
it would certainly render it less. It is not to be sup-
posed, therefore, that the oysters deposited in the creek
for fattening would all, or indeed many of them, become
contaminated by the typhoid material, but that only ex-
ceptional conditions would produce the result* Where
a private sewer containing typhoid excreta opens in the
vicinity of such an oyster-bed, the danger must certainly
be considerable. Where the typhoid material is mixed
in the city sewers with the large amount of sewage, and
is subsequently diffused through a considerable body of
salt water when the sewer empties into the sea, the dan-
ger of oyster contamination must be considerably less.
But there must be danger to public health from oysters
fattened in any fresh water in the vicinity of sewage.
Doubtless many cases of mysterious typhoid have been
due to such a cause. To trace these cases is a matter of
extreme difficulty. The peculiar conditions which have
occurred here have been such, however, as to bring the
matter into clear light, and to throw with certainty
blame of typhoid distribution upon a source which has
for some time been suspected, but not demonstrated.
That the practice of fattening oysters in the mouth of
rivers and in the vicinity of sewers is dangerous to the
public health, is beyond question shown by the combina-
tion of conditions which have made it possible to trace
the Wesleyan typhoid outbreak to the eating of a lot of
infected raw oysters.
AN IMPROVED METHOD OF THE RADICAL
OPERATION FOR CARCINOMA OF THE
BREAST.1
By WILLY MEYER, M.D.,
PROrS3tOK OP svigbky at tiw new vokk post-gkadoatk medical school
AMD HOSPITAL J ATTENDING SUEGEOM TO THE GEBMAM AND NEW YORK SKIN
AND CANCER HOSPITALS; CONSULTING ^SURGEON TO THE NEW YORK IN-
PIRMARY.
Since Heidenhain has shown that in a great number of
cases of cancer of the breast the pectoralis major muscle
is also involved by the disease, and that, if left in place,
the growth is more liable to recur,8 it has become, I be-
lieve, the duty of the surgeon always to remove this mus-
cle with the breast and the axillary contents. Only, if
carried out according to this plan, the operation should
be called radical.
According to well-known methods the surgeon gen-
erally first removes the breast with the axillary contents.
If he believes in doing in every instance as radical work
as feasible in fighting this treacherous disease, he will
then cut out the pectoralis major muscle from its origin
to its insertion.* It means no serious addition to the
1 Read before the Section on Surgery of the New York Academy of
Medicine, November 12, 1894.
" Lothar Heidenhain : Ueber die Ursachen der localen Krebsreci-
dive nach Amputation Mammae. Verhandlungen der deutschen Ge-
sellschaft fur Chirurgie, Berlin, 1889, and von Langenbeck's Archiv
fur klin. Chir., 1889, vol. xxxix. , p. 07.
* Heidenhain believes that it might be best to remove the strip of
periosteum of clavicle and sternum, to which the muscle is attached,
with the latter. Before making this addition to the operation, I, per-
sonally, should rather wait and see whether future observations prove
that by leaving in place the respective pieces of periosteum a re-
gional recurrence is favored.
operative procedure, but rather still more radical work,
also to extirpate the pectoralis minor muscle at the same
time. It enables the operator to remove the loose con-
nective tissue and fat under this muscle, which is often
diseased.
Within the last three yean I have operated, according
to this plan, on six female patients, and found by in-
creasing experience, with reference to the technique :
i. That the extirpation of the pectoral muscles, car-
ried out in this way, means an addition of about fifteen
to twenty minutes to the operation, including ligatures.
2. That it saves blood and time to first cut off the in-
sertion of the muscles on the humerus and coracoid pro-
cess, and then to reflect the muscles downward. The
arterisB perforantes being on the stretch, can then be
well seen and caught with the forceps close to the inter-
costal muscles, before being divided. If we pursue the
reverse method, viz., cut off the origin of the muscle on
ribs and sternum first, and then turn up the same toward
the humerus, these arteries often tear near the intercostal
muscles and the ribs. It is then difficult to catch and
ligate the bleeding points.1
The parasitic theory of the etiology of cancer is yet
unproved. On the other hand, inoculation of small
pieces of cancerous tissue into the peritoneal cavities of
animals has been successful. A cancer of the same type
developed in such a spot. Clinical observations also
make it highly probable that small particles of cancer-
tissue, if entering hitherto healthy tissue, can there pro-
duce the same growth. Kraske gives a resume of the
special literature on this subject, and relates two very in-
teresting cases in this respect.8 He found in two cases of
ulcerating cancer of the rectum, where the tumor could
just be reached with the finger, low down immediately
above the sphincter muscle, secondary small cancerous
nodules of the type which was represented by the main
growth. In both patients a healthy strip of mucous
membrane, of at least 10 ctm. length, was interposed
between the original and, as he explains it, the second-
ary tumors. He believes that the latter originated from
the proliferation of the living epithelial cells which had
severed their connection with the primary carcinoma,
and had then been implanted in the lower portion of the
rectal mucous membrane. Small tears in die latter,
made by the examining finger or instruments, the hyper-
emia and catarrhal condition of the lower end of the
rectum always present in these cases, will favor the de-
velopment of the inoculated particles.
With reference to the breast, the unavoidable handling
of the tumor by the operator's hands and the assistants'
hooks has been considered harmful, and called upon to
explain the distressingly low percentage of cures after the
operation. It has been assumed that during these manip-
ulations cancer-cells, or, if we accept to-day the theory
of the parasitic origin, the parasites themselves, might
be pressed into the lymphatics and thus disseminate the
disease through the body.8 It has therefore been pro-
posed to attack the axillary cavity first, clean out its con-
tents before severing their connection with the breast,
and then to remove the breast and axillary contents to-
gether.4 This procedure may be of some importance.
Yet there are multiple other lymphatic vessels, which are
1 The arteriae perforantes are branches of the intercostal arteries.
They are of tolerably large sue. After having traversed the inter-
costal muscles, which they supply with blood, they enter and feed
(besides the serratus anticns major muscle and a portion of the ab-
dominal muscles) the pectoralis major muscle and the mammary
gland. Heidenhain emphasizes the fact that these arteries and their
ramifications are accompanied by cancerous lymphatics above the
fascia of the pectoralis major muscle. He therefore advises to di-
vide the vessels '■ within " the latter. It is, in my opinion, a still bet-
ter plan to divide them " underneath " the muscle, just above the in-
tercostal muscles.
■ Ccntralblatt fUr Chirurgie, p. 801, 1880.
• A. G. Gerster, on the Surgical Dissemination of Cancer, New
York Medical Journal, February s8, 1885.— It has been my personal
misfortune to have had among the patients on whom I removed a
cancer of the breast, quite a number in whom there was no regional
recurrence of the disease, but who died within one year and a half
after the operation, helpless, almost paralysed, and with great pains,
from metastatic growths in the spinal column.
* Gerster : Loc. cit
December 15, 1894]
MEDICAL RECORD.
747
not touched by the knife in such an operation, and which
can carry away infectious material in different directions,
thus, for instance, to the opposite side, to the supra-
clavicular region, etc. (It is, of course, understood, that
in cases of long standing these regions may have become
Fig. x.
infected before an operation for the removal of the can-
cer of the breast is undertaken.) As Dr. Gerster wrote
me the other day, the result, as far as recurrence is con-
cerned, has not been improved by this procedure. This
fact is a matter of course, since we know that the fascia
of the pectoralis major muscle and this muscle itself, as
well as the loose fatty tissue below the same and below
the pectoralis minor muscle, so often are the seat of can-
cer. And this, not very rarely, in cases where the tumor
is yet comparatively small and the breast freely movable
over the underlying tissues.
The most harm is surely done during the manipulations
with the knife, the hooks, and the hands " within the
operating field itself," as long as we work "within"
and not "outside of" the diseased area. During the
operation lymphatic vessels between breast and fascia,
those of the pectoralis major muscle, between and below
the pectoral muscles, in the axillary, sub- and infra-clavi-
cular fat, all more or less filled with epithelial cells, are
compressed, cut, and torn. Their contents enter the
fresh wound. Direct local infection of hitherto healthy
tissue by cancer is liable to take place. I believe that
especially the primary tearing off or preparing the breast
tumor with the knife from the subjacent fascia of the
pectoralis major muscle, or from the superficial layer of
its fibres, if the tumor be adherent to the fascia — as it hat
been the general custom of operators up to date — may at
times directly infect the large fresh wound with micro-
scopical elements of cancerous tissue. It has been
shown that just the fascia of the pectoralis major muscle
and the superficial layer of fibres of the latter, often contain
a very large number of microscopical cancerous deposits.
By first excising the breast with the axillary glands and
then extirpating the muscles, the latter procedure form-
ing the second part of the operation, we also increase
the loss of blood. Many vessels are cut — and have to
be tied — twice.
In view of these considerations I have thought that
in order to avoid local or remote infection, also to save
loss of blood, and still to be as complete in the work as
possible, that the following might be an improvement :
Not to excise the breast tumor in connection with the
axillary contents first, and then to remove the pectoral
muscles and clean out the sub- and infra-clavicular space ;
but " to extirpate the breast, the contents of the axillary
and of the sub- and infra-clavicular region, and the pec-
toral muscles, in one mass.1' In other words. I thought
I would try and let the knife never enter the infected
area (cancer), but work "everywhere" around the lat-
ter in healthy tissue, of course as far as this may be
feasible in such cases.
For this purpose the operator must first come down to
landmarks, when reflecting back the flaps of skin, before
attacking the seat of the cancer proper. These land-
marks, as I mapped them out, would be : a . Above : ce-
phalic vein and clavicle, b. Outward : The tendon of
the pectoralis major muscle on the humerus, c. Below :
the border of the latissimus dorsi muscle, d. Inward :
The sternal extremity of the clavicle and the sternum itself.
My plan of operation was the following :
1. Skin incision as usual, embracing a liberal piece
of skin around the nipple, which incision is at once run
up into the axillary cavity, about an inch and a half to
two inches farther than in the ordinary operation. This
in order more easily to reach the tendon of the pecto-
ralis major muscle on the humerus. (See Fig. 1, A, B.)
2. Additional skin incision from the clavicle at the
junction of its middle and outer thirds downward, meet-
ing the first wound at right angles. (Fig. 1, C, D.)
3. Reflection backward of the three skin flaps with as
thin a layer of the underlying fat as possible, leaving just
enough so as not to endanger a future necrosis of the
flaps,1 exposing: a. The insertion of the pectoralis
major muscle on the clavicle and sternum, b. The in-
sertion of the same muscle on the humerus, the cephalic
vein in Mohrenheim's sub-clavicular space (guide !). c.
The border of the latissimus dorsi muscle. (See Fig. 2.)*
4. Division of the pectoralis major muscle in its tendon
close to the ^humerus (the raised arm of the patient
must be somewhat lowered for this purpose), and prep-
aration of the same downward (Fig. 2) to its insertion
on the clavicle. Here it is cut off at once down to the
sternal extremity of the bone, in order to thoroughly ex-
pose the contents of the axillary cavity and the infra-
and sub-clavicular region. During this time an assistant
exerts some traction on the breast, to put the tissues on
the stretch.
5. Preparation and excision of the sub clavicular, infra-
clavicular, and axillary fat, glands and lymphatics, with
the knife, beginning over the bundle of nerves and
vessels high up in the cavity, and continuing this pro-
cedure from the lower border of the subclavian and axil-
lary vein downward. As soon as freed, these contents,
having been divided on the outer side from the fat in the
Fig. 2.—/, Pectoralis major muscle; /. tendon pectoralis major muscle ; ct v%
cephalic vein ; ^ </, latissimus dorsi muscle.
upper part of the sulcus bicipitalis of the arm, are
raised and cut out from the outer side inward. This
means, beginning from the border of the latissimus dorsi
1 Further experience must show how much fat must be left at-
tached to the skin. It means, no doubt, abetter prognosis, with refer-
ence to recurrence, to say : " the less the better," or, "none whatever."
a This plate has been drawn by the artist without his having wit-
nessed the operation. He was obliged to work guided only by my
explanations.
748
MEDICAL RECORD.
[December 15, 1894
muscle. This excision is continued, including the fat
on the sub-scapularis and teres major muscles, until the
chest-wall, viz., ribs, intercostal, and part of the serratus
anticus major muscles, are plainly before us, and until the
"lower" surface of the pectoral muscles is reached.
Fat with glands and lymphatics are nowhere cut into,
bit remain in one piece and attached to the outer lower
border of the pectoral muscles in their normal anatomi-
cal relation.
6. Division of the tendon of the pectoralis minor
muscle on the coracoid process.
7. Gentle elevation of the breast and muscles by an
assistant's hands in order to put the blood-vessels which
enter and leave the pectoralis major muscle on the
stretch. As mentioned above, they are clamped before
they are divided.
8. Amputation of the pectoralis major muscle at its
insertion on the sternal extremity of the clavicle, and
of both muscles at their insertion on the ribs and ster-
num with the knife close to these bones. This insertion
forms the pedicle of the whole mass. If cut off along-
side the sternum after having been separated from the
ribs, the extirpation of the cancer is finished.
9. Suturing of the wound as far as possible; plate-
sutures for the sake of better coaptation of the skin-flaps,
drainage of the axillary cavity as usuaL
10. Dressing ; the large defect is always to be covered
with rubber tissue in order to favor rapid healing under
the moist blood-clot ; good compression.
Grafting of the resulting granulating wound, which
will follow the removal of a liberal piece of skin, may
be done in about eight or ten days without narcosis,
ethyl-chloride being used for anaesthetizing the area
of the arm or thigh, from which the grafts are taken.
The granulating surface need not be scraped for this
purpose.1
On September 19, 1894, I had my first opportunity to
operate according to this plan.
Mrs. F. O , aged thirty-seven. Slowly increas-
ing tumor of the left breast since eighteen months. It
never ached, and thus made the patient neglect to con-
sult a doctor. Examination on September 15 th showed
a tumor of goose-egg's size in the centre of the breast.
Nipple not retracted. Axillary glands hard and infil-
trated. September 19th operation as just described, with
the exception of omitting the additional incision from
the clavicle downward. One upper flap only and one
lower one were thus formed. This was a mistake. It
somewhat impeded the easy reach of the attachment of
the muscle on the clavicle. I should advise always to
make this incision, especially in fat patients. I had
done so, in fact, in my former cases, in which I first cut
away breast and axillary contents, and then the muscles.
The operation was not difficult. Only when preparing
from the edge of the latissimus dorsi muscle inward and
upward, in order to reach the chest-wall and the pecto-
ral muscles (from below), I found it somewhat incon-
venient in comparison with the former method of oper-
ating, to have the great mass of tissue above. Clever
assistants will here be of great help. Temperature never
rose above ioo° F. First dressing changed on the sixth
day; primary union throughout ; drainage-tube removed ;
patient out of bed. To-day arm freely movable. The
specimen which I hand around will show nicely, how rad-
ically the operation has been done. The whole mass is
in one piece. The microscope substantiated the diag-
nosis of cancer.
As seen in this, as well as in my former cases, where I
extirpated the pectoralis major muscle entirely, the loss
of the latter never interfered with the motion of the
arm. On the contrary, the patients were able to sooner
move the arm in all directions than I have seen if the
muscles be not or only partially removed. The strong
inner (clavicular) portion of the deltoid is fully able to
1 Julius Schnitzler u. Karl Ewald : Zur Technik der Hauttrans-
plantation nach Thiersch, Central blatt fur Chirurgie, 1894, No. 7,
page 148. According to my experience, immediate grafting on the
very uneven basis of the fresh defect is not advisable.
adduct the arm. Some patients complained of a tight
sensation over the chest, they " felt their ribs exposed."
This annoyance was soon, however, overcome. In order
to avoid stiffness in the shoulder-joint, the patients
should be. ordered to begin with active and passive
motions after the first change of dressing, viz., between
the eighth till tenth day after the operation.
I am, of course, fully aware that also this most radical
method of operation will not prevent recurrence of the
growth " in loco/' nor metastases in remote parts, espe-
cially not, if the patients be subjected to the operation
in an advanced stage of the disease. Yet I venture to
consider it a step in trying still further to reduce the
chances of probably infecting the fresh wound and the
entire system with cancer by our work "during" the
operation ; also to do as complete work as possible.
In this view I thought it permissible to communicate
this method to the Surgical Section, having so far had
only one personal practical experience.
Mr. President and Gentlemen, the idea ot removing
the carcinoma of the breast in this way was conceived
by me last winter. By a peculiar coincidence not one
case of carcinoma of the breast came under my care
since then until September, even not during a four-
months' service at the German Hospital. This paper
was written in the latter part of September. It was
announced to the Secretary of the Surgical Section at
about October 20th. Before doing so, I had very care-
fully perused the newest literature, especially the elab-
orate articles on the subject by Dennis, Weir, and Bull,
in order to ascertain whether others* had removed a
cancer of the breast in the way just described. I did
not find this procedure mentioned. Now, ten days ago,
on November 2d, the November issue of the Annals cf
Surgery has come into my hands. In this issue Dr.
William S. Halsted, of the Johns Hopkins Hospital, has
published a brilliant article upon the results of operations
for the cure of cancer of the breast, performed by him
at the Johns Hopkins Hospital from June, 1889, to Janu-
ary, 1894, in which he recommends practically the same
way of operating just proposed by me, viz., the removal
of the breast, fat, and glands of the axillary cavity and in-
fra-clavicular region " in one mass. ' ' He thinks it advis-
able to explore and clean out also the supraclavicular
region in almost every operable case.1 He has operated
in this way on most of the fifty patients whose histories
are recorded. As will be seen by comparison, our meth-
ods differ in some respects. I shall mention those
which seem to me to be of some importance.
Halsted surrounds the base of the breast with an in-
cision, and reflects a triangular flap of skin downward
and outward.
I first reflect back three flaps of skin, two upper ones
and one lower one, so far, until I reach the landmarks
mentioned above, namely : the tendon of the pectoralis
major muscle, the cephalic vein, the clavicle and ster-
num, the border of the latissimus dorsi muscle.
Halsted's third step of the operation reads : " The
costal insertions of the pectoralis major muscle are sev-
ered, and the splitting of the muscle, usually between its
clavicular and costal portions, is begun, and continued
to a point about opposite the scalenus tubercle on the
clavicle." The sixth step reads : " The splitting of the
muscle is continued out to the humerus, and the part of
the muscle to be removed is now cut through close to its
humeral attachments ; " and the eighth to tenth : " The
lower outer border of the minor muscle having been
passed and clearly exposed, this muscle is divided at
right angles to its fibres, and at a point a little below its
middle.11 "The tissue, more or less rich in lymphatics
and often cancerous, over the minor muscle near its cor-
1 This is, no doubt, a very wise addition. I shall certainly add this
point to my plan of operating laid down above, in every case coming
under my care. By lengthening the additional incision as proposed
by me (Fig. 1, C, D.) upward above the clavicle, this operation can
be easily and rapidly done. Of course, we shall clean out the supra-
clavicular space thoroughly, by removing the fat with glands and
lymphatics also " in one piece.*
December 15, 1894]
MEDICAL RECORD.
749
acoid insertion, is divided as far out as possible, and then
reflected inward in order to liberate or to prepare for the
reflection upward of this part of the minor muscle.11
" The upper, outer portion of the minor muscle is drawn
upward with a broad, sharp retractor. This liberates the
retractor which until now has been holding back the
clavicular portion of the pectoralis major muscle."
In the manner as I have planned and performed the
operation/ the belly of the pectoralis major muscle, as
well as that of the minor, is not touched at all. To re-
peat briefly what has been said above : I first cut off the
humeral attachment of the pectoralis major muscle, pre-
pare its upper border tree from the cephalic vein, and
detach it with the knife close to the clavicle. Then the
muscle is turned downward and inward, until the tendon
of the pectoralis minor muscle can be cut off from the
coracoid process. Later — that means after the tissue
over the bundle of vessels and nerves high up in the ax-
illa, and after the axillary, sub- and infra-clavicular fat,
glands, and lymphatics have been carefully prepared in
the well-known manner, " but left in their original ana-
tomical relation to the breast and to the muscles91 l — both
muscles are raised and cut away from above downward
and inward.
Further: Halsted turns the mass over to the outer
side and cuts it off on the base of the skin-flap, which
had been primarily formed and reflected outward. This
I believe will be more convenient for the operator.
As my procedure follows the direction of the fibres of
the pectoral muscles from above downward, the mass
must be turned upward and inward first, when preparing
from the axilla, and then inward. A clever assistant will
be easily able to hold it out of the way. When the pedi-
cle, the sternocostal insertion of the pectoralis major
muscle, is reached, a few strokes with a sharp knife com-
plete the operation.
Further experience must show whether Halsted's or
my plan of operating deserves preference.
I personally should prefer the operation as proposed
above and carried out by me. It seems to me to be
more anatomical than that of Halsted. It also is, I trust,
still more radical, since in every instance the entire pec-
toralis major muscle (and the minor) will be removed. I
think, this is absolutely necessary, in order to do radical
work. Heidenhain specially states, that he considers a
muscle, which has been invaded by cancer, suspicious
from its origin to its insertion. " Not a fibre of the mus-
cle should be left behind. M On this ground I should also
prefer to abstain from all splitting of the pectoralis major
muscle between its different portions. By not working
within the belly of the muscle whatsoever, we shall, no
doubt, be best guarded against infection of the fresh
wound with cancer, and against regional recurrence.
The nucleus of the operation, however, is the follow-
ing rule : " Lift all the tissue, that may be diseased, and
often will be found on microscopical examination to be
diseased throughout, out of its bed in one piece"
That this kind of radical operation will be " the " oper-
ation for the extirpation of carcinoma of the breast, there
can be no doubt. It is proved by Halsted's unprece-
dented percentage of cures. He so far records cure in
ninety-four per cent, of his cases, including the cases
operated up to February, 1894, a number which has never
been reached by a surgeon before.
I venture to hope that, by absolutely and continuously
working everywhere around the seat of disease, by never
trespassing on the belly of the muscles, and always re-
moving the latter completely, this extremely gratifying
result might be also secured by others.
Thus will then, at last, it is to be hoped, also this ter-
rible foe of suffering mankind, this dread especially of
the female sex, become oftener silenced and made more
submissive to the surgeon's knife, provided the operation
is done early, before remote parts of the system have be-
come infected.
1 The lower outer border of the minor muscle is thus not clearly
exposed, but remains attached to the axillary fat
A RrtSUMrt OF THE SUBJECT OF BILIARY
CALCULI.1
By THOMAS S. SOUTHWORTH, M.D.,
ASSISTANT TO THB CHAIR OP MEDICINE, VANDKEBILT CLINIC \ INSTRUCTOR IN
DISEASES OP CHILDREN, NEW YORK POLYCLINIC \ PATHOLOGIST TO THE NURS-
ERY AND CHILD'S HOSPITAL.
To approach intelligently the question oi the forma-
tion of biliary calculi it is necessary to have a clear con-
ception of the physiology of the liver and of the biliary
secretion in and from which they are formed. It is not
essential for this purpose that we should deal here with
the anatomy and minute histology of the liver, but we
may proceed at once to a brief review of our knowledge
of the bile itself. For, although from the size of the
liver, and consequently its apparent importance, its func-
tion was studied as early as that of any of the other
abdominal viscera, it was not until the full development
of the sciences of organic chemistry and experimental
physiology that satisfactorily definite information could
be obtained concerning the secretions and functions of
this organ.
Bile is formed continuously, but the rate at which it is
produced is subject to great variations. The flow dimin-
ishes during abstinence, increases immediately after
meals for about an hour, decreases somewhat thereafter,
and again flows freely during the third and fifth hours of
digestion. Much difficulty has been experienced in ar-
riving at an approximate estimate of the quantity secreted
in the course of twenty-four hours. There can be but
little accuracy in reasoning by analogy from the secretion
in the lower animals, and the operative fistulae in man
upon which observations have been made have in most
cases existed under pathological conditions which would
greatly interfere with the results obtained. Moreover, as
the presence of the bile in the intestines influences the
quantity and quality of the bile excreted by the liver the
results obtained by the observation of biliary fistulae
must differ very much from those which would be pro-
duced were the bile pouring normally into the intestine
to be partially reabsorbed by the portal system and re-
turned to the liver. Thus we only know definitely that
where reabsorption from the intestine cannot take place,
the quantity of bile in man is from a pint to a pint and
a half per day.3 Under normal conditions we presume it
to be somewhat larger.
Comparisons made between the pressure in the veins
of the portal system and that in the bile- ducts have
shown that the biliary pressure is two and one- half times
as great as that of the blood supplied to the hepatic cell,
proving conclusively that the process is not one of filtra-
tion but of definite secretion. As it flows from the intra-
hepatic ducts the human bile is a non-viscid.fiuid of a golden
red color, sweet-bitter taste, feebly alkaline reaction, and
a specific gravity of about 1.010. The viscidity which we
usually associate with it is acquired from admixture with
a substance secreted by the mucous membrane of the gall-
ducts and gall-bladder. This is known as the mucoid
nucleo- albumin of the bile, and increases in amount
in proportion to the length of time the bile remains in
the gall-bladder. The bile contains as the direct secre-
tory product of the hepatic cell the so-called bile acids,
glykocholic and taurocholic acids, the former preponder-
ating, and the biliary coloring matter bilirubin, which is
readily oxidized to biliverdin, or by intestinal action
changed to other derivatives. In addition to these specific
products of the liver it also excretes through the bile
cholesterin, neutral fats, soaps, lecithin, traces of a dias-
tatic ferment, mineral matter, and gases, of which the
chief is CO,. While, if we disregard the very slight traces
of a diastatic ferment, we know that the bile has no
power to decompose starches, proteids, or fats, we are
still convinced that in addition to its excretory functions
it undoubtedly plays a by no means unimportant part in
1 Read before the Section on General Medicine, New York Acad-
emy oi Medicine, November ao, 1894.
9 Arthur Gamgee : Text-book of the Physiological Chemistry of the
Animal Body, vol. ii.t p. 376.
75°
MEDICAL RECORD.
[December 15, 1894
the intestinal economy by neutralizing the acidity of the
chyme, and thus preparing the way for pancreatic activ-
ity, as well as its direct or indirect saponifying, antisep-
tic, and laxative effects.
Gall-stones, as shown by autopsy records, are of much
more frequent occurrence than we would suppose were
we to judge only from clinical evidence. Schroder
found at the autopsies in the Strassburg Hospital gall-
stones in 4.4 per cent, of the men and 20.6 per cent, of
the women. They are rare under thirty years of age,
more frequent from thirty to sixty, and after the latter
age occur very often. Women, and especially those who
have borne children, furnish by far the largest number of
cases. The large majority of biliary calculi are formed
and found in the gall-bladder ; certain forms, however,
may rarely be found in the larger ducts, or even in the
intra hepatic ducts. Stones which are found in the cys-
tic or common ducts have, however, almost invariably
come from the gall-bladder. Their specific gravity is
very low, so low that when dried they may even float
upon water until the air which they contain has been ex-
pelled. The calculi are rarely single, but usually multi-
ple (5 to 30), and have been found in a single case to
the number of seven thousand eight hundred and two.
In size they vary from fine sand to masses 15 ctm. in
length. The average size is that of a hazel nut. They
are composed chiefly of cholestrin, bilirubin calcium,
and calcium carbonate, singly or in combination with
each other. The color and consistence depends upon
the composition. White or light-colored stones are en-
tirely or largely composed of cholesterin ; brown, green,
and black tints are given by bilirubin-calcium, biliverdin,
and other derivatives of the biliary coloring matters.
Calcium carbonate is often found in a green external
layer. All calculi from the same gall-bladder have usu-
ally the same composition, structure, and color. Their
shape is affected by the space in which they lie. The
facets upon their surface depend upon their numbers and
are almost invariably due to mutual pressure while soft,
and not to attrition.
When stones are sawn in two they present, as a rule,
1, a central nucleus ; 2, a middle zone of multiple con-
centric lamellae ; 3, a laminated external layer or shell.
These three divisions are very often of diverse color and
composition. The nucleus is of the greater interest ; it
is more commonly formed of a combination of biliary
pigment and calcium, called bilirubin- calcium, or of
mucus and epithelial cells. These latter by desiccation
- may leave a hollow centre. Very rarely foreign bodies,
such as needles or intestinal worms, have been found as
the nucleus of the concretions.
The most common and most numerous variety of cal
culi, " the habitual tenants of the gall-bladder," are the
mixed cholesterin calculi, yellow or whitish-brown in
color, occurring in groups of varying numbers, often 70
to 100 together, from the size of a pin's-head to that of
a small cherry, faceted by mutual pressure, frequently
lamellated on section, and often soft and friable before
exposure to the air. Other much rarer varieties of cho-
lesterin stones are the white crystalline and the stratified
cholesterin calculi. The former are usually single, often
of considerable size, of pure white transparent crystalline
structure, and are usually found in a recess of the gall-
bladder or in the common or cystic ducts, encircled by
the wall, which is frequently even adherent to the stone.
The stratified variety, although containing sixty per cent,
of cholesterin, are usually darker from an admixture of
biliary coloring matters, and more frequently multiple
and faceted than the former. On section they appear
to be formed of concentric lamellae of varying color,
throughout which crystallization, beginning at the centre,
has advanced to variable distances.
Less frequent as a class than the cholesterin stones are
those formed of the compound of bilirubin and calcium.
These may rarely be pure, in which case they are small,
dark concretions. Usually, however, they are mixed
with some cholesterin or calcium carbonate, in which case
they are still dark, occur singly or at the extreme by
twos or threes, are found in the gallbladder or ducts,
and are made up of broad, structureless lamellae which
may be arranged about a crystalline cholesterin nucleus.
Other occasional forms are described, including those
made up of calcium carbonate.
When we approach the question of the formation of
gall stones we have to deal with a delicate problem. It
has long been recognized that increasing age enhances
the liability to biliary lithiasis, as well as anything which
tends to retard the movement of the bile in its passage.
Now two of the main factors in keeping up a movement
of the bile are exercise and deep respiratory action.
Both of these are usually lessened as age advances, and
to these may be added sedentary habits, and, in women,
diminution of diaphragmatic respiration by the wearing
of corsets and during the existence of pregnancy.
Neither heredity, nationality, diet, nor diathesis seem
in any way to influence the incidence of cholelithiasis,
for the amount of cholesterin and calcium salts in the
bile bears no relation to the general tissue change or to
the food of the patient, but they are constant in their
amounts as proven by elaborate experimentation. We
know that while bilirubin is abundant in the bile, choles-
terin is excreted in comparatively small quantities, yet
we have just seen that the cholesterin stones are by far
the largest and most numerous, while bilirubin-calcium
enters into the composition of calculi in smaller amounts
and less frequently. We must therefore look for some
local causative factor which shall explain the precipita-
tion of the elements of the calculi from the biliary secre-
tion. Naunyn 1 believes this agent to be the bacterium
coli commune, which penetrates from the intestine along
the ducts to the gall-bladder. When there is no stasis
in the biliary system, and the gallbladder is frequently
emptied no harm results, but if the flow of bile be re-
tarded the continued presence of the bacterium sets up a
catarrhal condition of the mucous membrane, during
which calcium salts are excreted by it in excess. These
combine with the bilirubin to form bilirubin-calcium,
and the albumin from the mucous membrane of the gall-
bladder aids in its precipitation. On the other hand,
the cholesterin, of which by far the larger number of
stoneq is composed, has been conclusively shown to be
the product of the epithelium of the ducts and the gall-
bladder, and to bear practically no relation to the small
amount excreted by the liver. This has been proven by
the fact that the percentage of cholesterin increases in the
bile in proportion to the time it remains in the gall-
bladder, and also that pure cholesterin stones will in-
crease in size in the gall-bladder when there exists com-
plete occlusion of the cystic duct, whereas, for the growth
of bilirubin stones fresh supplies of bilemust at least reach
the gall-bladder at intervals. Naunyn found that in the
gall-bladder of persons dying with gall-stones the epi-
thelial cells contained or were extruding myeline masses
of a glassy, structureless character, which under the action
of acetic acid became clumps of cholesterin crystals.
These myeline masses are then rudimentary or embryonal
calculi, ready to crystallize upon any opportune object,
usually about little masses of bilirubin-calcium or clumps
of epithelial cells and mucus. If now there be free exit
for the bile through the cystic duct, these microscopic
masses may be swept out by the flow of bile into the
intestine, but if the flow be tardy, or there be obstruction,
their further growth, by the addition of subsequent lamel-
lae is readily understood.
The radiating crystalline character which is noticed
throughout the whole or a part of many of the pure or
mixed cholesterin calculi requires a word of explana-
tion. This is a subsequent change which takes place
later and more slowly than the growth of the stone by
the accretion of structureless cholesterin. The process
begins in the centre, either in an original cholesterin
nucleus, or more often in myeline material which has
penetrated by infiltration and filled a hollow at the cen-
1 KUnik der Cholelithiasis. Lelpsic, 189a.
December 15, 1894]
MEDICAL RECORD.
75i
tre left by the drying or escape of soft or semi-fluid sub-
stances which formed the original nucleus. From this
centre crystallization extends outward in radiating striae
through the different lamellae, aided perhaps by fresh
cholesterin, which penetrates from the outer zone along
minute canals called infiltration canals. It is even pos-
sible that, during this process, in many cases, bilirubin-
calcium may be dissolved and displaced.
It is hardly necessary for me to consume your time
in reciting the classic symptoms of biliary colic — sudden
pain, chill, fever, sweating, vomiting, and often, later,
swelling and tenderness of the liver, distention of the
gall-bladder, discoloration of the urine, icteric hue of the
skin, and clay-colored stools. Of far greater interest to
us, as pertaining to diagnosis, are the more unusual varia-
tions. It is very difficult to understand in all cases why
stones which have lain quiet in the gall-bladder for a
long period should suddenly be forced into the cystic
duct. Where errors in diet, over exertion, falls or jars,
child-birth or menstruation have immediately preceded,
it is easier to form an hypothesis and believe that un-
usual peristaltic action is excited in the walls of the gall-
bladder, either indirectly by reflex nervous influences,
or directly from extension outward along the muscular
fibres of the bile-ducts of unwonted peristalsis in the in-
testine. Prodromal symptoms in the way of sensitive-
ness in the epigastrium, chilliness or slight icterus, some-
times exist for a day or two before the attack of colic ;
but it is much commoner for this to begin suddenly.
Murchison1 states that the attacks occur shortly after the
ingestion of food ; Naunyn, however, contends that they
are more likely to take place some hours after eating, when
the chyme begins to pass into the duodeneum and thus
explains the frequent occurrence of a first attack about
midnight. The pain of biliary colic is usually severe and
hard to bear, of a rending, boring character, and radiat-
ing upward. In other instances, however, it may only
amount to a slight burning sensation, or even be entirely
absent. Fever may either be absent or play a very im-
portant rdle. It is frequently preceded by a chill, and is
generally of short duration, but may continue for days
if the other conditions persist. Vomiting is usually
severe and prostrating. Occasionally it brings to light
some of the stones which have caused the attack. The
muscular contractions or cramps in the abdomen, legs,
arms, or hands are of reflex origin. With these symp-
toms only the attack may terminate, after a short time,
by the falling back of the stone into the gall-bladder, or
by its passage from the common duct into the intestine ;
but if its progress is slow after it has reached the com-
mon duct other symptoms are added. The bile, which
is secreted continuously, cannot escape by its usual out-
let but distends the gall-bladder, which may be felt in
one-third to one-half of the cases under the right rectus
or to the outer side of that muscle. The gall-bladder
filled, the intra-hepatic ducts become distended, with re-
sulting tenderness and enlargement of the liver, and
finally the bile is forced into the lymphatics and passes
through the thoracic duct into the blood. Here it first
shows itself in discoloration of the urine, but when it
passes into the blood more rapidly than it can be ex-
creted by the kidneys it begins to be deposited in the
tissues, revealing itself first in the conjunctivae and later
in varying intensity in the skin. The bile being thus
diverted from the intestine the stools become pale or
day-colored and the movements constipated.
As is the case in many another affection, of which the
text-book description is clear and classical, in actual ex-
perience there are many variations in the occurrence, in-
tensity, and sequence of the cardinal symptoms. As
Charcot • has pointed out, the chill may precede the pain,
or the chill and fever may not be proportionate to the
intensity of the pain. In other persons there may be
pain and chill without fever, or fever without chill, or
fever without pain. Many of the attacks, estimated at
1 Clinical Lectures on Diseases of the Liver.
9 Lemons sur les Maladies da Foie. Paris, 1887.
fifty per cent., pass off without jaundice, or this may de-
velop, with its attendant train, as early as twelve hours
after the inception of the attack. The duration of the
pain may be half an hour or half a day, or it may persist
continuously or recur intermittently for several days.
Without going exhaustively into the question of differ-
ential diagnosis it may be mentioned that where icterus is
absent the case must be distinguished from cardialgia, lead
colic, renal colic, fecal impaction, peritonitis, appendicitis,
and intussusception. Death, though rarely, may occur
during the course of an attack, from suicide, collapse,
syncope from pre-existing cardiac lesions, or rupture of
the ducts or gall-bladder, with consequent infectious peri-
tonitis. In the latter instance prompt laparotomy has
saved life.
If, as Naunyn claims, in old age every tenth man and
every fourth woman has gall stones, how shall we reconcile
this fact with the infrequency of biliary colic in general,
and among the aged in particular. S6nac believes that
hepatic colic originates only between the twenty fifth and
thirty-fifth years, and that after sixty stones are frequently
passed without reaction or pain. It is quite possible that
calculi in the gall-bladder may be not only latent but en-
tirely harmless ; in fact, unless their mere mechanical pres-
ence cause ulceration or infectious conditions they give
no signs of their presence until they enter the ducts.
Arrayed on the one hand as factors opposing the progress
of the stone are the small size and peculiar conformation
of the ducts, the elasticity of the walls, and the reflex
spasm of the muscular fibres from irritation, as well as the
size, consistence, and form' of the stone itself. On the
other hand, assisting its progress we have the slight press-
ure of the bile and the much more important peristaltic
contractions of the muscular coat of the gall-bladder and
ducts. The cystic duct has a diameter of but 3 mm.,
while that of the common duct is 6 mm. Here we per-
haps have an explanation of the partial alleviation of the
pain which often takes place in the course of an attack,
probably as the stone passes from the smaller cystic to the
larger common duct.
While after death the gall- ducts offer much resistance
to attempted dilatation, it is evident from postmortem
findings' in those who had suffered from repeated passage
of gall-stones that the ducts can not only be dilated but
remain so permanently. The opening of the common
duct into the duodenum is the least distensible portion,
as shown by the greater frequency with which stones are
arrested at this point than at any other. Histology has
contributed the important fact that in youth muscular
fibres are abundant in the walls of the ducts, but that in
old age they are much atrophied or have disappeared en-
tirely.
We are now in a position to understand some of the
possibilities why the passage of stones in different cases
and at different ages may be accompanied by such vary-
ing reaction. If, as we may readily concede, the pain of
biliary colic is due to the stretching of the ducts and the
reflex spasm of their walls, we can see that the passage of
a small calculus through an already dilated duct may be
accompanied by little or no pain, while it is easy to con-
ceive, with Naunyn and others, that the atrophy of the
muscular fibres in old persons either prevents the violent
peristalsis in the gall-bladder which forces the stones into
die duct, or renders impossible the reflex spasm of the
duct, which is probably the chief source of the pain, so
that gall-stones which are much more frequent at this age
may remain indefinitely in the gall bladder or be passed
without the knowledge of the patient. A very few per-
sons escape with but one attack of biliary colic in a life-
time. Most frequently, however, the attacks are repeated
at longer or shorter intervals. The successive attacks in
the same individual may be marked by great differences
in the intensity of the suffering, or one may be of short
duration, the next extend with exacerbations and re-
missions over several xlays.
One stone or many may pass during a single attack.
One instance is recorded where two hundred and forty-
752
MEDICAL RECORD.
[December 15, 1894
four calculi were recovered from the stools in five days.
Smaller numbers are much more frequently found. Much
difference of opinion has existed as to the size of stones
which can be passed through the ducts. The majority of
those so passed are not larger than peas ; it is probable,
however, that calculi as large as the kernel of a hazel-nut
can also pass. The chief hindrance, as we have already
seen, is usually encountered where the common duct
enters the duodenum. Here a rupture of the tissues
with the formation of a duodenal fistula may allow even a
large stone to escape. Recorded instances of the passage
per anum of very large stones are probably the result of
direct ulceration from the gall-bladder into the intes-
tine.
Directions are usually issued that the stools shall be
examined for calculi after an attack of colic, but the con-
cretions are not always found, often because of careless
methods or lack of persistency. The surest method is
to pass the softened stool under the action of running
water through a piece of muslin or a hair-sieve. This
treatment should be extended to all stools for eight days,
for although in most cases the stones appear in the faeces
after twenty-four to forty- eight hours, cases are recorded
where they have been retained until the eighth day.
Apropos of this question, one fact which is not generally
appreciated is worthy of especial consideration. Experi-
mentation by causing gall-stones of varying composition
to be swallowed by healthy men, and search instituted
therefor in the stools, has shown that only firm or hard
stones, or those having a hard cholesterin shell, reappear in
the dejections. Soft stones and those of pure or mixed
bilirubin- calcium suffer disintegration in the intestine.
Naunyn, in his extensive researches, has found but one
such stone in the stools, and that showed signs of erosion.
It is therefore evident that however valuable may be the
positive evidence of stones passed per rectum, the failure
to find the same cannot be considered as proving that
the preceding attack of pain did not result from the pas-
sage of a calculus.
Besides the acute attacks above described, accompany-
ing the expulsion of calculi through the biliary passages,
there is a further extensive group of affections of the liver
and biliary tract dependent upon the continued presence
of calculi. These are grouped under the comprehensive
term " irregular cholelithiasis." An attack of acute bil-
iary colic may end in three ways : 1, By the falling back
of the stone into the gall-bladder ; 2, by its expulsion
into the intestine ; 3, by its impaction in the biliary pas-
sages. Stones thus impacted usually give rise, for a time
at least, to repeated attacks of colic, and it is evident
that the occurrence of jaundice and associated symptoms
will depend upon whether the site of the impaction be
in the cystic or common duct. Gall stones are often
found post mortem in these ducts. The majority are
large stones, larger than cherries, ofttimes they are the
size of a walnut or even greater. Such atones may have
been formed in situ, but in the majority of cases they are
doubtless stones which have become impacted and grown
by accretion. They may allow the bile to pass them into
the intestine, in which case they may exist for years with-
out harm and without symptoms. They may furnish the
necessary factors for the development of various infectious
and ulcerative conditions, or again they may intermit-
tently or permanently interfere with the exit of the bile.
In the latter event chronic icterus results.
When chronic icterus is established, and this may hap-
pen as readily from a stone which has lain for years in
the duct as from a freshly impacted calculus, the patient
may succumb as early as the tenth day, or he may live
for weeks, or months, or even years. It is not the ob-
struction alone which causes death, but the complications
to which it gives rise. Everything depends upon whether
the obstruction is partial or complete. If the occlusion
of the duct is absolute, so that no bile can pass, the ducts
behind the obstruction become dilated, the gall- bladder
is distended, jaundice increases, gastric and intestinal di-
gestion become disturbed, and the patient succumbs from
hemorrhage or from emaciation and marasmus. Where
chronic icterus exists, with but intermittent or partial ob-
struction, the degree of icterus is variable, the liver re-
mains of normal size, or is but slightly enlarged, and
there is no distention of the gall-bladder. Itching of the
skin is usually a distressing symptom, and hemorrhages
from the mucous membranes may take place, but the in-
testine continuously or intermittently receives some bile,
as shown by the color of the faeces, and the nutrition of
the patient does not suffer as rapidly as in the previous
case.
Among the common baleful results of cholelithiasis,
more especially with obstruction of the common duct, is
the production of cholangitis, or an inflammation of the
biliary radicles. Here again we find the bacterium coli
commune as a specific cause of the infection of the bile.
Cholangitis is not always purulent, even when it produces
fatal results. Where the process has been distinctly sup-
purative, cultures have shown an admixture of staphylo-
cocci and streptococci. Still greater importance attaches to
the fact that cholangitis leads to cholecystitis and hepatic
abscess. Infectious cholecystitis is excited by the pres-
ence of the bacterium coli commune where calculi are
retained in the gall-bladder, especially when the cystic
duct is blocked by a stone. The contents of the gall-
bladder are at first the retained bile and the infected
secretion of the mucous membrane. The biliary constit-
uents are, however, promptly reabsorbed and the gall-
bladder then is filled with a sero-purulent fluid, contain-
ing usually but a small number of pus cells. The more
abundant the pus the more applicable to thislcondition
is the term " empyema of the gall-bladder." This should
be clearly distinguished from a condition known as "hy-
drops of the gall bladder " which arises when the cystic
duct is blocked without previous infection of the con-
tents. The bladder then contains after a time a semi-
transparent strongly mucilaginous fluid, which is sterile
and without any traces of pus.
Hepatic abscess above referred to may result from sup-
purative cholangitis, by extension from an empyema of
the gall-bladder, or from the pressure of a stone in the
common duct upon the portal vein causing thrombosis
and pylephlebitis. Carcinomatous involvement of the
biliary tract is of such frequent occurrence with chole-
lithiasis-as to suggest strongly its dependence upon that
condition. Its possible existence should always be kept
in mind in cases of chronic jaundice occurring in old
people.
What, then, is the fate of the stones which remain in
the gall-bladder? In many instances doubtless they re-
main unrecognized and innocuous, for they are revealed
by the necropsy when no symptoms occurred during life
which could be referred to their existence. But in other
cases their presence is more or less pernicious. Hyper-
trophy of the muscular fibres of the gall* bladder" occurs,
with slow contraction of the viscus about the mass
as a whole, or else it becomes sacculated with enclosure
of one or more calculi in the recesses. Sooner or later
a desquamative catarrh of the mucous membrane is set up,
with thinning or ulceration of the mucosa from pressure.
Ulcerations may heal with the production of cicatrices,
or perforation of the walls may take place with conse-
quent peritonitis or the formation of an encapsulated
abscess beneath the liver ; or again, where adhesions have
previously been formed to the other viscera or to the ab-
dominal wall, fistulae may be formed opening externally,
or into the stomach, duodenum, ileum, or colon. Through
these latter fistulae the stones incarcerated in the gall-
bladder may escape into the gastro intestinal tract and
be passed per anum, provided their smallest diameter
does not exeed 3 cm., otherwise they may be arrested at
the ileo-csecal valve. Larger stones or masses of small
stones have often caused intestinal obstruction and called
for surgical interference.
The treatment of biliary lithiasis naturally resolves it-
self into four divisions : 1. Treatment of the acute at-
tack. 2. Treatment directed to resulting conditions.
December 15, 1894]
MEDICAL RECORD.
753
3. Prophylaxis against repetition of the attacks. 4.
Surgical indications in acute and chronic cholelithiasis.
During the acute attack the indications are clearly to
relieve the pain, relax the spasm, facilitate the expulsion
of the stone, and prevent subsequent complications. The
pain of biliary colic is usually so intense that the patient
demands that our first efforts be directed to its relief.
This is most promptly and efficiently accomplished by
the subcutaneous injection of morphine in full dose
(gr. }() repeated at intervals according to indications.
Morphine, however, may aggravate rather than allay the
vomiting, and also tends to decrease the biliary secretion.
It is therefore best combined with atropine, which does
not influence the secretion of bile, but does restore the
disturbed tone of the muscular fibres, assisting in the
subsequent expulsion of the stone by normal peristalsis
in the ducts* Where the attacks are prolonged opium
and extract of belladonna by the mouth are better borne
than morphine, and in very long or intermittent cases
other analgesics — antipyrine, chloral, amylo - valerianic
ether, or sodium salicylate may be wisely substituted.
Relaxation of the spasmodic contraction will be favored
by prolonged hot baths (95° to ioo° F.), and chloroform
by inhalation may be temporarily required. Vomiting
is best allayed by repeated large draughts of sodium bicar-
bonate and hot water ( 3 j.- 3 ij. to Oj.). This is at first
rejected but afterward retained. Later gastric irritation
may call for the usual sedatives — bismuth, dilute hydro-
cyanic acid, and carbonated waters. The pain and spasm
somewhat relieved, our next interest is to hasten the pas-
sage of the calculus through the duct. For this purpose
such cholagogues as are known to favor the secretion of
more abundant and more fluid bile must be called into
requisition. Salicylate of soda, besides its analgesic
power, stands here in the front rank, with ox-gall, glyc-
erine, and calomel. FerrandV experiments not only
show that glycerine in massive doses ( 3 v.- \ j.) is taken
up by the lymphatics of the stomach and carried to the
liver, where it produces a free secretion of fluid bile, but
its ingestion has also produced prompt alleviation of the
pain and apparent passage of the stone. Calomel, like
other metals, is arrested by the liver, where it passes into
the portal system, and produces a direct stimulation of
the hepatic cells. Ether and chloroform act reflexly by
their action on the stomach. Aloes, euonymin, and
podophyllin, and the benzoates of sodium and lithium
are also much vaunted in this connection. Durand's
mixture — ether, 3 parts, turpentine, 2 parts — once
much in vogue in doses of 3ss.-3j. in bouillon, but
badly borne by the stomach, has now been relegated to
the treatment of more chronic cases. Olive oil, recom-
mended by Chaiiffard in doses of § vj.- § viij., and given
in two portions, with an interval of a quarter of an hour,
with the patient lying upon his right side, is both safe
and inoffensive, and often well tolerated by the stomach.
Willemin has seen it followed by almost instantaneous
relief of the pain, which occurred so quickly as to be
probably the result of reflex action. The more prolonged
the attack, the greater the danger of secondary complica-
tions. When congestion is marked and inflammatory
conditions in the liver threaten, moist heat applied over
the liver by poultices or fomentations relieve pain by
lessening congestion, and reduce the liability to inflam-
matory reaction. If the process be more advanced and
there be signs of cholecystitis or hepatitis, more active
antiphlogistic remedies may be indicated — eight to ten
leeches, mustard or vesicants, or cold in the form of ice-
bags may be cautiously employed.
Infectious cholangitis and hepatic fever call for anti-
septics which will be excreted in the bile. Calomel is
best given in three to eight grain doses every two to three
days. The benzoates, and especially benzo-naphthol,
have been strongly endorsed. Salol and salicylate of
soda are particularly useful when there is fever. In con-
sidering certain of the above indications for treatment it
is impossible to sharply distinguish between cases of short
1 Gar. des Hop., September, 1894, p. 947.
and long duration! if we would avoid useless repetitions,
and much that has been said is applicable to cases where
the stone remains impacted in the duct. In the intervals
between the attacks, to remove the impacted stone
or to prevent the occurrence of fresh crises, glyce-
rine, 3 j- to 3 iv. per day, may be given in slightly alka-
line water, or olive oil may be administered in $ ij. por-
tions at bedtime. A method taught in one of our largest
clinics, and practised with considerable success, is the ad-
ministration of the oil, once daily, in milk, one table-
spoonful the first day, and an additional tablespoonful
each day until upon the sixth day six are taken. What-
ever the method of giving the oil may be, it should cease
on the sixth or eighth day, and not be resumed until the
same number of days have elapsed.
Prophylaxis is of course only applicable to those who
have previously suffered from the passage of calculi. It
. is therefore to be considered after, rather than before, the
treatment of the acute attack. It should be directed
toward securing a free secretion of bile by the use of chol-
agogue remedies, and toward favoring satisfactory evac-
uation of the bile from the gall-bladder. To this latter
end active exercise, massage, and hydrotherapy are use-
ful in themselves, and also because they favor deep res-
piratory efforts. Our knowledge of the influence of diet
upon the incidence of cholelithiasis is so slight that we
can only caution against over eating and the excessive
use of rich food-stuffs, alcohol, or condiments. Daily
evacuation of the bowels should be secured, and the
clothing should be such 'as to allow unimpeded play of
the .abdominal and respiratory muscles. No case of
chronic biliary lithiasis need be considered hopeless, or,
if the symptoms be not urgent, condemned to surgical
procedures, before testing the result of a course at Vichy
or Carlsbad, or some other of the hot sodium, or sodium
and magnesium springs, for the results under such treat-
ment are often surprisingly prompt and successful.
Surgical interference may be required both in acute
and chronic cases. In the former, where rupture of the
ducts or gall-bladder has taken place during the parox-
ysm, with escape of bile and threatened peritonitis. In
chronic cases, to relieve an incarcerated calculus in the
duct, or to remove Ynasses of calculi from the gall-blad-
der when these conditions have caused ulceration, infec-
tious cholangitis, cholecystitis, or empyema of the gall-
bladder, especially where there is danger to the patient
from the continued temperature, emaciation, or threatened
general infection. Jaundice, and its accompanying hem-
orrhagic tendency enhances, many fold, the dangers of
operative interference, but does not in itself constitute a
counter- indication.
19 West Forty-sixth Stmbt*
Football Casualties and Fatalities.— B. Foote, a stu-
dent at the Fairfield Seminary, near Little Falls, N. Y.,
became violently insane a week ago because of injuries
received in a football game in which he played centre
rush. He rushed around the dormitory all Sunday night
in his football suit, and was only secured by a ruse at
daybreak. He was then taken to the Utica Insane Asy-
lum, where he is now confined. Daniel McTiernan,
fourteen years of age, who played at Worcester on Satur-
day, December 8th, in a school game, was fallen on in a
rush, and was so injured that he died during the night. At
Shreve, O., on December 8th, Walter Blackburn, nineteen
years of age, received injuries in a football game which
caused his death. While " interfering " with another
player, Blackburn was thrown heavily to the ground and
five or six of the players fell on him. When he was ex-
tricated he was paralyzed from the neck down, and a
surgical examination disclosed the fact that the spinal
column had been fractured.
" Teratalogia " is the name of a new quarterly journal
devoted to " ante-natal pathology." It is edited by Dr.
J. W. Ballantyne, of London.
754
MEDICAL RECORD.
[December 15, 1894
Medical Record:
A Weekly Journal of Medicine and Surgery.
GEORGE F. SHRADY, A.M., M.D., Editor.
Publishers
WM. WOOD &. CO., 43, 45, &. 47 East Tenth Street.
New York, December 15, 1894.
THE REPORT OF THE SURGEON-GENERAL
OF THE NAVY.
The report of Surgeon- General Tryon for the year just
past contains one item of more general interest than such
documents usually do, namely, the treatment of pneu-
monia. During the year there were thirty-three cases of
acute pneumonia admitted to the hospital in this city,
and of that number thirty-one recovered. This unu-
sually low mortality-rate is naturally regarded as a result
of the method of treatment adopted. This method con-
sisted in the hypodermic injection of one- thirtieth to
one-twenty-fifth grain of sulphate of strychnine every
three or four hours, together with a very free use of
alcoholic stimulants. The health of the Navy in general
was excellent. The remarkable immunity of the officers
and men on board the ships in the harbor of Rio de
Janeiro, during the yellow-fever epidemic there a year
ago, is referred to with a pardonable show of satisfaction.
There was but one case of yellow fever on an American
man-of-war out of a total complement of 1,762, and this
case might have been prevented had the sanitary regula-
tions been obeyed. During this time of practically com-
plete immunity on American war-ships, there was disease
on board the vessels of every other nation in the harbor,
while many merchant vessels lost nearly their entire
crews. A circular has been issued calling for reports
relating to the sanitary measures employed in the pre-
vention of yellow fever on board war- vessels, and it is
hoped that such reliable information will be obtained
from the answers to this letter, that the medical depart-
ment will be able to formulate sanitary rules and regula-
tions on the subject that will be of value as a guide to
vessels of the Navy when obliged in future to serve in an
infected port. When such general sanitary rules, em-
bracing special precautionary measures against the intro-
duction of yellow fever and cholera or board vessels of
war have been formulated, they will be submitted to the
authorities with the request that they be made depart-
ment regulations.
Concerning the Naval Museum of Hygiene, the report
states that the exhibits have now all been transferred to
the building, formerly the Naval Observatory in Wash-
ington, which was recently set apart by the Secretary of
the Navy for this purpose. " The interest that has been
manifested by the service and by professional and scien-
tific bodies, in the growth and development of a museum
identified with the practical study and advancement of
sanitary science, is shown by the steady increase in the
number of exhibits. By the removal of the museum to
commodious and permanent quarters, the object of its
organization can now be satisfactorily fulfilled, and
opportunities offered for accomplishing good work in the
future. One hundred and ten new exhibits were added
to the collection during the past year, including the
complete and interesting model of the system of disinfec-
tion practised at the quarantine station at New Orleans.
This model was exhibited at the Columbian Exposition
at Chicago, and presented to the Museum by the Louisi-
ana State Board of Health. Thirty specimens of animal
parasites, contributed by the Department of Agriculture,
have also been received, remounted, and labelled."
The necessity of organizing a hospital corps is insisted
upon, for the services which such a corps, well drilled
and equipped, could render would be invaluable to the
Navy. Such a corps exists in the Army, and its useful-
ness has been demonstrated time and again. Other
navies are introducing it, and much time and thought are
there being given to its perfection, and the Surgeon-
General therefore urges that some legislative action relat-
ing to this subject be taken by Congress at an early date.
Dr. Tryon refers again to the strange oversight in rela-
tion to the sick quarters in the new ships. " On board
of ten vessels no quarters are designated for the treatment
of the sick and wounded ; in the case of the Minneapolis
the omission was probably due to an oversight, as this
vessel was designed on similar lines to her sister ship
the Columbia. Subsequent to the examination of the
plans of our uncompleted warships, the drawings of the
armored cruiser Brooklyn and the battleship Iowa were
submitted to the Bureau and, in consultation with the
President of the Board of Inspection and Survey, and the
Bureau of Construction and Repair, suitable sick quarters
were located." In view of the omissions in the past, it
is very reasonably suggested that, hereafter, the medical
department be consulted as to the location of sick-bays
on ships which may hereafter be constructed.
THE MICROBES OF THE EYE.
The researches of bacteriologists have shown that the
conjunctival sac is a famous feeding-ground for microbes
of all kinds. A very complete and learned review of the
question by Dr. A. Cu6nod {Gazette des Hopitaux), shows
the present status of the subject and indicates that, in
time, all inflammatory conditions of the conjunctiva will
be distinguished nosologically by their specific microbes
rather than by the vascular reactions. Thus, he shows
that the acute catarrhal inflammations are due sometimes
to the bacillus of Weeks and, more rarely, to a pneumo-
coccus or streptococcus organism. The purulent con-
junctivitis of genital origin is usually due to the gonococ-
cus. Croupous conjunctivitis may be due to the bacillus
of Loeffler, but is oftener a mixed infection.
In chronic inflammatory conditions there have been
found the trachoma coccus (Koch, Poncet, Michel), the
gonococcus, and a microsporon described by Noisewski.
In xerosis, the bacillus of pseudo-diphtheria is present.
The bacilli of tuberculosis and of lupus also may develop
in the conjunctiva.
According to Cuenod, in the healthy conjunctival sac
one never finds the microbes characteristic of the three
principal forms of acute conjunctival inflammation (blen-
December 15, 1894]
MEDICAL RECORD.
755
orrhagic, diphtheritic, and contagious catarrhal). Only
exceptionally does one meet with staphylococci, strepto-
cocci, and pneumococcL The conjunctiva is, therefore,
reasonably aseptic in healthy eyes. The constant flow
of lachrymal fluid across its surface is believed to have
some antiseptic influence.
TYPHOID FEVER AND SOCIETY.
Typhoid fever, like death, is no respecter of persons.
A lay journal laments the fact that this very democratic
disease has attacked several members of "society " dur-
ing the past fall, and has thereby interfered sadly with
many high social functions. Dr. Samuel Wilks, in a re-
cent address, asserts that typhoid fever seems to need no
specially adapted soil, but seizes upon the vigorous and
healthy as quickly as upon the weak. This is the general
experience, though as age increases some immunity is
experienced. Most intelligent persons nowadays know
that typhoid is communicated through what we eat — and
especially through what we drink. In the houses of the
intelligent and of the wealthy, and in many well-con-
ducted hotels, sterile waters are largely provided. Yet
the disease continues to affect the rich and poor. This
only shows that the watchfulness is not complete enough ;
it is easy to forget when the enemy is a subtle and invis-
ible one, and one that lurks in dark and unexpected
places, as do the germs of enteric fever.
FRIGO-THERAPEUTICS.
French medical science seems unhappy without some
sensation. Perhaps the very latest is that which goes
under the name of " frigo- therapeutics." Accounts of
it have been telegraphed to our daily papers. Professor
Pictet, we are told, recently explained the new method
before the Academy of Medicine. He began the devel-
opment of his new treatment " by experimenting on dogs,
and found that when they were plunged into a bath at
low temperature and were kept there for some time, they
became ravenously hungry. Being himself a sufferer
from stomach disease, he had forgotten what it was to
have an appetite. So he descended into the refrigerating
tank at a temperature many degrees below zero. He
wrapped a thick pelisse and other warm clothes about
him, but after four minutes he began to feel hungry. At
the end of eight minutes he climbed out of the tank with
a painfully keen appetite. Many such experiments were
made. All meals taken after a short stay in the refrig-
erator agreed with him. He found that his dyspepsia
was cured after the tenth descent."
This account has a very up-todate flavor about it.
The idea of curing dyspepsia by making the patient sit
in a cold tank is certainly original, but it will, we fear,
apply only in carefully selected cases, and the freedom
from dyspepsia may be accompanied with colds, coughs,
and rheumatism.
And who knows but that sitting in a hot tank might
not be still more effective. Dr. Ashmead describes, in
the University Medical Magazine, the hot-tank treatment
of the Japanese, which there seems to be very popular.
He says that " In Bungo, Japan, near a town of a thou-
sand homes and five thousand inhabitants, on the coast of
Kiushiu, at the foot of an old volcano, there is a warm-
spring watering-place much frequented by poor people.
They crowd there between the barley harvest and the
June rice planting. Eighty-two springs belong to the
place. A peculiar way of taking this treatment is the
sand-bath, and this is the manner of it : Some of
the springs, all of them hot, are so near the beach that
they are covered by the full tide. When the waters re-
cede, basins are dug in the sand heated by these, and
frequenting patients bury themselves in these holes up to
the neck. Those who use the sand-baths usually remain
for several hours in them, umbrellas being held over
their heads to protect them against the sun."
It is going to take a good deal of skill to determine
whether the cold tank or the hot sand is the better way
to cure chronic invalidism. In attempting to make a
choice between the two it may be safest to follow the
habitual rule when supping with the Sheolistic gentleman
who blows hot and cold in the same breath, and use a
long spoon.
Hews at tUc ftfteetu
Spurious Antitoxin. — It is reported that there is a
spurious antitoxin in the market. The Health Depart-
ment has very properly and promptly determined to in-
stitute proceedings against such as can be proven to be
offenders.
Appointments of Deputy Coroners. — Dr. Emil W.
Hoeber, Coroner-elect, has appointed Dr. John B. Huber
Deputy-coroner, with the very commendable view of util-
izing autopsical material for pathological study. The
choice was made after consultation with several leading
physicians. Dr. W. O' Meagher, also Coroner- elect, has
appointed, with the same ends in view, Professor James
E. Kelly, M.D., well known as a skilful surgeon, a
thorough anatomist, and an accomplished pathologist.
Errata in Dr. Cleaves's Article. — On page 718, first
column, eighteen lines from the bottom : " There was a
rise in the temperature of from 1 to 8 degrees," should
read, "of from .1 to .8 degree."
The Death of Dr. Stuart Douglas. — At the seventieth
stated meeting of the Society of Alumni of Bellevue
Hospital, held at the Hotel Brunswick, Wednesday, De-
cember 5, 1894, the following resolution was adopted :
Whereas, In the death of Dr. Stuart Douglas, the So-
ciety of Alumni of Bellevue Hospital has lost one of its
most esteemed members and friends, whose ability had
already brought distinction and gave promise of a brill-
iant future ; therefore, be it
Resolved, That this Society extend to the members of
his family their most heartfelt sympathy. And be it
further resolved, that this resolution be spread upon the
minutes of the Society, and a copy sent to his family and
the medical press of New York and Virginia. Matthew
D. Field, William E. Studdeford, John M. Brooke,
Committee on Resolutions.
Examinations for the Public Services. — An esteemed
correspondent writes that an item appearing in a recent
issue concerning the proportion of successful candidates
for the medical staff of the Army and Navy, might con-
vey a wrong impression as to the difficulties of the ex-
756
MEDICAL RECORD.
[December 15, 1894
aminations. The item was gleaned from the reports of
the Surgeon-general of the two services, and of course
did not make mention of the previous training of the
candidates. Our correspondent states that a large ma-
jority of those who succeeded in passing the examina-
tions had studied under teachers who make a specialty
of preparing candidates for such examinations; while
most of those who failed had made no such special study.
The examinations are rigid but fair, and no young grad-
uate who studies faithfully under competent instructors
need despair of success.
Edward Henry Van Winkle, M.D., died of paralysis
of the heart, at 25 West Ninth Street, last week, aged
seventy-nine. Dr. Van Winkle was born in the town
of Aquackanorick, N. J. He was graduated from the
College of Physicians and Surgeons, and began to prac-
tise in 1838. Three years ago he retired.
Opening of a Vew Hospital for Incurables Seton
Hospital, at Spuyten Duyvil, was formally opened on
December 4th. Twenty years ago Sister Irene, Mother
Superior of the New York Foundling Asylum in Sixty-
eighth Street, began to raise funds for a hospital for those
afflicted with incurable diseases. She is an old woman
now, and was unable to attend the opening of the in-
stitution, but she had the satisfaction of knowing that
her purpose had been accomplished.
The hospital overlooks the Hudson, and is surrounded
by spacious grounds. It is named for Mother Seton,
the founder of the order of the Sisters of Charity in the
United States. The building is of brick, four stories
high, 250 feet front, and 200 feet deep. To the east
and west there are two wings, each 90 feet deep. The
building was begun about three years ago and cost
2 33°>o°o- All expenses have been met and the hospital
opens entirely free from debt It will be in charge of
Sister Mary Dolores, and a board of managers yet to be
appointed. The chief of the medical staff will be Dr.
J. West Roosevelt
Tablet to the Memory of Dr. Wells.— A tablet of
bronze erected to the memory of Dr. Horace Wells, of
Hartford, Conn., was unveiled on December nth, with-
out ceremony, owing to the inclemency of the weather.
It commemorates the fiftieth anniversary of the discov-
ery by Dr. Horace Wells of nitrous oxide gas as an
anaesthetic. On December n, 1844, the late Dr. John
M. Riggs, at Dr. Wells's request, administered nitrous
oxide gas to him and extracted a tooth without pain.
The tablet bears a medallion portrait of Dr. Wells and
the inscription :
" To the memory of Horace Wells, the dentist, who
upon this spot, December 11, 1844, submitted to a
surgical operation, discovered, demonstrated, and pro-
claimed the blessings of anaesthesia."
Two hundred and fifty dentists in this country con-
tributed to the fund for the tablet. The Connecticut
State Dental Society gave a banquet in honor of the
event.
A Popular Subscription to Supply the Poor with
Diphtheria Antitoxin has been started by the New
York Herald, which paper subscribes $1,000.
The Elmira Reformatory. — The commission appointed
by Governor Flower to investigate the Reformatory has
made a majority report in which it is said, as a conclu-
sion : The Elmira Reformatory is not a perfect institution
in all respects, as this report indicates. There is room
for improvement in some matters that could not properly
be covered in this report. As it is organized and con-
ducted, however, it is a model reformatory. Its results
have been extraordinary as regards its success in the
reformation of criminals. It probably stands pre-eminent
among the reformatories of the world. These results are
due to the unselfish devotion of the managers, and the
extraordinary qualities of Mr. Brockway as an organizer
and executive officer, added to his intimate knowledge
of the criminal character. The managers are fully justi-
fied in the confidence they have reposed in their General
Superintendent. Whatever defects we have noticed, as
brought out by this investigation, have in no way in-
volved hardship or injustice to any inmate, as far as has
been shown by the evidence, except in the single case of
Aaron. This case is one among more than 6,000 con-
victs who have been received at the institution since its
establishment. A very few changes, not difficult to effect,
and involving but little additional cost, would render this
an ideal institution of the kind.
1. The number of inmates should never exceed the
number of cells, and the number of cells should not be
increased. Doubling up has evident evils to which it is
unnecessary to refer. Intelligent and efficient treatment
of inmates requires a close study of individual character-
istics. We believe that the work of the Reformatory
could be better done with a population of 600 than with
1,200.
2. The Reformatory physician should have an assistant,
who should reside in the Reformatory, and the medical
care and supervision of inmates should be conducted on
the lines indicated in the body of this report.
3. Should the administration of corporal punishment
be restored, no blows should be given except on the but-
tocks, except in self-defence or in instances of violent re-
sistance. Very respectfully submitted.
Austin Flint, Israel T. Deyo,
Commissioners,
A minority report by Judge Learned thinks that pun-
ishment was inflicted too often, and criticises the laws
regarding the institution. Governor Flower Hi«mi«— «
the charges. On the whole, the general management of
the institution has been amply justified.
Progress of Serum Therapy.— A Sero-therapeutic In-
stitute for the east of France is in process of formation.
At Amsterdam serum is being prepared by Professor
Forster. Various journals, both political and medical,
are collecting subscriptions, and considerable sums have
already been obtained. In Spain the preparation of se-
rum has been begun in the Municipal Laboratory of Bar-
celona, under the direction of Dr. Jaime Ferrin. Two
horses are being immunized by Drs. Robert amd Llor-
ente. Dr. F. Spat writes to the Munchener medidnische
Wochenschrift to point out that the germ of " sero-thera-
py M is to be found in a passage of Pliny which has been
overlooked by Sprengel, Haeser, and other historians of
medicine. It is well known that Mithridates, the famous
King of Pontus (b.c 124-64) was believed to have made
himself proof against poisons, apparently by a system of
graduated dosage till tolerance was established. As the
December 15, 1894]
MEDICAL RECORD.
757
result of his experiments on himself, he is said to have
hit upon a kind of universal antidote which was famous
in the ancient world under the name of mithridaticum.
One ingredient in this antidote seems to have been the
blood of the Pontic duck, which the King added be-
cause that fowl lived on poison (sangutnem anatum Pen-
ticorum antidotis miseere quoniam vcnenum viverent Pliny,
Natural History, Lib. xxv., S. iii., Ed. Harduin, p.
210). In the Riforma Medica of October 30th, Dr.
Ricardo Agostini calls attention to some experiments on
the preventive and curative inoculation of the diphtheria
poison, made some thirty five years ago by Dr. Giuseppe
Babola, of Santa Margherita di Montagnana. In 1859
that practitioner referred, in the Gazzctta Medica Itali-
ana, to two such experiments which might serve as the
basis of future researches. He states that he inoculated
two healthy girls with membrane taken from the throat
ot a sister who was seriously ill with the disease, the re-
sult being a very mild attack in each case. Some years
later he returns to the subject in the same journal,
(March 7, 1863). In the same periodical for February
13, 1864, he reported a further series of experiments, for
which he claimed fairly successful results, especially as
regards the prophylactic effect of the inoculation. His
method was to make two or three punctures on the arm
with the point of a lancet that had been dipped in diph-
theria products removed from a patient's throat with for-
ceps. Babola compares his method with vaccination and
the inoculation of syphilis, and attempts to explain its
mode of action.
The Index Hedieus is to be discontinued.
A Medical Fasse-Partout.— The head of the Berlin
police has decided on issuing to practitioners in that city
what may be translated as a "crowd threader," on the
presentation of which all constables will be bound to as-
sist the possessor in making his way through crowds.
The privilege is to be applicable to foot doctors only ;
the carriage-keeping section of the fraternity must make
their way by their own unaided efforts, or rather by
those of their coachmen.
The Profits of an Amateur Sport. — The expenses of
one football team (Yale) for one year (1892) were $15,-
284.62 and the gross receipts $31,300.71, leaving the net
receipts $16,016.09. The net receipts last year were for
the same team, $22,914. In 1892 the team paid for
drugs, surgical supplies, medical services, and rubbers,
$857.89.
St. Francis Hospital, Hew York. — Dr. John Doming
has been appointed Visiting Physician to the St. Francis
Hospital.
Exportation of Live Cattle to Germany. — The Ger-
man Ambassador at Washington has notified the Secre-
tary of State that, in consequence of the introduction of
Texas fever into Germany by means of two shipments
from New York, the importation of fresh beef and cattle
from the United States to Germany will soon be pro-
hibited. No such disease is reported among recent ship.
ments, however, and it is believed that that is only an
excuse, and that the real reason is to retaliate against
this country on account of the discrimination against
German beet-sugar in the new tariff law.
JOHN MILLS BROWNE, M.D.,
KX-SURGEON-G&NKRAL UNITED STATES NAVY.
John Mills Browne, Ex-Surgeon- General, United
States Navy, born in Hinsdale, N. EL, May 10, 1831.
Graduated at the Medical Department of Harvard Uni-
versity in March, 1852. Appointed from New Hamp-
shire, March 25, 1853 ; entered the service as Assistant-
Surgeon and performed first duty on board the storeship
Warren, Lieutenant Commanding Fabius Stanly, at Sau-
celito, opposite San Francisco; in September, 1854, the
Warren, Lieutenant Commanding D. McDougall, pro-
ceeded to Mare Island and became the temporary resi-
dence of Commander D. G. Farragut, the inaugurator
and first commander of the Navy Yard ; Medical Officer
of the Navy Yard until May 10, 1855 ; then duty on
board Coast-survey steamer Active, Lieutenant Com-
manding, James Alden ; attached to Active until No-
vember, 1857; Active employed in surveying the coast
and harbors of California, Oregon, and Washington Ter-
ritories in the winter of 1855-56, with the steamer Massa-
chusetts and the sloop Decatur; Passed Assistant Surgeon,
May 12, 1858 ; brig, Dolphin, Lieutenant Commanding,
John N. Maffit, June 1, 1858, Home Squadron off Cape
Verde, Cuba, Dolphin captured the brig Echo with over
three hundred slaves destined for the Cuban market;
Echo sent to Charleston, S. C, subsequently the surviv-
ing negroes were taken to Liberia in the frigate Nisagra ;
October 1, 1858, steamer Atlanta, Commander D. B.
Ridgly, Paraguay expedition ; December 25, 1858, Hos-
pital Norfolk, Surgeon Ninian Pinkney; May 9, 1859,
sloop Constellation, Flag Officer William Inman, Fleet
Surgeon Thomas D. Smith, Flag Ship of African Squad-
ron ; visited Madeira, Cape de Verde Islands, St. Helena,
Liberia, St. Paul de Loanda and other ports and islands
along the west coast of Africa; September 25, i860, at
night off Congo River, Constellation captured the bark
Cora with seven hundred and five slaves, which was sent
to Liberia; commissioned as Surgeon June 19, 1861 ;
December 23, 1861, steam sloop Kearsarge, Commander
Charles W. Pickering, special duty coast of Europe;
visited Cadiz, Algesiras, Gibraltar, Tangier, Ferrol,
Brest, Cherbourg, Boulogne sur-Mer, Calais, Ostend,
Flushing, London, Margate, Ramsgate, Deal, Dover,
Folkstone, Hastings, Queenstown, Azores, Madeira,
Teneriffe; off Cherbourg, June 19, 1864, Kearsarge,
commander John A. Window, alter an engagement of
one hour and two minutes, destroyed the rebel steamer
Alabama; Kearsarge left Europe in August, 1864, for the
Azores, and from thence proceeded to Fernando de
Noroha and Las Rocas, off Brazil, in search of the rebel
steamer Florida, returned to Barbadoes, thence to St.
Thomas, and arrived at Boston November 9, 1864; De-
cember 23, 1864, temporary duty Navy Yard, New York ;
April 29, 1865, Navy Yard, Mare Island; special duty
to superintend the erection of the Naval Hospital at Mare
Island ; duty in charge of the hospital at Mare Island,
1870-71 ; Fleet Surgeon, Pacific Fleet, 1871-72. Com-
missioned as Medical Inspector, December 1, 1871 ;
Navy Yard and Naval Hospital, Mare Island, 1873-74;
Fleet Surgeon, North Pacific Station, 1874-76; Naval
Hospital, Mare Island, 1876-80. Commissioned as
Medical Director, October 6, 1878; President of Medi-
cal Examining Board, Washington, D. C, 1880-82;
Member of Board of Visitors, Naval Academy, Annapo-
lis, Md., 1 88 1 ; Naval Representative at the Interna-
tional Medical Congress, London, Eng., 1881 ; duty in
charge of Museum of Hygiene, 1882-85 ; duty on Board
of Naval Regulations, 1882 ; Member of National Board
of Health, 1883; Naval Representative at International
Medical Congress, Copenhagen, 1884; Member of Retir-
ing Board, 1885-88. Chief of Bureau of Medicine and
Surgery, with title of Surgeon General of the Navy, from
April 2, 1888, until date of retirement, May 10, 1893.
758
MEDICAL RECORD.
[December 15, 1894
QmiwoB mx& Notices of gtoofes.
The Medical Record Visiting List, or Physicians'
Diary for 1895. i6mo. New York : William Wood
&Co.
The present edition of this very popular Visiting List
has been revised to increase the amount of matter calcu-
lated to be useful in emergencies. The most important
change is in the list of remedies and their maximum
doses in both apothecaries' and decimal systems, and the
indication of such as are official in the United States of
America. The items of essential information which
really meet the pressing emergencies of the bedside are
«o well arranged for ready reference, under appropriate
headings, as to occupy but a small amount of space, leav-
ing ample room for the simple and effective record of
daily visits, weekly charges, ledger posting, and memo-
randa. It still retains its convenient pocket size, with
suitable flap-cover and pencil-carrier.
Therapeutics : Its Principles and Practice. By H.
C. Wood, M.D., LL.D., Professor of Materia Medica
and Therapeutics, and Clinical Professor of Diseases of
the Nervous System, in the University of Pennsyl-
vania. Philadelphia: J. B. Lippincott Company.
1894.
This is the ninth edition of Professor Wood's well-
known treatise on therapeutics, "a work on medical
agencies, drugs, and poisons, with especial reference to
the relations between physiology and clinical medicine."
There is little that can be said of a standard work, such
as this has become, whose popularity is attested by the
call for a new edition every two or three years. The
present edition has been adapted to the new Pharma-
copoeia of the United States, all of the new remedies
therein admitted, as well as a number of unofficinal
drugs, being carefully and adequately discussed. To the
few who do not know the work, we can recommend it as
one that shares, with Ringer's Therapeutics and a few other
classical treatises, the honor of being an indispensable
requisite to the therapeutic division of every medical
library.
Syllabus of Lectures on Human Embryology : An
Introduction to the Study of Obstetrics and Gynecol-
ogy. For Medical Students and Practitioners. With a
Glossary of Embryological Terms. By Walter Por-
ter Manton, M.D., Professor of Clinical Gynecology
and Lecturer on Obstetrics in the Detroit College of
Medicine. i2mo, pp. 126. Philadelphia: The F. A.
Davis Co.
Though being, in accordance with its title, only a sy-
noptical outline of the facts of embryology, this little
book will be found convenient and useful for the general
student. The essentials of the subject are set forth
clearly, a useful chapter gives hints as to practical meth-
ods of study, and a satisfactory glossary is appended.
Interleaved blanks add to the convenience kof the^book
for laboratory use.
Materia Medica, Pharmacy, Pharmacology, and The-
rapeutics. By W. Hale White, M.D., F.R.C.P.
Edited by Reynold W. Wilcox, MA., M.D., LL D.
Second American Edition, thoroughly revised. Phila-
delphia : P. Blakiston, Son & Co. 1895.
This book is presented to the profession entirely re-
modelled according to the last edition of the Pharmaco-
poeia. It has been especially prepared to adapt itself
to the wants of American medical men. It is concise,
and still gives clearly all the points anyone cares to know
on the newest drugs, their doses, method of application,
in short, just what each physician ought to know.
Especially interesting we note the chapters pertaining
to prescription writing, doses of drugs, incompatibles,
etc.
Besides the carefully written chapters on action of
drugs on various organs, we note : 1 , Pharmacopceial
inorganic materia medica; 2, pharmacopceial organic
vegetable materia medica; 3, pharmacopceial animal
materia medica. Remedies officinal in B. P.
A great many new drugs have been added to this new
edition, e.g., Borium strontium preparations, hydrogen
dioxide, etc. We also note additions of various or-
ganic drugs, strophantus, rhamnus, puishiano-aspido-
sperma, ami many others.
The authors are to be congratulated on the rapid ap-
pearance of this second edition, and this book well de-
serves a place in the library of every practitioner.
A Practical System of Studying the German Lan-
guage, for Physicians and Medical Students. For
Self- instruction. By Albert Pick, M.D. Newtonville,
Mass. : Pick & Tanner. 1893-94.
We have previously noticed the first six parts of this very
practical work for self-instruction in medical German,
and need only add that the complete work folly justifies
the opinion then expressed, that the method offers to the
diligent student a less difficult means than most other
self-instructors of acquiring the amount of German neces-
sary for reading books or journal articles written in that
language. There is no easy road to German, but this
work appears to open up a shorter path than any we have
yet seen to the acquirement of that smattering of the
language which is all that most of us have the time or
the ambition to gain. The separate parts are conveni-
ent for carrying in the pocket and studying in the car-
riage, the street-car, or during long vigils of the night.
A Practical Treatise on Nervous Exhaustion (Neu-
rasthenia). Its Symptoms, Nature, Sequences,
Treatment. By George M. Beard, A.M., M.D.
Edited, with notes and additions, by A. D. Rockwell,
A.M., M.D. Third edition, enlarged. New York:
E. B. Treat. 1894.
This well-known treatise, for many years a classic, ap-
pears on later reading as interesting and original as when
first published. Accepted throughout the thoughtful
world as conclusive, the ideas that it embodies are still
too little a part of general medical knowledge. The
physician who is endeavoring to practise medicine with-
out them is earnestly advised to secure the new edition
of this book, and increase his power of usefulness by
familiarity with the symptoms and treatment of a very
common and distressing disorder. The original text is
made still more valuable by Dr. A. D. Rockwell's care-
ful notes and additions, which bring the work well up
to date, and offer many practical suggestions.
When All the Woods are Green. A Novel. By S.
Weir Mitchell, M.D., LL.D., Harvard. New York :
The Century Co. 1894.
Not long since a French journal published an elaborate
article on medical novelists, the writer of which, with the
strange national egotism of most of his race, had seemed
to think it needless to mention, if indeed he had ever
heard of, any but Frenchmen. He discovered two
whose art consisted in weaving into a romance some of
the cases of sexual psychopathy collected by v. Krafft-
Ebing and others. It is a pity the writer had not seen
this delightful story of the Canadian forest, with its inci-
dents of salmon-fishing and love-making, for it would
have shown him that medical novelists need not treat of
medical subjects, but can excel in the field of pure liter-
ature without calling in forbidden topics to give their
tales a spice. We believe that Dr. Mitchell's fame will
rest upon his work as a physician rather than on what he
has done in the field of poetry and romance, yet that he
well deserves the high rank which he already holds as a
poet and novelist no one can gainsay. He has the talent,
at least, of giving us living men and women in his tales,
and he holds the interest of the reader to the end.
December 15, 1894]
MEDICAL RECORD.
759
MISSISSIPPI VALLEY MEDICAL ASSOCIATION.
Twentieth Annual Meeting, held at Hot Springs, Ark.,
November 20, 21, 22, and 23, 1894.
First Day, Tuesday, November 20TH.
The Association was called to order by the Chairman of
the Committee of Arrangements, Dr. Thomas E. Holland,
of Hot Springs. Prayer was offered by Rev. Joseph A.
Dickson. An address of welcome on behalf of the State
was delivered by Governor George W. Fishback. Hon.
W. H. Martin, of Hot Springs, followed with an address
of welcome on behalf of the citizens.
The Uses of Medical Societies.— Dr. X. C. Scott, of
Cleveland, O., delivered the presidential address. All
medical associations, he said, should be carried on for the
purpose of elevating the profession and producing a bene-
ficial influence upon its members, and also that they may
meet face to face and thus learn to know each other per-
sonally and better. They should elevate personal char-
acter, afford protection to professional interests, and ad-
vance personal attainments. To be successful the financial
affairs of the Association should be conducted with the
same careful and rigid supervision that pertains to any
private business. He thought the idea of reading all
papers before the general body would afford larger au-
diences, create better and more interesting discussions,
and consequently result in greater good to the majority
of the members. Since the last meeting some of the
States have passed excellent laws governing the practice
of medicine, surgery, and midwifery, but he was sorry to
note that other States failed in the passage of similar
laws.
Some Observations on the Eights and Duties of Medi-
cal Witnesses.— Hon. W. S. Kerr, of Mansfield, O.,
read a paper with this title. The weight of expert medi-
cal evidence depends upon two qualities — first, the skill,
learning, and experience of the witness, and, second, his
honesty. The latter quality can be and should be alike
in all. The former, in the nature of things, must vary
and differ in degrees almost infinite in number. The
evidence of an expert should be compensated for, com-
mensurate with its value. In criminal cases the amount
should be fixed by the court, in civil by agreement be-
tween the expert and the party calling him. The medi-
cal expert should never have his opinions for sale.
Bone and Joint Tuberculosis, the Future Field of
Litigation against Railways.— This paper was read by
Dr. Emory Lanphear, of St. Louis, Mo. The author
submitted the following conclusions: 1. Most chronic
joint affections are tuberculous; "scrofula" has no ex-
istence, being but an attenuated tuberculosis. 2. Hie
family history is unimportant, as tuberculosis is always
acquired, never inherited. The presence of tuberculosis
in the family simply gives a better opportunity for in-
fection. . 3. Infection may occur very early in life, but
the germs may lie dormant for many years in the lymph-
glands, and local tuberculosis develop only after an ac-
cident. 4. An injury to a bone or joint must be slight
in order to cause tuberculosis. If severe, the resultant
inflammation is not favorable to the proliferation of the
bacilli. 5. An injury alone can never produce tuber-
culosis. The bacillus must always be present in the
system, or introduced into a wound at the site ot injury.
6. Per contra, bone or joint tuberculosis would never
develop without a slight local injury. 7. If after a rail-
road accident, falls, wrenches, or other accidents may
have possibly occurred, the local trouble may be due to
them as well as to the railway injury. There must be a
direct sequence to attribute the disease to the local in-
jury.
Enlargement of the Heart without Valvular Dis-
ease.— Dr. Robert H. Babcock, of Chicago, read a pa-
per on this subject. The author said that idiopathic en-
largement of the heart, as Fraentzel designates it, affecting
primarily the left ventricle, is due primarily to prolonged
high arterial tension, and this increase of arterial ten-
sion may be secondary to a cirrhosis of the kidneys,
chronic arterio-sclerosis, congenital narrowing of the ar-
terial system, and some obscure condition probably de-
pendent upon defective assimilation and elimination, which
is not fully understood, connected probably with the circu-
lation of toxines in the blood. Prolonged high arterial
tension he considered the chief factor concerned in the
production of this form of enlargement of the heart.
The enlargement may involve either the right or the left
side of the heart, or both. Prolonged high arterial ten-
sion, when independent of organic disease of the kidneys
or blood-vessels, seems to be due to what the Germans
call luxus consumption. It is observed in individuals who
belong to the better class, who are more or less sedentary
in occupation, who are hearty feeders, and oftentimes
great diners-out The treatment was divided into, first,
the treatment of the stage of loss of compensation, in
which the heart is at first broken down in its resistance.
Rest is the important factor, along with cardiac stimu-
lants and the administration of remedies calculated to
decrease the high arterial tension. Digitalis, strophan-
tus, and their congeners are not suitable to the cases in
the stage of loss of compensation, since the effect of
digitalis, and to a less degree strophantus, is to increase
the resistance within the arterial system, and thereby
increase the strain, already too much for the impaired
right ventricle. It is preferable to administer an ar-
terial stimulant rather than one of the so-called cardiac
tonics. Under the effect of rest and cardiac stimulants
improvement in the condition is generally manifested
speedily.
The author then referred to the Schott method of
treating these cases, which consists of baths and gymnas-
tic exercises.
Malaria a Water-borne Disease, was the title of a
paper read by Dr. W. H. Daly, of Pittsburg. The
author said, in summing up the evidence in a given case
of so-called malaria, it is important to remember that
the water- vehicles of malaria may include contaminated
land water, taken into the stomach on the stalks of cel-
ery or on the leaves of lettuce, or it may find its vehicle
in the rinsing of milk-cans with malaria water, or in the
adulteration of milk with contaminated water containing
the Laveran germ ; the cistern water stored under the
earth may be easily contaminated by the earth water con-
taining the germ, if the cistern itself is cracked or other-
wise inefficient. The author defined his position on this
question by quoting from an article published in the
Medical Record of September 15, 1894.
The Influence of Early Treatment on the Late
Manifestations of Syphilis. — Dr. A. Ravogli, of Cin-
cinnati, said that syphilis must be seriously treated.
Mercury is the true antitoxin for this disease. It is
necessary in instituting treatment, to take under consider-
ation the general condition of the patient, his habits, his
general health, his surroundings, etc., which have great
influence in the toleration of the medicine. The author
believes that early, well-directed treatment of syphilis
will prevent tertiary symptoms. Mercury can be admin-
istered either by the stomach, by subcutaneous injections,
by inunctions, or by baths. The selection of the method
should rest on the good judgment of the physician.
Second Day, Wednesday, November 2ist.
Intestinal Indigestion. — Dr. A. P. Buchman, of
Fort Wayne, Ind., read a paper on this subject. He
said that intestinal putrefaction is, in its incipient stages,
not due to a pathological condition of the tube below
the stomach and duodenum, but is dependent solely
upon errors of gastric and pyloric digestive processes.
Excess of food ingested will universally induce such pu-
trefactive processes, which in infancy and childhood are
exhibited in the bowel diseases of early life, and can
760
MEDICAL RECORD.
[December 15, 1894
with reasonable certainty be differentiated from deflec-
tions by other causes, by the odor and appearance of the
dejecta. The toxic elements generated in this process,
sooner or later, render glandular and cell environments
of the intestinal tube unhealthful. The air patients
breathe, the water they drink, and the food they eat, are
charged with a miasm which absolutely forbids a healthy
reaction, hence most complicated and decidedly serious
pathological conditions arise. Another chief source of
intestinal indigestion arises from the inability of the tube
below the pylorus to successfully cope with the relatively
enormous quantities of carbohydrates and hydrocarbons
that are daily and continually ingested. The second and
third stages of intestinal indigestion were then dwelt
upon. Colon baths properly medicated are very useful
in the general treatment and care of patients suffering
with intestinal indigestion.
Abortion of Typhoid Fever.— Dr. J. E. Woodbridge,
of Youngstown, O., read a paper in which he gave his
experience during the past year in support of his theory.
The Importance of Urinalysis in Diagnosis.— Dr. A.
B. Walker, of Canton, O., held that no opinion of a
case of any importance should be given without there
having been made a careful examination of the urine.
He believed many a case of Bright's disease might be
prevented, if, when the first symptoms of the disease
manifest themselves, a careful examination of the urine
were made, and the proper treatment and diet prescribed.
An interesting case was cited in point
Physicians' Prescriptions.— Dr. Starling Loving, of
Columbus, O., read a paper with this title, in which he
alluded to the difficulties which young practitioners en-
counter when they essay their first prescription. He
said we seldom read of mishaps from defectively written
prescriptions in England, Germany, or France, where
prescription writing is more extensively and systemati-
cally taught. Sufficient attention is not always given in
this country to compatibilities, chemical and therapeutic,
to solubilities, the influences of light, temperature, air,
and of other circumstances affecting the condition of
drugs and chemicals. Many failures in treatment and
many accidents, some serious in character, result from
carelessness or want of accuracy in the directions given
to nurses and patients for the administration of medicines
after they have been brought ready for use.
Poisons.— Dr. William F. Barclay, of Pittsburg, fol-
lowed with a paper on toxics. Toxics enter the circula-
tion, and their action on the normal cells produces toxines,
and the multiplication of these products brings on path-
ological conditions. Nothing is more easily demonstrated
than that the emunctories throw off toxics. We observe
at once, upon the entrance of a toxic into the circulation,
that all the functions of the body are impaired to a
greater or less degree, and the vital forces are at once
disturbed or arrested. Primarily the circulation, and
secondarily the nervous system, are impaired, and shock
is superinduced. In the stage of shock nature seems in-
tent upon relieving herself of all effete matter by the
discharge of the contents of each viscus of the body. All
such efforts should be assisted by artificial means.
Quinine in the Treatment of Chorea,— Drs. Frank R.
Fry, and M. A. Buss, of St. Louis, briefly reviewed
Professor H. C. Wood's theory that chorea is due to dis-
turbances in the spinal inhibitory apparatus, and the sug-
gestion derived from it, that inasmuch as quinine Had
been found physiologically to stimulate spinal inhibition
in animals, the drug be given to patients affected with
chorea. The writers recited a number of their own cases
from clinic and private practice, in the treatment of
which they have been using quinine, and their results
confirm those of Dr. Wood and others. They called
attention to the fact that they have not used as large
doses as others, yet had very satisfactory results. They
suggest that this drug has a decided value in the treat-
ment of certain infectious diseases, in which class, ac-
cording to the opinion of some authorities, chorea
belongs.
Keflex Irritation as a Cause of Disease. — Dr. Edwin
Walker, of Evansville, Ind., said that no error in
modern times has had such a tenacious hold on the pro-
fessional mind as that of reflex irritation as a cause of
nervous disease. The speaker said that he had never
seen a case of epilepsy, insanity, catalepsy, hysteria, or
grave neurasthenia, nor any organic disease of the ner-
vous system cured, or even permanently benefited, by any
operation on the genital tract, done either by himself or
anyone else.
Third Day, Thursday, November 22D.
The Mental Symptoms of Cerebral Syphilis. — Dr.
Frank P. Norbury, of Jacksonville, 111., read a paper
with this title, of which the following were the conclu-
sions: 1. Somnambulism and allied states, lapses of in-
telligent conceptions with associated loss of memory, are
mental symptoms of cerebral syphilis. 2. Sudden som-
nolence with ocular spasm or paralysis points to syphilis ;
when preceded with headache and monoplegia, is almost
pathognomonic. Headache, quasi-periodical, as defined
by Gray, with marked insomnia, suddenly ceasing and
followed by psychical disturbance is due to syphilis. 3.
Melancholia or mania, when following periodical head-
aches, insomnia, and somnolence (a) with ocular spasm
or other form of monoplegia or heterogeneous paralysis,
is due to syphilis. (£) Pseudo paranoia. By this he
means cases presenting all symptoms of paranoia, system-
atized delusions depending on hallucinations of sight,
hearing, taste, or smell, with slight impairment of general
mental functions, is due to syphilis, as we know that
syphilis causes isolated local losses of power, and it is
noteworthy when the special senses are involved that
mental derangement usually results, (c) Pseudo-paresis,
characterized by fibrillary tremor of tongue, indistinct
speech (partial or complete aphasia), uncertain and trem-
bling gait, with delusions of grandeur and occasional
outbursts of maniacal excitement, pupillary involvement,
all characteristic symptoms of paresis, but which yield
readily to antisyphilitic treatment, we can say it was due
to syphilis. 4. Class four have had epileptiform and
apoplectiform attacks. We find cases in which treat-
ment was undertaken too late. The symptoms are those
of terminal dementia, only occurring in patients of pre-
vious sound mental condition and with no special hered-
itary history.
The Surgical Treatment of Injuries of the Head. —
Dr. Charles B. Parker, of Cleveland, O., contributed
a paper on this subject, of which the following were the
conclusions : 1. In a case of doubt as to the character
of a head injury, explore by incision, if necessary. 2.
In the case of wounds, especially the smaller and punct-
ured, enlarge them for exploration and cleansing. 3.
In all cases of fracture, depressed or fissured, operate,
elevating the depression and exploring the fissure for a
depression of the inner table, winch so often occurs. 4.
Leave principal fragments of bone after elevation, if
surgically clean, even if entirely detached from the dura
mater and pericranium, thus averting cerebral hernia,
vertigo, and other cerebral disturbances. 5. All these
operative measures should be conducted under the most
rigid aseptic and antiseptic measures.
Traumatic Lesions of Cranium and Brain. — Dr.
George N. Lowe, of Randall, Ran., reported four in-
teresting cases. The first case was one of depressed
comminuted fracture of the right parietal bone at the
junction of the temporal bone, caused by the kick of a
horse. There was also a contused lacerated wound of all
the soft tissues along the entire ramus of the left inferior
maxillary. In this case the author trephined and elevated
the depressed comminuted bone fragments. Recovery.
Castration for Hypertrophied Prostate. — Dr. B. Mer-
rill Ricketts, of Cincinnati, reported a case of castra-
tion for hypertrophied prostate. The arteries were
twisted, the wound closed, and integument coapted with
a continuous silkworm-gut suture. The patient rallied
December 15, 1894]
MEDICAL RECORD,
761
well from the chloroform and suffered no inconvenience
or pain thereafter. The wound was examined on the
fourth day and primary union was found to have taken
place. The patient left the hospital at the end of the
sixth day. On the second day after the operation he
said that he could urinate with greater ease, and that
the pain was slight; that he could sleep four hours at a
time during the night, whereas formerly he had been
getting up once every hour.
Tumor Albus of the Knee-joint.— This paper was read
by Dr. William E. Wirt, of Cleveland, O. The author
classified the treatment under the two headings of con-
stitutional and local measures, and the local under the
subdivisions of conservative and operative treatment.
The author first considered constitutional treatment,
and then the local treatment, which he divided into the
conservative and operative. The conservative measures
to be carried out in the treatment of this affection are
counter-irritation and local applications, fixation, pro-
tection, rest, and correction of deformity. These were
considered under their respective heads.
Beseotion of the Knee for Separation of the Lower
Epiphysis of the Femur.— Dr. A. H. Meisknbagh, of
St. Louis, said separation of the epiphysis is a condition
that may occur either on account of trauma or disease.
There seems to be a difference of opinion by writers as to
the frequency of its occurrence, especially as the result
of trauma. Traumatic separation of the lower end of the
femur occurs in about from one-fifth to one- third of all
the reported cases, and in the majority of instances pre-
vious to the sixteenth year, seldom later. The forces
that are necessary to produce this separation are various.
Thus during childbirth traction may produce it. Volk-
mann states that he has produced it when the hip is
diseased, when making rotation in seeking for crepita-
tion, or extension in the application of plaster- of-Paris
dressings.
Other forces are indirect external violence, usually of
a twisting character, or lateral, or at right angles to
the axis of the limb. The readiness with which the dis-
location of the separated diaphysis into the popliteal
space occurs can be explained : r, on account of the
anatomical structures of the surrounding parts ; 2, the
force and position of the patient, the popliteal space
being in the direction of least resistance, while on the
anterior aspect we have the quadriceps tendon, the pat-
ella, and the ligamentum patellae. The occurrence of
pathological separation of the epiphyses is regarded by
the latest writers on surgical pathology and diseases of
the bones, as a not infrequent accident in diseases of the
bones and joints. It is noted in osteomyelitis of the
long bones.
Hydrocele —Dr. W. C. Weber, of Cleveland, O.,
read a paper on this subject. He first dwelt upon the
anatomy of the testis, and then alluded to congenital
and acquired hydrocele. The congenital form results
from an imperfect closure between the cavities of the
tunica vaginalis and the peritoneum. Acquired hydro-
cele occurs in children, and most frequently in early adult
life. Its cause is not always known, though traumatism
is probably the most constant factor in its production.
In a hydrocele of small or ordinary size, the date of
its origin being recent, an evacuation by means of a small
trocar and cannula may be all that is necessary to accom-
plish a core. Should this fail in its purpose, it becomes
necessary to adopt measures whereby sufficient irritation
of the tunica vaginalis may be produced to secure inflam-
matory adhesions of the opposing surfaces. This end is
usually attained by the injection of tincture of iodine,
alcohol, carbolic acid, perchloride of iron, and other sub-
stances into the sac after the removal of its adventitious
contents. Among other methods of treatment may be
mentioned excision, incision, and the seton. The author
reported a case in which he used carbolic acid, which
illustrated very nicely what can be done in the way of
radical treatment in apparently extreme cases. The re-
sult was very satisfactory.
Treatment of Traumatic Cataract Attended with
Eapid Swelling of the Lens. — Dr. James M. Ball, of
St. Louis, Mo., held that in cases of traumatic cataract
with rapid increase of intra ocular tension, an operation
should be performed, and it should not be linear extrac-
tion, but an extraction made with the Graefe knife, and
with the incision located in the cornec-scleral junction.
The knife should cut from one-third to twc-fifths of the
corneal circumference, according to the extent to which
the softening process in the lens has advanced. If glau-
comatous symptoms supervene with softening of only a
small part of the lens, the corneal incision should be
large. If the softening involve the whole of the lens,
the incision should be of less extent. The chief merit of
the operation lies in the avoidance of the valve which
is produced by the linear method. In other words, the
author's method permits of free evacuation of all the
lenticular substance with the least amount of traumatism.
An iridectomy is not made. All debris is removed at
once. This cannot be accomplished by the linear
method.
Some Observations on Sore Throat Due to Concretions
in the Tonsils. — Dr. Lewis C. Cline, of Indianapolis,
Ind., read a paper in which he said that every experi-
enced practitioner could recall cases of recurring tonsil-
litis or sore throat that often developed without any ap-
parent cause, but which were doubtless due to chronic
inflammation of the follicles, altered and retained secre-
tions. It was to this class of cases that the essayist in-
vited attention. His remarks dealt more particularly
with the cheesy bodies, and not the calculi, which are
probably the outgrowth of the long retained cheesy de-
posits acting as a nidus for the deposit of the more solid
materials, as phosphate and carbonate of lime, iron,
soda, and potassa, etc. These concretions are doubtless
the result of a catarrhal condition of the mucous lining
of the follicles, often coupled with a uric acid diathesis.
Some writers believe them to be parasitic in origin.
They predispose to attacks of quinsy, and in the author's
judgment are the cause of the majority of these cases,
and they can be permanently cured by carefully search-
ing for and destroying all the crypts and pockets in
which these bodies are formed. The author reported
several interesting cases, and closed by stating that per-
verted secretions of the follicles of the tonsils from ca-
tarrhal inflammation resulting in cheesy concretions were
the cause of more sore throats and quinsy in adults than
any or all other causes combined.
Fourth Day, Friday, November 23D.
The Eemoval of the Auditory Ossicles for the Belief
of Chronic Deafness and Other Abnormal Conditions.—
Dr. Robert C. Heflebower, of Cincinnati, contributed
a paper with this title, of which the following were the
conclusions: 1. No bad results attend the excision of
the malleus and the incus, but removal of the stapes is
not without the most serious danger, both to life and
hearing. 2. That the removal of the malleus and incus
alone is far preferable to the removal of the stapes. 3.
The operation is of extreme service in chronic suppura-
tion in suitable cases, frequently avoiding mastoid and
other serious disturbances of an equally serious nature.
4. It should be performed in cases where there is a high
perforation, or where the membrana flaccida is perfor-
ated, and where the ossicles are necrotic. 5. Tinnitus,
headaches of ear origin, and vertigo are relieved. 6. In
suitable cases it is invaluable for relieving deafness,
whether from chronic suppuration or from chronic ca-
tarrh and sclerosis.
Circumcision. — Dr. Bransford Lewis, of St. Louis,
Mo., read a paper on this subject in which he detailed a
method of performing that operation, for which he claimed
many advantages. The operation was done with the as-
sistance of two instruments, a clamp and prepuce-tractor,
which enabled the operator to carry out the following
762
MEDICAL RECORD.
[December 15, 1894
steps of procedure: 1. The prepuce is drawn strongly
forward, the traction being applied to its inner surface
by means of the serrated tractor mentioned. 2. The
glans penis being repressed, the curved, fenestrated
clamp is applied. 3. With these as a support and guide,
ten per cent, cocaine solution is injected between the
two layers of foreskin, anterior to the clamp. 4. After
effective anaesthesia has been secured, six double length
(ten inch) catgut sutures are run clear through the clamp-
fenestra and the four layers of foreskin. 5. With strong
scissors the latter is cut off at one sweep. 6. Tractor
and clamp being removed, the double - length sutures
being divided, two additional sutures are placed at the
dorsal and frenal sites, previously occupied by the tractor.
7. The vessels are secured and sutures tied all around.
The Treatment and Management of Corporeal Endo-
metritis was the title of a paper read by Dr. William
H. Humiston, of Cleveland, O., in which the author
said that nine-tenths of all cases that he treats suffer from
some form of endometritis, and its baleful influence on
the sympathetic nervous system is marked and manifested
by numerous and varied symptoms.
The first and important principle in treatment is to re-
lieve the passive congestion of the uterus, and this is
accomplished by medicated tampons. The first tampon
should be medicated with boro-glyceride, iodo-glycerine,
or icthyol-glycerine, and supported by sterilized, non-
absorbent cotton tampons. The septic cases must be
treated on modern surgical principles — rest, asepsis,
drainage, and curetting. When the cases are diagnosed
early and the proper treatment instituted, the author says
the abdominal surgeon will not have his belt hanging full
of suppurating tubes and ovaries.
The Belation of Besidnal Urine to Vesical Irrita-
tion.— Dr. G. Frank Lydston, of Chicago, contributed
a paper with this title. He said it is generally accepted
that most of the symptomatic disturbances incidental to
certain chronic bladder diseases, especially in cases of
prostatic enlargement, are dependent upon the accumu-
lation of residual urine. The author has long been im-
pressed with the idea that residual urine per se is not as
important a factor in genito-urinary irritation as is or
dinarily believed. He is satisfied that in a large propor-
tion of adult males there is always a greater or less resid-
uum of urine remaining in the bladder after micturition.
If prostatic enlargement or other obstruction attacking
the mouth of the bladder develop, we have the typical
accumulation of residual urine characteristic of such
cases. It will then be seen that there may be, at varying
periods of life, extreme differences in the degree of ac-
cumulation of residual urine. The author believes that
the residual urine is simply an incident upon which, if
taken alone, the symptoms of vesical irritation in no wise
depend. Ideally perfect drainage of the bas-fond can
only be accomplished by thorough drainage from above
the tube through the trigone and out of the rectum.
There were certain objections to this method which the
author said it was not necessary to dilate upon. He
simply stated as his opinion that only by some such pro-
cedure can the bas-fond be thoroughly drained.
Laparotomy for Pelvic Diseases is no Longer a ne-
cessity.— This paper was contributed by Dr. R. Stans-
bury Sutton, of Pittsburg. The assertion found in the
text of the paper was founded upon the following argu-
ment : 1. We have a substitute for laparotomy in total ex-
tirpation of the uterus and appendages by the vagina, either
with or without morcellement. 2. The operation has
already been proven to be effectual and successful by
many in Europe and in the United States. 3. Total
extirpation of the uterus and appendages per vaginam
gives a lower mortality than laparotomy for the removal
of the appendages alone. Morcellement of small fibroid
tumors gives a lower mortality than laparotomy for the
removal of similar tumors. 4. These operations by the
vagina shorten the convalescence of patients, who are
out of bed on the seventh day. 5. In all cases of gonor-
rhoea!, tubercular, or other infectious type of endometri-
tis with chronic salpingitis and chronic ovaritis, a cure is
not effected save by total extirpation of the uterus and
appendages. The vaginal route is the best. 6. In all
cases of fibroid tumors of the uterus, not reaching above
or quite to the umbilicus, when the uterus must be sacri-
ficed, total extirpation of the organ, tumor, and appen-
dages by morcellement can be best effected through the
vagina. 7. Small cysts of the ovary or broad ligament, or
solid tumors of the ovary can be reached and, by morcelle-
ment and puncture, be removed through the vault of the
vagina, leaving the uterus and opposite ovary and tube in-
tact. 8. In all cases of pyosalpinx or of multiple pus centres,
with coexisting solidification of the pelvic roof, total ex-
tirpation by morcellement per vaginam is the only feasi-
ble operation, and it cures the patient. 9. Total extir-
pation per vaginam is followed by a cure in the greatest
majority of cases, as compared with laparotomy. 10.
The following sequels after laparotomies do not occur
after total extirpation by the vagina: cancer of the
uterus, adenoma of the uterus, tuberculosis of the uterus,
gonorrhoea! infection, hemorrhages of the uterus, filthy
catarrhal discharges from the uterus, ventral hernia, fecal
and other fistulas, the mark of a wound on the abdomen.
The nerve-storms subsequent to total extirpation are not
as great as after laparotomy. The patient is restored to
perfect health. This is not the case in more than fifty per
cent, of laparotomies for pelvic diseases. 1 1 . The bacte-
riology of infectious diseases demands removal of the
uterus with the appendages. 12. Total extirpation by the
vagina is in strict conformity to anatomical relations. 13.
The physiological results following total extirpation are
free from jarrings, and the patient is functionally a smooth-
ly running mechanism. 1 4. Laparotomy for these diseases
is followed by all manner of physiological disturbances
which affect the vascular, muscular, nervous, and digestive
systems. 15. In the face of this argument, laparotomy
for pelvic disease is no longer a necessity, but in the
author's opinion should be abandoned excepting in very
rare instances, indeed.
Modern Surgical Technique. — Dr. Henry O. Marcy,
of Boston, emphasizes the importance of a most careful
bacteriological training on the part of him who would
become proficient in surgical practice. In the prepara-
tion of the operating-room, Dr. Marcy pointed out the
ease and safety with which an ordinary living room, by
preference the kitchen, is made comparatively sterile,
when from necessity the surgeon is called upon to act
promptly and suddenly. In abdominal wounds, where
irrigation is not advised, he substitutes for it a slowly
flowing stream of oxygen gas from a compressed cylinder.
This sterile gas is heavier than atmospheric air which it
displaces, and as a consequence renders the wound less
likely to infection from the products of respiration and
atmospheric contamination. Dr. Marcy reiterated his
well-known views upon the value of tendon sutures, bur-
ied in all aseptic wounds for the approximation and re-
inforcement of the structures, emphasizing the importance
of abandoning the drainage-tube in all aseptic wounds,
and hermetically sealing of the same with iodoform col-
lodion. Aseptic wounds made in aseptic structures
aseptically closed, and sealed, are always followed by
primary union.
Election of Officers. — The following officers were
elected for the ensuing year: President, Dr. W. H.
Wishard, of Indianapolis: First Vice-President, Dr.
Thomas E. Holland, of Hot Springs; Second Vice-
President, Dr. Charles B. Parker, of Cleveland ; Secre-
tary, Dr. Frederick C. Woodburn, of Indianapolis;
Treasurer, Dr. Harold N. Mover, of Chicago.
The next meeting will be held in Detroit, Mich., Sep-
tember, 1895. Chairman of Committee of Arrange-
ments, Dr. H. O. Walker, of Detroit.
Dr. William P. Overton, president of the Queens
County Medical Society, died recently at his home in
Cold Spring Harbor, L. I.
December 15, 1894]
MEDICAL RECORD.
763
NEW YORK ACADEMY OF MEDICINE.
SECTION ON SURGERY.
Stated Meeting, November 12 9 1894.
W. W. Van Arsdale, M.D., Chairman pro tem.
Lead-pencil in Axilla Mistaken for Fracture of Clavi-
cle.— Dr. Sinclair Tousey presented a young man
who, prior to the time when he saw him, had been going
around for about six weeks with a broken lead-pencil,
four inches long, in the axilla, which had been mistaken
at different hospitals for fractured clavicle. At one of
the larger hospitals an abscess had been opened under
ether, but it was decided to wait until the supposed
fragment of clavicle had separated before an attempt
should be made to remove it. When Dr. Tousey saw
the patient the probe introduced into one of the sinuses
came in contact with a substance which felt like bone,
and as it was quite movable he administered an anaesthet-
ic and took out what proved to be a piece of lead-pen-
cil. The patient then remembered that it must have
entered when he slid down a lamppost and caught the
pocket containing the pencil on a projection. What
appeared to be a scratch marked the point of entrance.
Dr. Francis H. Markoe had seen a somewhat sim-
ilar case, the accident occurring at the elbow. A door
had shut as the patient was passing through, striking her
arm and shawl. She consulted Dr. Markoe next morn-
ing on account of pain. He found no bruise, no abra-
sion, no fracture, but a hard body could be felt lying
across the elbow-joint. Under ether a long shawl-pin was
extracted. It had felt much like a bony fragment.
Carcinoma of Transverse Colon ; Excision ; End-to-
end Anastomosis with Murphy's Button. — Dr. H.
Lilienthal presented a strong-looking man, of middle
age, who prior to the time he first saw him, in May,
had been ill fourteen months, with variable pains in the
abdomen, paresthesia, gurglings, marked emaciation.
In May a tumor could be felt, the size of a large egg,
apparently in the transverse colon. Its location was
confirmed by an operation. It was removed, with about
four inches of the gut, and the divided ends were united
by a Murphy button of very large size, so large that it
was of tight fit and caused some fear that it might not
come away safely. As it had not passed on the eigh-
teenth day, he had gentle massage made over the abdo-
men from right to left and an enema given. Soon after-
ward the button passed, and a little blood with it. Hie
patient had been given solid food from the sixth day.
Some of the mesenteric glands were found enlarged, and
a relapse was to be expected, although at present the
patient was in good condition! The tumor was cancer.
The danger of using too large a button was shown in
a second fatal case. The woman had a fecal fistula
which had led him to make an artificial anus, and subse-
quently she had submitted to laparotomy seven times at
the hands of different surgeons. As she wished the arti-
ficial anus closed, Dr. Lilienthal made use of the Murphy
button to establish end-to-end anastomosis and then
closed the wound. The gut below was much atrophied,
and the button proved a tight fit, so tight indeed that it
led to gangrene and death, the button having partly
passed out along with faeces into the peritoneal cavity. In
a third case he hesitated, but the patient insisted on hav-
ing his artificial anus closed. After the experience with
the second case Dr. Lilienthal used a button a quarter of
an inch less in diameter, and did not at once close the
artificial anus, but introduced a strip of gauze drain down
to the lower segment of gut, which, as in the other case,
was atrophied. This patient got through all right, the
button being passed on. the sixth day. Dr. Lilienthal
thought there was more danger from sepsis in anasto-
mosis for closure of artificial anus than in other forms of
intestinal resection because of the difficulty of cleansing
the wound thoroughly in the former, whereas Dr. Van
Arsdale, during the discussion, expressed surprise at this
statement, since he believed operations for closure of ar-
tificial anus gave the best results.
Dr. Willy Meyer thought the button shown was
enormous, and that if we would follow the directions
given by Dr. Murphy, using only the sizes which he had
indicated, and made in the manner which he had de-
scribed, our results would be equally satisfactory. The
button should always be at hand on going to laparotomy
cases.
Dr. Van Arsdale had had a case of gastroenteros-
tomy go wrong in spite of the button, the man dying of
inanition ; nothing — no gangrene — found at the site of
the button to account for death.
Dr. Lilienthal said this sized button had been made
by instruction of Dr. Gerster. It was, however, too
large except for anastomosis of the rectum, and there
even a larger one would be required if one would avoid
forming a constriction in the ampulla.
Case of Ideal Cholecystotomy.— Dr. C. L. Gibson
presented seven gall-stones, as large as hazel-nuts, re-
moved from the gallbladder and duct at a single oper-
ation. Vague gastric symptoms had existed several
months before the patient entered the hospital. A tumor
was felt in the region of the right kidney, and was
thought to be cystic kidney, the mistake clearing up
only on exploratory operation, when it was found to be
the distended gallbladder. Convalescence had been
uneventful.
Dr. Dawbarn said that about the time when the
Murphy button was first used in New York he sent to
Chicago and got one which he used in a case of gall-
stone, the diagnosis having been confirmed by the opera-
tion. The gall- bladder seemed remarkably friable, and
at autopsy— <ieath having occurred in forty eight hours
—-a distinct tear was found at the edge of the button.
There was also a diffuse form of cancer of the liver, and
this had probably led to the friable condition of the
gall-bladder, although this viscus was not carcinomatous.
He had sent an account of the case to Dr. Murphy be-
fore the latter had reported a collection of one hundred
successful cases, and had afterward written Dr. Murphy to
learn why this fatal one had been omitted. The answer
was that he did not suppose the author of the case
would care to have it reported since it was unsuccessful,
and also because it was an attempt to unite a cancerous
gall-bladder with the duodenum, which was not true.
Resection of Beotum for Malignant Growth ; Persist-
ent Heuralgia in Scar. — Dr. Van Arsdale presented
a man, fifty- four years of age, about six inches of whose
rectum he had excised through the sacrum, for carcinoma,
in 1892. The proximal end of the gut was drawn down
and sutured to the anus, a secondary operation was done
the same summer, and in March, 1894, two small carci-
nomatous nodules were removed from the rectal mucous
membrane. Since then the man had been in good
health, and had control over the bowel. Advice was
asked with regard to the relief of pain which existed
along the line of union between mucous membrane and
skin.
Case of Volvulus of the Sigmoid Flexure, with Com-
ments.— Dr. Francis H. Markoe said it had been his
intention to present a paper on intestinal obstruction,
based on sixteen cases which had come under his obser-
vation, but for lack of time he limited himself on this occa-
sion to a recent one of volvulus of the sigmoid flexure, with
comments. The man had had symptoms of intestinal
obstruction about eleven days before he was brought to
Bellevue, where Dr. Markoe saw him, there having been
no passages since the third day. He found the abdomen
much distended, especially on the right side. High
rectal injection was made in the knee-chest position, but
nothing came away. He then opened the abdomen and
found a loop of the large gut completely turned upon
itself and greatly distended with gas. This was gently
untwisted after letting out the gas. An ecchymotic
spot, the size of a silver dollar, was found and the loop
was secured at the bottom of the wound by a gauze strip
764
MEDICAL RECORD.
[December 15, 1894
passed through mesentery. There was no evidence of
congenital or acquired stenosis. The patient improved
steadily for four days, and on the night of the fourth day
had several passages in response to small doses of calomel.
°* the fifth day he suddenly collapsed, colotomy was
performed in the attached loop, but he died soon afterward
from perforation at the ecchymotic spot, which had be-
come gangrenous. Dr. Markoe asked discussion on how
to prevent recurrence.
Dr. De Garmo inquired whether the gangrene took
place at the point of puncture for letting out gas. He
had observed tendency to gangrene even after puncture
with very small trocar.
Dr. Markoe thought the question a pertinent one,
but in this instance the gangrene had occurred at the
point of doubtful vitality, a little above the puncture.
An Improved Method of Radical Operation for Car-
cinoma of the Breast— Dr. Willy Meyer read the
paper. See page 746.
Dr. H. J. Boldt said he had not removed the breast in
one mass as described in the paper, but in two cases
he had performed the operation as radically, removing
muscle. One patient had died. The other, who was
operated upon two months ago, could not use the arm
as well as before, and had some interference with the
circulation. He did not doubt the superiority of re-
moving all that it was intended to remove in one piece.
The Axillary Operation Heedless.— Dr. Thomas H.
Manley said that according to his own experience it
was entirely needless to go up into the axilla in removal
of cancerous breast. Going down to the pectoral mus-
cle increased the danger to life— danger of injuring the
axillary vessels and brachial plexus. When the parts
were closed in, the scar held the arm down and inter-
fered with the circulation in the axilla. Moreover, the
theory on which such extensive removal was based, that
cancer was a local disease, had not been proven. He
remembered a statement made by the elder Markoe,
some years ago, when removal of the axillary glands was
coining into vogue. Dr. Markoe had said he did not
believe in it, for the axillary enlargement was only due
to tumefaction, and this went down as predicted, in the
case on which he was operating, after he had removed
the diseased breast. Unless it were in special cases, Dr.
Manley did not think such extensive dissection as had
been described by Dr. Meyer was necessary.
The Axillary Operation Imperative.— All the re-
mainder of the speakers took pains to combat Dr.
Manley's view, that removal up into the axilla was not
necessary. Even where no infiltration in the axillary
glands had been apparent, microscopic examination had
shown the presence of cancer cells. The statistics oi
cures had been much better after the more radical ex-
cision than previously. All thought well of Dr. Meyer's
procedure, some claimed to have been in the habit of
removing muscle along with the gland tissue, and the
question of priority was raised even as to removal in
bulk, commencing in the axilla. The speakers were
Drs. Dawbarn, Gallant, Morris, Fowler, Lloyd, Van
Arsdale, Meyer. Dr. Francis H. Markoe said that in a
recent conversation with his father the latter had ad-
mitted the superiority of the radical operation as having
been proven by recent statistics.
The Tenement-house Commission appointed by Gov-
ernor Flower last spring, in accordance with a bill passed
by both houses of the Legislature, find that a new list of
more than five thousand houses require especial investiga-
tion. They further find that three-fourths of this city's
population live in tenement* Of course a large deduc-
tion may be made in favor of high- class flats and apart-
ment-houses, but the law does not discriminate between
Fifth Avenue and Chrystie Street. Three or more fam-
ilies constitute a tenement according to the legal defini-
tion.
OUR LONDON LETTER.
GLADSTONE ON CLARK — DRUGGIST- APOTHECARIES AND SIR
B W. RICHARDSON — THE MARYLEBONE EPIDEMIC — TES-
TIMONIALS— LISTER — HUGHUNGS JACKSON WALTER
RIVINGTON — MEMORIAL TO BEAVEN RAKE — DEATHS OF
ALBERT NAPPER AND SURGEON GENERAL ERASER — MEDI-
CAL COUNCIL — SMALL-POX — DIPHTHERIA AND ANTI-
TOXIN— CLINICAL EVENINGS AT THE SOCIETIES — IN-
TERESTING EXHIBITS AT THE MEDICAL AND CLINICAL
SOCIETIES — OPENING THE CECUM — LARGE CALCULUS —
HEREDITARY SYPHILIS — CRETINS — RUPTURED NECK OP
BLADDER — EXCISION OF SCAPULA — EXTENSIVE TUBER-
CULOSIS OF PERINEUM, PROSTATE, AND RECTUM — TRE-
PHINING FOR EPILEPSY — CURIOUS NODULES, ETC. — MED-
ICAL DEPUTATION" TO THE HOME SECRETARY — MARRIED
WOMEN AND FACTORY WORK — DEATH CERTIFICATION
MASSAGE SCANDALS — LONDON DEATH RATE PUBLIC
HEALTH — DEATH OF DR. DICKSON, R. N.
London, November 24, 1894.
I hear that Mr. Gladstone is about giving to one of
your American magazines some reminiscences of his
late friend Sir Andrew Clark. This reminds me that
the considerable fortune left by the respectable medical
baronet has given rise to much gossip as to its origin.
It is not infrequently said that the sum was accumu-
lated from practice, and as it exceeded ,£200,000, that
is enough to make any physician's mouth water. I hap-
pen to know, however, on the best authority — Sir An-
drew's own — that he was careful and fortunate as to
investments, and to them we must attribute a considera-
ble share in the accumulation. A daily newspaper has
lately discussed the " Fortunes Left by Doctors/' bat
without affording any important information.
Sir B. W. Richardson has returned in his last Ascltpiad
to his proposal to legalize druggists as counter-prescribers.
He would have an order of " pharmaceutical apotheca-
ries " to occupy itself with inferior practice as well as dis-
pensing, and pretends that such an order would quickly
accept medical etiquette and submit to the rule of their
professional superiors. It is a pity that, with all his abili-
ties, Sir Benjamin should have such self-consciousness
as to fancy he has only to speak to settle any difficulty.
It is a wonder that his love of admiration did not prompt
him to drop his proposal when he saw how unpopular it
was. But he has spoken and seems to think that is
enough. He will perhaps yet see his error. The idea of
relieving the overcrowding and resulting degradation of
the profession by flooding it with unqualified practition-
ers, is original enough, and worthy of the fertile fancy of
the Ascltpiad. Why does he not also offer to take in our
sanitary inspectors ? These persons, elect of our vestries,
are forging ahead, and in some districts evidently intend
to assume as many as possible of the functions of the
medical officers of health. Perhaps they hope to become
the chief advisers of our sanitary boards. Let Sir Benja-
min extend his hand in time and recognize them as special*
ists in preventive medicine. Then hygeia would indeed
be established, and physicians might be relegated to an
inferior order.
During the late outbreak of small-pox in Marylebone
Dr. Greenwood vaccinated 1,725 persons and revac-
cinated 2,306. There was in fact a local scare, and a
rush to obtain the protection which had been so much
neglected. It appears from Dr. Greenwood's report
that about twenty-six per cent, of the inhabitants had
been guilty of such neglect. After the performance of
these operations only two or three cases of small-pox oc-
curred in the whole number, and these were already in-
cubating the disease. The anti-vaccinators will find
small comfort in these figures, but I suppose will not
cease to propagate their pernicious prejudice. Perhaps
an occasional scare of this kind is the only way to teach
December 15, 1894]
MEDICAL RECORD,
765
them the futility of their fad when the public finds dan-
ger approaching.
Testimonials are much in vogue, and make no small de-
mands on the often too slenderly furnished purses of
medical men. Just now three important ones are before
us— one to Lister, one to Hughlings Jackson, and one to
Rivington. All three desire the support of those whose
finances make it easy to subscribe. It may be thought
that Lister has already received all the honors that are
necessary during life, and that the rest might be left for
posthumous commemoration ; but no doubt the ever-
widening circle of antiseptic surgeons, at any rate the
prosperous ones, will hasten to enroll their names.
Hughlings Jackson has also done a great and lasting
work, and neurologists everywhere will be glad of the
opportunity to honor him.
Walter Rivington's work has been so closely connect-
ed with thfe London Hospital, and he has been so favorite
a teacher, that it was only natural for his numerous
pupils and admirers to seize the occasion of his retire-
ment from active service to testify their esteem. Ac-
cordingly he was entertained at a dinner last week, and
presented with a silver tea and coffee service. Mr. Riv-
ington thanked the numerous friends who had gathered
to honor him, as well as those who were unable to be
present but had subscribed to the handsome testimonial
— adding with the sly humor which never fails him, " and
also those who had judiciously refrained from doing so."
From testimonials to the living, it is natural to pass to
memorials to the honored dead. The work of the late
Dr. Beaven Rake, of the Trinidad Leper Asylum, is
worthy of admiration, and his premature death, leaving a
widow and children but ill-provided for, is the occasion
of a proposal to raise a sum of money for their benefit.
It is impossible not to wish success to the subscription.
The scientific spirit was strong in Dr. Rake, and he died
too soon to make suitable provision for his family — a too
common occurrence in our ill-remunerated calling.
The death of Mr. Albert Napper took place last week,
somewhat suddenly, in the seventy-ninth year of his age.
He will be remembered as the Founder of the Cottage
Hospital system, now so generally in vogue that, to the
younger members of the profession it must seem strange
that one life should cover the time since there were no
such institutions. Mr. Napper's earnest advocacy and
unfailing perseverance succeeded in establishing the sys-
tem which everyone now admires.
Another veteran also died last week, Surgeon- General
John Fraser, aged seventy-five. He had seen much ser-
vice, including the Crimea and the Indian Mutiny. He
had received various honors, and on his retirement a
distinguished service pension.
Next week the General Medical Council will be in
session.
The public health continues good. The small-pox
epidemic, in London, has apparently subsided, and diph-
theria deaths have diminished. In regard to the last the
serum treatment is occupying great attention, and is be-
ing tried wherever a supply can be obtained. The suc-
cesses reported are very striking, and it is to be hoped
the British Institute will soon be in a position to meet
the demand for the new remedy.
What are called clinical evenings at the societies are
becoming very popular. They are devoted to the exhi-
bition of cases and specimens with a few remarks to
explain them, and attract larger attendances than set
papers. The Medical Society of London has begun to
hold such meetings, as the Clinical has long done. Both
these had such evenings at their last meetings, and both
were well attended and the exhibits were of great inter-
est. Thus at the Medical Society, which met on Monday
last, Mr. Harrison Cripps gave an account of a most
interesting case of intestinal obstruction in a woman,
aged thirty-one, who had sustained two severe operations,
but ultimately made a good recovery and is now in good
health, and has resumed her occupation as a domestic
servant.
Mr. Goodsall showed a man who had come to him
with intestinal obstruction due to cancer of the rectum.
He performed left inguinal colotomy to relieve the .
obstruction, but the colon was so distended and packed
with putty-like feces, that he was unable to draw the gut
out of the wound. He waited for seven days in the hope
that some bulging would take place, but as the patient at
that time began to get into a serious condition, he de-
cided to attack the csecum. He found this filled with
the same putty-like feces, but managed to pull it out,
and he opened it forthwith, with a satisfactory result.
This was the third time he had opened the cecum, and he
was inclined to regard this operation in certain cases as
presenting advantages over colotomy. Among the other
cases shown was one by Mr. Astley Bloxam, in which
thirteen ounces of calculus were removed by bim through
a lumbar incision. The curious point about the case was
that the symptoms at no time suggested the presence of
anything approaching so large a mass of calcareous
deposit.
Dr. Hall showed a boy sixteen years of age, who had
developed hereditary syphilis as late as in his eighth year
of age. Some other late cases were mentioned by those
present, one of whom said he had seen it as late as the
twentieth and even thirtieth year of age.
Mr. Clutton showed a boy thirteen years of age, who
had had the humerus dislocated, and the surgical neck of
the bone fractured. The fracture and joint were ex-
posed, ivory pegs employed, etc., and perfect movement
of the joint resulted.
Some cretins were exhibited. Thyroid gland treat-
ment had produced excellent results in some of them.
The Clinical Society of London held their meeting on
Friday, November 9th. Mr. Hurry Fenwick showed a
patient with traumatic rupture of the prostatic neck of
the bladder, who had been buried while excavating.
Twelve hours after the accident suprapubic incision re-
vealed the condition, and the bladder was drained
through a perineal incision. Mr. Fenwick urged that in
all doubtful cases suprapubic incision should precede
the opening of the peritoneum, and he believed that
most extra-peritoneal uncomplicated ruptures ought to
bee ured.
Dr. W. P. Herringham gave an acount of a case of
scleroderma in a seaman, thirty-nine years of age, who
had been for sixteen years a diver.
Mr. Watson Cheyne showed a man, fifty years of agc9
from whom he had removed the scapula five weeks pre-
viously, on account of a large enchondromatous tumor of
seven years' growth, involving the whole bone and pro-
jecting forward into the axilla. The tumor weighed
over ten pounds. The wound healed by first intention,
and the patient left the hospital sixteen days after the
operation. The movements of the arm are steadily in-
creasing in range and power.
Mr. Arbuthnot Lane showed a case of extensive tuber-
cular disease of the perineum, prostate, ischiorectal
fossa, and rectum, which he treated successfully by the
introduction of glycerine and sulphur into the cavities ;
which was begun on September 4, 1894, when he
weighed eight stone eleven pounds ; now he weighs ten
stone, and is free from pain.
Dr. Barlow showed a case of extensive primary atrophy
of the muscles of the limbs and trunk, with lordosis and
some contraction of hips, in a lad five years of age. No
particular muscles were atrophied more than others, the
atrophy being pretty general, but in some respects the
case resembled pseudo-hypertrophic paralysis, but was
difficult to classify ; and Dr. Ormerod suggested that it
belonged to the "myopathic" group of pseudo-hyper-
trophic cases.
Mr. Butlin showed a man in whom he had performed
trephining for traumatic epilepsy following a fall of
eight feet, the head striking against the mantel- piece.
He removed a second piece of bone, but discovered
nothing further. He let out the fluid in the subarach-
noid space, and the man made a good recovery, though
766
MEDICAL RECORD.
[December 15, 1894
his mental condition remained unsatisfactory for some
time.
Mr. Gould mentioned a curious case of a man who
had struck his head in a bath. After operation he ap-
peared to be better, but his mental condition never be-
came satisfactory, and he was not altogether free from
fits. He was lost sight of for a time, but Mr. Barker
said the man had come into the hospital under his care
some days since. He gave an altogether misleading his
tory of himself, denying ever having had fits or having
been operated upon. The examination of the scalp led
one to think that there was a depressed fracture, but on
receiving the real history the idea of operating thereon
was abandoned, the supposed depressed fracture, on
shaving the scalp, being obviously the scar of Mr. Gould's
operation.
Mr. Jacobson showed a man who had been operated
on for bullet wound of the parietal lobe, inflicted while
skirmishing on the west coast of Africa, where he was
struck by a bullet which lodged in the lower part of the
left parietal lobe, or at the junction of this with the tem-
poro-3phenoidal. He became unconscious, and after five
weeks he returned to England, his wound closing for a
time, then, reopening, giving exit to pieces of bone and
discharge. During this period there had been no hemi-
plegia, no hemianaesthesia, no crossed amblyopia. Se-
vere headaches frequently occurred when the wound
closed for a time. On June 27th an attempt was made
at Plymouth to remove the ball, but as brain -matter es-
caped this was desisted from. Save for the headaches
his general health was excellent. On October 19th the
opening was exposed and enlarged, when one came upon
the mouth oi a sinus-like track in the dura mater, blocked
with granulations. This membrane was quite healthy
all round. Two small pieces of bone were removed
from a spot about three-quarters of an inch from the
mouth of the sinus. Two inches further in, the probe
struck the bullet, which was removed by the aid of a sharp
spoon. He made a rapid recovery, and has since entirely
lost his headaches.
Dr. Hale White showed a boy aged ten, who, when
near the end of a first relapse of typhoid fever, developed
a severe eczema which rapidly spread — the whole face and
ears were covered, the eyes being affected with conjunc-
tivitis— and slowly subsided in about six weeks.
Dr. Harry Campbell showed a case of acromegaly in a
man aged forty-six.
Dr. Scanes Spicer showed a case of incomplete Graves's
disease with nasal polypi, in a young woman. After re-
moving a large number of polypi, the patient had im
proved in some respects, and he thought that the con-
nection between these two conditions was something
more than a coincidence.
Dr. G. Stoker said he had had a case of goitre along
with intra nasal growths, in whom the treatment of the
nasal condition was followed by the disappearance of the
goitre within two months.
Mr. Godlee showed a man aged twenty-eight, with
multiple nodules of doubtful nature which began in
April. There were numerous hard nodules in the eye-
lids, on the forehead, jaw, arms, condyles, etc., and on
the knuckles. Microscopically, the nodules were said to
be composed of fibrous and not lymphatic tissue.
Mr. Boulby showed a man, aged fifty- eight, with Char-
cot's disease of the hip with dislocation. The evidences
of tabes are as follows : Lightning pains in limbs, dim
vision, and gray atrophy, absence of knee jerks, and in-
ability to stand with the eyes shut.
Mr. Edgar Willett showed a similar case.
On Wednesday, November 14th, Mr. Asquith received
at the Home Office a deputation got up by a committee of
the British Medical Association. The object was to influ-
ence the minister on three questions, viz., the employment
of married women in factories, death certificates, and the
factory laws. The injury to children from the employ-
ment of their mothers in factories has often been brought
forward as an argument in favor of legislative prevention,
m and Dr. Reid urged this view on the Home Secretary
' with considerable force, estimating that the infant mor-
tality was twenty eight per cent, greater in factory towns
than in other parts. He insisted that women should be
prohibited from such work for three months after the
birth of a child. Mr. Asquith asked if the month before
birth was not equally important, but was told that was a
separate question, and apparently the deputation were not
agreed upon it. The minister has evidently thought out
the subject, and the newspaper reports show that, although
he grasped and sympathized with the object of Dr. Reid,
yet, looking at the matter from a broader standpoint, he
saw some difficulties in the way. Thus, though employ-
ers are generally ready to keep a woman's place open far
her return, it is by no means certain they would do so
for a period of three months. Again, he remarked that,
although it was a good thing to check improvident mar-
riages, it would be the reverse to engender a feeling that
the child was in the way. Then, as to criches, there was
a rather strong prejudice against them, and though only
a prejudice, yet its existence was a fact to be reckoned
with. Mr. Asquith said he did not make these remarks
in a hostile spirit, but they were objections that must be
carefully weighed, and he promised that the subject
should be carefully considered.
As to death certification, assurances were offered
on the part of the government of their concurrence, sav-
ing the question of cost, and whether the time of Par-
liament would suffice. There was also little difference as
to the factory acts.
Of course Mr. E. Hart was much en evidence, and he
seized the opportunity to mention the massage scandals
lately reported in the British Medical Journal, and which
he is continuing to publish in very short instalments
double leaded and " to be continued," after the manner
of sensational chapters in "penny dreadful1' periodi-
cals.
Mr. Asquith expressed his disinclination to deal with
such a subject in public, and said it was not in his judg-
ment fitted for such an occasion ; but as Mr. Hart had
chosen to introduce it, he would simply say he was wil-
ling to receive any authenticated information to show
there had been, or was likely to be, any breach of the law.
He pointed out that the police are not guardians of
morality and could hardly interfere on moral grounds
unless the law was infringed ; but Mr. Hart might rely
upon the co-operation of the police within their proper
functions. The view of the home secretary is naturally
unsatisfactory to Mr. Hart, who is evidently already tired
of the sensation he has tried to get up. Accordingly I
see the Journal to-day says it is " eminently desirable that
the police should take this matter off our hands as speedily
as possible."
No doubt that would be a course to afford gratification
to others than the staff of the Journal, but the probability
of such success should have been weighed before embark-
ing on so dangerous and disgusting a course of sensation.
Nevertheless all may hope that good will come out of
the exposure that has been made, and some way of deal-
ing with the subject arrived at.
The public health continues to be excellent in spite
of the most trying weather. Last week the death-rate
in London was only fifteen, although diphtheria still lin-
gers with us. But the cases are diminishing week by
week.
The Registrar-General reports that last quarter (ending
September 30th) was the first summer quarter since 1837
that the annual rate fell below 15 per 1,000. This last
it only reached 14.2. Yet the summer was marked by
low temperature, excessive rain, and deficient sunshine,
and though we are still having what is generally declared
" most unseasonable " weather, the mortality returns are
most favorable.
Dr. Walter Dickson, R. N., medical inspector of H.
M. Customs, died on the 9th inst., in the seventy-fourth
year of his age. He was a roan of considerable learning
and literary tastes. He had done no little service in the
December 15, 1894]
MEDICAL RECORD.
767
Royal Navy, and had received many medals and other
recognitions.
His published writings and addresses were numerous,
and all were characterized by a thorough grasp of his
subject, which he put in an attractive form.
MALARIA AND DRINKING-WATER.
To thb Editok or tub Medical Record.
Sir: I have noticed several articles on malaria as a
water-borne disease in the Medical Record of the last
few weeks.
Allow me to side with Dr. Dalrymple, and suggest a
few more objections to the theory of Dr. Daly's.
I lived as a boy in Southwestern Missouri, when that
portion of the State was metamorphosing from a stock-
raising to a farming community, and am familiar with
about all forms of malaria, and speak from personal ex-
perience. I have seen families drinking surface water
remain free from all infection, only to become prostrated
as soon as they began breaking land. This was not in a
few instances, but was the regular thing.
The old settlers, who lived on the creek-bottoms and
who arose early, before the sun had dissipated die morn-
ing fog, were always sick, while their neighbors living
higher on the hills, and who awaited the rising sun be-
fore beginning work, would frequently escape. Sleeping
on the ground would always bring on an attack of the
chills, while sleeping twenty feet above the surface gave
immunity even when the same water was used*
Intermittent fever has followed the settlement of this
country from Indiana to California, keeping pace with
the turning of the sod.
It was also noticed that in Ohio and Missouri, during
the time of making maple- sugar, to use the sap with any-
thing like freedom was invariably followed by intermit-
tent fever. This was well known and added zest to
every swallow of that exhilarating fluid. This was before
the advent of the plasmodia malarise into medical litera-
ture, and was a curious clinical fact with no tenable
theory to support it then.
It has seemed to me, too, that the persons who used
sorghum molasses freely were rather more susceptible
to the poison than others, and that the young and grow-
ing, who needed sugar to keep up muscular growth and
activity, were more likely to become intoxicated with
the poison.
I have never seen any account of cultures of the Plas-
modia, but I could venture a guess that it would only
grow in a medium containing an appreciable percentage
of sugar.
The value of the eucalyptus-tree as a prophylactic, as
proven by the experiments made near Rome, must rest
on the germicidal qualities of the rootlets — in the oil
that they contain — and not in the minute particles of
that oil given off by the leaves to the passing breeze.
I think quite likely that the home of the plasmodia is
in the sap of vegetable life rich in sugar. While water
is the frequent, perhaps common, source of infection,
yet I know that it does enter the system from other
sources as well.
Rawlins Cadwallader, A.M., M.D.
Fall Rive* Mills, Cal.
THE MARRIAGE OF SYPHILITICA
To thb Editok or thb Medical Rkcoed.
Sir: In your issue for November 24th, under "The
Marriage of Syphilitics," Dr. W. K. Otis, of New York
City, criticises the "positive stand" taken by myself,
in a previous issue, on the above-named subject Whether
my replies to Dr. Burnside Foster are satisfactory to him
or otherwise, I leave for him to answer for himself. If
my answers to Dr. Foster's queries are not acceptable to
himself, he certainly had better continue his investiga-
tions far enough and thoroughly enough to satisfy him-
self that " allowing our syphilitic cases to marry " and
procreate is, at all times and in nearly all cases, a hazard-
ous thing to do.
Dr. Otis says, "Unfortunately Dr. Maine has taken a
very positive stand in this matter, and one that is wholly
(italics mine) unwarranted by either authorities or
facts." I desire right hereto ask, "unfortunately " for
whom ? Certainly not for myself, and most assuredly
not for all good and honored representatives of pure
American citizenship.
If "unfortunately" for the band of syphilitics who
would prey upon innocent purity through the sacred
marriage contract, or "unfortunately " for the physician
who would sanction such marriages, and overlook the
greatest good to the greatest number, and cater to the
selfish purposes of thoroughly selfish unfortunates, I glory
in the "unfortunately " " positive stand " I have taken.
When Dr. Otis says, " Wholly unwarranted by either
authorities or facts," I take again my " positive stand,"
and am ready to take issue with the doctor and declare
that both "authorities and facts," in far more than the
average, fully bear me out in the "positive stand " I
have taken.
Yes ! I have taken a "positive stand" and am ready,
were it necessary, to stand alone for what I believe to be
right (but I have not found it necessary to stand alone,
as I have already received many words of commendation
and encouragement from numerous sources), and in the
defence of pure marriages and the propagation of a race
that shall be an honor to the nation.
I desire, furthermore, to be understood as to the
sources from which I have gleaned a large percentage of
the " facts " which have led up to the formation of my
opinions and my "positive stand: " 1. To the evi-
dences furnished by a careful study of the works named
by Dr. Otis, to which list I also desire to add the names of
Fournier and Wood. a. Considering the guarded manner
in which all present the conclusion " that it may in cer-
tain instances be safe for syphilitics to marry." 3. To
this strong line of evidences, that there is danger in
permitting syphilitics to marry, I attach the evidences
gathered from journal statistics published during die past
twenty years; and 4, last and least, my own experience
ranging over a longer period than that, which (though,
since graduation, I have not had the advantage of
" study of the disease in the rich fields for research only
obtainable in great cities") have yet been sufficient to
teach me, at least, the dangers of syphilitic marriages.
But I do not want Dr. Otis to think that the " great
cities" have all the "luxuries," for even in my own
" small city " the vile enemy to health, happiness, and
home lurks; and, sad to relate, we have rich fields for
study, and have plenty of material from which to observe
and draw conclusions respecting that blight and blot on
everything good and pure that it touches (syphilis), even
in the country districts.
Having thus briefly stated the sources from whence I
have drawn the "facts'1 which have led me "to feel
justified in presenting my opinion " (no matter to whom
it is in opposition), simply passing the doctor's comment
on my mention of scrofula, with the sole explanation that
in my former paper I merely referred to it as one of the
conditions handed down from past generations ; barely
adding that I have at my command the latest " works on
general pathology " and am able to see that opinions
differ in respect to the subject, I will pass on and draw a
few conclusions:
1. No writer says every syphilitic can marry.
2. Every writer declares great care should be exercised
in permitting the marriage of syphilitics.
3. Every writer who has carefully compiled statistics
(so far as I can find), has followed but the first two gener-
ations, except in a very few special instances not amount-
ing to three per cent, of the total.
4. The average ages of the children, or second gener-
ation, when pronounced apparently healthy (by all
statistics at my command), is a little over fourteen years.
768
MEDICAL RECORD.
[December i 5. 1894
5. In a little over fifty-three per cent, of the parents
(first generation) who had suffered from syphilis previous
to marriage, the cases have showto unmistakable evidences
of syphilis subsequent to the birth of siid " apparently
healthy child or children."
Now, allowing a moderate average, say fifty per cent.,
of the said remaining, forty-seven per cent, might have
died from other causes without showing a recurrent syphi-
lis, but would had they lived, and taking out twenty-five
per cent, more of the remaining forty- seven per cent, as
having passed out from under observation (and that is
small enough), and we have left a very small percentage
as even questionably safe to permit marriage to be con-
tracted ; and who is competent to select that small per-
centage in the early days of the syphilitic cases? I ac-
knowledge that I am not, and statistics show that others
have made serious mistakes.
6. If a parent who, apparently cured, procreates (and
these conclusions are arrived at from the printed statis-
tics of writers favorable to allowing " the marriage of
syphilitica " under certain conditions) children who at
ten, twelve, or fifteen years are apparently healthy, and
then the parent, in from one to twenty years thereafter
develops unmistakable evidences of syphilis in the later
types of brain degeneration, cerebral and spinal gumma,
syphilitic nodes of various bony structures, or other equal-
ly or more grave lesions of syphilis, does any physician
believe that that child of such parent has no syphilitic
taint lurking in its economy? Does any physician be-
lieve that that child will not some day show unmistak-
able signs of syphilis, unless specific treatment has been
kept up during gestation or for the child after birth ?
Does any physician believe that the third generation, or
child of that child, will be an honor to the human race ?
I, for one, do not.
I quote Dr. Otis's own words : " Some of the most
healthy persons of my acquaintance have been born of
parents, one of whom, at least, had been a sufferer from
syphilis before marriage ; nor have I observed the slight-
est trace of the disease in any form passed down to the
third generation." I must ask then : 1. What can be
the condition of health of the people of Dr. Otis's ac-
quaintance who have not been " blessed " with one par-
ent, at least, who has suffered from syphilis ?
2. What would have been the health of those " most
healthy persons" of his acquaintance, had both parents
been " blessed " with pre-nuptial syphilis ?
3. Dr. Otis's experience, in his field of observation,
being so different from that of all writers down to the
present time, will the readers of the Medical Record be
willing to accept his conclusions and opinions, which
almost place a premium on people who have had at least
one parent who has suffered from syphilis before mar-
riage?
4. Is it possible, in the great field for observation which
New York City furnishes, that the doctor has not " ob-
served the slightest trace of the disease, in any form,
passed down to the third generation?" I must infer
that he has either shut his eyes to the bare-faced facts
which are constantly confronting all his brethren in the
profession ; that his experience has been very limited ;
or that he has not seen the third generation yet born.
Conclusions drawn from a few special cases, when the
facts and experience of thousands of cases in opposition
as observed by every-day experience, are at hand, would
form a precedent unwarranted, and one which might lead,
yes, would lead, to untold misery if generally followed
by the profession, and the unlimited marriage of syphil-
itics be permitted. It is the general public we are to
defend for the best good of all, and deal with those who
are a menace to the general good in such a way as shall
best fulfil that purpose.
I now reach the doctor's conclusion, and with all re-
spect to the titled author of those closing words, I must
take my positive stand once more and first of all say : If
syphilitica must be satisfied, let that satiety be in whore-
dom and concubinage, its honest birthplace and proper
habitat, and not in the home which is the avowed heart
of a nation, and on which a nation's welfare depends.
Let us not be blinded by individual calamities and
thereby bring national degeneracy.
The doctor's last clause, of his quotation, reads, "Would
probably not in the least diminish the prevalence of
syphilis." I admit the force of this argument, and
again I say, let it remain where it belongs and not let it
enter the sacred home of the pure and innocent, and
bring upon such misery and death, or what is worse than
death.
By all that is good in man, by all that is dear to wom-
an, by all that is sacred of home, let this nation be
populated from the homes of purity, or else let it follow,
as it certainly will, the course of some of its " illustri-
ous" predecessors.
Frank E. Mains, M.D.
Aubuin, N. Y., November 98, 1894.
THE CAUSE OF BERIBERI.
To tub Bmtok or ths Medical Record.
Sir : Dr. Siegfried, in an article published in your journal
of December 8th, declares it his opinion— and let me say
the opinion is not new — that the chief causative element
in the etiology of beriberi is " the lack of the nitrogen-
ous foodstuffs, particularly of the fresh flesh sorts, in the
habitual diet of the natives " affected by this disease.
I beg Dr. Siegfried to see how he can reconcile the
following facts with this theory : Baelz says " that the
Japanese diet, far from being wanting in albumin, is, for
the lower classes, at least as rich, perhaps richer, in albu-
min than the food of the poor in most European coun-
tries." " That rice," he says, " cannot produce kakke
in any manner, is distinctly shown by the circumstance
that in the interior, where rice is a much more impor-
tant factor of the popular diet than on the coast, where
fish is abundant, die disease is incomparably rarer than
on the littoral." Of course the interior is the region of
high ground.
" Persons of strong constitution are more frequently
affected," says Baelz, " than weak persons ; likewise per-
sons placed in favorable social conditions more frequent-
ly than those belonging to the lower classes. Of 626
policlinic patients, there were 593 of strong constitution,
27 of middle constitution, and 6 of weak constitution.
Such numbers," says Baelz, " are simply annihilating for
the theory according to which kakke is the result of in-
sufficient alimentation and consequent weakness. Sim-
mons also speaks very earnestly against that theory."
" The best fed, the best nourished, and best cared for
are usually the most frequent subjects of the disease,
while the weak and destitute are only exceptionally at-
tacked by it."
" According to some physicians fat people are quite
peculiarly disposed to kakke."
"The adzuki bean enjoysa great repute as a food for
beriberi patients, which is well deserved by its unques-
tionable diuretic properties, so important in this special
disease."
" Among the Japanese, the flesh eaters, that is soldiers
and sailors, the best nourished part of the nation, are
more affected by kakke than the rest."
Even with the addition of the adzuki bean diet, it is
considered essential by every Japanese, or foreign, doctor
in Japan to send the patient to a high elevation. And
why is elevation so important ? Are patients better fed
on elevated ground ? Why does not an analysis of the
blood show a deficiency of red corpuscles ?
Yours truly,
Albert S. Ashmead, M.D
New York, December 8, 1894.
The Irish School of Medicine is said to be declining
both in the quality of its teachers and the number of its
students.
Medical Record
A Weekly yournal of Medicine and Surgery
Vol. 46, No. 25.
Whole No. 1259.
New York, December 22, 1894.
$5.00 Per Annum.
Single Copies, ioc.
THE PRESENCE OF ALBUMIN AND CASTS
IN THE URINE OF FOOTBALL PLAYERS.1
By ANDREW MACFARLANE, A.B., M.D.,
INSTRUCTOR IN PHYSICAL DIAGNOSIS AND CLINICAL MICROSCOPY, ALBANY (N. Y.)
MBDICAL COLLBOS.
When in 1827 Dr. Richard Bright announced the clini-
cal unity of dropsy, albuminous urine, and disease of the
kidneys, the significance of albuminuria became at once
apparent. Since that time the importance of the ex-
amination of the urine and the diagnostic value of the
determination of its proteid constituents have held high
place in clinical work. The effect of the discovery of
this association of symptoms, however, was to lead to the
inference that the presence of albumin in urine always
indicates renal disease, and renal disease with a rapidly
fatal termination, a belief which prevailed until about
twenty years ago. . But in the past two decades a num-
ber of distinguished clinicians, Leube, Senator, Posner,
T. Grainger Stewart, Saundby, Mahomed, and others,
have found that albumin was at times found in the urine
of people in whom there was no detectable disease of the
kidneys. Some have even asserted that albumin could
be found in the urine of every person if sought for with
sufficiently delicate tests ; thus Posner found an albumi-
nous body in the urine in all of seventy persons ; Chateau-
bourg in 592 cases out of 701 ; T. Grainger Stewart in
275 healthy soldiers, and in seventeen per cent, of 50
children.
This claim of physiological albuminuria has, however,
had many opponents, and to-day the latter hold that
renal albuminuria always indicates diseases of the kid-
neys, which, though concealed for a time, will eventually
reveal itself. They assert that Bright's disease develops
intermittently by acute periods of inflammation inter-
rupted by remissions more or less complete, which may
last for years, during which time the albumin entirely
disappears, due to the cicatrization of the lesion ; that
granular kidney seems to date its existence to some period
of anxiety or worry, and that increased tension of the
pulse is met with in certain states of nervous excitement.
Temporary albuminuria of the neurotic is likely, therefore,
in their opinion, to have a serious even if remote end-
ing.
The believers in a physiological albuminuria claim that
albuminuria frequently occurs without present or future
disease of the kidney, and unless accompanied by other
symptoms has no pathological significance. They main-
tain that the albuminuria which occurs in conditions of
nervous excitement, after physical exertion, from the
consumption of egg albumin, after baths, after sexual
excitement, at the beginning of puberty, after marked
sweating, does not indicate a lesion of the kidneys.
This incomplete summary indicates briefly the general
character of the opposing opinions as to the significance
of albuminuria. That this subject is one of the deepest
interest to all physicians is self-evident. It must be a
matter of some importance to all of us, and of the deep-
est concern to our patients, that we properly interpret a
condition which may be either the danger-signal of an
1 Abstract of a paper, Albuminuria, its Detection and Signifi-
cance, read before the Albany County Medical .Society, November
ax, 1894.
incurable malady or a trivial occurrence of no special sig-
nificance.
It will not be necessary to consider in detail the dif-
ferent kinds of albuminuria, but merely to recall them to
your recollection. I shall, however, take the liberty of
considering more at length a cause of albuminuria which,
although always recognized, does not appear to have been
sufficiently investigated.
The forms of albuminuria are naturally divided, for
clinical purposes, into two great classes — accidental albu-
minuria and renal albuminuria.
Accidental albuminuria is the result of an admixture
of albuminous fluids, as blood, pus, chyle, with urine it-
self free from albumin. In such cases the urine usually
contains a small quantity of albumin, and invariably a
sediment of elements characteristic of the fluid admixed,
as blood-cells, pus-cells, etc. To this class — the acci-
dental albuminurias — belong many cases which, I believe,
have too often been denominated functional or physiolog-
ical albuminuria. Sir Andrew Clark, with his remarkable
medical acumen, recognized this fact, and stated that " in
some young men excited by sexual desire and denying it
indulgence, there was secreted from the urethra or its
adjacent glands a fluid which, mixing with the urine,
yields evidence of the presence of serum albumin " (al-
bumose?). Sir William Gull probably had this same fact
in mind when he said, "albuminuria is almost as com-
mon in young men as spermatorrhoea." Many of the
functional albuminurias of puberty, and probably also a
number of the cases of neurasthenic albuminuria prop-
erly belong to this class.
Renal albuminuria may also, for clinical purposes, be
subdivided into — 1. Albuminuria, due to a primary lesion
of the kidneys. 2. Secondary or complicating albu-
minuria, due to (a), circulatory derangements, as in car-
diac disease — this may, however, eventuate in renal dis-
ease ; (£), febrile conditions depending upon changes in
blood-pressure and in the epithelium of the kidneys, and
also the result of the excretion of the toxines of disease ;
(V), changes in the composition of the blood, as in anae-
mia and chlorosis. 3. Functional or so-called physio-
logical albuminuria, the result of muscular exertion, men-
tal strain, cold and cold bathing, diet, and without any
other symptom of Bright's disease. Of these only the
so-called physiological albuminuria need be considered,
as the significance of albumin in the other forms of albu-
minuria is beyond question.
Functional albuminuria is commonly said to be char-
acterized by— 1 , absence of all other symptoms of Bright's
disease; 2, chance detection while the person was ap-
parently in good health ; 3, quantity of albumin is com-
paratively small, and at times in the twenty- four hours
is entirely absent ; 4, absence of the casts.
That albumin due to the above-mentioned causes is at
times found in the urine has been known for a long time.
In Germany, albumin has been detected in the urine of
soldiers after long marches. In England, Pavy found al-
bumin in the urine of Weston, the walker ; T. Grainger
Stewart, in persons after violent exercise, and Mason in
two out of five school- boys after a run of six miles. In
this country Lambert, of the Equitable Life, has found
that when the temperature goes to zero or below, or
when it passes 90 ° F., the percentage of healthy men
having albumin in their urine increases from two per
cent, to five per cent., until the temperature reaches nearer
the mean. Gray, in a recent paper, states that he has
772
MEDICAL RECORD.
[December 22, 1894
seven cases, not a dozen and a half of them being per-
forations of the nasal septum. In ten of these seventy-
seven cases a perforation of the septum was found without
any sign of ulceration or necrosis at any other point
within the nasal cavities. Jurasz,6 in ten years1 time, at
Heidelberg, examined over four thousand nose and throat
patients, and noticed perforation of the nasal septum in
only thirty-seven of them, and then only once was the os-
seous portion found perforated. Hermet,7 in the course
of a discussion on this subject at a meeting of the Laryn-
gological Society of Paris, asserted that perforations of
the nasal septum are very rare in France. They are not
of frequent occurrence in New York City. Taking eight
annual reports of the New York Eye and Ear Infirmary
(1874-80-84-85-87-88-89, and 1890), it will be found
that ten thousand cases of nose and throat diseases were
recorded, two thousand one hundred and nine of which
were diseases of the nose. And only twenty cases of
perforation of the nasal septum are recorded. During
the year ending May, 1894, at the New Amsterdam Eye
and Ear Hospital, four hundred and ninety-three cases of
nose and throat diseases were examined, and only three
times were perforations of the nasal septum recorded.
There have been years at the New York Eye and Ear
Infirmary when not a single case of septal perforation
was seen. Certainly these figures prove this much — per-
forations of the nasal septum, though not of exceptional
occurrence, are by no means common or frequent.
Sex. — Schaeffer found his twenty- two cases seven times
men and fifteen times women. In this respect the ex-
perience of Weichselbaum, Hajek, Jurasz, others, and
my own, has been the contrary, that is, about two to one
in favor of males.
Age. — Jurasz found the ages of his patients ranging
from ten to over seventy years. And Hajek found sep-
tal ulcerations and perforations oftenest in those between
twenty and fifty years of age — that is, during the most
active and most exposed period of life.
Side of Development.— Perforations develop from
ulcers on either side of the septum, or from both sides
simultaneously. Rossbach found their point of origin
oftenest on the right side ; but Hajek found it to be on
the right side five times, on the left side nine times, and
on both sides simultaneously six times.
My Own Cases. — During the past two years I have
had, in private practice, seven cases of perforation of
the nasal septum in my care. Five were men, and two
were women. The ladies were respectively thirty- one
and forty- eight years old. Two of the men were in the
fifties, two in the forties, and one was eighteen years
old. In five the cartilaginous portion of the septum was
the site of perforation. In one case the bony portion
only was perforated, and that was a case of very late
tertiary syphilis. The seventh was a traumatic case, and
the perforation involved both the bony and cartilaginous
portions of the septum. Two of the cases were seen
while still in the ulcerative stage, and several months
before perforation at last took place. In these cases —
the one syphilitic and the other non-syphilitic — the
trouble began on the right side of the septum. The syphi-
litic presented extensive infiltrations over the right mid-
dle and inferior turbinated bones, and later on ulcera-
tions, besides perforation of the hard palate. Necrotic
pieces of bone were taken from the palate. The palatal
trouble healed up quite rapidly. The cartilaginous part
of the septum remained unaffected while the patient was
under observation, and the trouble remained limited to
the palatal and vomer bones. Infiltration and ulceration
were much more marked in the right than in the left nasal
cavity.*
• This man, aged fifty, at first denied ever having had syphilis ; but
finding his assurances disbelieved, he finally acknowledged having
been treated for the disease while soldiering in Russia and Siberia
twenty-five years ago. Within the last three years two of his infant
children have died of hereditary syphilis. The one * hen nine months
old, and the last when three weeks old. I saw the first child only
twice before it died. This child was supposed by the parents to be
sick with only diarrhoea. It had coryza, headache, and anal condylo-
mata, besides a roseolaceous rash on the buttocks which shaded off
In only one of the other five cases was it possible, from
the character of the existing ulcerative process, to deter-
mine that in all probability the trouble began on the
right side of the septum. The other three cases — not
counting the traumatic one — presented perforations in
such a perfect state of finished development, that it was
impossible to say whether the perforations began on the
right or the left side, or on both sides simultaneously.
In the one woman the cartilaginous portion of the sep-
tum was bent into the left nasal cavity, but not enough
so as to block up entirely the respiratory passages, and
in this case it was plain the ulcerative process began on
the right or concave surface. Once the perforation was
associated with atrophic rhinitis and pharyngitis ; once
with hypertrophic rhinitis ; once, as already mentioned,
with extensive syphilitic infiltrations (syphilis nowhere
else than in the nose, mouth, and throat) and ulcera-
tions; and once the perforation complicated fracture
and dislocation of the cartilaginous portion of the sep-
tum. Only two of the cases applied to be relieved from
nasal symptoms that were directly due to the ulcero per-
forative process, which was limited, and on the cartilagi-
nous portion of the nasal septum.
In the course of an interesting and instructive essay on
bacteria and cocci in the nasal cavities, Doctor Jonathan
Wright * says, " The day of theorizing has gone by. A
theory now-a-days should be considered as little better
than confession of ignorance 9 ' — mere words. With great
truth has it been said that there are more false facts than
false theories. The fallacies of a theory do not worry us
much, and never for a long while. Life itself is theory,
and we can no more escape from the necessity of theor-
izing than we can from the necessity of quoting others,
unless we end by suicide. Such a thing as the " scien-
tific imagination " has been spoken of by many scientific
and unscientific orators, and in varying senses. As a
not exact expression for the highest kind of mental ac-
tivity, it may be allowed to pass unchallenged. All the
sciences and all the arts owe much to it, and so does
rhinology. The scientific imagination revels in attempts
at unravelling the riddles that confront and puzzle us.
It builds theories by combining the facts that are seen by
all with those that are forgotten or have never been
known before. It finds and marshals facts into their
co ordinate places. It breathes life into facts that seem
dead. It organizes knowledge and makes it all-power-
ful. And yet, as has been said over and over again for
hundreds and hundreds of years, to quote Glanvill, " we
erre and come short of science, because we are so fre-
' quently misled by the evil conduct of our imaginations;
whose irregular strength and importunities doeth almost
perpetually abuse us. ' ° A comparative study of rhinologi-
cal writers on perforations of the nasal septum reveals to
us that they have been and are thoroughly human, and
that they have seen and reported facts often enough, only
partially, not to say falsely ; and they have not foiled to
build theories which have crumbled away under the
grinding weight of time. And so, by the irregular
strength and the importunities of the imagination — not
because of any theory as such, however fallacious — writers
who meant well have imposed on the often too ready
credulity of those who must needs consult them for pro-
fessional mental fodder, or ready-made opinion. Let
us see:
Etiology. — The study of the causes of perforations of
the nasal septum may be considered conveniently under
five heads, namely : 1. Congenital or developmental in-
fluences, a. Traumatisms. 3. Contiguous pathological
processes. 4. Diseases that engender such constitutional
and local conditions peculiar to syphilis, tuberculosis,
lupus, scrofula, rheumatism, diphtheria, fevers, etc. 5.
Local inflammatory and allied processes.
down the thighs. Its life ended in convulsions. The last child was
plump and apparently healthy when born ; but soon it had a coma
and a sore anus, and it died soon of syphilitic marasmus. The mother
nursed neither of these children. A girl six years old betrays none **f
the ordinary well-known signs of hereditary syphilis. The mother is a
strong woman, and she states nerer had any miscarriages, etc
December 22, 1894]
MEDICAL RECORD.
775
Congenital or Developmental Causes. — Hilderbrandt
(anatomist) had a hole in the anterior portion of his
nasal septum, which he considered congenital because he
was not able to account for it in any other way. In the
course of many years Hyrtl observed such perforations
three times in anatomy subjects. He too considered
them congenital in origin. Bosworth * quotes Schmiege-
low as having seen a perforation which was believed to
be congenital, and in which case a large portion of the
cartilage was wanting. Without giving specific instances
or references to such, £. Klebs 10 states, " roundish holes
in the nasal septum are observed in foetuses — the borders
of these perforations are covered with a smooth mem-
brane, and it has not been demonstrated beyond a doubt
whether these holes are caused by some foetal ulcerative
process or by arrested development/1 And no less an
anatomist and rhinologist than Harrison Allen u says,
" Congenital defects in the nasal septum are apt to be
multiple, and the septal opening to be associated with
the presence of a hyperostosis in the roof of the mouth,
or asymmetry of the facial bones. " Congenital de-
fects are, says Harrison Allen, as a rule in the cartilage,
although they may be found in the perpendicular plate of
the ethmoid bone. A case of congenital defect is quoted
from Germs by Beely; " parts of the vomer in the child
were missing, and the nasal cavities of both sides com-
municated. In this case the hard palate was very much
arched, and thus in a manner compensated for the de-
ficiencies of the vomer.
Traumatic Causes. — Bosworth u has seen perforations
of the nasal septum result from injuries to the nose. In
those cases splinters of bone (the vomer) ulcerated away
and left a defect in the bony portion of the septum. My
case, mentioned above, was a man over fifty years old,
and the victim of a runaway accident. Being jerked
from the carriage seat he struck his face against the pave-
ment. The septal cartilage was dislocated antero-infe-
riorly into the right nasal cavity, and above into the left
nasal chamber, besides being bent or broken longitudi-
nally, the convexity of the cartilage jutting against the
turbinated bone of the left side of the nose. The ante-
rior portion of the lamina perpendicularis was fractured.
A probe could be passed through from the right into the
left nasal cavity, above and behind, near where bone and
cartilage join. The dislocated and fractured parts were
easily replaced and fixed by means of long and firm
pledgets of absorbent cotton and borated gauze. The re-
sult is good. There is no visible external deformity, and
there is no obstruction to nasal respiration. For four
weeks after the accident a healing ulcer was seen at the
point where the probe had been passed through the sep-
tum. The ulcer was seen longest on the right surface of
the septum, where it had always been larger. The acci-
dent had caused much hemorrhage from the nose, and con*
siderable flattening, besides a good deal of dizziness,
which persisted for weeks afterward.
An interesting case of bullet traumatism mentioned by
L5ri,14 may be quoted here : A soldier who had been shot
years ago through the nose, the bullet having entered a
little below the glabella, and, without injuring the hard
or soft palate, penetrated into the pharynx, from whence
it was expectorated. An irregular fleshy mass extending
from the lower nasal passages away up into the attic of
the nose, was found on both sides. At the posterior parts
occupied by this mass of granulation tissue, the septum
was found to be defective.
According to Harrison Allen,15 imperfect surgical ope-
rations may give rise to septal perforations. Zucker-
kandl w quotes a case from Velpeau, in which the oper-
ating surgeon put a hole through a very much bent
septum which he had supposed was a polyp.
It is well known that certain barbarous people perfo-
rate the septal cartilage for the purpose of wearing deco-
rative rings, and for purposes of religious ceremonies.
There is one other instance of septal perforation, al-
leged to be due to causes which are traumatic rather than
anything else. I refer to Professor Bosworth's theory,17
by which he not only explains the cause of nasal hemor-
rhages, but also the manner in which round or oval per-
forations are developed in the cartilaginous portion of
the septum. The theory is simple enough, but so purely
mechanical as to deny life to the septum, and reduce it
to the grade of an inorganic partition without the power
of reacting against injury. It is simply frictional ero-
sion, sans ulceration, sans inflammation, sans constitu-
tional taint. The theory is novel in rhinological and
pathological literature. Cognizant of the eminence of
the author, it is only just that he be quoted verbatim et
literatim : " The most common cause of this perforation
is to be found in the projection of the cartilage into one
or the other passage, whereby its prominent portion be-
comes subjected to the current of inspired air, laden as
it is with dust and other impurities, whereby a process of
erosion is established, under which the cartilage is grad-
ually worn away until an opening occurs. This is a
purely local process, and involves no suspicion of a sys-
temic taint. The existence of the erosion is attended
with annoying crust formation over its site, causing a
frequent picking of the nose, by which the process of
erosion is much hastened. This process, as we see, is
really a conservative effort on the part of nature to relieve
the patient of an obstructive lesion in the nose, and one,
moreover, which I have frequently seen attended with
signal success, since the removal of the obstruction
seems to be the primary effect of the process, while the
establishment of a perforation is to an extent adventi-
tious. I cannot agree with Zuckerkandl in the view that
these cartilaginous perforations are due in a large major-
ity of instances to an ulcerative or inflammatory action,
in that the simple erosion in my experience is never at-
tended with either of these processes. " Reading all this
simple talk of Bosworth's makes one think of a saying of
Emerson's — " power and purpose ride on matter to the
last atom." But it is all too good to be true. McBride
criticises the theory quite mildly by calling its assump-
tion of a projecting cartilage arbitrary. There are
many points of cartilage in the nose that jut out into the
current of inspired air, but they remain intact and are
not filed away by the dust-laden impure wind ; perhaps
so, for the sole benefit of the operating rhinologist.
Then, too, according to pathological specialists, an ero-
sion is a superficial ulcerative and inflammatory process, in
which the tissues that are being subjected to erosion are
bereft of regenerative, but not reactive, capacity, because
the destructive agents are slowly, but surely and continu-
ously, at work (Weigert). Thus, this theory of Bosworth
demands concessions that cannot be granted, for it seeks
to explain a biological question by ignoring biological
factors, and thus runs short of science, and becomes a
mechanical mystery.
Contiguous Pathological Phenomena. — It is known
that a rhinolith, or a polypus, may cause a perforation
of the septum to take place, apparently by continuous
pressure against the septum. Jurasz M reports having seen
a case of each.
Influences Engendered by Constitutional Diseases,
Scrofula, Lupus, Tuberculosis, Syphilis, Rheumatism,
Diphtheria, Fevers, etc. — Scrofula, lupus, and tuberculo-
sis, though related affections, and believed to have been
such long before their consanguinity was accentuated by
Koch's discovery of the bacillus tuberculosis, differ suffi-
ciently in their clinical phenomena to justify the conclu-
sion in the minds of very capable clinicians (Kaposi and
Voltolini among others) that they are not identical mala-
dies. They affect the mucous membrane and other tissues
of the nose, and particularly the septum. They give rise
to a catarrhal condition, to infiltrations, to tumors, and
to perforations.
Scrofula : Maldenhauer " describes a septal perichon-
dritis, due to scrofula, which ends in the formation of
abscesses, and perforation of the cartilaginous portion of
the septum. Sir James Paget20 describes a similar con-
dition. These abscesses may come on spontaneously,
or a slight, under other circumstances indifferent, injury,
774
MEDICAL RECORD.
[December 22, 1894
to the nose may start them. The anterior portion of the
septum is usually affected, and as a rule on both sides.
Paget's description is: " Small abscesses form between
the mucous membrane and the septum. With these the
portion of cartilage beneath may be softened or ulcer-
ated; and it may be perforated when similar circum-
scribed abscesses form on both sides of it ; but when the
pus is discharged there does not, I believe, follow any
extension of ulceration in either the cartilage or the
mucous membrane, and they heal leaving a small thin-
edged opening in the septum/' Maldenhauer's descrip-
tion differs somewhat from Paget's, being more acute and
involving a larger area of surface ; and patients apply for
relief usually when the cartilage has become disorganized,
and a perforation permanent. Maldenhauer states, what
older writers have too, that the bony portion of the sep-
tum may become defective through scrofulous disease.
Lupus : Max Bender found the mucous membranes in-
volved one hundred and seventy five times in three hun-
dred and eighty cases of lupus collected at Doutrelepont's
clinique. In thirty one per cent, of all cases the disease
began in mucous membranes, which, says Crocker,21 is by
far more than is usually supposed. Only six times were
the mucous membranes alone affected. One hundred
and fifteen times the mucous membrane of the nose was
involved. Crocker says that lupus is almost rare in
America, and is seen less often in England than on the
continent of Europe. It is more frequently seen in
women than in men. Carl Seiler a says that he has never
seen a case of lupus of the nasal mucous membrane.
And Sir Jonathan Hutchinson * tells us that he has seen
as many as three cases with septal perforation in one
day. Such is the irregular run of practice. I have seen
three cases of lupus in which the mucous membrane of
the nose was affected, but in none of them* was the sep-
tum perforated. My friend Professor George T. Jack-
sonf knows of about a dozen cases of nasal syphilis that
had been diagnosticated as lupus. Two such cases, he
says, had been operated on by competent surgeons who
supposed that they were dealing with lupus. Mistakes
of this kind, Jackson holds, Only show that the differen-
tial diagnosis of syphilis and lupus is not always an easy
matter. Ausspitz and Schuster, and other syphilograph-
ers, would agree with him. So much for the rarity of
lupus, and the difficulty of recognizing it
Medicine, especially clinical medicine, is still so im-
perfect in its methods of investigation and demonstration,
that the name of a teacher often does duty for alleged
facts or the validity of a theory. And sometimes such
facts and theories are circulated by other teachers with
their endorsement and commendation. At other times
such facts become distorted, and the original teacher is
falsely quoted, and approximate, not to say true, science
comes short. In so far as lupus of the nose is concerned,
this has been the case with the honored name of Kaposi.
A number of respected rhinologists (Schech and Mac-
donald among others) have quoted Kaposi u as saying
that the bones of the nose do not suffer in intra-nasal
lupus. Kaposi says nothing of the kind. He simply
makes no mention of bones when speaking of lupus of
the mucous membrane of the nose. He does say on a
previous page that lupus spreads via connective tissue,
and that there are no grounds for asserting that muscles
and bones directly succumb to lupus. Further on in
this same article he says, concerning the bones of the
extremities, periostitis, ostitis, caries, and necrosis, occur
when no evident preceding inflammation or infiltration
has taken place in the superjacent skin. Rosenthal25
makes the general and unsubstantiated remark that it is an
undecided question whether or not lupus affects the bones
of the nose. Haughton,* Crocker, Schuster, and Ausspitz,
and KLebs" affirm that the bones as well as the cartilage
of the nose may become implicated in the lupus process
and drop out. Kaposi says that the septum cutaneum
is less frequently affected by lupus than by syphilis. He
• All women, two of German and one of Irish extraction,
t Oral communication.
also observes, what others have remarked, that fungous
lupous granulations may conceal a perforation of the
septum.28
Tuberculosis of the mucous membrane of the nose is
very rare, and perforation of the septum due to it much
rarer. In sixteen hundred autopsies Willigk found four
hundred and seventy- six tubercular subjects, and in only
one of them tuberculosis of the nasal mucous membrane.
It is believed that primary tuberculosis of the nasal mu-
cous membrane has been observed, but such observations
are not beyond question. Up to 18S9, Seifcrt* was
able to collect only thirty- eight cases of intra-nasal
tuberculosis.
Greville MacDonald saw a case of tubercular perfora-
tion of the nasal septum (case 31, p. 339, Treatise on
Diseases of the Nose) ; and others have reported similar
cases. Such perforations exist in connection with other
tubercular ulcerations, infiltrations, and tumors in the
nose.
From the foregoing remarks on scrofula, lupus, and
tuberculosis, it may be concluded that only very rarely can
they be the causes of septal perforations. But that they
do give rise to such perforations cannot be denied ; and
that even the c«seous portion of the septum may be
perforated by them must be allowed as a possibility.
And however rare an eventuality they must needs be
taken into account when the differential diagnosis of any
perforation of the nasal septum is being considered.
Syphilis.— In 1885, G. H. Makenzie (Edinburgh)
claimed, what many practitioners believe to be the case
to-day, that perforations found in the septum are proba-
bly always symptomatic of syphilis; and McBride®
stated, about the same time, in criticising Makenzie's
claim, that most specialists (rhino-laryngologists ?) look
upon them with suspicion, but not as being pathognomo-
nic of syphilis.
This is not an unimportant question. The gravest
family complications may arise from the assertion that
septal perforations are always syphilitic in origin. One
of my cases, a lady engaged to be married to a lawyer,
was told by me, that besides other troubles for which she
was being treated, she had a hole in the septum of her
nose. Innocently enough she told the lawyer of this,
and he wasted no time in calling on me to have the sig-
nificance of the perforation explained to himself. I could
positively say that the hole had no particular significance,
and had nothing to do with syphilis, hereditary or other-
wise. Not only a patient's family and social group may
be upset by the announcement of a mistaken diagnosis,
but the physician or surgeon may come to grief because
of it. Ctuari 81 in his group of seventy-seven cases of
" ulcers, cicatrices, and defects " of the nose, found sixty-
two of these lesions caused by syphilis, five by lupus,
four by scrofula, one by blenorrhoea, one by tuberculo-
sis, one by diphtheria, and two were due to causes that
could not be found out. These figures illustrate approx-
imately the relative frequency of syphilis as a probable
cause of perforation of the nasal septum, as compared
with the possible etiological value of the other diseases
already reviewed.
Syphilis, when it attacks the nose, like scrofula, lupus,
and tuberculosis, shows a conspicuous liking for the ante-
rior portion of the septum. In fifty-five cases of nasal
syphilis recorded by Jurasz, thirty-one times the septum
was attacked, and only once the bony portion. Twenty
times in thirty-seven cases of septal perforation, syphilis
was found to be the cause. Only in three cases out of six-
teen of septal perforations could A.B. Thrasher *® (Cincin-
nati) get an undoubted history of syphilis.*
Moritz Schmidt w would hesitate in calling a perfora-
tion syphilitic in origin if it did not involve the bony
part of the septum as well as the cartilaginous portion.
This assertion ignores much common experience, and,
* Dr. St. C. Campbell saw thirty* five cases of septal perforations —
all in the cartilaginous portion, and their chief causes lie believed to
have been, 20 syphilitic, 9 anaemia, 5 ozaena, and 1 tuberculosis. — W.
J. Swift (Lefferts) Reference, International Centralbl. fur Laryn-
gologie, etc., voL viii., p. 9.
December 22, 1894]
MEDICAL RECORD.
775
though it may be based on much individual observation,
it would lead into' many diagnostic and unfortunate
therapeutical mistakes if depended on as a diagnostic
mark. Bresgen81 would have the favorite site of syphil-
itic ulceration (and consequently of perforation ?) to be
at those points where bones and cartilage unite. Ka
posi * claims that the dormal, cartilaginous, and osseous
parts of the septum may become perforated, and that
syphilitic perforation will oftenest take place at the junc-
tion of the cartilage and skin portions. These observa-
tions may be supplemented by one of Bosworth's,80 that
" syphilitic ulcerations show a marked hesitancy in trans-
gressing anatomical boundaries." All these observa-
tions are more or less true, but anybody with no very
extensive experience will have learned that they must be
taken and depended on with caution. Most perforations
that are discovered are round or oval, but McBride*7
quotes Michelson who says that, " syphilitic perforations
are usually longitudinal, and tubercular ones round or
irregular." McBride neither denies nor does he confirm
this assertion of Michelson's, he merely passes it on.
Jurasz88 tells of a case of perforated septum — cartilagi-
nous portion— which had been published in the jour-
nals by another physician "as being non-syphilitic; but
which, from facts subsequently elicited, was believed to
be syphilis after all, not, however, because of any par-
ticular shape of the perforation. Another interesting
case reported by Jurasz may be referred to : A young
man, aged nineteen, had luetic infiltrations on both
sides of the septum. There were deep ulcerations be-
sides, and the cartilage beginning to become denuded,
necrosis and perforation threatened to take place. Iodide
of potash brought about a comparative normal condition
in a short while — the ulcerations healed and no perfora-
tion developed. A case of no less interest just because
its history is somewhat indefinite, and reported by Die-
trich89 (Elbing), is instructive : Widow, aged forty five,
moving in good society, whose husband had been an
official. A nasal catarrh had been treated with question-
able success by another medical man. Recently she had
slight repeated nasal hemorrhages. In the cartilaginous
portion of the septum anteriorly, there is now a perfora-
tion about the size of a half-dime. Its borders are ir-
regular and dirty in appearance, with here and there
small dirty- brown crusts. The ulceration bleeds when
touched with a sound. There is a moderate amount of
chronic naso-pharyngeal catarrh, but the breath is not
fetid, nor is there any loss of the sense of smell. Syph-
ilis not being suspected, the ulcerating perforation was
looked upon as simple, and cure was thought certain
within a short time. The ulceration was treated gal-
vano-caustically according to Voltolini's recommenda-
tions j but, instead of healing, the ulcerating perforation
slowly but surely enlarged, and the nose had become
slightly flattened. Syphilis was now looked for, but
nothing pointing that way, except that the lady was
childless and had aborted four times, could be found.
She was given iodide of potash, and immediately every-
thing prospered to a surprising extent. The ulceration
began to heal, and finally cicatrized perfectly ; and the
chronic catarrh also improved very much.
These cases, aside from their intrinsic interest, offset
the obiter dicta of the distinguished authors quoted a
while ago ; but in connection with Dietrich's case, a re-
flection from Sir John Hutchison " is worth remember-
ing; even when there is a clear history of syphilis, "if
the ulceration be slow, and without tendency to diffuse
inflammation, or exfoliation of bone, it will usually be
found that the internal treatment by specifics does very
little good, while local treatment will cure.11
May not a perforation have existed before syphilis was
acquired? And, is it not a valid question to put, may
not perforative influences work their effects, even while
syphilis is doing its share of evil in the same body ? A
syphilitic history surely does not make all pathological
phenomena syphilitic.
Rheumatism may give rise to septal perforations due
perhaps to a rheumatic perichondritis. Mackenzie41 re-
fers to French journals on this head, and quotes a case
from Roger: Young man, severe articular rheumatism
and well-marked cardiac symptoms, lost a portion of the
cartilaginous septum, the size of a grain of rice, two
months before he died.
Typhoid, typhus, and other fevers may give rise to
ulcers on the nasal septum which end in perforation.
But these are very rare and exceptional eventualities.
Gelli * reported a case of a young man of sixteen, who,
during an attack of typhoid fever had a good deal of
nasal hemorrhage, from the beginning to the end. Dur-
ing the fever he emaciated very much. The nasal sep-
tum was thin. In this case the septal ulceration pro-
gressed, and perforation of the septum was the result ;
and all because, it was supposed, the patient picked his
nose so much.*
Diphtheria gives rise to extensive intra-nasal ulcera-
tions and even necrosis of the bones. Chiari reports
such a case. This disease may just possibly give rise to
septal perforations.
Carcinoma has been known to perforate the septum.
Hajek * came across such a case. Metastatic carcinoma-
tous deposit in the septum broke down and left a hole.
Local Inflammatory and Allied Procestes.— In the
course of his description of the sequelae and complica-
tions of chronic coryza, Massei44 says that ulcers develop
under crusts deposited on the surface of the mucous mem-
brane, and that this occurs oftenest in people whose labor
obliges them to inhale air laden with irritating substances.
He also avers that the lower turbinates are the common
sites of this process, but that the same process may take
place on the septum and perforate it. These ulcerations
and perforations, says Massei, may affect the lamina per-
pendicularis of the ethmoid bone and the vomer, and
that the lower anterior portion of the septum almost al-
ways escapes. f This may be true for Italian noses.
Moritz Schmidt, on the other hand, locates the encrust-
ing and erosive process at the anterior cartilaginous por-
tion. Bresgen and others, ditto. }. Sob's Cohen * has
a description all his own under the heading of Chronic
Coryza, and the sub- heading, Fetid Coryza, which reads
(after mentioning that the disease having existed some
years, destroying mucous membrane and bones), "so
that the cartilaginous septum is in many instances found
to have been pierced through, sometimes in one or two
small perforations, but more frequently in a single large
irregular hole, perhaps admitting the end of the little
finger, or the end of a larger one, and looking as if it had
been gouged out with some rude tool." 46 These two
pictures of " chronic coryza M J strike one as being made
up of different and distinct diseases, are confused and ex-
aggerated. They differ as to the location of the ulcero-
perforative process.
D. Newman, of Scotland, and J. N. Makenzie, of
Baltimore, Md.,47 have found the anterior (cartilaginous)
portion of the nasal septum perforated in laborers work-
ing in chromic-acid factories. Toeplitz, of New York,48
examined thirty-nine laborers employed in a single arsenic
(Schweinfurth GrQn) factory, and found nineteen of them
with perforations in the cartilaginous portion of the
* Dr. George F. Shrady has kindly given me permission to mention
the following case of perforation of the cartilaginous portion of the
nasal septum due to typhoid fever, which occurred in his practice years
ago. The patient was a girl (the child oi a friend), about ten years of
age. The fever was of a prolonged tedious type, but the temperature
of which never at any time went above 102&0 F. About the fourth
week of the fever, nasal bleedings occurred, ard an ulcer was dis-
covered on the cartilaginous portion of the septum. This was readily
noticed because the child had wide and prominent nostrils. In a
short time the ulcer developed into a perforation. Dr. Shrady is pos-
itive that nose-picking had nothing to do with causing the ulcer to
develop into a perforation.
t Note to Massei. — On page 124 Massei has a section devoted to
" simple catarrh," in which crusts develop on the anterior portion of
the septum which irritate, and which in connection with nose-picking
with the fingers result in ulceration and perforation of the nasal
septum.
X Note to Cohen.— Both Cohen's and Massei's pictures refer ap-
parently to the same mixed pathological conglomeration of diseases.
It is proper to state that both M. and C. are cognizant that they are
depicting mixed pathological conditions.
776
MEDICAL RECORD.
[December 22, 1894
septum. Eight others who had not been employed for
so long a time in this factory had ulcers varying in size
and depth on the septum, apparently on the way to per-
foration. In none of these arsenic cases were the bones
affected. Alexander G. R. Faulerton," of England,
found a hole in the cartilaginous portion of the septum
(anteriorly) of a man who happened to be a cement
worker. On this single observation speculations as to
the rise and progress of septal ulcers were based that
have been quite generally adopted, even by Zuckerkandl,
as though Faulerton's assumptions had the sure basis
of comparative statistics and wide discriminating ob-
servation. He stated, without giving any proofs, that
such septal perforations are found often in cement
workers. So much made "sure," a "rationale" was
easy to manage, and thus : Cement dust causes rhinitis ;
then formation of crusts ; irritation from these which is
relieved by picking at the nose, then ulcer in conse-
quence, finally further nose-picking, until ulcers become
perforations. This is simple, but all on the surface,
and leaves much out of account. However, R. Otto,®
of Darpat, Russia, after having examined thirty cement
workers, found only one who had a perforated septum.
The number of people who bore about in their noses
is very large, and yet in comparison how few septal
perforations are discovered. No doubt after an ulcer
has been started, whatever the cause be, digging about
in the nose may accelerate a progressive ulcerative proc-
ess. As a rule, people do not hurt themselves when they
can avoid it, and when picking into the nostrils for the
removal of crusts or for counter irritant effect, hastens or
favors perforation, some grave pathological change in the
septal tissues may be assumed. Normally the mucous
membrane heals very rapidly and thoroughly, and when it
will not do so something is wrong with it, and the rhinol-
ogist will not use his drills, chisels, saws, scissors, knives,
and cauteries. Surely picking at the nose does not deter-
mine tuberculosis, scrofula, lupus, and syphilis to seek
the cartilaginous septum for ulceration and perforation.
Furthermore, do not catarrhal ulcers so called heal in spite
of nose-picking when they occur in healthy people ? Yes.
Perichondritis and abscess of the septum not due to
scrofula, Friedreich51 said, almost always end favorably,
and without leaving deformity of the nose. But Wunder-
lich « and Duchek58 affirmed, in a general way, that those
affections may leave a perforation of the septum or des-
troy it entirely, and leave the nose flattened and de-
formed. These processes may obstruct the nasal passages
partially or entirely, they may affect only one side of the
septum or both sides, they may be located high up and
posteriorly, or inferiorly and away to the front. So said
Wunderlich. These observations have been confirmed
by rhinologists of our day, and from cases that they have
reported, I shall refer to one of D. Bryson Delavan's.54
An otherwise healthy girl, sixteen years of age, had a
very severe septal perichondritis and abscess on both
sides of the septum, and perforation took place near
where the bonp and cartilage unite. After proper treat-
ment the perforation closed up and only a scarcely notice-
able amount of flattening remained. Whether or not
oval or round openings of a permanent character remain
after the acute symptoms of these maladies have subsided,
it is impossible to affirm positively.
Theodore Harke,56 in his post-mortem examinations,
came across an interesting case of facial erysipelas and
hemorrhagic naso septal lesion that may be mentioned
here. Erysipelas affected the right ear and the face.
The mucous membrane of the nose was generally red
and congested, and covered with muco purulent masses.
Under the mucous membrane and perichondrium of the
left side of the septum, a diffuse hemorrhage had taken
place, involving all the cartilaginous and one half of the
bony portions of the septum. There were no signs of
abscess formation. The covering mucous membrane
was of a dark-greenish color. Would necrosis and per-
foration have followed in this case if the patient had
lived ? It is possible.
Perforating Ulcer of the Vasal Septum.— Weichsel-
baum, Voltolini, Sir J. Hutchison, Sir James Pfcget,
Jessop, Hajek, Zuckerkandl, Rossbach, Freudenthal, and
others, have reported cases of perforating ulcers of the
nasal septum. Analogically, they have been compared
to perforating ulcers of the foot and those of the stom-
ach. All authors agree that they have necessarily noth-
ing to do with syphilis or tuberculosis. The majority
of German writers opine with Weichselbaum and Hajek,
that they are a local affection due to parasites. Taking
all the developmental theories and their shortcomings
into account, one may conclude that the real or essen-
tial causes of perforating ulcers of the septum are un-
known, or else a number of various causes and influences
have to do with their origin and development.
These ulcers are found in people who have neither
syphilis nor tuberculosis. They are found in people
who have died of tuberculosis and were suffering from
tertiary syphilis. They have been found in those who
have had syphilis ; and in those in whom syphilis is ac-
tive. One-third of Hajek's M cases of septal perforations
were tubercular subjects, and all of Weichselbaum's w
sixteen cases had succumbed to tuberculosis. None of
my five cases were tubercular. These perforations may
vary in size from that of a lentil to that of a twenty-five
cent piece. Usually there is only one, but two and
more have been observed in the same septum.
Their pathological history may be divided into three
stages : A preparatory, an ulcerative, and a perforative
stage.
As to the first stage, a number of opinions, none of
them even similar, have been advanced. A favorite
opinion is hemorrhagic, after some manner or other.
Voltolini * fancied that hemorrhage from some ruptured
venule or arteriole was the origin of the progressive ul-
cerative process, with the vesicular or arterial break as
the centre of ulceration. Nasal hemorrhages are very
common and frequent, and usually from the septum ; but
septal perforative ulcers are rare and uncommon in com-
parison. This theory of Voltolini is a mere guess ; and
Voltolini did not think of explaining or guessing at the
tissue changes in the vessels that must precede the vesic-
ular break and predispose it to spread peripherally, nor
did he enlighten us about the causes that must be at
work after the ulcer was progressing, nor finally by
which influences it was stopped short. These ulcers be-
gin on both sides, at symmetrical points, simultaneously
sometimes ; and, in such cases we should be obliged to
assume like conditions on both sides. And nobody ever
saw such a condition of affairs.
Dietrich's * theory is an advance on the logic of Vol-
tolini. He posits that the nasal septum is very vascu-
lar and the circulation slow, and thus prone to throm-
botic and depraved local nutritive troubles. If injury to
the mucous membrane like that caused by nose-picking
starts an ulcer, then the succeeding steps of the progres-
sive ulceration, it is supposed, are easily imagined. And
that is not the case. This theory, too, ignores many
antecedent and post - ulcerative influences. Dietrich
holds that the presence of bacteria in the ulcer is acci-
dental and not essential or causative.
Zuckerkandl m has given us the most elaborate and
plausible of all the hemorrhagic theories ; but his the-
ory is weak and comes short of science, because it does
not in most instances cover clinical experience. After
long mechanical injury of some kind, as boring about in
the nose with the finger or inhaling irritant substances,
hemorrhages into the mucous membrane take place, and
at last a condition known by him as zanthosis is devel-
oped. The mucous membrane assumes a yellowish ap-
pearance and has become atrophied. The blood- vessels
have in the meantime undergone degenerative changes.
If bacteria and cocci now get a chance to invade the
parts, they overcome tissue resistance so successfully that
perforation quickly follows ulceration. Most cases of
perforating ulcer reported by clinicians have not shown
up that way. At any rate, my five cases did not.
December 22, 1894]
MEDICAL RECORD.
777
Rosenfeld's tt (Stuttgart) theory is not hemorrhagic,
bat neuropathic. It is trophoneurotic ; and it is pecul-
iar because he locates the ulcers so high up as to be out
of the reach of the finger nail, and from the fact that he
claims to have seen these ulcers develop from within
outward ; that is, it is said that he has seen cases in which
perforations developed under necrotic mucous membrane.
This theory hobbles along without the help of germs,
primary degenerative vascular changes, or sinister hem-
orrhages, or finger-nail pickings, or finger-nail toxic
local infection. This theory, too, accounts for but little
that clinical observation uncovers — it is but a match
struck in the dark, and just lets us know how dense the
darkness is.
And now for the bacterial theories. Frankel's ■ opin-
ion respecting parasites carrying havoc and destructive
ulceration, and finally perforation, into Jacobson's organ,
runs counter to so much clinical experience, that merely
to be mentioned is about all the attention it deserves.
Hajek's theory also limps. As the first step he finds
a limited area of mucous membrane, or dotlets thereof,
discolored a dirty gray, due to the formation of a pseudo-
membrane and degeneration of the epithelium. There
is nothing passive about this discolored spot. It is de-
structively active, and it is assumed that the greatest
amount of activity is at the central parts. The mem-
brane becomes disorganized, and makes room for the
ulcer, which has sharply defined borders. This ulcer
shelves off toward the centre, where it is deepest. In
time the ulcer becomes something like a terrassed cone —
the point at the centre, and its base bounded by the
borders. At the beginning of the ulcerative period
detritus of pseudo membrane and coagulated blood may
be found hanging to the surface of the ulcer or to the
borders. Later on muco-purulent crusts may form over
them and hide them, but the destructive process con-
tinues ; and scarcely ever is this known to the patient.
The mucous membrane, the perichondrium, and the car-
tilage having become perforated, healing may set in and
become complete by leaving a thin tapering-edged hole
in the septum. Possibly healing may take place before
the perichondrium has become implicated, but if this
does occur, it does so for reasons unknown. Often these
perforations are seen with their edges still ulcerating at
points, and necrotic cartilage jutting beyond the mucous
and perichondrial coverings of the septum. Before com-
plete healing has become established, it is said the mu-
cous membrane may or can be lifted from its subjacent
tissues, and the perichondrium from the cartilage. This
could not be done in any of my cases. This malady
does not go on without some reaction at or near the
borders of the ulcer, and around the blood-vessels ; but
for the most part the process, taken as a whole, simulates
a local gangrenous process. And all these changes, say
Weichselbaum and Hajek, are caused by bacteria and
cocci; especially, according to Hajek, to streptococci
pyogenes and staphylococci pyogenes aureus. Those
cocci do not wander away from these foci of ulceration,
but continue to play high jinks there until perforation
has taken place ; and the edges of the perforation having
become healed, they
" Fold their tents like the Arab*
• And as lightly steal away."
These ulcerative perforations constitute a disease sui
generis — a specific disease, and says Sir James Paget,
" the definite shape (of the perforation) may be a char-
acteristic of their being due to parasitic influence, just
as are the definite shapes of parasitic diseases on leaves."
However all this may be, neither Weichselbaum's nor
Hajek's bacteriological investigations have disclosed any-
thing of a specific nature. The clinical significance of
what has been said concerning perforations of the nasal
septum may be summarized by saying that they vary
according to their etiology and pathology:
1. Congenital or developmental perforations are ex-
tremely rare ; and, if we must believe authorities, they
are of two kinds at least : (a) 'Those due to perverse or
arrested development, such as are hinted at by Harrison
Allen, and of which Germs' case is an instance ; (£)
those due to a pathological process implanted on the
developing tissues, such as are hinted at by Klebs; and
which a number of observers believe they have seen.
Concerning this field of observation we know positively
very little, and large opportunities here await the scien-
tist.
2. Perforations due to severe direct violence, and con-
tiguous pathological processes must tally with the in-
jury received or the growth giving rise to them. These
also are rare occurrences.
3. Perforations due to constitutional influences are
usually accompanied by the signs and symptoms pecul-
iar to those diseases, respectively, while the perforation
is developing. Besides, the various local manifestations
of the respective constitutional diseases crop out at other
points of the intra nasal mucous membrane, although
that of the septum is a favorite site with all of them.
They very rarely develop septal perforations, and when
they do, other manifestations, peculiar to any special one
of diem, show up with the perforation. In most cases
even syphilis is no exception to this last remark ; al-
though syphilis may leave a perforation which bears all
the marks of the so-called " perforating ulcer of the nasal
septum, ' ' according to Jurasz and other observers. How-
ever, the clinical history, and a course of experimental
therapeutics, will differentiate them when any doubt as
to their respective character exists. The mere existence,
however, of a history of syphilis in a patient is not posi-
tive proof that the perforation has been caused by syphil-
itic influences.
4. Purely inflammatory affections of the septum —
perichondritis and abscess— may give rise to perforation
(even to the extent of nearly half an inch in diameter, as
in Delavan's quoted case) during the inflammatory proc-
ess, but the defect is apt to heal up again with more or
less or no deformity. It may be just possible for a typi-
cal roundish or oval perforation to result ; but whether
such have been seen is not certain.
5. Most perforations that are discovered by many
observers are almost always found located in the cartilag-
inous portion of the septum, and are roundish or oval-
shaped, their long axis being parallel with the long axis
of the cartilaginous portion of the septum. According
to the majority of observers, they have nothing to do
with syphilis etiologically in most instances. They are
in most instances probably purely local gangrenous
manifestations, possibly due to bacterial influences, pos-
sibly due to local tropho neurotic causes, possibly to a
combination of many causes ; but the true nature of this
disease still remains to be discovered. There has been
nothing wrong with the mucous membrane or the other
intra-nasal tissues beyond the ulcer or ulcerating perfora-
tion, in many of the cases that have come under observa-
tion, according to the testimony of a number of authors.
Therapeutics.— Patients with ulcerations on, and per-
forations in, the nasal septum, when these lesions are not
discovered casually, come to be relieved from the nasal
discomfort caused by crusts blocking up the nasal pas-
sages, etc. ; or they come to have small intermittent nasal
bleedings checked ; or else, in rare instances, on account
of whistling noises which occur when the air is quickly
or forcibly inspired, and such cases have been observed
by Bosworth, L. Bolton Bangs, Hutchison, Jessop, and
others.
The successful treatment of ulcers demands, first of all,
that the causative pathological influences be done away ;
and next, that the best favorable conditions be estab-
lished, with local and general remedies, for aiding the
recuperative forces of the local tissues to cover the losses
they have sustained. When this is not or cannot be
done, cure will be impossible.
The aggregate experience of all observers allows the
conclusion to be drawn that simple perforating ulcers
and perforations cannot always be differentiated, by
778
MEDICAL RECORD.
[December 22, 1894
appearances, from those" developed by syphilitic influ-
ences. When this happens, specific treatment with mer-
curials, and iodide of potash, etc., will, so far as is known,
clear up the diagnosis. The syphilitic ulcerations will
heal under the influences of the specific drugs that have
no appreciable effect on the simple perforating ulcer.
Although simple perforating ulcer of the nasal septum
has a stage of growth and development that prepares
local conditions which favor subsequent ulceration and
finally perforation, its therapeutics, unfortunately, can-
not be considered after any such methodical manner.
Our present knowledge of this malady obliges us to fol-
low up the process by attacking it with only such general
empirico-clinical remedies which have been found effective
in other cases of tissue destruction of a non-specific char-
acter.
Freudenthal * reports the case of an otherwise healthy
girl, twelve years of age, who came to him to be cured
of persistent epistaxis. On the anterior portion of the
septum a dirty grayish-white patch or deposit was dis-
covered, besides some superficial ulceration. The bor-
ders of this ulceration were found to be congested.
These finds were considered typical of the early stages of
simple perforating ulcer. The remedies applied were
mild astringents, which and in what strengths are not
mentioned. Freudenthal saw the case only four times,
and, when last seen, the ulcer seemed to be doing nicely,
and, the patient not returning again, the doctor con-
cluded that the ulcer must have healed. All of us may
not concur in the diagnosis nor accept the assumed thera-
peutical optimism. However, a case of mine, already
referred to, will not be out of place alongside of this one
of FreudenthaTs : A young man and student, aged eigh-
teen, quite a cigarette smoker, came to me on account
of bleedings from the nose, besides (right) orbital pains
that radiated from the nose. Examination revealed a
flat triangular ulcer on the anterior portion of the right
side of the septum. The ulcer (very superficial) was
about the size of a three-cent piece, with sharply defined
borders that were not particularly congested or swollen.
Its surface was very finely granular, but did not bleed
when touched with a probe. There was some hyperses-
thesia at and near the borders, but not over the surface
of the ulcer. There were no crusts, nor pseudo-mem-
branal detritus, nor dried blood on or about the ulcer.
He admitted that he picked his nose, but only to get rid
of crusts ; and then his nose would bleed, after which
the orbital pain would subside considerably. This young
man was not strong and robust, but not any more anae-
mic than one would expect to find in a person confined
to rooms. He complained of malaise which might be
attributed to tobacco or malaria. There was a slight
amount of naso-pharyngeal catarrh.
To the ulcer itself I applied a scruple to the ounce so-
lution of nitrate of silver ; and to the nose and pharynx
a three-grain solution of the same metal. Internally he
was given
Ext. nux vomica,
Ext. hyoscyamus . . .
Quinine sulphate . . .
.aa gr. £
... gr. iij.
four times a day. He was given general and local ad-
vice, and
Hydrarg-rub. oxidi gr. v.
Vaseline J j .
M. Ft. unguentum,
to be applied to the ulcer. Two weeks later I saw him
again. Generally he felt better. Locally, appearances
seemed better, although the ulcer had not diminished in
size ; it had not bled because crusts had not formed as
often as had been the case before, and besides he had
not been tempted to pick at his nose as often. The orbi-
tal pain was still present, but came less often, and was
not nearly so severe as it had been. He now went off
on his vacation to the mountains.
The ulcer was thought to be simply catarrhal; and its
size was attributed to the fingernail injuries. There was
no sign of zanthosis here, nor interstitial hemorrhages! nor
pseudo-membranal deposits, nor varicosities. I hoped
with better air, more exercise, etc., the young man would
return to his studies in the fall with an intact and sound
nasal septum. But when he returned, several months
later, I was surprised to find an oval perforation in the
septum, and other typical appearances. During his vaca-
tion his nose did not trouble him in any way. At places
the mucous membrane had healed over the cartilage, bat
at other points the necrotic cartilage jutted beyond the
perichondrium and mucous membrane, and the tissue
struggle for cicatrization was going on. This condition
of affairs reminded me of a case of gangrene of the auri-
cle in a child that I had treated at the New York Eye
and Ear Infirmary. This gangrene originated from
chicken pox. And here, too, the cartilage (necrotic, of
course) jutted beyond the limits of the skin and peri-
chondria! tissues.
For hastening the process of cicatrization in these
cases, scraping away necrotic tissues, and applying nitric
acid have been recommended and practised by Jesaop.
Others have used the solid nitrate of silver. Sir J.
Hutchison has used and recommended the acid nitrate
of mercury. The electro- cautery was recommended by
Voltolini and others. Hutchison64 also used the yellow
oxide of mercury salve. Whatever active treatment in
the way of curetting and caustics is resorted to, too
much irritation and destruction of nutrient tissues (mu-
cous membrane and perichondrium) must be scrupulously
avoided. And even then, in spite of careful constitu-
tional treatment and observant local care, this healing
process will sometimes continue to remain tedious, and
even refuse to heal; because we fail to influence the
cause, of which everybody is, as yet, ignorant.
406 Wbst Thikty-fourth Sthet.
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Skin, aded., p. 509. P. Blakiston & Son. Philadelphia, 1893.
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Throat, vol. ii.. p. 24. J. B. Lippincott Co., Philadelphia, 2893,
*' Sir J. Hutchison : Arch, of Surgery, vol. iiL, p. 904.
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December 22, 1894]
MEDICAL RECORD.
779
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,J1Dr. Th. Harke: Beitrage zur Path, und Therapie der Ohren
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41 Made during a discussion of Rosenfeld's theory, at the Heidel-
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« W. Freudenthal: N. Y. Medizin. Monatsschrift Bd. iii, No. 5,
1891, pp. 185-190.
•* Sir F. Hutchison : Med. Times and Gazette, July 5, 1884, p. 7.
HINTS ON THE TREATMENT OF ECZEMA.
By MARTIN F. ENGMAN, M.D.,
assistant dermatologist to dbmu.t dispensary ; late assistant dr.
dnna'i klinhc, Hamburg; ex-house surgeon mew york skin and cancer
hospital.
In giving the treatment of different forms of eczema, a
classification according to its etiological factors and a
short and concise description of the different forms so
classified, will assist us materially.
Eczema is a word applied to a class of skin affections
of which we know too little. The definition given by
most of our standard authorities is, that it is a catarrhal
inflammation of the skin producing a multiformity of
lesions, papules, vesicles, pustules, etc.
With an eczema we should have in some part of its
course a discharge of some character, either serous or
pustular. The term is one that has been and is too
widely used to express conditions which' do not fill all
that the definition requires. A thorough knowledge of
the pathology of many of the so-called eczemas, I am
sure will take from this wide cover- word some of its old-
est occupants, and give us a more exact and practical
knowledge.
Eczemas are popularly divided into acute and chronic,
and subdivided into papular, vesicular, or pustular, ac-
cording to their clinical and objective symptoms. They
are also named from their location and manner of pro-
gression. This classification gives us some forty differ-
ent forms. Of course such terms are .very well for
methods of description and give us an exact idea of the
condition and its appearance. Yet for one who is not
familiar with all of these technical terms, it is bewilder.
ing and confusing ; so for matter of convenience, of the
moment, I will give below a simple classification accord-
ing to the etiology, and try to give in a few words a de-
scription of the different forms.
In treating an eczema or any pathological condition
of the skin, one must not forget that it is an important
and active organ of the body ; having its work to per-
form, through its glands, vessels, and nerves, as the liver
or kidneys. It is an excretory organ of the greatest im-
portance.
Again, one must remember that it is subject to all the
external influences, heat and cold, irritants both organic
and inorganic. No portion is free from organisms. If
scrapings be taken from any part of its large surface and
examined, cocci and bacilli will be found in great quan-
tities. Therefore in treating and observing the condition
and course of an eczema, we must take into consideration
all of these influences. Many of the complicated appear-
ances of an eczema are produced by calling into active
life some of these many organisms, as the catarrhal in-
flammatory condition gives them soil and food for growth
and development, while some internal derangement may
be at the same time producing these suitable media.
Again the eczema may be alone caused by the organism
or organisms having been brought into activity or con-
tact with the skin from unknown external causes.
We will divide eczema into two general classes, any
form may of course be acute or chronic, according to the
duration: 1. Neurotic eczema. 2. Irritative eczema;
a, caused by irritants or poisons from within the body
(internal) ; b> caused 'by irritants or poison from without
the body (external).
As was said before, to conform to our standard defini-
tion of an eczema, one should have a catarrhal inflamma-
tion associated with papules, vesicles, or pustules. The
so-called trade eczemas are from traumatic or chemical
influences and should be classed with the dermatites.
In giving the above division we do not, of course, in-
clude all the varieties in an exact and precise manner, but
for the purpose, as to hints for treatment, it will suffice.
1. Neurotic eczema is a catarrhal inflammation of the
skin produced by reflex or neurotic causes. It is sym-
metrically distributed, more or less in the course of the
nerves, has marked exacerbations and remissions. Oc-
curs mostly in children, but affects also adults. The dis-
ease is typically eczematous, the papules forming quickly
into vesicles, which easily rupture and discharge freely.
The crusts are very thick and tough, as the serum seems
to quickly dry, covering the surface. The disease occurs
more or less in patches, of varying size from that of an
inch in diameter to the covering of a whole limb. The
patches are rather sharply defined with vesicles and pap-
ules at the periphery. There is great pruritus, and from
inoculation by the scratching the crust soon becomes
very black, from the dirt and organisms. If the crusts
are removed a weeping, inflamed surface is exposed, but
the discharge again rapidly crusts. The pus organisms
seem to find favorable soil in the discharge, as one often
sees punched-out ulcerations on removing the crusts.
It may be located anywhere upon the body, but usually
seeks the external surfaces of the extremities, and the
head and face. In children we see it located mostly on
the face or head ; occupying the cheeks, chin, but leav-
ing peculiarly the region immediately around the mouth
perfectly free. There is a very little thickening of the
skin, as it can be pinched up easily if the thick crusts are
thoroughly removed. I think here the crusting and
scaling is quicker than in any other form of eczema. We
have though in adults, in the nervous and debilitated
with cold and clammy hands and feet, a form of neurotic
eczema, whose only exhibition is a few transient vesicles
very itchy and troublesome, with possibly a little scaling.
If each case of a symmetrical eczema answering to the
above description be carefully studied, one will find exac-
erbations and remissions occurring with some derange-
ment of the health, maybe only some slight thing, but
will act powerfully refleily.
78o
MEDICAL RECORD.
[December 22, 1894
I have seen many cases where the eczema will clear up
on the cutting of a tooth ; when another is forcing itself
through the gums a fresh attack will occur. In children
it occurs with the numerous bowel disorders, diarrhoea
or constipation, with indigestion. Cases have been cured
by thorough stripping of an adherent prepuce or circum-
cision, the adherent prepuce and retained smegma caus-
ing violent reflex irritation. I have now such a case
under observation, which has entirely recovered after cir-
cumcision, without any local treatment whatever. In
women we have the disease occurring with the menstrual
flow, and with ovarian troubles.
It is of course often very difficult to find the cause of
the reflex irritation, but in a catarrhal inflammation of
the skin, symmetrically distributed over the body, with
papulae and vesicles which quickly discharge and crust
we should look for a cause of reflex irritation, which may
be one or more of the many disorders that affect the
economy. Such should be looked into and treated as
they generally are, using such remedies on the skin as
will reduce the itching, influence the vessels, prevent
crusting, and render the subjective discomfort of the
patient more endurable. In other words, use sedative
astringent applications as in any acute or subacute ec-
zema. (Dr. Dyer, of New Orleans, and Dr. Barham, of
Pittsburg, have written some interesting papers on neu-
rotic eczema ; the former on the disease in children and
the latter in adults.)
2. Irritative eczema is a catarrh of the skin produced
by poisonous or irritative influences : (a) from within the
body, as those occurring in BrighYs disease; in rheu-
matism and gout ; in cirrhosis of the liver and other he-
patic diseases ; in ptomaine poisoning and disturbances
of the chylopoetic system.
(£). From without (external), which are parasitic in
origin.
(a) It would be very difficult, moreover dogmatic, to
draw a sharp line of clinical difference between the first
subdivision of irritative eczema and that of the neurotic
type, yet I think there are certain points which are dis-
tinctly different and assist one to a proper etiological di-
agnosis.
How the irritant or poison acts in being excreted, I am
unable to say, but that such poisons do cause eczema-
tous conditions clinical experience teaches every day.
The skin being an active execretory organ, is inflamed
and irritated generally, or in certain parts by these path-
ological products.
This being the case we, of course, would expect to find
the disease occurring at points of active secretion, which is
generally so, but I believe external irritation, mechanical
or chemical, is a most important determining factor;
the skin being in such a condition from the constant ir-
ritation of these poisons that the slightest violence to its
texture will cause an outbreak of an eczema. In many
cases we find it occurring on the instep or ankle, from
irritation and rubbing of the shoe where ordinarily such
irritation would cause no disturbance whatever. Again,
it is frequent on the neck from the collar or shirt. In
like manner in any situation that may be subject to irri-
tation ; the scratch of a pin or pride of the nail causing
or starting an outbreak, which may slowly extend over
the whole or part of the body, the action of the delete-
rious products remaining the same.
The clinical symptoms of an eczema so produced are
not widely different in their ensemble from one of the
neurotic type, yet there are some characteristic features
which point to its proper diagnosis.
The disease may occupy any portion of the body ; it
is indolent in character, die inflammation starting with
mild burning and itching, gradually increasing in inten-
sity to papulation, vesiculation, and weeping. The out-
break is not acute and violent, covering large areas at
once, as in the neurotic type. The patches are not
sharply defined but shade off into the apparently healthy
skin. The itching is of moderate intensity. The im-
petiginous element is very rare, as the discharge does not
seem to be as suitable for the propagation of the organ-
isms as in the neurotic, in which we find thick, dirty,
pustular crusts.
Crusting and scaling is not so marked, the crusts
being thin and moist, of yellow color and easily detached,
leaving a reddened weeping surface. There is generally
thickening from the beginning, which increases more
rapidly than in any other form of eczema. The inflam-
matory changes here are deeper than in other forms,
and there is a greater cell diapedesis and infiltration.
The infiltration gradually shades off into the healthy
skin, and can always be readily made out ; in feet, the
whole tendency of the process seems to be toward a sub-
acute or chronic type.
The principal points of difference between this and a
neurotic eczema, are : (1) The location, not following at
all the course of the nerve distribution. (2) The patches
are not sharply defined, but gradually shade off into the
healthy skin. (3) The subjective symptom is more of a
burning sensation than an itching. (4) The crusts are
yellow, thin, and moist, not dry and thick. (5) The
skin is found to be infiltrated after removing the crusts.
(6) The indolence of the process. (7) It is found most
frequently in adults, and those who have passed middle life.
The treatment of such inflammatory conditions should
be both internal and local.
The history of the patient should be carefully inquired
into and a thorough examination made of the general
health. The urine examined for albumin, casts, and
sugar, for urates and uric acid, etc. ; any abnormal con-
stituents being carefully noted.
In old drinkers we find cirrhotic changes with prob-
ably albumin in small quantities, with casts. In the
rheumatic and gouty, highly acid urine with full, excited
pulse ; often such individuals will predict a crop of ec-
zema by the color of their urine, noticing it to be highly
colored and " burning." In the later cases of Bright's
disease, where little urine is passed, and the kidneys
thoroughly inactive, we often see very severe cases of
eczema. I remember three cases of Bright's where death
occurred after a violent outbreak of eczema.
It would be useless here to go into a risumi of the
treatment of gout, rheumatism, and Bright's disease, for
I merely wish in connection with this form of catarrhal
inflammation of the skin, to point out the importance of
careful research into the general health of the patient.
(£) The second subdivision of our irritative eczemas, that
is, those caused by the effects of external irritants, is
comparatively a new field in dermatology, and one
which promises much for the future.
With this class are included the parasitic eczemas. As
was said before, the so-called trade eczemas should be
classed with the dermatites and not here. Although, as
in many other diseases, the parasites for these several
conditions have not been isolated, yet there are suffi-
cient clinical reasons for treating them from a parasitic
stand-point, and often be surprised with the happy and
rapid results.
In this class would be included the eczema seborrhicum
of Unna, who, in 1887 read a paper before the Congress
of Washington, demonstrating this affection, beyond a
doubt, to be a catarrhal inflammation of the skin, prob-
ably of parasitic origin, and showing the erroneous ideas
of the old masters in relation to the so called seborrhceas.
From further study and research Dr. Unna is more con-
vinced of the correctness of his observations in this mat-
ter, and also of the parasitic origin of eczema se-
borrhicum, believing his Morrorcocci to be the specific
cause, as he finds them in the scales and horny layer of
the diseased patches. The disease begins as a pityriasis of
the scalp, which may have existed for years, extends
down over the face, neck, or it may invade any portion
of the body, but a pityriasis or "dandruff" of the scalp
will always be found accompanying it. The eczematous
patches may vary from a small, greasy, scaly, yellow patch
to one of intense weeping, with highly marked inflam-
matory symptoms.
December 22, 1894]
MEDICAL RECORD.
781
The disease is generally characterized by well- defined
patches, varying in size, with abrupt borders. The
patch is covered by yellow, greasy scales, which are
easily detached. It spreads peripherally, clearing up
somewhat in the centre; therefore one or* more patches
may coalesce, forming patches of various shapes. Its
favorite location is the neck, face, back, and chest, but
may occur in any portion of the body. There is not
much itching except when the patient is overheated.
The disease is generally superficial, with no marked thick-
ening of the skin, but often there are patches of infiltra-
tion resembling a psoriasis lesion.
Another type of parasitic eczema to which I can only
here briefly refer, is a form that was first pointed out to
me by Dr. George T. Elliot, of this city. Since then I
have, studied the condition closely, and thoroughly agree
with him in considering it of undoubted parasitic origin
and differing markedly in its clinical appearance from
the eczema seborrhicum of Unna.
The majority of cases that I have seen occur in vari-
cose conditions of the legs, and an eczema here, we all
know, to be of a very stubborn and persistent character.
These cases, which have existed for years under soothing
applications, internal medication, and bandaging, I have
seen markedly benefited and cured by active parasitic
remedies. The leg is, of course, subject to other forms
of eczema, but I have found the parasitic vastly in the
majority, from the non resisting powers of the cells of
the leg in those past middle life. Again, it is very fre-
quent in those whose hands are frequently exposed to
water, in housewives, working-girls, barkeepers, waiters,
etc
The disease occurs as an undermining of the epithelial
layer, a splitting or peeling up of the epidermis, with few
papules or vesicles here and there, all enclosed in sharply
defined patches.
The intensity of the process and the objective symp-
toms depends, of course, somewhat on the activity and
amount of the poison ; on the location and on the pe-
culiar idiosyncrasy and susceptibility of the individual.
Therefore we may have a sharply defined patch of the
disease, with only slight scaling and a peripheral under-
mining and splitting up of the epidermis, to an intensely
inflamed one, raised slightly above the surface, deeply
red, with hemorrhage into the follicles, and the charac-
teristic progression by splitting up the horny layer at
the borders.
The disease though as usually seen consists of well- de-
fined red patches, varying in size, slightly scaly, dotted
here and there with papules, but with relatively few of
the latter. The borders sharp, and if closely noticed
the horny layer will be found to be loosened, peeled
up, and can be pulled of£ in large, thin laminae. There
is very little itching or burning. The patches spread
peripherally, several may coalesce, but there is generally
only one or two in a locality, the disease spreading from
these over a leg or arm in a more or less serpiginous
manner. The milder cases have a tendency to heal in
the centre leaving a slightly yellow pigmentation. The
whole affection, as usually seen, is very dry and only
slightly scaly unless it is greatly inflamed.
The favorite location is the hands and arms, legs and
feet, the face, as these portions of the integument are more
exposed to external influences. But I have seen the disease
generally scattered over the whole person in small, sharp-
ly defined red patches. It can readily be differentiated
from eczema seborrhicum by i, the color of its patches,
which is decidedly red, while that of eczema seborrhi-
cum is yellow ; 2, the scales here are dry, and not yellow
and greasy ; 3, the characteristic undermining and spik-
ing up of the epithelium in this form, which you do not
see in any other form of eczema. It mostly resembles
the orbicular eczema of the text- books.
The disease is undoubtedly a parasitic one from its
clinical manifestations, and is readily cured by proper
parasitic remedies.
I bring these few points forward, not to stand on a
high pedestal of dogmatism and to grandiloquently wave
each case, after a mere glance, to its proper etiological
division, but hoping that they will help some one to a
more definite and comprehensive knowledge of the sub-
ject.
131 East Thisty fourth Stebbt.
3£K00t»00 of fpjeAicKl jftcteuc*.
The Relation of Chololithiasii to Primary Carcinoma
of the Gail-Bladder.— According to Dr. Ames two di
rectly opposite views are held respecting the relation of
gall-stone formation to cancerous growth in the gall-
bladder. According to such men as Klebs, Von Schup-
ple, Murchison, Durand Fardel, Krauss, Zenker, and
others, the new growth may be directly attributed to the
prolonged irritation produced by gall-stones, especially
in persons predisposed to cancer. Zenker holds that an
adenoma develops by irritation, and that it changes into
an adeno - carcinoma, which is the primary atypical
growth. On the other hand, Lutton, Lancereaux, Lang-
Heiniich, Fdrster and others hold that the presence of
the neoplasm favors the formation of calculi, and is the
cause, not the result, of gall-stone formation. It is a
well-recognized fact that biliary concretions are found in
a very large percentage of cases of carcinoma of the gall-
bladder. In Courvoisier's list, the percentage in which
stones were actually found was 91 per cent. There is
good reason to believe, however, that these figures should
be larger, as in a number of cases in which calculi were
not found there were such evidences as scars and strict-
ures of the ducts to show the former existence of chololi-
thiasis. In Musser's cases the percentage was 92 per
cent., while in those that I have collected stones were
found in 30, were noted as absent in 1, and were not
mentioned one way or the other in 7, making the per-
centage of cases with, to those without, concretions, 95.4
per cent. These figures are too great to allow us for an
instant to suppose that the association of these two con-
ditions is merely accidental. The most important point
to be settled, and the one which it seems would be con-
clusive, is whether the formation of gall stones precedes
or follows the cancerous degeneration. Evidence in
favor of die former view is plentiful, while that to support
the latter is very meagre, though there are a number of
theoretical considerations used as arguments that it will
lead us too far to discuss here. I have been able to find
but one case, i.e., that of Ord, cited by Musser, in which
a calculus existed which was definitely proved to be post-
cancerous in its formation, and this stone was not a cho-
lesterin formation, but consisted of phosphate and car-
bonate of lime with altered mucus. On the other hand,
there are numerous observations that go to prove the ex-
istence of stones prior to the carcinomatous growth. In
one of Zenker's cases, for example, fragments of calculi
were found, and in the first case I have reported this
evening the calculi were much disintegrated, which
would seem to point to a degeneration, not to a forma-
tion of gall-stones. This fact, in connection with the
long-standing history of biliary colic, is conclusive, and
would lead us to believe that in all cases when there has
been a previous history of biliary colic, and when no
stones are found at autopsy, they have existed, but have
undergone some such disintegration before the death of
the patient
Again, in one of the cases reported by Klobe an old
stone was found with commencing cancer of the neck of
the bladder. Klobe states it as his belief that the small
size of the gall- bladder in many cases of cancer would be
against the formation of calculi, while Zenker holds that
the growth in the bladder and ducts would tend to pre-
vent the bile entering the bladder, and so prevent the
formation of stones. Quetsch reported a case in which
stones had been passed by a biliary cutaneous fistula for
782
MEDICAL RECORD.
[December 22, 1894
three years prior to any signs of cancer; and cases are
reported in which stones were found although the cystic
duct was occluded ; they have also been found buried in
the mass of the neoplasm. From all these facts it would
seem that if we are justified in ascribing a causative in-
fluence to local irritation in case of cancer in other situ-
ations, we should look upon gall stones as exerting the
same influence in these cases. Finally, in closing, we
may briefly summarize the most important points, follow-
ing closely the conclusions reached by Dr. Musser, as
follows: 1. Primary carcinoma of the gall-bladder is
much less uncommon than was formerly believed. 2. It
occurs most frequently in women, the ratio being 3-5 : 1.
3. It is a disease more particularly of the middle decade
of life. 4. Gallstones are found in from 91-95 per
cent, of the cases, and probably bear a causative relation
to the disease. 5. Metastasis is not extensive ; invasion
of neighboring organs by continuity common. 6. Ad-
hesions to adjacent organs frequently occur. Ulceration
and perforation are more rare. 7. Pain, jaundice,
cachexia, emaciation, tumor, indigestion, nausea, vomit-
ing, constipation, or diarrhoea, with occasional ascites
and oedema, are the chief symptoms. 8. Pain occurs in
62 per cent. (Musser). 9. Jaundice occurs in 69 per
cent (Musser.) 10. Tumor occurs in 68 per cent.
([Musser). 11. The disease is always fatal, and usually
in a short time, the average duration varying according
to the best authorities from 3 to 6^3 months. 12. Death
is due to exhaustion, peritonitis, metastasis to other or-
gans, and to biliary obstruction.— -Johns Hopkins Hospi-
tal Bulletin.
Intracranial Aneurism.— The subject of intracranial
aneurism was discussed by Dr. Bradford, who presented
the history of a case, and by Dr. White, who related the
history of two cases in young subjects unaffected with
syphilis or malignant endocarditis. Dr. Bradford's pa-
tient had slowly developing symptoms such as vertigo,
noises in the head, and later, occipital headache and
stiffness of the neck. A severe attack of vomiting was
followed by intermittent pulse and retention of urine ;
later in the same day he became comatose, with irregular
breathing, and death quickly followed without the occur-
rence of convulsions, or pupillary changes. The autopsy
revealed a ruptured aneurism of the basilar artery.
In the cases reported by Dr. White the symptoms set
in suddenly. The first patient fell off her chair while at
dinner and became insensible. After regaining con-
sciousness she had headache, vomiting, bradycardia, and
a few days later retraction of the head and pain down
the spine. A week later complete paralysis of the left
third nerve. Then a week after this, a fit, and two days
afterward she suddenly became worse and died in ten
minutes. There was an aneurism of the left internal
cirotid near its termination. There was a large amount
of clot on the under surface of the brain ; it extended to
the fourth ventricle, and was one-eighth of an inch thick
all down the spinal canal in the subarachnoid space.
The second case was a man, who had no symptoms ex-
cept slight frontal headache, until he fell down uncon-
scious. Then the pupils became dilated and immobile,
right external strabismus, and occasional spasm of ex-
tremities. On the outer side of the optic disk was a large
subretinal swelling. The drawn-off urine contained sugar.
Death followed rapidly after the development of symp-
toms. There was found on post-mortem examination, a
small ruptured aneurism of the right internal carotid ar-
tery.
The Treatment of Typhoid Fever. —Of all the branches
of the medical sciences it is hygiene upon which we have
to look as the most promising study and the branch of
medicine to which belongs the future ; for, notwithstand-
ing the great progress that has been made within the last
few decades in the etiology of diseases, the treatment in
many instances is not much further advanced than it was
several decades ago. We still have to rely more upon
scientific nursing than upon the healing powers of drugs,
and in many instances the patients will do better without
any medication whatever, excepting, perhaps, when it is
used for the psychical effect upon the patient. The rules
laid down by Sir William Gull could not be improved
upon at the present day. Gull's views with regard to
the treatment of typhoid fever were as follows : 1. Ty-
phoid fever is a disease which runs a more or less definite
course. It cannot be stopped or cured by medicines.
2. The chief thing to be done at the outset ot an attack
is to send the patient to bed, so as to save strength
from the beginning. 3. No strong purgative medicines
are desirable. 4. As the fever develops and the strength
grows less, light food should be given at short intervals
— i.e., water, toast- water, barley-water, milk and water,
light broths (not made too strong or too gelatinous). 5.
If there be restlessness or much agitation of the nerves,
wine (port, sherry, or claret) or brandy in moderate doses
as short intervals. This must be directed medically, but
in general it may be said that the amount required is that
which induces repose and sleep. 6. The bowels may be
left to themselves. Ii unmoved for twenty-four or thirty-
six hours a lavement of warm water may be necessary,
but this will be directed medically. 7. The restlessness
or wakefulness in fever is best remedied by the careful
giving of wine or spirit with the food, or in hot water.
Sedatives such as opium are inadmissible — mostly in-
jurious. 8. The bedroom to be kept at a temperature
of 620 to 650 F. 9. Great care is necessary to keep the
bed clean and sweet. This is most easily done by hav-
ing a second bed in the room, to which the patient can
be removed for two or three hours daily, while the other
is thoroughly aired and the linen changed. 10. All
fatigue to be sedulously avoided. No visitors admitted,
and no other person but a nurse and one attendant to
help her. 1 1 . Patient's room never to be left unattended
for a moment, as in the delirium of fever patient may
jump from the bed and injure himself. 12. As to medi-
cines and the treatment of complications, the immediate
medical attendant must be responsible. 13. As it is pos-
sible that the discharges from the bowels in typhoid
fever may be a source of contagion, it is desirable that
before being thrown down the closet they should be
largely mixed with Condy's fluid or some other disin-
fectant. On the same principle the strictest cleanliness
must be observed in the sick-room. 14. There is no
reason to believe that typhoid fever is contagious from
person to person, in the ordinary way. The largest
experience shows that it does not extend, like an ordi-
nary contagious disease, to nurses or others attending
upon patients suffering under the disease. — Medical He-
view.
Jejunoitomy. — According to Dr. Hahn the fistula
must be made high up in the small intestine, otherwise
death will occur from inanition. The author refers to
the recorded cases of jejunostomy, especially by Maydl.
He thinks that the making of a fistula in the duodenum,
as has been proposed, is undesirable, owing to the diffi-
culty in the operation and to the impossibility of the pa-
tient feeding himself. Dr. Hahn gives details of five
cases in which he has performed jejunostomy. Case I. —
A man, aged sixty- nine, suffering from gastric carcinoma,
recovered from the operation, but died a fortnight later
with increasing weakness. Case II. — A patient with
oesophageal carcinoma improved after the operation.
Nine weeks later the fistula closed, and the feeding took
place exclusively by the mouth. Case III. — A man, also
with malignant disease of the oesophagus, died four days
after the operation of increasing inanition. Case IV. —
A girl, aged nineteen, attempted suicide by means of
strong acid. Nearly two months later only a fine oeso-
phageal bougie could be passed. As the sounding was
followed by some bleeding, jejunostomy was performed.
She made a good recovery. The fistula closed about a
month after the operation. She was in good condition
some three years later. Case V. — A girl, aged twenty-
three, also drank sulphuric acid. About three weeks
December 22, 1894]
MEDICAL RECORD.
783
later an obstruction was found about thirty centimetres
from the mouth. There was great wasting. Jejunos-
tomy was done a fortnight later, but the patient died
some eight days afterward. The indications for the
operation are, according to Dr. Halm, the following :
1, Corrosion of the stomach and oesophagus when a fatal
result is to be feared, as in the above cases; 2, car-
cinoma involving the cardia and lower end of the
oesophagus when gastrostomy is impossible ; and 3, car-
cinoma of the pylorus where no other operation is possi-
ble. The incision should not be too small, so that the
commencement of the jejunum may easily be found. If
the nutrition of the patient permit of it, the intestine
need not be opened for several days, otherwise this must
be done at once or after twenty- four hours. — Deutsche
Medicinische Wochenschrift.
Diphtheritic Conjunctivitis. — In the Gazette des Hdpi-
taux, April 24, 1894, the subject of diphtheritic conjunc-
tivitis is treated at some length by Gilbert Sourdille, who
defines diphtheritic ophthalmia as the infection of the
conjunctiva by the Klebs Loftier bacillus. There are two
distinct kinds of pseudo-membranous conjunctivitis : the
croupous form, characterized by a thin, elastic, shin-
ing, opaline false membrane, leaving on removal an
almost normal mucous surface; and the true diphthe-
ritic form, a profound interstitial infiltration, making
the conjunctiva look like bacon rind, thick, blood- shot,
dirty-yellow, and dotted with ecchymotic spots. Unlike
the croupous form, there is no detachable membrane.
The first condition is benign; the second of special
gravity, owing to constitutional states, to climatic influ-
ences, to various chemical and physical agents. Accord-
ing to Mackenzie the nature of diphtheritic conjunctivitis
lies in some inherent disposition of the mucous surface
itself. A question arises, as to whether these two condi-
tions are not different degrees of the same morbid state ;
clinically, the croupous variety appears to be the superfi-
cial form of the same disease, of which the second is in-
interstitial or diphtheritic (Venneman, Gerke, Kam,
Uhthoff, Moritz). If these are really distinct entities,
then diphtheritic conjunctivitis may be said to be very
rare ; but if the so-called croupous condition enters into
the group of affections due to the presence of the Loftier
bacillus, the disease is at once recognized as relatively
common.
Diphtheritic conjunctivitis may be the first point of
localization of this special bacillus, and is then a primary
disorder ; or it may be an extension of the diphtheritic
process elsewhere, and is then secondary. It is usually
a primary affection, seldom occurring with the ordinary
diphtheritic angina, about once in two hundred cases.
It occurs most frequently in cold, damp countries, as
Germany is, especially in the city of Berlin. In Paris,
it appears with relative frequency, and at Nantes some
condition favors its appearance still oftener. Both sexes
are equally afflicted, from two to eight years of age being
the period of predilection. It is also seen in adults and
in the new- bom. Previous conditions of health are im-
portant factors in its production. Infectious diseases,
especially measles and whooping-cough, are among the
general causes. Much of the purulent ophthalmia of in-
fants is in reality diphtheritic conjunctivitis. Diphtheria
of the ordinary form is comparatively rare in nurslings,
but in the eye the disease manifests itself among them
with greater frequency than is usually supposed.
In the superficial or croupous form of the disease, a
trifling catarrh first appears, with sensitiveness of the
eyes to wind, artificial light, weeping, a sensation of
sand in the eye, etc. Then the discharge becomes
muco-purulent, gluing the eyelids together after sleep.
Careful examination shows this discharge to be more
fibrinous, more coagulable, than that of ordinary ca-
tarrh. The conjunctiva is red, vascular, sometimes
ecchymotic. That inside the eyelids is even redder, in-
jected, and oedematous. This state lasts from twenty to
thirty-six hours. Then the epithelium of the palpebral
conjunctiva undergoes a rapid change. It takes on a
brilliant varnished appearance. A fine layer of trans-
parent mucilage seems spread over it. This is the be-
ginning of the false membrane. The eyelids are more
or less oedematous, the ciliary border takes on a violet
tinge, and the secretion is citrine in color. As in the
insterstitial form, the false membrane is confined almost
always to the mucous surface of the lid. If the conjunc-
tiva of the globe is involved, it is by extension, and
never primarily. The false membrane is thin, elastic,
and adherent. It can be rubbed off with a piece of
linen or removed by forceps. Sometimes the membrane
is shed in bits ; sometimes in unbroken form, giving a
perfect cast of the parts involved. Underneath, the
membrane is supple, congested, bleeding on the slight-
est friction, without apparent fibrinous infiltration. Yel-
lowish spots, here and there, that bleed less easily than
the rest of the surface, suggest the beginnings of such in-
filtration. This period of the disease lasts from three to
ten days. Then begins the purulent or third period,
characterized by purulent discharge, decrease of pain
that has been pretty severe, and a reddened granular
condition of the palpebral conjunctiva, now denuded of
the false membrane. Too energetic treatment will now
bring back the false membrane and cause it to persist
with more or less obstinacy. Suppuration diminishes
rapidly, and the disease is ended in about two weeks,
leaving no scars. During its entire course there is
scarcely any fever, some slight emaciation, and a certain
uneasiness. In spite of this apparent benignity, serious
complications may arise at any moment, especially mor-
bid conditions of the cornea.
In the interstitial form of diphtheritic ophthalmia, the
onset is variable. Sometimes it begins by the super-
ficial or croupous form just described, differing only by
the shortness of duration of these three stages, that may
follow each other so rapidly as to escape observation.
Then, again, it appears suddenly as a full fledged infil-
tration from the start. The eyelids are swollen, oedema-
tous, overhanging, purplish, and the seat of an acrid
burning. The surface thermometer may show one and a
half degree of abnormal heat. The lids are often one
centimetre in thickness and of cartilaginous hardness.
The discharge is not abundant. It is citrine in
color, dull, flecked with opaline debris, with a fetid
sanguinary odor. The inside of the lid is thickened,
smooth, yellowish-gray, ecchymotic, exactly like a bit of
ham rind. It is perfectly bloodless ; and cross-rubbing
and scarification fail to draw one drop of blood. The
fibrinous exudation pervades the entire conjunctiva, im-
plicating the blood-vessels. In certain cases this infil-
tration is disseminated, appearing in localized patches
surrounded by a reddened and vascular mucous mem-
brane. The bulbar conjunctiva is at first slightly in-
jected. Then it is secondarily invaded, though the false
membrane never equals in thickness that on the palpebral
surface. Symptoms increase in severity. There is con-
siderable fever, loss of appetite, insomnia, emaciation,
and albumin in the urine. This stage lasts a week,
during which the condition is one of uniform severity or
of aggravated symptoms. If there is perforation of the
cornea, as often happens, the situation is pitiable in the
extreme. The eye, seen as at the bottom of a deep
sewer, moves in a mass of bloody corruption. By de-
grees things improve, the swelling diminishes, the dis-
charge changes in character and is less profuse, the
patches disappear, and the patient generally recoveis if
no secondary infection occurs.
Professor E. Klebi, formerly of Carlsruhe and now of
Strassburg, claims to have obtained most satisfactory re-
suits from the use of his antiphthisin in the treatment of
tuberculosis. The antitoxin has also been tried to some
extent in America, those who have used it speaking most
enthusiastically of its action. Professor Klebs is now in
this country.
784
MEDICAL RECORD.
[December 22, 1894
Medical Record:
A Weekly Journal of Medicine and Surgery.
GEORGE F. SHRADY, A.M., M.D., Editor.
Publishers
WM. WOOD & CO., 43, 45, &. 47 East Tenth Street.
New York, December 22, 1894.
THE REDUCTION IN THE MEDICAL CORPS
OF THE ARMY.
The American Congress is often foolish in its extrava-
gances, but it never betrays a greater imbecility than in
some of its attempts at economy. One of the most short-
sighted and unnecessary of these penny-wise efforts was
the reduction in the army medical staff, passed last win-
ter, whereby the country is saved $30,000 a year, and
the efficiency of the medical department is seriously
threatened. In the annual report of the Surgeon General
just issued this subject naturally receives some attention.
The members of the Committee on Military Affairs of the
House of Representatives, upon whose recommendation
this measure was adopted, had better have given no rea-
son for their action than to put forth what they did.
One of their arguments was that there were 210 military
posts in the country in 1 8 70, and but 1 20 in 1894; "if 193
officers in this department were sufficient when the num-
ber of posts and stations was 210, there can be as great a
reduction as is proposed in this bill when the number of
posts and stations is reduced to 120."
The fallacy of this is shown by the fact that there were
then 184 acting assistant-surgeons in addition to the
regular staff, while now there are none. The committee
suggested that, if there were not enough army surgeons
to attend to all the garrisons, private physicians living in
the neighborhood could be called in and paid by the
visit. In reply to this the Surgeon-General shows that
the expense to the Government in paying for medical
attendance by the visit would in most posts be greater
than the pay of an assistant-surgeon.
" Moreover, a post medical officer has various and im-
portant duties to perform in addition to caring for the
sick. In fact, his presence as a member of the garrison
is more important than that of any other officer, for no
other officer can perform his duties, whereas any line
officer present can perform the duties of quartermaster,
commissary of subsistence, adjutant, or commanding offi-
cer of a garrison."
But it is mainly as injuriously affecting the efficiency
of the medical department in case of war or active service,
that the parsimony of Congress is to be deplored. The
Surgeon-General very justly says that the weakness of a
Medical Department, consisting in part of medical men
attending and paid by the visit, would be mainly felt when
troops were ordered out for active service. The principal
reason for supporting an army in time of peace is that an
efficient organization may be maintained which will be
ready for service in any emergency, and serve as a nucleus
for the larger army which will be required in case of war.
This applies to the Medical Department as well as to the
fighting force. The duty of our medical officers is not
only to attend to the sick at their stations, acting at the
same time as health officers for their command, but to be
prepared, and to prepare their Hospital Corps detach-
ments, for any emergency, and especially for field service.
The call to service in the field is more common in our
army than is generally supposed. During the year 1893
the number of medical officers who were out with the
various detachments which constituted the average field
strength was 69. The largest number of medical officers
out in one month was 23, in September, with detach-
ments aggregating 2,954 men, and giving an average
strength for the month of 1,663 men. It is for such field
service that the need of the junior officers of the Medical
Department is chiefly felt. In 1892, 76 medical officers
were on field service, the average number of men thus
serving having been 1,010. In 1891, 93 medical men
were out with various detachments of troops having an
average strength of 899 men, and in 1890, 143 medical
officers with an average strength of 1,210 men. If at-
tendance on the sick at military posts be made the gauge
of the strength of the Medical Department, no provision
of medical officers can be made for troops on active ser-
vice unless certain posts be deprived of their medical
officers*
"It must be remembered also, that medical officers are
as liable as other officers to break down under the ex-
posures and accidents of field service, or from other
causes. During the past three years a little over five per
cent, of them have been constantly non-effective from
sickness, or 10 officers out of the 192 allowed by law
up to the time of the passage of the current appro-
priation bill. Again, these officers are as much en-
titled as other officers to leaves of absence ; but inas-
much as the Regulations of the Army prescribe that
leaves will not be granted 'so that a post will be left
without competent medical attendance,' many of the
medical officers have to do, year after year, without leaves
such as are enjoyed by others. During the past ten years
the leaves of absence granted to medical officers were
equivalent to an average leave annually of a little less
than fourteen days for each. To enable the Department
to permit its officers to have one month's leave annually,
and at the same time provide competent medical attend-
ance at post, a strength of 8.3 per cent is needful over
and above that necessary to man the post."
"In view Of these considerations," Dr. Sternberg
concludes, " I regard with regret the policy which has
cut off fifteen officers from the Department."
The regret will be shared by all who have been ac-
customed to point with pride to the efficiency of our
army medical service.
The Sew York Orthopedic Dispensary and Hos-
pital has received from Mrs. Richard T. Auchmuty,
$ 1 0,000, to endow two free beds in perpetuity, in mem-
ory of her husband; from Mr. James H. Jones, $5,000,
to endow a free bed in perpetuity; from "a friend "
$4,000, to build a modern operating room; and from
two of the trustees, $500, to furnish and equip the same.
December 22, 1894]
MEDICAL RECORD.
785
TYPHOID FEVER IN THE DISTRICT OF CO-
LUMBIA.
The city of Washington has long had the unenviable rep-
utation of being one of the cities most visited by typhoid
of any in the country. The Medical Society of the Dis-
trict of Columbia recently appointed a committee to in-
vestigate the causes for the prevalence of the disease there,
and to suggest measures adapted to its suppression. In
the search for these causes the committee investigated es-
pecially the water-supply, the drainage, and the milk-sup-
ply. The water-supply of the District is derived from the
Potomac River and from wells. The water derived from
the first source is comparatively good, as the river flows
for the most part through a mountainous country, and
there are no large cities on its banks above Washington.
The water of the wells, however, is almost uniformly bad,
sewage bacteria having been found in a great majority of
the samples of well-water examined. This is readily un-
derstood from the condition of the soil, saturated with
fecal matter escaping from leaky sewer pipes and overflow-
ing privies. A study of the geography of the typhoid dis-
tricts has shown that there is a coincidence between a
soil polluted with the leakage of the excreta from typhoid
fever patients, the drinking of infected well-water, and
an extensive distribution of typhoid fever ; that where
these first two conditions exist to the greatest degree ty-
phoid fever is most prevalent.
The committee concludes, as a result of its investiga-
tion, that " the daily pollution of the soil by the fecal
discharges of our patients suffering from typhoid fever,
with the resulting contamination of well-water, must be
recognized as the chief source of the diffusion of the dis-
ease. It is a case of auto-infection. We are daily breed-
ing the poison which poisons us, and the inevitable round
from intestine to soil, from soil to well, and from well
back to intestine, goes on and on with the most tragic
uniformity. We sustain all the conditions favorable to
rapid and perfect propagation of the bacilli. Granches
and Deschamps have experimentally shown that typhoid
germs placed on the surface of frequently moistened
ground will penetrate nearly two feet into the soil, and
will there retain life for five and a half months. They
multiply rapidly in illy drained soil, live for an indefinite
time in privy vaults, and have a much longer existence
in cisterns and wells than in running water. In Wash-
ington we supply all these necessary conditions — leaking
privies for the reception of the excreta and their con-
tained germs, a damp and illy drained soil for their re-
ception and rapid growth, neighboring wells for the
resulting, the inevitably resulting, contamination of
drinking-water consumed by a thirsty population. What
more conveniences can we supply? What more success-
ful means can we adopt to raise our mortality to a point
higher than that of Brooklyn, New York, Baltimore, and
Boston ? We are among the most successful cultivators
of the deadly bacillary plant in this country/9
To remedy this condition the committee urges the
abandonment of all wells within the city limits, the sedi-
mentation and filtration of the Potomac water, the puri-
fication of the existing sewerage system, and the building
of new sewers in parts not yet supplied with drainage, the
suppression of all privies in the city, and finally the care-
ful inspection of dairies and regulation of the sale of
milk. There is no innate reason why Washington should
not be one of the healthiest cities in the country. A
great deal has been done for the sanitary improvement
of the city in the past thirty years, but much yet remains
to be done. It is a hopeful sign that the Medical Society
of the District has taken the matter up, and if the District
commissioners will but follow the recommendations of
the Society, one of the chief causes of mortality in the
city may be suppressed.
THE LIVER AND ITS GLYCOGENIC FUNC-
TION.
Dr. Pavy has recently made some rather radical state-
ments regarding the functions of the liver in its relation
to sugar and to the pathology of diabetes.
This distinguished investigator asserts that there is no
increase of sugar in the blood leaving the liver, that
glycogen is not converted into sugar, that sugar does not
disappear in the circulation, and that it is all excreted by
the liver. The liver in fine has no more to do with
sugar than other tissues, and not so much perhaps as the
muscles.
Dr. D. Noel Paton, however, in an article on the
"Physiology of the Carbohydrates1' (Edinburgh Medi-
cal and Surgical Journal, December, 1894), denies seria-
tim these views of Pavy, and says that not one of them is
proven. " The evidence for the constant production of
sugar in the liver," he says " the evidence that glycogen
is a source of sugar, the evidence that sugar disappears in
the general circulation (I do not say is used in the tis-
sues), is overwhelming, and thus the glycogenic theory
of Bernard holds its ground unshaken."
Dr. Paton further asserts that one of the great func-
tions of the liver is to produce sugar will not, at the
present time, be denied by any physiologist. The theory
of Pavy, repeated in nearly every text-book, that the liver
is a sugar destroying and not a sugar-forming organ,
rests on so unsubstantial a basis, and has been so com-
pletely refuted by the work of Seegen and other investi-
gators, that it need not be considered.
When experts disagree, it is difficult for those who are
not in possession of special physiological knowledge to
decide. We trust, however, that the truth will soon be
reached, for there are few questions of more practical in-
terest than that of the physiological chemistry of sugar.
FILLING FORCED VACANCIES.
The trouble in Philadelphia concerning the dropping of
an attending physician from the staff of the Philadelphia
Hospital, has a wider significance than that which per-
tains to the results of an ordinary election of officers.
In this instance the Commissioners of Charities and Cor-
rection, who make such appointments, presumed to de-
cide upon the merits of a vital and scientific question of
medical treatment, without consultation with the staff,
and in an under handed manner to elect another gentle-
man in the place occupied by the alleged offender. This
rebuke was made more pointed by re-electing all the
other members of the medical board. It is surprising to
learn that the medical board had no disposition to resent
this insult, and still more so to know that a good man
could be found to accept the position thus made vacant,
786
MEDICAL RECORD.
[December 22, 1894
and thus tacitly acknowledge the validity of the prin-
ciple.
Dr. Walk, who was the only member of the board of
trustees to support Dr. Daland, very properly maintained
that the question of medical treatment in the hospital
was a technical matter, and that laymen were not com-
petent to decide it. If the board had any objection to
any method of treating patients, it should have had a
commission of physicians to pass upon it It was, in
fact, not within the sphere of the board.
Such doings are, fortunately, not common, and gen-
erally occur when managing boards are ignorant of their
duties and when a staff lacks pluck and spirit. There
are always men waiting for vacant places, no matter how
they are created. Managers know this and act accord-
ingly. The principle involved is one thing and the place
is the other. Usually they do not come near enough to
each other to get acquainted.
A BELATED ASSAULT ON THE GERM-
THEORY.
We do not know whether anyone pays attention to the
attacks of Mr. Lawson Tait upon vivisection and the
germ-theory of disease. At any rate, no one who reads
this gentleman's last criticism of microbic pathology,
"based on the Baconian Method," will entertain any
longer the idea that Mr. Tait understands what he is writ-
ing about when he takes up this subject. His " Bacon-
ian " argument is that, because his own surgical mortality
is light, therefore the germ-theory is false, strikes one as
possessing simply the merit of an infantile simplicity.
The germ-theory of disease, or of some diseases, is as
firmly established as any fact in human science, and Mr.
Tait's mortality-rates must be made to fit the facts ; the
facts are not to be stretched to the Procrustean bed of
hospital statistics. Evidently Mr. Tait believes that
"the sun do move."
FURTHER REPORTS OF THE ANTITOXIN
TREATMENT.
Reports regarding the use of the antitoxin of diphtheria
continue to come in from all parts of the world. In
Paris, Roux's serum has reduced the mortality fifty per
cent, according to published statistics. In London
"good results" have been obtained at St. Bartholo-
mew's Hospital in cases not too far advanced. The in-
vestigations of the efficacy of the serum are, however,
being conducted with much secrecy, according to the
British Medical Journal. Three kinds of serum are
used, Behring's, Aronson's, and that made in London.
Whatever the future results will be when the remedy is
widely employed, it has not yet been used enough to les-
sen the very large mortality from diphtheria in the city
of London.
At Buda-Pesth, Professor Bokai has reported the re-
sults of the treatment of 35 cases of diphtheria with Beh-
ring's serum. The number of children who died was 5,
giving a mortality-rate of 14.28 percent. Of the 30
children who recovered intubation was done in 12. Drs.
Gottstein and Schleich, of Berlin, have attacked both
the theory of the antitoxin treatment and the hospital
statistics which have been quoted in its support.
At a recent meeting of the Medical Society of Munich,
which was attended by more than three hundred practi-
tioners, the serum treatment formed the subject of a pro-
longed discussion. Professors Buchner, von Ranke, and
C. Seitz presented a report on the subject, and resolutions
were passed to the effect that the time was not yet ripe
for a definite judgment as to the value of the method, and
that trials of the remedy on an extensive scale would be
necessary to settle the question. It was considered im-
portant that this view should be impressed not only on
the profession, but on the public. A committee, consist-
ing of Professors Buchner, von Ranke, Bollinger, Oertel,
C. Seitz, von Kerschensteiner, and Wertheimer, was
appointed to study the whole question thoroughly.
In France, the War Department has authorized the
antitoxin treatment in the army ; the cities of Lille and
Havre have voted money for undertaking the new treat-
ment.
In Belgium, a sero-therapeutic service has been organ-
ized in Brussels, and similar work has been begun in
Milan, Piacenza, Turin, and at Lisbon.
In this city the Board of Health has already begun to
prepare the serum, and a plant is being established in
Washington under the direction of the Marine Hospital
Service.
H*ws of tfee fflleetu
Dr. William H. Flint, having suffered from a bron-
chial ailment, since an attack of grippe which he had in
the spring of this year, has decided to leave New York for
some time, in the hope of regaining his health. Dr. Flint
hopes to resume his practice in this city early next fall.
The Twenty-fifth Anniversary of the Northwestern
Medical and Surgical Society was celebrated by an
evening reception to the members, their wives and guests,
on Thursday evening, December 13 th, at the house of the
President, Dr. W. Gill Wylie, 28 West Fortieth Street,
New York. About one hundred and twenty-five persons
were present, and the evening was thoroughly enjoyable.
This society is one of several in this city organized be-
tween 1865 and 1870, just after the war ; and its public
celebrations have become famous for the generous social
spirit among the members and friends.
Hewark is to have a new hospital for contagious and
infectious diseases.
Br. Martin L. Banney died at his residence in this
city, 317 West Twenty-ninth Street, on December 14th,
in his sixty fifth year. He had practised medicine in
this city for more than forty years, and was one of the
best known physicians on the west side. He was the
brother of the late Dr. Lafayette Ranney. Dr. Ranney
leaves two children and two brothers.
National Association of Eailway Surgeons.— The
following are the officers for 1894 and 1895 : President^
Dr. Samuel S. Thorn, of Toledo, O. ; First Vice-Presi-
dent, Dr. N. Y. Leet, of Scranton, Pa. ; Second Vice-
President, Dr. C. H. Wilkinson, of Galveston, Tex.;
Third Vice-President, Dr. B. L. Riardon, of Toronto,
Canada ; Fourth Vice-President, Dr. W. B. Morrow, of
Walton, N. Y.; Fifth Vice President, Dr. A. O. Will-
December 22. 1894]
MEDICAL RECORD.
787
iams, of Ottumwa, la. ; Sixth Vice-President, Dr. G. A.
Hollister, of Toledo, O. ; Seventh Vice-President, Dr.
W. R. Priest, of Concordia, Kan.; Secretary, Dr. J. M.
Dinnen, of Fort Wayne, Ind. ; Assistant Secretary, Dr.
J. H. Ford, of Wabash, Ind. ; Treasurer, Dr. Eugene
R. Lewis, of Kansas City, Mo.; Editor of Journal, Dr.
R. Harvey Reed, of Columbus, O.; Executive Committee,
Dr. C. K. Cole, of Helena, Mont. ; Dr. A. J. Mullen,
Jr., of Michigan City, Ind.; Dr. J. B. Murphy, of Chi-
cago, 111.; Dr. A. A. Thompson, Waxahachie, Tex.;
Dr. D. E. Welsh, of Grand Rapids, Mich. ; Dr. C. D.
Evans, of Columbus, Neb.; Dr. F. H. Peck, of Clinton,
N. Y.; Chairman Committee on Transportation, Dr. W.
B. Outten, of St. Louis, Mo. ; Chairman Committee on
Arrangements, Dr. A. I. BoufHeur, of Chicago, 111.
The Promised Life of Sir Andrew Clark is being pre-
pared by Canon MacColl, with the co-operation of Dr.
W. H. Allchin. An introduction will be contributed
.by Mr. Gladstone. The book is not expected to be
ready for some time yet.
A Typhoid Antitoxin. — A rumor was current on the
Stock Exchange of Frankfort on-Main the other day,
that the Hochst Works would shortly bring on the mar-
ket a typhoid antitoxin of Behring's discovery. The
consequence was a decided rise in Hdchst shares !
Bequests to Medical Institutions of Philadelphia. —
By the will of the late Dr. William Goodell, of Phila-
delphia, the sum of $ 50,000 is donated to the Medical
Department of the University of Pennsylvania. The
College of Physicians will from the same source fall
heir to $10,000.
Kentucky School of Medicine. — On the 22d inst. the
Faculty of the Kentucky School occupied for the first
time their commodious new hospital and dispensary.
Honors to Medical Ken. — The Sultan has conferred
the honor of Grand Officer of the Medjidieh Order
on M. Monod, Director of the Assistance Publique of
France ; Professor Grancher and M. Roux, of the Pas-
teur Institute ; and M. Pozzi, the well-known gynecolo-
gist. M. Martin, of the Pasteur Institute, has received
the decoration of a Commander of the same Order.
Ohio State Association of Bailway Surgeons. — The
annual meeting of this body was held at Dayton, Octo-
ber nth and 12th.
The Southwestern Association of Bailway Surgeons.
— The following are the officers of this organization :
President, Dr. C. A. Smith, of Tyler, Tex.; Vice-Presi-
dents, Dr. E. A. Neeley, of Memphis, Tenn.; Dr. W.
G. Jameson, of Palestine, Tex. ; Dr. E. F. Yancey, of
Sedalia, Mo. ; Dr. B. F. Eads, of Marshall, Tex. ; Dr.
N. J. Pettijohn, of Kansas City, Mo. ; Secretary, Dr. J.
A. Lightfoot, of Texarkana, Ark.; Treasurer, Dr. L. H.
Callaway, of Nevada, Mo.
The Association of Military Surgeons of the United
States. — The following are the officers for 1894 and
1895 : President, George M. Sternberg, Brigadier-
General and Surgeon- General, U. S. Army, of Washing-
ton, D. C; First Vice President, Louis W. Read, Colo-
nel and Surgeon-General, N. G. Penn., of Norristown,
Pa.; Second Vice-President, Albert L. Gihon, Medical
Director, U. S. Navy, of Washington, D. C; Secretary,
Eustathius Chancellor, Lieutenant Colonel and Medical
Director, N. G. Mo., of 515 Olive Street, St. Louis, Mo.;
Assistant Secretary, Julian M. Cabel, Captain and As-
sistant Surgeon, U. S. Army, of Washington Barracks,
Washington, D.C.; Treasurer, Lawrence C. Carr, Major
and Surgeon, N. G. Ohio, of 143 W. Seventh Street,
Cincinnati, O. Meets at Buffalo, N. Y., May 21, 22,
and 23, 1895.
A Bequest to the Massachusetts General Hospital.—
By the will of the late Thomas E. Proctor, the Massa-
chusetts General Hospital, of which he was a trustee, re-
ceives J 1 00,000. This sum is to be held in trust until
principal and interest reach the amount of $400,000.
The West Side German Dispensary.— The members
of the staff have founded a clinical society styled the So-
ciety for Medical Progress of the West Side German
Dispensary. The officers are : Dr. Augustin H. Goelet,
President; Dr. Lewis Morris and Dr. V. Fuentes, Vice-
presidents; Dr. Aristides Agramonte, Secretary ; and Dr.
H. C. Hazen, Treasurer.
Diphtheria in St. Louis. — Diphtheria is so prevalent
in certain portions of St. Louis as to be considered epi-
demic. A large number of the earlier cases are said to
have been reported by the physicians as "croup" or
"laryngitis."
The German Medical Society of the City of Sew
York held a festival last Saturday evening, at the Arion
Club, to celebrate its thirty-fourth anniversary. The
entertainment consisted of a dinner followed by a ball.
Speeches were made by Drs. Jacobi, Willy Meyer, Vul-
pius, and Heitzmann.
Manufacture of Vaccine Virus by the State of Illi-
nois.— A committee has been appointed by the Illinois
State Board of Health to promote legislation by the next
General Assembly for the establishment of a State vaccine
farm. It will be remembered that within the last year
efforts were made to secure such legislation in Massachu-
setts. These attempts, unfortunately, were not success-
ful.
Beoeipts from Portrait Exhibition. — The exhibition
of portraits of women, organized by a number of ladies
of society, which has just closed at the Academy of De-
sign, netted about $20,000 for St. John's Guild and the
Orthopedic Dispensary.
The Antitoxin Treatment of Tetanus. — Dr. £.
Schwarz reported last week on a case of tetanus treated
by Tizzoni's antitoxin. The treatment was commenced
on the second day of the disease, and the spasms disap-
peared under the treatment, but the temperature rose dur-
ing this time from 37.30 C. to 4o-3°> and the patient, after
the fourth injection, died from heart failure. It was clear
that the leucocy tosis was increased in consequence of the
treatment. The number of the leucocytes was 11,000
before the first injection,' rising to 18,000 on the next
day, and was 17,000, 16,000, and 15,000 on the follow*
ing days. Dr. Schwarz recommended the use of strong-
er doses of the antitoxin than those prescribed by Tiz-
zoni.
A Gold Cup for Discovering a Sew Microbe. — The
citizens of Nagasaki have presented Professor Kitasato
with a beautiful gold cup in honor of his discovery of the
bacillus of the plague.
788
MEDICAL RECORD.
[December 22, 1894
GEORGE A. PETERS, M.D.,
NSW YORK.
Dr. George A. Peters, one of the most prominent
of New York Surgeons, died December 6th, of chronic
Blight's disease. Dr. Peters was graduated from the
College of Physicians and Surgeons in 1846, and his ca-
reer was a most successful and interesting one. For the
last four years he had retired to a large extent from active
practice, but at the time of his death he was still consult-
ing surgeon to the New York, St. Luke's, St. Mary's, and
the Woman's Hospital.
During his medical course he was a private pupil of
the late Dr. Alfred C. Post. After his graduation he
served the prescribed period on the house staff of the
New York Hospital, and a few years later he was ap-
pointed a surgeon to that institution, also to St. Luke's
Hospital. Although his hospital work was wholly sur-
gical, he was for many years one of the most successful
and popular of the general practitioners of New York.
FRANK L. SIM, M D^
MEMPHIS, TKNN
Dr. Frank L. Sim, died at his residence in Mem-
phis, Tenn., November 23, 1894. He had been in failing
health for several months. Dr. Sim was born in Gol-
conda, I1L, April 29, 1834. 'His literary education was
received at Hanover College, Indiana. He graduated
from the medical department of the University of Louis-
ville in 1855, and a year later received an ad eundem de-
gree in the Pennsylvania Medical College. Returning
home in the spring of 1857, he practised medicine with
his father till 1861, when he left that part of the country
and shortly afterward entered the Confederate service as
a contract surgeon in the army, then stationed at Colum-
bus, Ky. Circumstances induced him to locate in Mem-
phis, where he ever since devoted himself to the practice
of his profession. He remained at his post of duty dur-
ing the dark days of Memphis in the various epidemics
of cholera and yellow fever. In 1882, Dr. Sim became
the editor of the Mississippi Valley Medical Monthly, but
afterward changed to the Memphis Medical Monthly,
under which name he has continued its editor and pub-
lisher. Dr. Sim at the time of his death was Professor of
the Principles and Practice of Medicine in the Memphis
Hospital Medical College and was Dean of the Faculty.
Dr. C. P. Gage, of Concord, N. H., died on Novem-
ber 26th, aged eighty-three. He was one of the original
members of the American Medical Association, and had
been president of the New Hampshire Medical Society.
gtortettrs atufl fj0tiaes of QooHs.
Transactions of the Forty-ninth Annual Meeting
of the Ohio State Medical Society, held at Zanes
ville, May 16, 1894. Toledo, O. : Blade Printing
and Paper Co.
Contains the usual assortment of papers, many of them
of considerable interest. As might be expected, tuber-
culosis comes in for rather a large share of attention.
Papers on sterilization and immunity, and pleas for
higher medical education, and for the cremation of the
dead, are also noteworthy as illustrating tendencies of the
times.
A Manual of Human Physiology. Prepared with
Special Reference to Students of Medicine. By Jo-
seph H. Raymond, A.M., M.D. Philadelphia: W.
B. Saunders.
Believing that only the main principles of the subject of
physiology can be imbibed by the medical student dur-
ing the limited time of his study, the author has at-
tempted to make these available in condensed form.
Without too fully endorsing the view that students should
be trained on manuals— especially in this day when the
tendency everywhere is to lengthen medical courses —
one may at least admit the value of concise, direct, and
unequivocal elucidation of principles; and it may be
freely conceded that the essentials of human physiology
are compressed within the three hundred and sixty-five
pages of this manual in a most attractive form. Numer-
ous creditable illustrations — some of them colored — rein-
force the text.
Fifth Annual Report of the New York State Com-
mission in Lunacy. From October 1, 1892, to Sep-
tember 30, 1893. Albany: James P. Lyon, State
Printer.
Judged quantitatively, this report certainly shows great
advances on the part of the Commission in Lunacy, inas-
much as it is six times as bulky as the first report,
issued in 1889. Considered as to quality, the advance
is not so striking. Of course there are good suggestions
in the report, but there is much that might advanta-
geously have been omitted or greatly condensed — for ex-
ample, the copy of the estimate for supplies, and the .
monthly treasurer's report of the Rochester Hospital,
which fills fifty printed pages, and the endless legal papers
giving details of the squabble between the Commissioners
in Lunacy and the authorities of Queens County.
Whatever the failings of the Commission in Lunacy, it
has never been accused of lack of self-appreciation, and
in this regard the present report shows no falling off.
Should the future historian come upon these volumes, he
will certainly be excusable if he reaches the conclusion
that in the last decade of the nineteenth century the ill-
used insane had but three friends in the State of New
York, these being, of course, the Commissioners in Lu-
nacy. But should the same historian come across sundry
letters and other unofficial documents relating to the
same subject that may chance to be preserved, we fear he
will be sadly puzzled. For in point of fact, there are
other friends of the insane in New York, and not a few
of them, differing very widely from these reports in their
estimate of the value of the work of the Commission in
Lunacy.
Twelfth Annual Report of the Provincial Board
of Health of Ontario. Being for the year 1893.
Printed by order of the Legislative Assembly. To-
ronto : Warwick Brothers & Rutter. 1894.
Contains reports on many topics having to do with
sanitation, some of them only of local interest, others
more general in their application, but all illustrating the
wide-spread interest in preventive medicine that marks
our generation.
The Principles of Bacteriology : A Practical Manual
for Students and Physicians. By A. C. Abbott,
M.D., First Assistant, Laboratory of Hygiene, Uni-
versity of Pennsylvania, Philadelphia. Second edi-
tion, enlarged and thoroughly revised. With 94 Illus-
trations, of which 17 are Colored. Philadelphia: Lea
Brothers & Co. 1894.
Although this second edition contains double the letter-
press of the first edition, the author explicitly states that
he has adhered closely to his original plan, making no
attempt to cover the field exhaustively, but referring
only to species that "are comparatively common, or of
importance in enabling the student to acquire a funda-
mental working knowledge, capable of wider application."
It is, in short, a work for beginners and general students,
and as such, of course lays no claim to originality of
matter ; but its method is concise and clear, and it gives
just such an account of the practical manipulations of
media and cultures as will prove of value to the student
who must learn laboratory methods by himself. A satis-
factory summary of the present status of the various
theories of infection and immunity has been added to
this edition.
December 22, 1894]
MEDICAL RECORD.
789
jfocietg Qupovte.
SOUTHERN SURGICAL AND GYNECOLOGI-
CAL ASSOCIATION.
Seventh Annual Meeting) Held in Charleston, S. C, No-
vember 13, 14, and is, 1894,
First Day, Tuesday, November 13TH.
The Association met in Artillery Hall, and was called to
order at 10 a.m. by the President, Dr. C. Kollock, of
Cheraw. Prayer was offered by the Rev. Dr. Campbell,
of Charleston. An address of welcome was delivered by
the Mayor of Charleston. Dr. Brodie, of Charleston,
followed with an address of welcome on behalf of the
local profession, and President Kollock responded in be-
half of the Association.
Br. Warren Stone. — Dr. William E. Parker, of
New Orleans, read a " Memorial Address " on Dr. War-
ren Stone, which was prepared by the late Dr. A. B.
'Miles, of New Orleans. He said as Professor of Surgery
in the University of Louisiana for thirty-five years, as
Surgeon to the Charity Hospital for thirty- eight, and as
general practitioner from 1832 to 1872, whose experience
covered eighteen epidemics of yellow fever and cholera
in New Orleans, the name of Warren Stone is impressed
indelibly upon the local history of a remarkable period.
In his surgical clinics he taught the advanced surgery of
the old school. He taught the principles of drainage in
suppurative arthritis, in hepatic abscesses, andinpyothorax.
He advocated resection of the rib to facilitate the drainage
in suppurative pleuritis. Whether in operative work or
in the liberation of pus he made free incisions. He was
among the first in the cure of aneurism of the vertebral
artery. In the surgery of the arteries he was an expert.
During fourteen years of his work at the Charity Hospi-
tal, he operated without an anaesthetic. Realizing the
difficulties under which he labored, he was ready to wel-
come the new era in surgery then about to dawn. The
lives of many men are mirrored in their books and pub-
lished papers, but the writings of Dr. Stone give but
meagre knowledge of his work, or his position as an
authority on surgery in the South. No man in the
profession was ever so universally beloved as Dr.
Stone. In his relations with other physicians he was
gentle and considerate, never intrusive or aggressive.
Many of the physicians in Louisiana to day who knew
him in life, speak of him affectionately as " Old Stone/'
and always with some expression of endearment and re-
spect. His position in New Orleans may be compared
with that of Physick, in Philadelphia, Mott, in New
York, Lister, in London, Velpeau in Paris.
Gonorrhoea in Women. — Dr. J. B. S. Holmes, of
Atlanta, read a paper with this title. He said there was
no disease that affected women that should engage the
serious and thoughtful consideration of the physician
more than gonorrhoea. There was no doubt but that
many of the chronic diseases of the ovaries and tubes
that came under the observation of gynecologists were
due to this disease. In the majority of cases the poor
woman was ignorant of the fact that she had had or has
any specific disease. Indeed, her husband might tell the
physician that months or even years before his marriage
he was a subject of gonorrhoea, which was cured and had
since shown no evidence of a return.
The essayest could conceive of nothing more danger-
ous than curetting the uterus in the presence of immense
pus-tubes with pelvic adhesions. The drawing down of
the organ necessary for curettage may break up pelvic
adhesions and pour out the contents of pus-sacs into the
peritoneal cavity, which would result in the majority of
cases in death to the woman. If her life is saved at all,
it will only be done by a prompt abdominal section,
with thorough irrigation and drainage of the abdomen.
Then why not, in the first instance, when pus is detect-
ed, promptly remove it by surgical interference. We
then treat the woman rationally and give her the very
best and only chance of relief and restoration to health.
Dr. George J. Engelmann, of St. Louis, called atten-
tion to the importance of differentiating between latent
or chronic gonorrhoea and the acute form of the disease.
He does not look upon acute gonorrhaea as a dangerous
disease in women, but he does the latent or chronic
form. He has not seen serious results from the acute
form, but it is the infection which is not observed from a
supposedly cured gonorrhoea in the male which produces
the suffering in women.
Dr. Bedford Brown, of Alexandria, Va., took excep-
tion to the statement made by Dr. Engelmann in regard
to the non-danger of acute gonorrhoea in females, and
cited the case of a female in whom acute gonorrhoea ran
its course, terminating finally in fatal nephritis. In this
case there was first urethritis, then cystitis, ureteritis, pye-
litis, and acute nephritis.
Dr. Richard Douglas, of Nashville, thought Dr.
Engelmann had sounded the keynote in that there is
quite a difference in the infection from acute gonorrhoea
and the latent form of the disease. Infection from the
latter was a mixed infection, not only with the gonococ-
cus, but with the streptococcus and staphylococcus also,
and that accounts somewhat for the virulence of the
trouble. That gonorrhoea is the cause of uterine fibroids,
he could scarcely accept, although he thought Dr. Price
was the author of that idea.
Dr. Joseph Taber Johnson, of Washington, D. C,
said in the treatment of pus-tubes the result of gonor-
rhoea! infection, the very radical suggestion of Dr.
Holmes was correct, viz., to resort to. abdominal section,
as he was satisfied that gonorrhoea! pus tubes were incur-
able by conservative measures. In addition to the re-
moval of pus-tubes, if present on both sides, the uterus
should be removed also, because it is through the infected
mucous membrane of the uterus that the tubes them-
selves have become infected.
Dr. William P. Nicolson, of Atlanta, said the general
surgeon was concerned in the treatment of gonorrhoea as-
well as the specialist. We are told that a urethra has-
been inflamed and subsequently restored to its normal
condition, and yet years afterward the man transmits
gonorrhoea to his wife. It is hard for him to accept such
a doctrine. If a man goes for months and years with a
gonorrhoea absolutely producing no effect whatever, if
he is not well, how are we to tell him that he is not?
We are told by the essayist that gonorrhoea is contracted
by the female when there is absolutely no evidence what-
ever of disturbance in the urethra of the male, or that
there is no trouble by which he can propagate disease.
Dr. A. M. Cartledge, of Louisville, thought the
essayist failed to differentiate between cases of subacute
and chronic salpingitis and the cases of acute infection
from gonorrhoea. He threw out the suggestion that
physicians were not fully conscious of the great preva-
lence of artificial abortions in youug married women of
the better as well as the lower class, and he believes that
in these cases of secondary infection from pathogenic or-
ganisms we have a more fertile source for the develop-
ment of the tubular and ovarian disease than from gon-
orrhoea.
Dr. W. E. B. Davis, of Birmingham, Ala., considered
the disease a dangerous one. The views of Tait, how-
ever, in regard to gonorrhoea were extreme. We have a
frequent cause of tubal disease in the puerperal state, in
delivery at term or in premature deliveries, frequently in
artificial abortions, brought about by mechanical means.
More or less infection occurs after all cases of abortion,
but if the patient is in good condition at the time, she
will not be materially affected. If we have a soil that is-
favorable for the development of septic germs, we will
get a severe inflammation — a mixed infection.
Dr. W. D. Haggard, of Nashville, desired to place
himself on record as opposed to the removal of the uterus
and tubes for pyosalpinx as the result of gonorrhoea, be*
790
MEDICAL RECORD.
[December 22, 1894
licving that by dilatation and judicious curetting patients
can be relieved of an endometritis produced by gonor-
rhoea.
Dr. John D. S. Davis, of Birmingham, Ala., emphasized
the importance of using the microscope in connection
with gonorrhoea and carefully examining the pus. Ex-
perience has demonstrated that the latent effects of gon-
orrhoea were not always directly due to the gonococcus
per se, but to a mixed infection ; that is, we have an in-
flammation as a result of the gonococcus, which is fired
up by another infection from the streptococcus. When
we have a mixed infection, we have as a result pus-tubes,
suppurative peritonitis, and finally death of the patient if
surgical interference is not resorted to.
Dr. Hunter McGuire, of Richmond, entered a pro-
test against the doctrine that a man can have gonorrhoea
and not get well. As for the idea that a man who has
had gonorrhoea should not get married, it is preposterous.
He had seen thousands of cases get well and remain so.
Dr. Holmes, in closing, said he was aware that many
cases of acute gonorrhoea resulted in no secondary
trouble, because they were recognized early and cured by
judicious treatment. He wished to be understood as not
indorsing the views of Mr. Tait, that gonorrhoea in the
male was never cured, but he insisted that general prac-
titioners were often too careless in advising patients who
have been the subjects of gonorrhoea to get married.
Some Oases of Acute Intestinal Obstruction With
Deductions was the title of a paper read by Dr. A. Mor-
gan Cartledge, of Louisville, in which he reported six
cases, three of which terminated fatally. The author
said that the limited number of operated cases reported
in his paper, together with an individual observation of
probably as many more not subjected to operation, con-
form to the accepted belief of the hopeless nature of
acute intestinal obstruction unless treated by early lapa-
rotomy.
While the author does not contend that we can dis-
pense with opium in the treatment of these cases, cer-
tainly where obstruction is in the least suspected we
should withhold its use until a diagnosis can be made:
The practice of masking every abdominal condition
characterized by pain with opium is far too prevalent,
and its practice gains additional calamity as surgery
advances in knowledge which refers relief of these very
conditions concealed by the cloak of opium and ignor-
ance.
The practical and cardinal points in avoiding a fatal
delay and making an early diagnosis, are to be found in,
sudden abdominal pain; a rapidly accelerating pulse;
the vomiting of much more fluid in a given time than
taken by the mouth ; the green tinged character of this
fluid ; the anxious expression of countenance when no
opium has been used, the fact that although enema may
be stained by the contents of the colon there is no ex-
pulsive movement of the bowels, and the passage of no
gas.
The burning question now is to educate men to know
that action to be successful must be quick ; that timely
aid depends upon the man who first sees the case ; that
when a physician from any reason suspects that a pa
tient's bowels will not move, he should drop everything
else and centre all his time and attention upon that pa-
tient. He should not waste his gray matter by trying to
determine if it be a probable intussusception, volvulus,
band, diverticulum or what not— leave that for the oper-
ation to determine ; it is the most reliable way to find out.
Second Day, Wednesday, November 14TH.
Hernia of the Diaphragm.— Dr. F. W. McRae, of
Atlanta, Ga., reported a case of this kind. The author
brought this subject before the Association for considera-
tion, not alone because it offered an inviting field for
experiment and investigation, but also because of a recent
interesting case where, without warning, he was forced to
meet the emergency without time for research into the
literature of the subject, and while he was not then sus-
tained by a knowledge of the opinions of the leading
authorities. He finds from subsequent investigation that
the course pursued was in accord with the recommenda-
tions of such eminent authorities as Laennec, Bowditch,
Guthrie, and Marcy. In the case reported, strangulation
had occurred five days before the doctor saw him. Had
an early diagnosis been made, he feels sure the strangula-
tion could have been relieved and the patient's life pro-
longed. The opening in the diaphragm was accessible,
and he believes it could have been dosed with a fair
chance of permanent recovery. The case serves to em-
phasize the necessity for early operation in all cases of
acute obstruction of the bowels.
Gunshot Wound of the Spleen and Kidney. — Dr. Louis
McLane Tiffany, of Baltimore, Md., reported the fol-
lowing case : The patient was a male negro, twenty years
of age. Two hours previous to entering the University
Hospital, March 21, 1894, he had been shot with a small-
calibre rifle from a distance of twenty feet, the weapon
being directly behind him, and he being erect. His
urine was slightly albuminous ; the pulse, temperature,
and respiration, normal. There was a bullet wound
three inches to the left of the spine just below the last
rib, from which blood oozed. After properly cleansing
the wound it was enlarged, and it was found that the
kidney had been injured and that a bullet had passed on-
ward, presumptively into the peritoneal cavity. The
wound was filled lightly with gauze by the resident
physician, and Dr. Tiffany was notified. External
examination of the abdomen by touch and palpation re-
vealed nothing, not even painfullness.
The patient was anaesthetized, laid on the belly, and
the wound, after being enlarged, was examined. The
upper portion of the left kidney was perforated, and
dark blood flowed from the peritoneal cavity beyond.
This large wound was filled with gauze, the patient turned
on the back, and the abdomen freely opened along the
left semilunar line. A moderate amount of blood was
free in the peritoneal cavity ; no wound of the intestine
could be discovered, but the spleen was found perforated,
blood flowing freely from the wound of entrance, as well
as from the wound of exit ; the latter wound, in the con-
cavity of the organ, was slightly the larger of the two.
The perforation through the spleen was about three
inches from the free lower border. Unwilling to subject
the patient to splenectomy, the essayist attempted to
arrest the bleeding in the following manner: A long
needle threaded with silk was passed entirely through the
spleen central to and parallel with the bullet track ; the
long ligature was then tied over the free border of the
organ so as to press the surfaces of the wound together
tightly enough to arrest bleeding, yet not to tear through
the splenic tissue ; the ends of the ligature were cut
short, the peritoneal cavity cleaned by copious irrigation
with hot water and the abdominal wound closed. The
kidney was tamponed with gauze through the dorsal
wound. Convalescence was uneventful; the anterior
wound healed by primary union ; urine flowed from the
dorsal wound for two days only, union by granulation
taking place. The patient left the hospital well, April
2 2d.
In this case, the wound being small, hemorrhage was
not profuse, and no abdominal organ save the spleen
was wounded.
Nsbvus. — Dr. William Perrin Nicolson, of Atlanta,
Ga., reported a severe case of nsevus, which was only
cured by the use of galvano-puncture. The case was one
of a large growth occupying the groove from the angle
of the jaw, up to and covering a portion of the ear, and
extending out upon the cheek, the entire tumor being
almost the size of a hen's egg.
Dr. Nicolson formulated the following conclusions as
having been reached in the long period covered in the
treatment of this case : 1. That while this treatment
may not be applicable to all cases, in many of those that
are reached by difficult dissection, and are subject to
December 22, 1894]
MEDICAL RECORD.
791
dangerous hemorrhage, as well as an unsightly looking
scar, this is undoubtedly to be preferred to any other
surgical proceeding. The time required in a cure is
more than balanced by the entire preservation of the
skin and the absence of danger from operative work. 2.
That as to the quantity and quality of the current to be
employed, as many as six cells of a zinc-carbon battery
may be sufficient in small growths, while twelve cells of
the same is perhaps the maximum to which it should be
carried if the current from the positive pole alone should
be employed. 3. The method of applying needles.
Various forms of needles may be employed, but the or-
dinary steel needle gives equally satisfactory results, as
the eschar produced in the skin at the point of entrance
is not sufficient to amount to anything, and the needles
can thus be changed at each sitting. That only one of
them should be inserted into the tumor, while the nega-
tive pole should be attached to a sponge electrode mois-
tened with a salt solution, and placed upon some indif-
ferent point, care being taken to remove it from point to
point in order to prevent blistering the skin. 4. Method
of attacking the tumor. Better results are -obtained by
passing the needle in from the periphery of the growth
on a line horizontal with the skin, and in directions ra-
diating from the circumference toward the centre.
Several of these punctures should be made at each oper-
ation. The length of the entire setting should not ex-
tend to more than twenty minutes or half an hour, while
intervals of two to three weeks, or longer, should be left
between operations to know whether there may not be a
progressive shrinking away of the tumor. 5. As to the
method of cure. He thought that several elements en-
tered into attaining the result, of which the coagulum of
the blood was one, and perhaps the least. The two re-
maining elements were the subsequent contraction of
the small eschar produced in radiating lines from the
tumor, and the effect of the current upon the vasomotor
nerve supply.
He felt sure that a thorough trial of this method as to
the settling of the various points considered, would re-
sult in its adoption in the treatment of perhaps a large
majority of these cases where we have a large elevated
blood- tumor with which to deal. He also believed that
perhaps pricking the surface with the needle attached to
a positive pole of battery, might result in a series of
small scars, which would result in removing the ugly
port-wine marks so common in this trouble.
Operations for Complete Perineal Laceration. — Dr.
Joseph Price, of Philadelphia, said that there are many
men who, essaying to be authorities on the surgical dis-
eases of the major order, have no conception whatever of
injuries of the perineum and cervix so far as their intelli-
gent repair is concerned. Indeed, there are many, with
a large obstetrical practice, who labor under the delusion
that they have never ruptured a perineum, and that all
their patients have entirely normal perinea. This mis-
conception is due to improper teaching more than to
any other cause. Perineal lacerations, unless extending
through the skin to or through the sphincter may escape
detection unless by thorough digital examination. All
these tears should be approached as distinct surgical
lesions to be repaired in the line of their anatomical de-
struction, and not as cosmetic operations, whose object
is to obtain superficial appearances without regard to
perfection and utility. Heaping up of tissue outside
the lines of resistance and tension, or mere thickening of
mucous membrane and skin does not make a true per-
ineum, neither does a set of outside sutures, however
much they may draw the parts together, afford any ana-
tomical counterpart of a perineum. From this basis all
the so-called outside flap-splitting operations for perineal
tears are only puckering operations, bringing parts
within the sutures that have never been severed, and in
many cases taking them out of their proper relations.
Big sutures, heavy ligatures, clumsy instruments, have no
more place here than in other surgery. The ordinary
short, strong sewing needle fills the bill exactly in most
cases, though the Emmet stray-fine short needle for gen-
eral use is preferable. Silk-worm gut or silver wire is the
preferable suture. The Emmet operation as originally
suggested, and afterward modified by its distinguished de-
viser, is the foundation for all successful operations on the
lacerated perineum, either with or without sphincter tear.
Dr. Price, in closing, said the tears of perinea are
often unavoidable, but their restoration is always pos-
sible, and their neglect is criminal.
President's Address. — President Kollock then de-
livered his annual address. He fiist thanked the Asso-
ciation for the honor conferred upon him in electing
him as President. He then alluded to the death of Drs.
William T. Briggs, of Nashville, and A. B. Miles, of
New Orleans. Dr. Briggs's life had been one of useful-
ness, lie had done excellent and remarkably brilliant
work, and had achieved an enviable reputation. Dr.
Miles, who had been made Professor of Surgery in
Tulane University, was a man full of youthful activity
and manly vigor, who by patient study and diligent re-
search, aided by a brilliant intellect, had won for himself
a high position in the profession, and in the estimation
of his fellow-men. To know him was to admire and love
him. His life was gentle and the elements so mixed
in him, that Nature might stand up and say to all the
world, " This was a man."
While in all branches of gynecology good progress
had been made, he noted with pleasure that surgery had
had its triumphs. Many reports of cases show enlarged
experience and continual improvement in the treatment
of appendicitis, hernia, intestinal obstruction, and many
other ills that flesh is heir to.
Action of Chloroform on the Functions of the Human
Brain and Spinal Cord. — Dr. Bedford Brown, of
Alexandria, Va., read a paper on this subject. He cited
the history of two cases of extensive compound com-
minuted fracture of the frontal bone and serious injury
and destruction of a portion of the frontal lobes of the
brain as the basis of his paper. One of these cases of
injury was caused by a kick of a newly shod horse, the
other by a spent grape-shot in battle. The subjects of
both of these injuries retained perfectly their powers of
consciousness and sensation.
The fracture in the first case involved a large portion
of the frontal bone. The fractured bones were driven
back into the substance of the brain quite an inch in
depth, lacerating the frontal lobes extensively. There
was a loss of about two tablespoonfuls of brain. During
the operation, which lasted more than an hour, the
patient was placed under the influence of a compound of
chloroform three parts, and ether one part, four different
times. Through this large opening in the skull the brain
could be seen perfectly and its varying changes of action
under chloroform could be observed perfectly. The in-
variable action of the anaesthetic was to suppress hemor-
rhage, to quiet cerebral pulsation and to positively reduce
circulation in the brain and arterial tension. These pe-
culiar effects were observed as many as three or four
different times. When the patient was threatened with
collapse from chloroform, stimulants injected in the
rectum produced increased circulation and arterial ten-
sion in the brain promptly.
Any struggling, mental excitement, or resistance while
inhaling chloroform caused marked increase in cerebral
circulation and pulsation, with increase of hemorrhage.
The second case was that of a Confederate soldier,
who in battle received a spent grape-shot in his fore-
head, causing an extensive compound comminuted fract-
ure of the os frontis, driving the fractured bones back
more than an inch into the frontal lobes. The wound
in the skull was quite two inches in diameter, and more
than an inch in depth. This patient was subjected to
chloroform three times during the operation, which lasted
an hour. The action of chloroform on the functions of
the brain in this was similar to that in the first. When
under full anaethesia each time the cerebral hemorrhage
ceased, the cerebral pulsations diminished to a mere
792
MEDICAL RECORD.
[December 22, 1894
tremor, and the arterial circulation was markedly re-
duced. This occurred three different times during the
operation. The action of alcoholic stimulants resorted
to in this case to prevent collapse from chloroform in-
creased the cerebral pulsations and circulation in a posi-
tive manner.
Hydro-Pyonephrosis ; Successful Removal of a Forty-
Pound Tumor of the Kidney. — Dr. Joseph Taber
Johnson, of Washington, D. C, reported the case.
The patient was sixty-three years of age, and had in-
herited and possessed until five years ago a remarkably
good constitution. At this time a lump appeared in his
right side in the region of the liver, and was supposed up
to the date of the operation to be caused by enlargement
and abscess of that organ. This lump gradually in-
creased in size, and the patient had gradually lost flesh
and strength until the date of the removal of the lump,
when he could not have weighed more than eighty
pounds. At no time did he suffer from pain, and only
a few weeks with fever.
There were several points of interest in this case, viz :
failure of a number of good men to make a diagnosis,
though the patient was under observation for nearly five
years. Failure of repeated examinations of the urine to
detect the slightest evidence of disease of the kidney.
The only explanation the writer suggests is that the dis-
ease at the time of analysis and subsequently had so de-
stroyed the function of the kidney as to prevent the es-
cape of any urine at all, and that the specimen examined
came from the other organ, which fortunately was
healthy. Failure of such large quantities of foul smell-
ing pus to produce more sepsis. Absence all through the
history of pain or fever. The median line incision, the
separate ligation of the renal vessels, and the ligation
and dropping of the ureter.
The writer is aware that the lumbar incision is pre-
ferred by nearly all nephrectomists, and that they often
bring out the cut end of the ureter and fasten it to the
abdomen. While the lumbar incision may be best in
small tumors and otherwise disease of kidneys, it cer-
tainly could not have succeeded, the author believes, in
a case of the magnitude of the one here reported, not
only on account of its great size, but also because of its
being so extensively adherent to the omentum and ab-
dominal wall. The colon had to be carefully separated
from the anterior surface of the tumor.
Gunshot Wounds of the Abdomen. — Dr. W. L. Rob-
inson, of Danville, Va., reported two gunshot wounds of
the abdomen, lacerating the liver and bowel. In neither
case were the symptoms commensurate with the injury ;
neither shock, hemorrhage, nor pulse portrayed the ne-
cessity for operation. Yet in view of the ninety-two per
cent, mortality from gunshot wounds of the abdomen
without operation, he did not hesitate. The first case
came so near dying on the table and his light being im-
perfect at 12 o'clock at night, he only found the liver
wound, failing to find the hole in the posterior border of
the hepatic flexure of the colon. The patient died in
three days. His second case was operated on promptly,
and the injury in the transverse and descending colon
was promptly repaired with the Murphy button. The
man was on a spree and had had no action from bowels
for three days. He pressed out much fecal matter, but
should have taken more time and ruptured the bowel as
far as practicable. For two dap no unfavorable symp-
toms presented themselves, but on the night of the sec-
ond day distress from tympanites and pain began. He
suggested to his associates the propriety of reopening the
abdomen, but enemata and grain doses of calomel were
tried. This, the author considered, was his fatal mistake,
for the waiting of ten hours had lost him the chance of a
life-saving operation. He reopened and with medium
trocar emptied the bowel of gas, but exudative lymph
was manifest on bowels, and obstruction of button by
fasces existed. The button held its tissue firmly, and no
leakage had occurred. He washed out the cavity, but pa-
tient died in ten hours of shock.
Movable Kidney.— This paper was read by Dr.
George Ben Johnston, of Richmond, Va. At the out-
set the author emphasized three propositions : 1. Mova-
ble kidney is extremely common. 2. It is capable of
producing very distressing symptoms, and in many in-
stances is a menace to life. 3. It is curable by a simple
and safe operation.
The author's own experience with movable kidney
from a surgical standpoint extends back a little more than
three years. Prior to the first nephrorrhaphy, which he
performed in May, 1891, those cases he has met with
were given little or no thought. Since the date men-
tioned, he has looked with more interest on his cases, and
has come to marvel at the frequency of the malady. He
has examined a limited number of persons likely to be
the subjects of movable kidney since his first operation
for its relief, and in a comparatively small number of
subjects he has encountered twenty-seven cases. Ede-
bohls, who had studied five hundred cases, fixes the rate
at one for every five or six women examined. Under
gives about the same rate. Osier makes no statistics,
but mentions it as a common occurrence in his hospital
wards. The records of these observers and Dr. John-
ston's cases justify the assertion that it is a ^pmmon
malady.
It occurs more often in women. He had never seen
one in a male subject. Age is a factor in its production.
His own cases have been in subjects varying in age from
twenty to thirty-five years. In only one instance has he
seen it in a women over forty. Both kidneys may be
movable at the same time. The right is the one that is
affected in the preponderating majority of the observed
cases. This is accounted for by the relation of the kid-
ney to the liver on this side.
Two anatomical facts help to explain the preponder-
ance of the right over left kidney displacement. 1, The
greater length of the right renal artery, and a, the firmer
attachments of the left kidney. The author has twice
seen a movable kidney follow obstruction of the ureter.
It happened that both of these cases were on the left
side. The increased weight of the kidney due to accu-
mulated urine and congestion must have played an impor-
tant part in the etiology of the dislocation in these two
cases.
In many cases of movable kidney there are no symp-
toms. In others, the symptoms are extremely distressing,
producing great mental disquietude, as well as intense
physical suffering. In a proportion of cases the symp-
toms are grave. Torsion of the ureter is common, partial
occlusion by bending is not uncommon, inducing a dis-
tention of the pelvis by dammed- up urine. Hydro-
nephrosis may follow. Calculus is thus invited by reason
of poor drainage. Apart from tumors of the kidney itself,
the condition most likely to be mistaken for movable
kindey is distended gall-bladder.
Nephrorrhaphy is not indicated in every case of dislo-
cated kidney, but only in such cases as manifest distress-
ing or dangerous symptoms. When gastrointestinal
disturbance impairs the general health, when nervous
symptoms are severe, when the dragging abdominal pains
are constant, when disease of other organs is simulated,
when hydronephrosis is threatened, when one or more
attacks of torsion have occurred, the operation is imper-
ative.
The author then outlined his method of operating on
movable kidney, and closed his paper with a report of
seventeen cases.
Acute Peritonitis. — Dr. Richard Douglas, of Nash-
ville, read a paper with this title. Appreciating the
condition under which the colon bacillus will escape
from its natural habitat and become actively pathogenic,
and knowing the supply is unlimited, the dose being
governed alone by the integrity of the bowel, naturally
we accord to this bacillus the first place in the causation
of peritonitis.
In obedience to the teachings of experimental work>
the surgeon must accept the classification of Pawlowski
December 22, 1894]
MEDICAL RECORD.
793
of two forms of peritonitis. 1. That produced by chem-
ical agents, with which we are not concerned, 2. That
produced by infection. The latter is more tangible. It
is fully in accord with our idea of the genesis of the dis-
ease. It harmonizes with clinical work. With Mor-
decai Price, the author agrees that every case of general
peritonitis has a demonstrable cause, and that cause is
septic in character. Pathological manifestations of peri-
toneal infection are subject to many variations which, in
a great measure, indicate the virulence of the poison and
guide us in forming a prognosis, but to simplify matters,
the author considered it under two heads, which illus-
trated the microscopic and macroscopic changes the
results of general peritonitis.
It is an indisputable fact that the type and virulence
of the inflammation is largely dependent upon the origin,
hence in our bed-side work we may consider the subject
under the following etiological classification :
Infection from Without.— Immediate : This is direct
infection of the peritoneal membrane through penetrat-
ing wounds of the abdomen, either accidental or surgi-
cal. Mediate : This form embraces all cases of contami-
nation of the peritoneum occurring from extension of
adjacent infected areas, as leakage from mural abscesses,
or puerperal infection.
Infection from Within. — Immediate: Visceral per-
foration or rupture and direct inoculation of the perito-
neal membrane with escaping contents, as in perforating
typhoid or gastric ulcer, appendicitis, or rupture of gut
and bladder. Mediate: Infection by emigration of
micro-organisms through visceral wall of impaired resist-
ance, as in incarcerated hernia, intestinal obstruction,
ruptured ovarian cyst.
The author then reported a few illustrative cases.
One case was reported of general purulent peritonitis.
The patient recovered, and the author considers that it
was due entirely to free incisions, thorough irrigation,
and ample drainage.
Third Day, Thursday, November 15TH.
History of Vaginal Extirpation of the Uterus.— Dr.
George J. Englemann, of St. Louis, read a paper on
this subject, in which he stated that at the New Orleans
meeting of the Association he was deeply interested in
vaginal hysterectomy, which he presumed was a com-
paratively new operation with very recent modifications ;
but Dr. Lewis, of that city, called his attention to an
old French pamphlet, showing that the operation had
been done in the '20's. Since then he has found it was
done still earlier, precisely as it is done to-day, the opera-
tion having developed step by step.
Dr. Lewis, of New Orleans, La., in the discussion
stated that the first vaginal hysterectomy was performed
by Dr. Dabourg in the little town of Autell, France.
Reminiscences of Br. J. Marion Sims in Paris. — Dr.
Edmond Souchon, of New Orleans, La., read a paper
with this title (see p. 705).
Cancer of the Gravid Uterus.— Dr. George H.
Noble, of Atlanta, Ga., read a paper entitled, " A Case
of Carcinoma of the Parturient Uterus, Removed Three
Days after Confinement ; Recovery." The woman had
previously been confined, sustaining a laceration of the
cervix uteri, which perhaps was a factor in the cause of
the disease. In the first few months of the last preg-
nancy the patient was treated locally by her family phy-
sician, and there was nothing to cause a suspicion of ma-
lignancy. Almost the entire vaginal portion of the
cervix was destroyed, less than one- fourth of its circum-
ference remaining intact. The induration extended
deep into the uterine tissue, but could not be felt be-
yond the limits of that organ. The roughened ulcerated
surface was easily traced for a considerable distance
within the cervix, the os being dilated to about five cen-
timetres in diameter. Her condition was unpromising,
and surgical interference was clearly interdicted, so the
os and vagina were cleansed thoroughly and lightly
dressed with gauze. She was then placed profoundly
under the influence of morphia sulphate with a view of
arresting labor, securing rest, and recuperation sufficient
to permit evacuation of the uterus, which occurred spon-
taneously twelve hours later. The child was poorly
nourished and lived only a few weeks, finally dying of
inanition.
The main point in the paper was to show the feasibil-
ity of hysterectomy in the puerperal state for cancer of
the uterus, as the case reported clearly demonstrated,
even though it is too early to claim immunity from the
return of the disease.
Ligation of Arteries.— Dr. John A. Wyeth, of New
York, reported two cases of ligation of the external
carotid artery. The reason for narrating these two cases
was to bring before the Association a consideration of the
inflammatory changes which occur in arteries which
have been ligated, and to discuss at length the best
methods to pursue in these operations to secure the
greatest safety to the patient.
In tying arteries, an important point to consider is
the selection of a ligature. It seems to the author that
in the animal ligatures, and especially in well-prepared
and properly asepticized catgut is found the best ligature
material. For the last ten years he had used catgut
almost without exception, only once or twice using silk,
and then in the ligation of the large venous trunk close
to the root of the neck, in which he was fearful that the
animal ligature might slip from the blood-pressure in the
act of vomiting as the patients came out from under the
influence of the anaesthetic.
Porta, in four hundred experiments, found that in
from one to two years, seventy per cent, of catgut liga-
ture had become absorbed, thirty* six per cent, of silk,
sixty-six per cent, of hemp and flax, and twenty per
cent, of horse-hair. Order of rapidity : catgut, hemp,
silk, horse-hair.
Simultaneous Appearance of Canoer in Breast and
Uterus.— This paper was read by Dr. James Evans, of
Florence, S. C. The subject of this interesting manifes-
tation of the disease was a lady of fifty-three years of
age, married, and the mother of six children. A striking
peculiarity in the history of the case was, that when the
disease was most active and destructive in the breast, it
rather checked and retarded its tendency in this direction
in the uterus. Excision of the cervix and removal of the
breast were proposed, but declined.
Tke author closed by saying that although there is a
very general concensus of opinion among surgeons that
the most successful treatment of cancer affecting the
breast and uterus is early and radical removal by the
knife, yet it is doubtful in the opinion of the author if
the operation is advisable when the disease appears in
multiple form and in distant organs. When the disease
is confined solely to the uterus and recognized at an early
stage of its invasion, the prompt removal of the organ is
usually followed by permanent recovery ; in fact, recur-
rence less often takes place than removal from any other
organ or part of the body.
Varicocele. — Dr. W. E. Parker, of New Orleans,
reported seven cases of varicocele treated by incision,
ligation, and shortening of the scrotum. An incision,
varying in length according to the size of the varicocele
is made, and the scrotum shortened by converting the
wound from a longitudinal into a transverse one. All
cases which recovered with union by first intention are
still doing well, the period since the first operation being
seven months. At the conclusion, he laid the following
general indications for the treatment of varicocele. The
milder form should be treated with a suspensory bandage
with proper attention to diet, exercise, and bowels. A
varicocele should be operated upon: r. If it is of large
size. 2. If it is painful. 3. If marked nervous symp-
toms are present. 4. If the testicle is atrophying. 5. If
the varicocele is increasing rapidly. 6. If it is an obsta-
cle to entering a public service. 7. If, on account of a
794
MEDICAL RECORD.
[December 22, 1894
patient's occupation, a suspensory is troublesome and he
desires an operation.
Eibroid Tumor of the Uterus with Suppurating
Ovary Discharging per Rectum. — Dr. Rufus B. Hall,
of Cincinnati, O., reported the following case : The pa-
tient, aged forty-four, ,was known to have a fibroid tumor
for five years. She had suffered from sepsis for five
weeks previous to the operation. In addition to the
fibroid tumor was a large suppurating ovary holding about
two pints of pus, which was discharged per rectum every
eight or ten days. The suppurating ovary was densely
adherent, and after its removal disclosed a large opening
in the rectum. The operation included total extirpation
of the fibroid uterus with the suppurating ovary, and re-
pair of the intestinal rent. There was no leakage of the
injured bowel after the operation. The patient recov-
ered.
The speaker drew the following conclusions: The
question of operation during sepsis is one that will admit
of discussion both/*? and con, but in the end it must be
decided by the merits of the individual cases and not by
rule. As to technique, total extirpation was given the
preference, as it gives the ideal condition both theoreti-
cally and practically for after treatment. The Baer
method was condemned, as it does not give thorough
drainage — a thing absolutely necessary where there are
extensive raw surfaces which have been bathed in pus,
and no peritoneum to close off the general peritoneal
cavity. The strengthening of the suture line with a tag
of adventitious tissue was advised. The packing of the
pelvis with gauze to protect the cavity from intestinal
leakage, should any occur, and to prevent intestinal ad-
hesions, was recommended. The gauze is usually re-
moved on the fourth day and peroxide of hydrogen used
as a wash for the cavity several times daily.
Again, forcible dilatation of the sphincter-am muscle
to cause incontinence, thus relieving the intra-intestinal
pressure from accumulating gases, the doctor says, adds
greatly to the chances for recovery. He first employed
it for this purpose on February 6, 1893, m *& operation
for extrauterine pregnancy with extensive bowel injury,
the patient recovering. He says, as far as he knows, he
is the first man to practice forcible dilatation for this
purpose.
Pelvic Surgery.— Dr. J. G. Earnest, of Atlanta, Ga.,
contributed a short paper in which he reported some
complicated cases of pelvic surgery. Two cases were
detailed simply to illustrate a method of treatment that
under certain circumstances is safer for the patient and
just as apt to give relief of symptoms as total extirpation
of the tumor ; also to emphasize a growing conviction
the author has that intestinal adhesions are frequently
tinkered with when it would be best to let them alone.
The essayist was no advocate of timid and imperfect
surgery, but in cases where the tumor can be effectually
dealt with without disturbing old, thoroughly organized
adhesions, which the history and condition of the patient
clearly show to be harmless, and in view of the fact that
if those adhesions are loosened they will almost certainly
anchor at some other point where they may be a source
of constant annoyance, or even produce a fatal obstruc-
tion of the bowel, he believes it best to leave diem undis-
turbed.
The Removal of an Intra uterine Eibroid Tumor
by Moroellement without Hemorrhage.— Dr. Herbert
M. Nash, of Norfolk, Va., read a short paper on this
subject. In September, 189a, he saw in consultation
Mrs. A , aged about forty-two, the subject of intract-
able hemorrhages from the uterus, lasting from two to
three weeks of each month, and which had been habitual
for several years. The uterus could be plainly felt above
the pubes, and by the conjoined method, sound, etc.,
the diagnosis of intra uterine fibroid was made. Not
wishing at that time any radical procedure, she contin-
ued under the care of her physician, whose best efforts to
control the hemorrhage proved fruitless. On July ix,
1893, she entered the hospital for surgical treatment.
On August 26th the essayist operated under ether. It
was found quite impossible to dilate the os to the extent
desired, but there was room enough for the manipulation
without dividing the cervix, and no difficulty was found
in seizing the presenting mass — the attachment of which
to the uterine walls had been made out to be sessile —
with a strong vulsellum. Upon making traction with
some force, in order to determine the best method of
procedure, the tissue gave way, and the withdrawn part
of the detached mass was quite large, but no bleeding
followed. This fact decided the doctor to proceed by
morcellement, and with forcepr, scissors, and the instru-
ment he exhibited, the whole growth was removed piece-
meal, and with only a slightly colored serous discharge.
The previous' packing had been so effectual that the growth
itself, and indeed the uterine walls, appeared to have been
exsanguinated. The fragments removed, when under
strong compression, presented a mass of fibroid tissue
nearly as large as an ordinary cocoanut. When the pa-
tient left the hospital the uterus had contracted firmly,
and measured a fraction over three and one half inches
in depth, occupied its proper position in the pelvis, and
the patient is to day entirely well, with perfectly noimal
functions.
Election of Officers. — The following officers were
elected : President, Dr. Louis McLane Tiffany, of Balti-
more, Md. ; First Vice President, Dr. Ernest S. Lewis,
of New Orleans, La. ; Second Vice-President, Dr. Man-
ning Simon, of Charleston, S. C; Treasurer, Dr. Rich-
ard Douglas, of Nashville, Tenn.; Secretary, Dr. W. E.
B. Davis, of Birmingham, Ala.
After introducing and adopting resolutions of thanks,
the Association adjourned to meet in the city of Wash-
ington, D. C, the second Tuesday in November, 1895.
THE NEW YORK PATHOLOGICAL SOCIETY.
Stated Meeting, November 14, 1894.
George C. Freeborn, M.D., President, in the Chair.
Spontaneous Babbit BepticsBinia. — Dr. Alexander Lam-
bert reported a spontaneous outbreak of septicaemia hem-
orrhagica occurring among rabbits. Among the rabbits
confined in the animal house connected with the patho-
logical laboratory of the College of Physicians and Sur-
geons, there occurred in January, 1894, a large number
of deaths from an unknown cause. These deaths were
among the rabbits which had been operated upon, and
among the healthy animals. The majority of these rab-
bits were fresh from the country, and had been confined
but a few days in the animal house. Nearly thirty died
within two weeks. Autopsies showed, in the majority of
cases, a slight congestion of the lungs and an enlargement
of the spleen. All the other organs were apparently nor-
mal. Cover glass smears and cultures of the heart's blood
of several of these animals, gave a small bipolar stained
bacillus, the morphology and biology of which, the
speaker said, he would give later on in these remarks.
In one case there was a universal exudative peritonitis.
The exudate was largely fibrinous, with but little puru-
lent fluid, and the intestines were matted together. The
spleen was large and dark ; the other abdominal organs
were apparently normal. Both pleural cavities, and the
pericardial sac, were filled with fibrinous exudate and pur-
ulent fluid. The lungs were congested.
In one other case the abdominal organs were apparently
normal, except that the spleen was small and pale. Both
lungs were, however, crowded and flattened against the
vertebral column by an abundant exudate. The exuda-
tion in the right pleural cavity was reddish-yellow and
fibrinous, and that in the left pleural cavity was a yellow
purulent fluid. The pericardium was also filled with a yel-
low purulent fluid.
Cover-glass smears and cultures of the peritoneal and
pleural exudates gave a bipolar stained bacillus, similar
to that in the heart's blood of the other rabbits already
December 22, 1894}
MEDICAL RECORD.
795
mentioned, and having the following characters: The
bacillus was small and round-ended, the ends being more
deeply stained than the centre. Sometimes the bacillus
was uniformly stained, especially after being in contact
for a long time with the staining fluid. These bacilli
may present themselves as small ovoids, hard to differen-
tiate from cocci. They stain easily with the anilin colors,
but are decolorized by Gram's method. The size varies
from 1.5 i*. long by 0.56 ft broad, to 0.7 p, long by 0.49
ft broad, the average being 1.1 /x long by 0.53 p. broad.
They appear single, and sometimes united in pairs or in
rows of three to four elements. They are non-motile,
and do not liquefy gelatin. In gelatin plates they form
small, light yellow, finely granular, sharp-edged colonies,
which, after a few days, usually show a darker yellow cen-
tre and concentric rings. The deeper colonies are of the
same appearance. The colonies are often circular, often
ovoid. Sometimes the colonies just below the surface
seem to grow better than the surface colonies. In punct-
ures in gelatin the growth usually commences just below
the surface, extending in a thin, white, finely granular
streak to the bottom of the puncture, the lower half of
the growth being made of fine, separate dots. The upper
half of the growth is formed by the coalescence of the
small colonies. The growth remains slight. Sometimes
there is a surface growth ; when this occurs it is a gray-
white, slightly raised growth extending but little around
the puncture opening. In agar at 37.50 C, a thin,
smooth edged surface growth occurs, extending not far
beyond the inoculation line. This is a bluish-white
by transmitted light, gray- white by reflected light. The
growth extends to the bottom of a puncture, and slightly
around the puncture opening. The growth is similar, but
slower at room temperature. On Wurtz litmus, lactose
agar, a good growth occurs, but with no change in the
color of the litmus, and without formation of gas. In
simple meat broth (one per cent, commercial peptone,
one- half per cent, salt, and meat infusion) the growth is
abundant, causing a diffuse turbidity of the medium with
a whitish ring around the edge at the surface of the broth,
with an abundant grayish-white viscid sediment. At
times the growth is more flocculent than at others. The
broth remains turbid after two months. With growth
for forty-eight hours at 37.5° C. in broth with one per
cent, peptone, and half per cent, salt, the indol reaction
is obtained by the addition of sulphuric acid without the
addition of nitrites.
In a bent tube containing broth with one quarter per
cent, peptone, one half per cent, salt, and two per cent,
glucose, the medium becomes turbid, but no gas is
formed, the growth occurring more abundantly in the
open than in the closed end of the tube. In broth with
o.r per cent, peptone, and 0.02 per cent, potassium ni-
trate, on addition of six drops of naphthalamine sulphate
and a few crystals of sodium anilate, it gives a pink color,
showing that it reduces the nitrates to nitrites. The
bacillus grows in milk without coagulation, but with' the
formation of an acid.
As a rule, I have not been able to obtain any visible
growth on potato, though a very slight invisible growth
was proven to exist. The one exception to this rule was
in the case of the rabbit with pleurisy without peritonitis.
This single exception may have been due to some differ-
ence in the composition of the potato itself, as potatoes
reacting 0.2 per cent., and 0.08 per cent, acid to phen-
olphtalein were used. A moderate growth was obtained
in an anaerobic hydrogen broth- tube.
To test the pathogenesis of the above germs, broth-
cultures, grown for forty eight hours at 37.50 C, were
used. Seven rabbits were given intra-peritoneal injec-
tions of r c.c. or 2 c.c. Two rabbits were injected with
germs obtained from the heart-blood culture, 2 c.c. be-
ing given to each. Both were found dead in thirty
hours. Two were injected with germs from the pleurisy
cultures, one of them with 2 c.c. and the other with 1
c.c. The former was found dead in thirty hours, and
the latter in thirty-six hours. Three were inoculated
with germs from the peritonitis cultures, the first with
2 c.c, the second with 2 c.c, and the third with 1 c.c.
The first animal was found dead in sixteen hours ; the
second rabbit remained alive ; the third remained alive
even after receiving, one week later, 2 c.c. more. The
inoculations were made late in the afternoon, and on the
following morning it was found that the animals had lost
their appetite, that they remained crouching in a corner,
and could not be made to run around, and that when
laid on their sides they regained their crouching posi-
tion with difficulty. When handled, they showed no
evidence of pain. Two had a decided diarrhoea. The
autopsies showed the animals emaciated \ the bellies
more or less distended ; the inguinal and axillary glands
enlarged and congested ; the subcutaneous vessels over
the abdominal wall filled with blood. Where the needle
had passed through the abdominal wall was an area of
purulent hemorrhagic oedema of considerable extent.
In two cases this was very large. It did not infiltrate
the abdominal wall itself to any great extent, but was
superficial in the subcutaneous tissue. On opening the
abdominal cavity, the intestines were seen to be adhe-
rent to the parieties, and glued together with purulent
fibrinous masses. Over the surface of the large intestine
were scattered petechial hemorrhagic spots, and large
and small hemorrhagic areas. The small intestine did
not, as a rule, show a hemorrhagic inflammation, though
in one case it was very marked, the Peyers patches
showing deeply infiltrated with blood, and the stomach
on its greater curvature, and extending over on to the
lesser curvatures, showing a great number of trans-
verse hemorrhagic striations. The omentum always
showed numerous hemorrhagic areas. The parietal
peritoneum was congested. The fluid exudate varied
from a slight increase of serous fluid to a large amount
of turbid, purulent fluid, or bloody exudate. The spleen
was invariably large and soft, and of a deep purple color.
The liver and kidneys were normal in appearance. The
lungs were sometimes normal in appearance, sometimes
deeply congested. In two cases the pericardial sac was
filled with turbid fluid. The thymus gland showed in
all cases numerous hemonhagic spots. The trachea and
bronchi showed marked submucous hemorrhagic infil-
tration, except in the rabbit dead in sixteen hours, in
which case they were normal. The spinal cord in the
three cases examined showed petechial hemorrhagic
spots on the membranes. The brain of these three ani-
mals did not show any abnoimal appearances.
The two animals which survived the inoculations were
killed after ten days, they having shown no loss of appe-
tite, or other symptoms. The one which had received
x c.c, and then a week later 2 cc intra-peiitoneally,
showed no lesions whatever. The other having received
2 cc, showed, at the seat of inoculation, a large subcu-
taneous abscess of yellowish white creamy pus. There
was no oedema, and but very slight inflammatory changes
around it. There were no other lesions. No cultures
were made of this abscess, but cover- glass preparations
gave the bipolar, stained, round-ended bacillus.
In the rabbits dying with peritonitis, cultures and
cover- glass smears were made in all cases from the ab-
dominal wall abscesses, peritonitic adhesions, spleen, left
kidney, liver, and heart's blood, and in the two cases
associated with pericarditis, from the pericardial exudate
also. The cultures and cover-glass smears thus obtained
showed pure cultures of the geim used for the inocula-
tions.
Similar outbreaks of septicaemia among rabbits are de-
scribed by Smith,1 and Eberth and Mandry.* The germ
so far described agrees very accurately with that isolated
by Smith, in morphological appearance, size, culture,
growth, and symptoms, and lesions induced in rabbits
inoculated with pure cultures.
The bacillus of spontaneous rabbit septicaemia de-
1 Smith : Journal of Comparative Medicine and Surgery, vol. viii.,
p. 24.
a Eberth and Mandry : Virchow's Archiv, Bd. 121 , p. 340.
796
MEDICAL RECORD.
[December 22, 1894
scribed by Eberth and Mandry, differs in its motility,
culture, peculiarities, and pathogenesis for rabbits, and is
a different, though closely related, micro-organism. The
germ I have isolated also agrees in morphology, culture
growth, and pathogenic peculiarities ior rabbits, with the
American swine plague bacillus described by Welch l in
1889. This germ appears to belong to the wide-spread
family of bacteria which contains the chicken cholera of
Pasteur, the rabbit septicaemia of Koch and Gaffky, the
Wildseuche of Hueppe, the Rinderseuche of Kitt, the
Schweineseuche of Schutz, the Buffelseuche of Oreste
and Armanni, and the American swine plague.
The comparative studies of Caneva8 and Bunzl-Fer-
dern 8 show the close relationship of the members of this
group, and these authors consider some of them as proba-
bly identical. Hueppe 4 also believes in this probable
identity, and classes these under one name, as the bacil-
lus septicaemia hemorrhagicae, from the form of septi-
caemia to which they give rise. Bunzl-Ferdern and
Caneva further classify as belonging to the same family,
but to another group, the bacillus of spontaneous rabbit
septicaemia of Eberth and Mandry, the French swine
plague at Marseilles, of Rietsch, Jobert and Martinaud,
and the ferret plague of Eberth and Schimmelbusch.
As soon as it was appreciated that a plague was de-
stroying the rabbits, all animals then in the animal house
were removed, and the house and cages thoroughly
washed out with a five per cent, carbolic acid solution.
After a few days the animals were returned to their
cages, and no further infection occurred.
Splenic Leukaemia.— Dr. W. P. Northrup reported a
typical case of splenic leukaemia. The patient was a man
thirty years of age, who had been sent to him by Dr.
Toms, of Bellport, L. I., who had made the diagnosis.
The man's work as an electrical engineer had exposed
him to very high temperature, and to a high voltage of
electricity. He had been in exceptionally good health
up to six weeks before admission, at which time the pres-
ent trouble was first noticed.
When first seen by the speaker his feet were greatly
swollen, his skin was bronzed, his nasal respiration was
greatly obstructed, and he was quite deaf. These symp-
toms were afterward decided to be due to adenoid
growths, and to enlargement of the tonsils. There were
numerous small nodules under the skin, and the parotid
gland was prominent and very sharply defined. The
cervical, supra* clavicular, axillary, and inguinal glands
were also distinctly enlarged. The spleen was enormous-
ly enlarged, extending eleven and three- quarter inches
below the free border of the ribs. The ratio of the white
blood-cells had been variously estimated by different ob-
servers as 1 to 3 and 1 to 4. They were largely mono-
nuclear cells, small lymphocytes. There were few multi-
nuclear cells. They were for the most part neutrophile ;
very few eosinophils His temperature ranged from
normal in the morning to 1020 F., in the evening for the
first week, and reached during the last five days of his
illness a maximum of 1030 F. The heart's action was
rapid, but the pulse was full and of very lax tension.
This was a very striking feature of the case. He also
suffered from a marked hard swelling of the gums— a
hemorrhagic gingivitis— very tender, with superficial ul-
cers. Night sweats were also quite severe. All that was
accomplished by treatment was an improvement in the
condition of the gums. Finally, he was taken with syn-
cope, followed by marked delirium, coma, and death.
When last estimated, the haemoglobin was between thirty
and thirty-five per cent.
The autopsy was made by Dr. George A. Turtle, who
found that the retro-peritoneal and mesenteric glands were
enlarged. The liver was of the nutmeg variety, and
weighed one hundred and one ounces, while the spleen,
which was simply hypertrophied, weighed seventy-three
J Welch : Johns Hopkins Bulletin, vol. i., December, 1889.
• Caneva : Centralbl. f. Bakterion und Parasitikenkunde, vol. ix., p.
557.
* Bunzl-Ferdern : Centralbl. f. BakL und Parasit. vol. ix.t p. 787.
4 Hueppe : Berliner Klin. Wochenscrift, 1886, Nos. 44, 45, 46
ounces. The thymus gland was enormously hypertrophied.
On section, it showed simple hyperplasia. There was no
evidence of internal hemorrhage in the various cavities,
as had been expected, but on the dura mater at the vor-
tex were limited areas which appeared to be either local-
ized pachymeningitis or lymphoid growths. There was
nothing to indicate any change in the marrow of the
bones. Specimens removed from the dura mater were
exhibited.
Dr. James Ewing said that he had counted the blood-
corpuscles in this case. At the first count there had
been 425,000 white and 880,000 red, and on the second
count, 430,000 white and 925,000 red blood-cells.
Dr. Northrup also presented some white gall-stones
which had been removed post-mortem from a gall-blad-
der. They were composed almost entirely of cholesterin.
A Frog with a Supernumerary Hind Leg was present-
ed by Dr. J. S. Ely. The condition, he said, was a rare
one, and had not been observed before at the college lab-
oratory, although many frogs were kept there. The ques-
tion arose — Was this frog an abnormal twin, or was this
simply a dichotomy of one of the lower extremities?
Bland Sutton says that all these dichotomies occur much
more frequently in the lower animals than in the human
subject, and he gives figures of both frog and toad show-
ing such a condition.
The speaker said that, as to whether this was a " para-
sitic monstrosity " or not, he would say that, although
the extra extremity seemed to be one extremity, there
was at the distal portion a suggestion of there being two
feet, there being six phalanges instead of five. When
first seen, the frog was alive, yet no motion in the super-
numerary limb had been observed, and no reflex move-
ments could be excited.
Lipomatosis of the Heart.— Dr. James Ewing pre-
sented the specimen. The heart had been taken from a
woman forty years of age, who had been received into
the Roosevelt Hospital in a dying condition, so that no
physical examination had been made. The heart showed
the thickness of the muscle at the tip of the left ventricle
to be less than one-sixteenth of a millimetre, and at the
thickest portion half an inch. The muscular wall of the
left auricle was almost invisible. The right side of the
heart was similarly affected. There was a very moderate
amount of interstitial myocarditis, and but little fatty
degeneration of the muscle. The other viscera showed
very advanced fatty degeneration. There was a phthisi-
cal process in the apex of one lung.
Thrombosis of the Auricle of the Heart.— The speci-
men was presented by Dr. George P. Biggs.
A laborer, thirty-nine years of age, was brought to the
New York Hospital in an almost moribund condition, and
consequently there was no clinical history. Some fluid
was drawn off from the chest to relieve the urgent symp-
toms. At the autopsy, there was no subcutaneous
oedema found. The peritoneal cavity was normal.
Each pleural cavity contained about 500 c.c. of serous
fluid, and the pericardium 250 c.c. of similar fluid. The
heart was very greatly enlarged, and the cavities distend-
ed with blood to their fullest extent. This blood was
almost entirely in the form of post-mortem clots. The
distention of the cavities was greatest in the left auricle,
the clot being fully as large as a man's fist. The dilata-
tion markedly predominated over the hypertrophy.
There was an unusually large appendage4 to the left
auricle, and in this, and extending into the auricle, was a
thrombus measuring 10 ctm. transversely, 4 ctm. verti-
cally, and 2% to 3j£ ctm. antcro-posteriorly. It was
perfectly solid throughout, and distinctly stratified.
The organ was enormously dilated, yet notwithstanding
this the walls were considerably thickened. The mitral
orifice was extremely narrow and the cusps were adher-
ent, so that the orifice had been converted into a narrow
slit, having extremely rigid walls. The left ventricle
was very greatly dilated. The cusps of the aortic valve
were thickened, and slightly retracted. The dilatation
on the right side of the heart was marked, but not so ex-
December 22, 1894]
MEDICAL RECORD.
797
treme as on the other side. The tricuspid orifice was so
much relaxed that four fingers could be easily passed
through it. There was also a largfe infarction occupying
nearly one-half of one of the kidneys.
Stenosis of the Tricuspid Orifice.— Dr. Biggs then
presented a specimen showing stenosis of the tricuspid
orifice. In this heart the tricuspid orifice was narrowed
so as to admit only two fingers with difficulty. It was
removed from a woman aged twenty-seven, who had
been in good health up to three years previously, at which
time she had had an attack of acute articular rheumatism.
She had recovered from this, but a few weeks before
coming to the hospital had suffered a second attack. At
the time of admission, the temperature was elevated;
the heart was displaced; there were said to be double
systolic murmurs present — one at the apex, and one at
the base ; there was slight pulsation in the veins of the
neck. The urine showed only a trace of albumin at
first, but later on the albumin reached as high as sixty
per cent. She developed marked anasarca, and finally
died with symptoms of ursemic poisoning. The chief
features of the autopsy were the lesions in the heart, and
an advanced chronic diffuse nephritis. The mitral, aor-
tic, and tricuspid valves showed lesions of a similar char-
acter, consisting of some thickening, and of a number of
small vegetations on the free border. The mitral valve
admitted only one finger; the narrowing at the aortic
and tricuspid orifices was not great. There were small
thrombi in both auricular appendages in this case, and
also behind the tricuspid valve. There were numerous
infarctions in both lungs. The great point of interest
was the appreciable narrowing of the tricuspid orifice.
Miliary Tuberculosis of the Liver. — Dr. Biggs pre-
sented still another specimen. It had been removed
from a case of tuberculosis which had run a rather rapid
course, with marked hectic symptoms and hoarseness.
At the autopsy the larynx was found to be considerably
ulcerated, and the lungs showed tuberculosis chiefly in
the form of a large area of cheesy pneumonia, extending
down one bronchus, and involving nearly two-thirds of
the lower lobe. There were old lesions — small cavities
and pigmented fibrous cicatrices — in both apices. The
chief point of interest was the liver, which was very close-
ly studded with small tubercles — a very diffuse miliary
tuberculosis of the liver without similar lesions in the
other organs visible to the naked eye.
The speaker said he had only seen this condition once
before, and then in a case of tuberculosis presenting no
unusual clinical features. &.. zsz;
Dr. J. S. Ely said he had seen a large number of tu-
bercles in the liver in guinea-pigs which had been inocu-
lated with tubercle bacilli in the abdominal cavity. Of
course, there was also a peritonitis under those circum-
stances. This had suggested to him that in the case un-
der discussion the infection had gone to the liver by the
portal circulation, and in that way had been filtered
largely out of the blood.
What is the Status of the Ophthalmic Colleges ?— In
Chicago are two institutions, the so-called ophthalmic
colleges, which manufacture oculists and opticians ad
nauseam. In either case, a course lasting six weeks suf-
fices to lead to a diploma. This diploma is not a degree
in medicine, in midwifery, in dentistry, or in veterinary
science. It is sui generis and has no standing in law.
If its possessor has been a registered physician who has
complied with the medical practice act of the State in
which he lives, he has a legal standing ; but his diploma
from the ophthalmic college does not of itself entitle him
to practise. Dozens of graduates from these institutions
are engaged in medical practice either as " opticians " or
as "oculists." Under the circumstances we wish to
know: What is the status of the ophthalmic colleges?
Will the Illinois State Board of Medical Examiners please
answer? — Medical Fortnightly.
NEW YORK ACADEMY OF MEDICINE.
SECTION ON OBSTETRICS AND GYNECOLOGY.
Stated Meeting, November 22, 1894
Malcolm McLean, M.D., Chairman.
Axis-Traction Forceps. — Dr. T. J. McGillicuddy ex-
hibited an axis-traction forceps which he had devised
in 1889, after a visit to Paris, where he learned that, be-
cause of certain objectionable features, the Tarnier for-
ceps had been discarded, even by Tarnier himself. His
instrument consisted of an ordinary Simpson forceps
with the additional feature of short folding handles pro-
jecting backward at a right angle from the others. These
shorter handles exerted traction in the axis of the brim.
On folding them, the instrument could be used as the
ordinary obstetric forceps. In an experience of over
one hundred cases they had proven very satisfactory.
The advantages claimed by Dr. McGillicuddy for this
instrument were: 1. That with its use axis traction is
simple and uncomplicated. 2. That it is superior to
Tarnier's, in the fact that while using it axis-traction at
the superior strait is perfect. 3. That while in relation
to Tarnier's instrument, a great deal has been said of
the indicator, in this forceps the indicator is in the
hands of the operator, and tells his conscience musculaire
the direction of traction as well as the resistance. 4.
That it does away with the trouble of Pajot's, Smith's or
other methods, and in its use one has plenty of power
and perfect control. 5. That it is easier to make rota-
tion in the posterior positions with the adjunct handles,
if it is thought best to use the forceps for that purpose.
6. That it is easy of application, and in its dual character
it has all the advantages of axis-traction and the ordinary
forceps, and saves the expense of buying two instruments
where one will do.
The Tarnier instrument is complicated, cumbersome,
and expensive, nullifying its good points — if it has any —
and has been condemned by the Paris Obstetrical and
Gynecological Society for these reasons. Its theory
may be very pretty and interesting for those who have
not had much experience in forceps delivery, but prac-
tically it is a useless and harmful instrument. No
woman should be delivered except by axis- traction, and
with these axis-traction handles you can determine the
exact amount of resistance and the proper amount of
force to employ, and readily and easily use it.
Dr. Leischman, in writing of the long forceps and
high operation, says : " It is now very generally be-
lieved by those who have had the greatest experience,
that a large proportion of the unfortunate results depend
upon improper instruments, and especially upon the use
of such as are deficient in power." The observations
which on this point we have already quoted from Dr.
Barnes, apply here with peculiar force. Power and con-
trol are co-relative factors toward the attainment of the
result which we desire, and if there is a deficiency in the
former, we can have but little confidence in the issue of
the case.
With this forceps we pull directly in the axis of the
brim. One cannot grasp the handles of the ordinary
forceps with comfort with both hands and still make any
great axis- traction. Most physicians say that the hands
become cramped and lose all their muscular power after
pulling for a short time.
In cases attended with some difficulty, who has not
seen physicians with their feet placed against the side of
the bed or the buttocks of the patient, hanging on to the
handles of the forceps and pulling away with all their
strength, while bathed in a profuse perspiration. These
violent exertions are entirely wrong and unnecessary, as
the arms alone should be used, and the body placed in a
position where the traction can be easily arrested if there
is any slipping of the blades. It is the improper use of
the wrong kind of forceps that makes it such fatiguing
and dangerous work.
798
MEDICAL RECORD.
[December 22, 1894
Dr. E. A. Tucker said that axis traction meant noth-
ing more than palling in the axis of the parturient canal,
and without it he could not understand how delivery could
be effected. He believed that he could get as good axis-
traction without complicated mechanism as with. He
had used the Tarnier instrument many times, but had
since utterly discarded it, and his feelings were about
the same with regard to all such instruments. The
obstetrician was apt to trust too much to the instrument,
and not to his own sense of the proper direction in which
to pull. One should be able to deliver with traction
exerted by one hand, if at all. The mistake was com-
monly made of hurrying things after applying the for-
ceps, instead of giving the head time to mould. He had
given even as long as fifty minutes after applying the
forceps, thirty of which were consumed in moulding the
head before any advance was made.
Dr. Marx thought well of axis-traction instruments,
which he believed were being used more instead of less
in this country.
Dr. Collyer and others also made some remarks.
Chloroform Bottle. — Dr. £. A. Tucker exhibited a
chloroform bottle which he had found in use among
firms who handled acids, the glass stopper being so
formed as to permit of escape of the fluid by drops or in
a stream, as might be desired. He said it was cheaper
and better than the bottle he had devised and shown to
the Section some months ago.
Nymphfebulation. — Dr. Herman L. Collyer ex-
hibited photographs of a case of nymphfebulation, or
locking of the nymphae, practised on the young woman
by her husband during his periods of absence. She had
come from Germany, was twenty-eight years of age, had
been married ten years. She had known her husband
before marriage in the oM country, and when she came
to meet him here he resorted to this method of keeping
her out of mischief while he was away. He first perfo-
rated the labia minora, and after the pain and swelling
had diminished he introduced a small padlock, which he
would remove on his return. He had practised this
five years. Dr. Collyer said he had known of cases
where buckles had been fastened over the labia, but this
was the only one known to him of perforating and lock-
ing them together.
Entanglements and Shortening of the Umbilical Oord.
— Dr. T. J. McGillicuddy read the paper. Probably
in twenty-five per cent, of all labors the cord was either
around the neck or in some other abnormal position
which it assumed during the movements of the foetus.
It might cut off the blood- supply and thus cause death of
the foetus ; where the cord was unusually long it might be
found wrapped two or more times around the neck, or
arotmd the neck, shoulders, and body. The author re-
lated two cases of death in the early months from con-
striction of the cord, in one the cord being found wound
around the neck three times, in the other encircling the
shoulder and body as well. A third pregnancy had gone
to about term before the strangulation had taken place,
due to the cord drawn tightly around the neck once. In
the fourth case the woman had been in labor thirty-four
hours. On extracting the child it was found in a state
of decomposition, the cord around the neck and shoulder.
A fifth case of death of the foetus was related, then a sixth
case in which the shortening of the cord produced by
being wound around the neck, had resulted in acute in-
version of the uterus fourteen hours before he saw the
patient. Some other cases were referred to in literature,
and then attention was called to the medico -legal interest
of such cases, for the mother might be charged with
strangling her newly-born, when in reality the strangula-
tion had taken place in utero from winding of the cord
about the neck. He also thought it was a cause of hem-
orrhage by traction on the cord thus shortened. He had
seen an infant with the cord wound four times around its
neck. In every labor he felt for it as a possible com-
plication. Excessive pulling upon the cord sometimes
caused flexion of the head upon the sternum and pre-
vented the occiput from presenting. The abnormal posi-
tion of the cord also favored exhaustion of the mother
from delayed delivery.' Labor was easier in the sitting
or squatting posture, and it tended to relieve the cord to
a certain extent.
A Pathetic Case. — Dr. A. Palmer Dudley had seen
a few cases in which the cord was wound around the neck
of the child one or twice. In one the woman had been
infected by syphilis from her husband, had had several
abortions in consequence before he saw her and dis-
covered the syphilitic history and gave iodide of potassium.
He succeeded in carrying her along to near term, when
one night she was suddenly awakened by a rat gnawing
at her face. In her fright she jumped completely over in
bed, and from that time ceased to feel foetal movements.
Dr. Dudley instituted labor, but the child was born dead,
having the cord wrapped twice around its neck, where it
had left a blue line. They feared for the mother's reason,
and she died suddenly some days later, exact cause un-
known.
Spontaneous Rupture of the Oord. — Dr. Simon Marx
said there were only two cases of spontaneous rupture of
the cord known to him. One, mentioned by Dr.
McGillicuddy, having come under his own observation,
and undoubtedly due to the presence of a gumma in the
cord. The woman was syphilitic. Entanglement of the
cord was quite common. If around the neck at labor, the
propriety of tearing or cutting it and extracting rapidly
arose ; otherwise strangulation might occur from tension.
Dr. E. A. Tucker thought the diagnosis of shorten-
ing of the cord or threatened strangulation could be
made by careful study of the case. Umbilical souffle,
rapid beating of the foetal heart, and tumultuous move-
ments were an aid. Where possible, he slipped the cord
over the head when wound around the neck, but foiling
in this, he extracted quickly, and had not lost a child.
The Chairman spoke of interference with natural ro-
tation where the cord was wound around the neck or
shoulders. In this way many cases of obstinate posterior
positions could be accounted for. The remedy was to
unwind the child in the opposite direction, turning it
completely around.
Surgical Treatment of Anteflexion of the Uterus.—
Dr. Charles Bell White read the paper. A sharp
bend in the axis of the uterus, which could not be
straightened by the finger or by bimanual palpation,
was accompanied in some cases by retroposition, in
others by descent of the uterus. In both forms the cer-
vix was apt to be elongated and the case likely to be
mistaken for ordinary retroversion. He thought the
condition began with menstruation, the heavy uterus,
lacking in tone and support, becoming bent forward and
gradually becoming fixed in that position. Dysmenor-
rhoea was attributed to interference with circulation, not
to obstruction of the outflow from the uterus. The or-
dinary forms of surgical treatment comprised divulsion,
curettement, amputation of the cervix, salpingo oopho-
rectomy. He did not know that anyone had advocated
lifting the uterus and fixing it in the new position. He
had so treated one case. The girl had suffered greatly,
and as other means had failed, he resorted to laparotomy,
expecting to find the utero-sacral ligaments taut and the
cause of the retroposition of the anteflexed uterus, but
was surprised to find them relaxed. Lifting the uterus,
he noticed that it straightened the bend, and therefore
he fastened the fundus to the anterior wall. The result
had been complete relief. Alexander's operation of
shortening the round ligaments would not lift the uterus
and straighten it. He would advise anterior fixation
only in severe cases.
Dr. W. E. Porter would treat anteflexion and the
dysmenorrhoea accompanying it by such measures as di-
vulsion, Wylie's stem drain, tampon, boro glyceride.
Dr. Collyer did not think so severe an operation as
laparotomy justifiable ; that cases could be relieved by
other measures. He would not introduce a stem, but
would rely upon gauze for drainage.
December 22, 1894]
MEDICAL RECORD.
799
Dr. Jarman had seen the case reported by Dr. White,
and approved of the treatment where other measures
failed to give relief from severe symptoms. Ventral fix-
ation was preferable to taking a reef in the round liga-
ments within the abdomen, as suggested in the remarks
of Dr. Porter, for the reason that these ligaments might
stretch sufficiently to let a knuckle of gut fall between
the uterus and abdominal walls, and become strangulated.
Dr. A. P. Dudley explained the dysmenorrhea on
the basis of interrupted circulation, which also was a cau-
sative factor of the original condition. The difficulty
with Dr. White's operation was to obtain consent to its
performance from the patient.
Dr. White closed the discussion.
OUR LONDON LETTER.
(From our Special Correspondent)
MBDICO-CHIRURGICAL SOCIETY — ACTINOMYCOSIS — PATHO-
LOGICAL SOCIETY — MALIGNANT DISEASE OF LARYNX —
ACUTE SEPTIC EPIPHYSITIS — MALIGNANT DISEASE OF
GROIN AND SECONDARY DEPOSITS — EPITHELIOMATOUS
CYSTS — WOLFFIAN ADENOMA OF KIDNEY.
London, November 28, 1894.
The Societies are making heavy demands on our time
and attention just now, though it often happens that
some of the most interesting are ill-adapted for a brief
report.
At the last meeting of the Medico- Chirurgical there
was a discussion on actinomycosis, which interested es
pecially the dermatologists but which cannot be profit-
ably reduced to a paragraph, and the paper on which it
was founded was hardly worth summarizing.
At the Pathological Society there was an interesting
exhibition of a number of specimens, and the reports of
the cases gave rise to some valuable remarks. Thus Mr.
Stephen Paget showed one of malignant disease of the
larynx of a man aged sixty-four. A question arose as to
whether it could be a sarcoma or carcinoma, and it was
referred to the Committee on Morbid Growths.
Mr. Stephen Paget also showed a specimen of acute
septic epiphysitis from a boy aged thirteen. A member
questioned the correctness of the name, and suggested it
was a case of acute pyaemia from the first, the wound
being probably inoculated with a streptococcus.
Mr. C. A. Morton showed a malignant growth in the
glands of the groin following the subsidence of a painful
enlargement of the glands, with secondary growths in
the skin at a distance from the primary tumor. The
glands of both groins were enlarged and very painful,
and then, on the subsidence of this condition, malignant
growth appeared in those of one side. The patient was
a man, aged forty- one. Many months later a similar
growth appeared in the glands of the other groin, and
secondary growths in the skin and subcutaneous tissue of
the abdominal wall, and in the lungs. The spleen was
not affected. There was no source of primary infec-
tion. The histology of the growth was that of sarcoma
rather than lymphadenoma ; but the clinical history
suggested that the disease was not simply primary sar-
coma of the glands.
Mr. Bowlby showed an epitheliomatous cyst of the
neck from a man, aged fifty-eight ; the tumor had been
noticed about two months before death. A similar speci-
men was shown by Mr. F. C. Wallis. The patient was
sixty years of age, and noticed the swelling six weeks be-
fore he went to the hospital, in January last, when the
swelling was the size of an orange. The growth event-
ually fungated, and the man died. A section showed
typical squamous-ceiled carcinoma.
Mr. Bland Sutton said these cases were of great clin-
ical importance on account of the rapidity with which
they proved fatal. They had been described by German
writers as " branchiogenous carcinoma/' and by Eng-
lish pathologists as " malignant cysts." If these tumors
arose in the bronchial clefts they would probably appear
in infancy or youth, and not after midlife. He regard-
ed the cervical lesion as secondary, the primary lesion
being some small neoplasm hidden away, perhaps in a
pharyngeal recess, and easily overlooked. One he had
seen had this origin.
Mr. Shattock doubted if the epithelioma in a bron-
chial cyst was usually squamous. He had recently in-
vestigated a case and found that the epithelium was co-
lumnar and ciliated.
Mr. Shattock also exhibited microscopic sections of
large adenoma of the kidney of a child, and discussed
the reasons for thinking that such growths arose in the
Wolffian body ; he did not himself see that any proof
had yet been adduced.
"ORIGIN OF THE TERM ANESTHETIC."
To tub Editor or tub Mkncal Record.
Sir : I notice, in your issue of December 8th, an ac-
count of a conversation upon this point, between Mr.
Edgar Willett and Dr. Oliver Wendell Holmes, when
the latter was in England, in 1886.
It is quite possible that Dr. Holmes had forgotten that
he had written to Dr. Morton a letter elaborately anal-
yzing the varied appropriateness of several names, and I
take pleasure in sending to you from among my father's
correspondence a copy of Dr. Holmes's original letter,
exactly corroborative of the conversation above referred
to. Dr. Holmes's letter reads as follows :
" Boston, November 21 , 1846.
" My Dear Sir : Everybody wants to have a hand in
a great discovery. All I want to do is to give you a
hint or two, as to names, or the name, to be applied to
the state produced and the agent.
"The state should, I think, be called 'anaesthesia.'
This signifies insensibility, more particularly (as used by
Linnaeus and Cullen) to objects of touch (see ' Good-
Nosology,' p. 259). The adjective will be * anaesthetic.'
" Thus we might say the state of anaesthesia, or the
anaesthetic state. The means employed would be prop-
erly called the anti- aesthetic agent. Perhaps it might be
allowable to say anaesthetic agent, but this admits of
question.
" The words anti-neuric, aneuric, neuro leptic, neuro-
lepsia, neuro etasis, etc., seem to be anatomical ; whereas
the change is a physiological one. I throw them out for
consideration.
" I would have a name pretty soon, and consult some
accomplished scholar, such as President Everett or Dr.
Bigelow, Sr., before fixing upon the terms, which will be
repeated by the tongues of every civilized race of mankind.
" You could mention these words which I suggest for
their consideration ; but there may be others more ap-
propriate and agreeable. Yours respectfully,
" O. W. Holmes.
" Dr. Morton."
When the young child now known as anaesthesia had
been born into the world by the public demonstration of
a painless capital operation at the Massachusetts General
Hospital, October 16, 1849, it: h*d no name, and none
could be immediately found for it, since the language
of the day had not as yet been called upon to express
the act or the state produced by the act. It was neces-
sary to christen it. Accordingly, a meeting was held at
the house of Dr. A. A. Gould, at which were present
Dr. Henry J. Bigelow, Dr. O. W. Holmes, and Dr.
Morton, and Dr. Gould read aloud a list of names which
he had prepared. On hearing the word "Letheon,"
Dr. Morton exclaimed, " That is the name the discov-
ery shall be christened." Dr. Gould and the others also
favored this name, derived from the mythological river
8oo
MEDICAL RECORD.
[December 22, 1894
Lethe. But after a subsequent consultation with Dr.
Holmes and a consideration of the terms suggested by
him in the above letter, Dr. Morton adopted the terms
anaesthesia, anaesthetics, and " etherization," the terms
now in common use.
While upon this subject it may interest your readers to
read another letter of Dr. Holmes's, written forty seven
years later on — in fact, only a few months before his
death — wherein no failure of his vigor or felicity of ex-
pression is wanting. This letter, now in the possession
of the writer, has been published only in part, in the
August number of the Century Magazine of the present
year, in an article entitled " Dr. Morton's Discovery of
Anaesthesia." It reads as follows :
" Boston, April 2, 1893.
" My Dear Sir : Few persons have or had better rea-
son than myself to assert the claim of Dr. Morton to the
introduction of artificial anaesthesia into surgical prac-
tice. The discovery was formally introduced to the
scientific world in a paper read before the American
Academy of Arts and Sciences by Dr. Henry J. Bigelow,
one of the first, if not the first, of American surgeons.
" On the evening before the reading of the paper con-
taining the announcement of the discovery, Dr. Bigelow
called at my office to read the paper to me. He pref-
aced it with a few words which could never be forgotten.
" He told me that a great discovery had been made,
and its genuineness demonstrated at the Massachusetts
General Hospital, of which he was one of the surgeons.
This was the production of insensibility to pain during
surgical operations by the inhalation of a certain vapor
(the same afterward shown to be that of sulphuric ether).
In a very short time, he said, this discovery would be all
over Europe. He had taken a great interest in the al-
leged discovery, had been present at the first capital
operation performed under its influence, and was from
the first the adviser and supporter of Dr. W. T. G. Mor-
ton, who had induced the surgeons of the hospital to
make trial of the means by which he proposed to work
this new miracle. The discovery went all over the world
like a conflagration.
" The only question was whether Morton got advice
from Dr. Charles T. Jackson, the chemist, which entitled
that gentleman to a share, greater or less, in the merit
of the discovery.
" Later it was questioned whether he did not owe his
first hint to Dr. Horace Wells, of Hartford, which need
not be disputed. Both these gentlemen deserve ' hon-
orable mention ' in connection with the discovery, but
I have never a moment hesitated in awarding the essen-
tial credit of the great achievement to Dr. Morton. This
priceless gift to humanity went forth from the operating
theatre of the Massachusetts General Hospital, and the
man to whom the world owes it is Dr. William Thomas
Green Morton.
" Experiments have been made with other substances
besides sulphuric ether, for the production of anaesthesia.
Among them, by far the most important, is chloroform,
the use of which was introduced by Sir James Y. Simp-
son. For this and for the employment of anaesthetics in
midwifery he should have all due credit, but his attempt
to appropriate the glory of making the great and immor-
tal discovery, as revealed in his contribution to the eighth
edition of the ' Encyclopaedia Britannica,' is unworthy
of a man of his highly respectable position. In the
ninth edition of the same work his article ' Chloroform '
is omitted and a fair enough account of the discovery is
given under the title ' Anaesthesia.1
" Yours very truly, O. W. Holmes."
I am, yours very truly,
William J. Morton.
New Yore City, December 9, 1894.
LOCALIZATION OF VISUAL CEREBRAL
CENTRE.
TO THB RDITOK OP THE MSDICAL RbCORD.
Sir : In the Medical Record for December 1st, there
appears an article entitled " A Contribution to the Study
of the Location and Physiology of the Visual Cerebral
Centre/' which is so misleading in its conclusions, that
it seems justifiable to call your attention and that of your
readers to its errors. Since the appearance of Nothna-
gel's classical work on Cerebral Localization, it has been
agreed that the only facts upon which reliance can be
placed in determining the location of function in the
brain are to be derived from cases of small lesion of long
standing with accurate autopsy.
The entire tendency of recent investigation upon the
visual area of the brain, as shown in Henschen's great
works, "PathoiogiedesGehirns" (1893) and Vialet,"Les
Centres C6r6braux de la Vision" (1893), and Noyes,
"Diseases of the Eye" (1894), is to prove that the pri-
mary cortical visual centres lie about the calcarine fissure
in the occipital lobe, that the angular gyrus has nothing
whatever to do with vision, and that there is no lesion
behind the optic chiasm, either in thalamus or visual
radiation or cortex anywhere which will produce a blind-
ness in one eye alone. All lesions posterior to the chi-
asm produce homonymous hemianopsia. The entire
consensus of opinion is opposed to the view first advanced
by Ferrier and the English school, that blindness in
one eye can be produced by a cortical lesion, and the
only case with autopsy, cited by Gowers, is unsatisfac-
tory and inconclusive, because of an imperfect clinical
examination of the visual field.
In the article which I beg leave to criticise, the author
has failed to recognize this consensus of opinion, citing
only the English case. He reports a case without au-
topsy, which is manifestly inconclusive, and which an
ordinary observer would easily recognize as a case of
hysterical blindness, regarding the nature of which theo-
ries abound but knowledge is wanting; the recovery
alone being sufficient to prove that no serious localizable
cerebral lesion was present.
Fearing that the readers of your journal might be mis
led by this article, I have taken the liberty to point out
its fallacies.
Yours very respectfully,
M. Allen Starr.
■a West Fokty-kighth Stukt, December 4, 1894*
Female Apotheoariei. — Paris has only one apothecary
shop controlled by a woman, while Brussels has five.
London had 1,340 female apothecariesvin 1891.
A Fight for a Tooth. — A peculiar case occurred lately
in Gera, and has not yet been definitely decided. A
gentleman who had suffered for some time from tooth-
ache consulted a dentist, and on his advice consented to
have the offending molar extracted. This was skilfully
effected, not without some trouble, for the tooth proved
to be a perfect monster in size, with roots measuring as
much as two centimetres. The dentist was naturally
desirous of preserving such a trophy, and, although the
patient claimed the tooth as his property, refused to part
with it. An action was accordingly commenced on the
charge of defraudation, the defendant claiming he acted
by the right of a time-honored custom, and that the
tooth on being removed was a res nultius, and belonged
to the first who took possession. I am afraid this will
prove quite a difficult quibble to settle. — Berlin Corre-
spondent Occidental Medico/ limes.
A Thirty-Pound Kan. — Abner Astrop, a dwarf, died
recently at his home in Johnson County, Ky., at the age
of fifty-two years. His weight was but thirty pounds,
and he was two inches less than three feet tall. His
parents established him in a small cross- roads store when
he was twenty years of age, and he spent his life in it,
refusing to exhibit himself in museums.
Medical Record
A Weekly Journal of Medicine and Surgery
Vol. 46, No. 26:
Whole No. 1260.
New York, December 29, 1894.
$5.00 Per Annum.
Single Copies, zoc.
<&rijjitral &vtitlzs.
IS IT THE BEGINNING OF THE END?
By JAMES WEIR, Jr., M.D.,
OWCNSBORO', KV.
When we come to examine the history of the world we
find evidence that certain nations have, at times, reached
a high state of prosperity, and have then degenerated to
such a degree that they have either passed entirely out
of existence, or have lapsed into a state of semi barbarity.
This has generally been brought about by conquest,
but the races conquered had first become enfeebled
by their habitudes of thought and manner of living. It
is a well-established fact that luxury brings debauchery,
and that debauchery occasions degeneration. All na
tions that have, heretofore, reached the zenith of their
prosperity, have been engulfed, at some time or other,
in the maelstrom of luxurious habits, and have fallen
under the lethal influence of a degeneration occasioned
solely by debauchery; for the luxury and debauchery
of one class brought increased poverty on, as well as
excess in, other classes, and poverty and excess are prom-
inent factors in the production of degeneration, as we
shall see further on in this paper. Says the brilliant
author of " Psychopathia Sexualis," Krafft-Ebing :
" Periods of moral decadence in the life of a people are
always contemporaneous with times of effeminacy, sen-
suality, and luxury. These conditions can only be con-
ceived as occurring with increased demands upon the
nervous system, which must meet these requirements.
As a result of increase of nervousness, there is increase
of sensuality, and, since this leads to excesses among the
masses, it undermines the foundations of society — the
morality and purity of family life. When this is de-
stroyed by excesses, unfaithfulness, and luxury, then the
destruction of the state is inevitably compassed in mate-
rial, moral, and political ruin."
Such was the condition of the Latin race when the
fierce and hardy Vandals overran the Roman peninsula ;
such was the condition of the Assyrians when Babylon
fell beneath the onslaughts of the great Macedonian;
such was the condition of the Egyptians when the north-
ern myriads swept down upon the fertile valley of the
Nile and destroyed forever the once powerful and all con-
quering kingdom of the Pharaohs ; and such, too, was
the condition of the French nation in 1794, when An-
archy unfurled its red banner at the head of the most
gigantic social revolution the world has ever known. At
the present time, community of interests, as well as
higher civilization, would utterly forbid the total subju-
gation of one civilized nation by another, such as oc-
curred in the olden times ; hence no nation need fear
annihilation from such a source. The danger comes from
another point and consists in the almost certain uprising,
at some time in the future, of degenerate individuals in
open warfare and rebellion against society.
The question whether the world is growing better or
worse is often debated, and can be answered affirmatively
on both sides. Better, because superstition, bigotry, and
dogmatism have given way, to a great extent, to the toler-
ance and freedom of higher civilization and purer ethics
in normal, healthy man ; worse, because crime (and I
mean by crime all antisocial acts) has greatly increased
on account of the pernicious influence of degeneration.
That superstition, bigotry, and dogmatism are on the
wane, and that they will, sooner or later, be entombed
in that depository of obsolete savage mental habitudes —
absolute and utter oblivion — a glance at the success that
science has achieved in the warfare waged against it by
the Church, will at once declare. (Throughout this
article I use the word Church to express priests of any
and every denomination, whether Jew, Gentile, or Pa gar,
Protestant or Catholic.) A short incursion into this
subject, i.e., the Church's warfare on science, is absolutely
necessary, for the triumph of science over its enemies
— superstition, bigotry, and dogmatism, coincidently,
ignorance and illiterateness — shows that the civilized
world, at the present time, is markedly different in some
respects from the world of ancient, mediaeval, and even
comparatively recent times; and, in summing up, this
changed condition will be a weighty factor in making up
an answer to the question which heads this paper.
When Olympus first faded away from the enlightened
eyesight of the Greeks, and changed into space be-
sprinkled with stars ; when Zeus no longer held his di-
vine court on its mystic summit ; when oracles became
mute and the fabled wonders of the * ' Odyssey ' ' either van-
ished or resolved themselves into prosaic commonplaces
under the investigations of the sceptic or the accidental
discoverer, the Church made a most strenuous protest
against the destruction of its traditions. Some of these
early seekers after truth were killed and their goods con-
fiscated. The Church issued its edict against heresy
(and any doctrine that taught a belief antagonistic to the
accepted tenets of pagan mythology and theogony was
heresy), and hurled its anathemas against the heretic.
Olympus, in the eyes of the Church, still existed, and
Zeus, the man-god, still quaffed the sacred ambrosia in
its shady groves. The Sirens still sang their entrancing
songs, whale Scylla and Chaqbdis were ever stretching
out eager arms toward unwary mariners. Gigantic one-
eyed Cyclops, with Polyphemus as their leader, still
patrolled the shores of Sicily and kept their " ever-watch-
ful eyes " turned toward the open sea. The hardy Greek
sailor landed on the Cyclopean island, and discovered
that Polyphemus, and Arges, and Brontes, and Steropes,
and all the other one eyed monsters were nothing but
sea-wrack, bowlders, and weeds. He sailed farther, past
Scylla and Charybdis, and discovered no greater dangeis
than sharp rocks and whirlpools. Yet farther he sailed
out into the mysterious sea, and the only Siren's song he
heard was the whistling of the wind through the cord-
age of his vessel. In vain the Church thundered against
the daring investigator. Neither fiie, nor sword, nor
imprisonment, nor death itself, could check the march of
truth. Mythology and pagan theogony had received
their death-blows ; superstition, bigotry, and dogmatism
were elbowed aside and gave place to dawning science.
The Church held that that which had been believed by
pious men for untold ages must necessarily be true.
Science, in the garb of philosophy, with cold, dispas-
sionate criticism proved that these hitherto accepted
truths were arrant fallacies. The poets and writers then
took up the subject, and finally the people fell into line,
so superstitious, bigoted, dogmatic mythology died, in-
tellectuality took its place, and higher civilization took a
step forward.
With every new discovery, with every victoiy o\er
superstition, bigotry, and dogmatism, civilization took a
802
MEDICAL RECORD.
[December 29, 1894
step upward until it stands to day as far above the civi-
lization of those old days as do the giant stems of the
mighty red-woods above the chaparal and undergrowth
of the California forests. In its battle with superstition
civilization has grown strong, hardy, and, above all,
vigilant. This last quality it will need most of all in its
coming battle with the combined hosts of antisocial
degenerates. In its battle against the Church civilization
has gained the right to think for itself. It has de-
manded, and is now receiving, to some extent, the right
of education, of erudition ; and education is, and will
be, a most potent warrior against degeneration.
That a luxurious manner of living eventually leads to
debauchery, and that debauchery is a prime factor in
creating degeneration, no physiologist of the present day
will for one instant deny. I wish to show, in this paper,
that luxury is hurrying us toward a social cataclysm, be-
side which the downfall of the Roman Empire, the de-
struction of ancient Egyptian and Babylonian civiliza-
tions, and the bloody days of the French Revolution, will
sink into utter insignificance.
A brief r/sum/ of certain historical epochs will be nec-
essary in order to furnish a parallel from which I wish to
draw several indisputable and incontrovertible conclu-
sions.
The Roman people, under the leadership of its ancient
heroes, was a nation of hardy warriors and husbandmen.
That pre-eminent military genius, Julius Caesar, had
carefully fostered this warlike spirit in the bosoms of his
compatriots, and by a series of brilliant campaigns had
made the Roman nation the most powerful on the face
of the globe. The Roman legions were not only vic-
torious on land, extending their conquests into Iberia,
farther Gaul, and still farther Britain, but the Roman
triremes also swept the Mediterranean, from the Pillars
of Hercules to the shores of Syria and Egypt. Wealth
poured into the country from all sides and the people
revelled in a boundless prosperity. Luxury had already
begun to enervate the hardy soldiery at the time of Cae-
sar's assassination, yet not enough to show degeneration
and demoralization. The empire under the first emperors
steadily grew richer and more powerful, and the luxury
of the rich more unlimited and licentious. At length a
change can be noticed. The Roman legions, hitherto
victorious over every foe, are now frequently vanquished;,,
conquered tribes uprear the standard of revolt and refuse
to pay tribute ; the territorial boundaries of the empire
materially shrink, and its once- conquered provinces pass
out of its dominion forever. The gradual degeneration
of this nation is faithfully mirrored in the characters of
the emperors who governed it. Nero, Caligula, Tiberius,
Caracaila, and Messalina, the depraved wife of Claudius
and daughter of Domitia Lepida, herself a licentious and
libidinous woman, were but accentuated types of the lux-
urious and debauched nobility. Not only did the no-
bility become victims of degeneration, but the poorer
classes also lost their virility, until at last we find the
stability of the nation preserved through the instrumen-
tality of foreign mercenaries. The greatness of this once
wide-spread empire dwindled away, the freedom of its
institutions contracting along with its shrinking bounda-
ries, until we find it lapsed into a state of barbarian des-
potism under the son of Aurelius ; and, had it not been
for outside influences, it would have eventually fallen
into a state of utter and complete savagery.
Now, let us turn to a much older civilization. When
the first conquerors of Egypt, about whom history can
tell us so little, first occupied the fertile valley of the
Nile, the country, in all probability, was inhabited by
negroes. This conquering race drove out or enslaved
the native population and founded the ancient kingdom
of Egypt. This kingdom waxed strong and mighty un-
til at the time of Rameses the Great, three thousand two
hundred years ago, it was the most powerful monarchy
in the whole world. This mighty son of Ra, Meiamoun
Ra, or Rameses, as he is most generally styled, was a
warrior and a statesman. He led his victorious troops
north, east, and west, conquering nations as he went,
until he dominated and brought into a state of vassalage
over two-thirds of the then known world. Wealth
flowed into his kingdom from all the surrounding coun-
tries, consequently luxury, with its never-failing asso-
ciate, debauchery, made their appearance and the deca-
dence of this mighty kingdom set in. It is true that
many Pharaohs reigned after Rameses, and that the mon-
archy maintained its greatness for a long period of time ;
but luxury had taken hold on the people at the time of
their greatest prosperity and had sown the seeds of de-
generation, which flourished and grew apace, until the
emasculated and effeminate people yielded up their inde-
pendence to the conquerors, and passed out of existence
as a nation forever.
Now, let us turn to a recent civilization. At the time
of Louis XVI. the French nation was thoroughly under
the influence of degeneration consequent to a luxury and
licentiousness that had had a cumulative action for sev-
eral hundred years. The peasantry and the inhabitants of
the faubourgs, owing to their extreme poverty, itself a
powerful factor in the production of degeneration, had
lapsed into a psychical state closely akin to that of their
savage ancestors. The nobility were weak and effemi-
nate, the majority of them either sexual perverts, or
monsters of sensuality and lechery. The middle class,
then as ever the true conservators of society, seeing this
miserable state of affairs, attempted to remedy it. Not
fully understanding the dangers of such a procedure, they
allowed the degenerate element to share in their delibera-
tions. Their moderate and sensible counsels were quickly
overruled by their savage associates, who brought about a
Reign of Terror (with such psychical atavists as Marat,
Danton, and Robespierre at its head), the like of which
the world had never seen before nor has ever experienced
since. I have demonstrated, in the three instances of
history cited above, that degeneration has invariably fol-
lowed luxury, and that a social and political revolution
has been, invariably, the result of this degeneration;
therefore, as we ourselves are entering upon an epoch
closely akin to the three several epochs just mentioned,
it will be well for us to study the phenomena that bring
about such revolutions.
It is conceded by everyone that man completed his
cycle of physical evolution many thousands of years ago.
Since his evolution from his pithecoid ancestor the forces
of nature have been at work evolving man's psychical
being. Now, man's psychical being is intimately con-
nected with, and dependent on, his physical being, there-
fore it follows that degeneration of his physical organism
will necessarily engender psychical degeneration. Hence,
if I can prove that man, by leading a life of luxury or
one of poverty and want, produces physical degeneration,
it will naturally follow that psychical degeneration will
also accrue; and, as one of the invariable results of
degeneration is atavism or reversion, both physical and
psychical, the phenomenon of a social revolution charac-
terized by pronounced savagery and barbarity, in which
society is overthrown and anarchy instituted in its stead,
will no longer appear strange and unnatural.
Neurasthenia, or the loss of nervous tonicity, is a prime
factor in the production of degeneration. The offspring
of neurasthenic parents always show degeneration in
some form or other. That luxury produces neurasthenia
can be demonstrated beyond the shadow of a doubt
Nine tenths of the clientele of the gynecologist is derived
from the wealthy, luxurious, and fashionable class. The
same may be said of the neurologist and alienist. Pa-
resis and kindred forms of insanity are, almost exclusively,
forms of degeneration affecting wealthy people, while the
proportion of sexual perverts among the rich is remarkably
high.
Let us see if we. cannot discover some of the fee-
tors in the causation of such wide-spread and abundant
neuroses among those fashionable and luxurious individ-
uals who arrogate to themselves the title of " Society."
Man is, naturally, a diurnal animal, but the fashionable
December 29, 1894]
MEDICAL RECORD.
803
world has reversed the natural order of things and has
made him a nocturnal animal. Now, the long continued
influence of artificial light exerts a very deleterious effect
on the nervous system ; hence it is not to be wondered
at that so many men and women of society are neuras-
thenic. Not only are those individuals who, voluntarily
and preferably, spend the greater portions of their lives
in artificial light, rendered nervously irritable, but those
also who are driven by force of circumstances to turn
night into day are likewise afflicted. Several years ago
I met a distinguished editor at Waukesha, who was suffer-
ing greatly from nervous exhaustion. He told me that
he was so situated that he did all of his work at night,
often writing until three o'clock in the morning. 1 ad-
vised him to quit this and to do his editorial work dur-
ing daylight. Not long after he wrote me that he had
followed my advice, and that he was a new man in point
of health. The loss of nervous vitality makes itself evi-
dent by a feeling either of exhaustion or irritability.
The fashionable devotee, in order to counteract this,
either stimulates the system with alcohol, or exorcises
the " fidgets " by the use of sedatives, such as chloral or
morphia. The baneful effects of such medication are
not at once appreciable, but if continued for any length
of time they will eventually result in a total demoraliza-
tion of the nervous system. Time and again have I
seen fashionable men and women, at the close of the
season, veritable nervous wrecks. What necessarily
would be the effect of physical and psychical lesions like
these on a child begotten by such parents ? The inevit-
able result would be degeneration in some form or other.
Again, many men and women stand the drain of a fash-
ionable season on their nervous systems without attempt-
ing to recoup through the agency of drugs, and at the
end find themselves physically and psychically ex-
hausted. They go to the seaside or some other resort,
and, in a measure, recover their nervous vitality, only to
lose it again during the next season. This continues for
season after season, the nervous system all the time be-
coming weaker, until some day there is a collapse end-
ing in hysteria, paresis, or some other of the hundred
forms of neurotic disorder. What will be the effect on
the progeny resulting from the union of such individ-
uals ? Again the answer must necessarily be— degenera-
tion. Artificial light is not the only cause of this nervous
irritability* The long and continued intercourse of the
sexes in the ball-room, where the women are dressed so
decollete that they excite sensuality in the men, very fre-
quently without the men being conscious of the fact,
must necessarily exert a deleterious effect on the nervous
system. Contact of the sexes in the dance is only pleas-
urable because of that contact. I am fully aware of the
fact that this idea is scouted and denied by those who
indulge in the waltz and kindred dances. They claim
that no thought of carnality ever enters into their feel-
ings. I know from personal experience that they are
honest in this declaration, yet from a psychical stand-
point they are wofully in error. ^Estheticism and car-
nality are by no means as dissociate as the aesthete would
have us believe. All pleasurable emotions that have
their inception in the senses are fundamentally of carnal
origin. The waltz is aesthetic, yet all of its pleasure is
based on an emotion closely akin to sensuality. Men
derive no pleasure from waltzing with one another, nor
do women under like circumstances.
Nature demands in the interest of health a certain
amount of exercise. The luxurious society man or woman
utterly disregards this demand of nature, consequently
indigestion, with all of its associated ills steps in, and be-
comes an additional factor in the production of nervous
exhaustion. To tempt the appetite, highly seasoned foods,
many of which are deleterious and injurious, are prepared
and taken into the torpid and crippled stomach. Finally,
nature rebels and the unfortunate dyspeptic is forced to
go through life on a diet of oatmeal, or, weakened by
lack of healthy sustenance, the brain gives way and the
victim passes the remainder of his or her life in a lunatic
asylum. Children begotten by miserable invalids like
these, beyond a peradventure, must necessarily be de-
generate. Indigestion is not the only ill that nature in-
flicts for any disregards of her laws. She is a rough
nurse but a safe one, consequently she forbids the rear-
ing of her hardiest creation, man, in hot houses, as
though he were a tender exotic. The luxurious individ-
ual pampers his body, following the dictates of his own
selfish desires and utterly disregarding the laws of nature,
and, before he reaches middle age, discovers that he has
become an old, old man, weak in body, but still weaker
in mind. The children resulting lrom the union of the
various neurasthenics described above are necessarily de-
generate. As they grow up they show this degeneration
by engaging in all kinds of licentious debauchery, and
unnatural and perverted indulgences of appetite. In
nine cases out of ten they will spend the fortunes inher-
ited from their parents in riotous debauchery, and will
eventually sink, if death does not overtake them, to the
level of their fellow-degenerates — those who have been
brought into existence by poverty and debauchery, and
who await them at the foot of the social ladder. Among
such degenerate beings the doctrines of socialism, of com-
munism, of nihilism, and of anarchy have their origin.
Now, let us turn our attention to the evidences of lux-
ury and debauchery, and the consequent evidences of
degeneration which obtrude themselves on all sides. The
reckless extravagance of the nobility of the Old World is
well known. Vice and licentiousness even penetrate to
the royal households, and princes of the blood pose as
route and debauchees. As I have demonstrated else-
where, degeneration in the wealthy classes of society gen-
erally makes itself evident by the appearance of psycho-
sexual disorders. The horrible abominations of the
English nobility, as portrayed in the revelations of Mr.
Stead, aze well known. Charcot, Sega'as, F6r6, and
Bouvier give clear and succinct accounts of the vast
amount of sexual perversion existing among the French,
while Krafft-Ebing informs us that the German empire is
cursed by the presence of thousands of these unfortu-
nates. When we come to examine this phase of degen-
eration in our own country, we find that it is very preva-
lent. This is especially noticeable in the larger cities,
though we find examples of it scattered broadcast
throughout the land. The editor of one of our leading
magazines, in a remarkable series of letters, has shown
that the wealthy New Yorkers revel in a luxuriousness
that is absolutely startling in its license. Thousands aie
expanded on a single banquet, while the flower bills for
a single year of some of these modern Luculli would
support a family of five people for three or four years.
Bachanalian orgies that dim even those of the depraved,
corrupt, and degenerate Nero are of nightly occurrence.
Drunkenness, lechery, and gambling are the sports and
pastimes of these ultra rich men, and it is even whispered
that milady is not much behind milord in the pursuit of
forbidden pleasures.
Psycho- sexual disorders are not the only evidences Of
degeneration in the wealthy, by any means. Many a
congenital criminal is born in the purple, who shows his
moral imbecility in many ways. Sometimes he sinks at
once to the level of a common thief, but generally his
education keeps him within the pale of the law. Always,
however, his sensuality is unbounded, and he will hesitate
at nothing in order to gratify his desires. This unbridled
license has already bad its effect elsewhere. We see
that it has even corrupted the guardians and conservators
of the public peace. The recent investigation of the po-
lice board of New York shows a degree of corruption
that is simply overwhelming, and that the same state of
affairs exists in Chicago, New Orleans, St Louis, and
other large cities, I have every reason to believe. There
are yet other evidences of degeneration ; witness the
eroticism that is to be found in our literature. Unless a
book appeals to the degenerate tastes of its readers it
might just as well never have been published. This is
not cynicism; it is plain, unvarnished truth — witness
8o4
MEDICAL RECORD.
[December 29, 1894
the success of " His Private Character," of " Is This
Your Son, My Lord?" of hundreds of other works of
the same character. Again, turn to the stage and we
find the same thing. Tne tragedies and comedies of
Shakespeare are shelved, while society plays and " living
pictures " hold the boards. Salacity, with only sufficient
covering to barely hide downright lewdness, is everywhere
apparent. Now, what is the result of all this ? There
can be but one answer, and that is degeneration. That
which happened centuries ago will happen again, for
man is governed by the same laws of nature now as he
was then.
Statistics show that insanity is markedly on the in-
crease. This is not to be wondered at when we take
into consideration the fact that debauchery is the rule,
and not the exception, among certain classes of people.
Syphilis, one of the most productive causes of degenera-
tion, is exceedingly active throughout the whole civilized
world. Blashko states that one out of every nine or ten
men in the city of Berlin is tainted with syphilis. This
is wholly attributable to the unbounded sensuality of the
people. Crime of every description is rearing its hydra-
head and clasping in its embrace an alarming proportion
of human beings. I have shown elsewhere l that the
congenital criminal is the result of degeneration, and
that he comes from all classes of society. He is, how-
ever, most frequently the product of the lower class, and
lives and dies among his congeners. I have shown also a
that the anarchist, the nihilist, and the socialist belong
to the same category of degenerate beings. Poverty,
brought on by the luxury of the rich, by war, and by
high taxation, has, during the last millenary period, been
very fertile in the production of degenerates in the Old
World. Lack of food and sanitation, the usual adjuncts
of poverty, are powerful factors in the production of de-
generate individuals. The Old World has gotten rid of
these people as rapidly as possible by unloading them on
our shores. Year after year, practically without restric-
tion, thousands of these antisocial men and women have
swarmed into our country, until we, comparatively
speaking a nation just born, contain as many of these
undesirable citizens as any of the older nations. They
still continue to enter our gates, and we are adding to
their number, as I have shown, by our own production.
Some day — and I greatly fear that day is not very far
distant — some professional anarchist (for there are pro-
fessional anarchists as well as professional thieves) will
consider that the time is ripe for rebellion, and, raising
the fraudulent cry of " Labor against Capital," instead of
his legitimate cry, which is " Rapine, Murder, Booty ! "
will lead this army of degenerates, composed of anarchists,
socialists, nihilists, sexual perverts, and congenital crim-
inals, against society. And who will bear the brunt of
this savage onslaught? The ultra-rich? By no means..
The great middle class — the true conservators of society
and civilization, will fight this battle. It will be a strife
between civilization and degeneration, and civilization
will carry the day. There would have been no French
Revolution had the middle class been as wise then as it
is to day. They were taken by surprise at that savage,
bloody time, but as soon as they recovered how quickly
they brought order out of chaos ! Education is the bul-
wark of civilization, and the great middle class, freed of
dogmatism, bigotry, and superstition, is welcoming edu-
cation with open arms. It is gaining recruits, and is
strengthening its defences, so that when the end comes
its enemies may find it fully prepared. When this fight
takes place, millions of dollars' worth of property will be
burned, and thousands of lives will be sacrificed, but
when the smoke of battle clears away civilization will
be declared the victor. And the ultra rich, what of
them ? They will simply open their purses, like they did
in ancient Rome, and pay for the privilege of being pro
tected. The sober middle class is a business people, and
> Vide American Naturalist, The Recidivist.
* Vide Century Magazine for October, The Methods of the Rioting
Striker an Evidence of Degeneration.
they will demand and obtain assistance from their
wealthy brethren. From the signs of the times and the
evidence before me, I have no hesitation in declaring
that I believe that the beginning of the end is at hand.
This social cataclysm may not occur for many years,
yet the agencies through which it will finally be evolved
are even now at work, and are bringing the culmination of
their labors ever nearer and nearer as time passes.
" Waveland."
EDUCATION A FACTOR IN THE PROPHY-
LAXIS OF DISEASES OF WOMEN.1
By FRANCES STORRS, A.B., M.D.,
TOPKKA, KAM.
Fifty one years ago Dr. Oliver Wendell Holmes,
whose loss we mourn to-day, published a paper upon the
contagiousness of puerperal fever, and struck the first
blow for prophylaxis in the diseases peculiar to women.
The clear argument of that famous classic won its way in
the face of bitter opposition and learned opinion — this,
too, without the aid either of microbe or microscope.
To-day the spirit of that paper is recognized as the spirit
of medical progress in the last half-century. Prophy-
laxis has revolutionized the practice of medicine, and
wrought a firm foundation for the splendid superstructures
of our systems of State medicine and boards of public
health. Parallel with the development of the prophy-
lactic management of disease, even dependent upon that
management for success, has been the growth and per-
fection of modern surgery. Hand in hand they have
entered hospical and infirmary, wards for children and
lying-in women, and the results have been good to hear*
It is a curious fact that to-day, in the department of
gynecology, the so-called diseases of women, prophy-
laxis has been so nearly lost sight of, while surgery has
usurped the field. I need not remind you of the multi-
plicity of the surgical articles upon gynecological, sub-
jects in medical literature during the past ten years, their
name is legion, and many are already relegated to the
dark ages ; but the indices to our recognized authorities
upon gynecology are worth considering for a moment,
and will illustrate my point. In the " Cyclopaedia of
American Gynecology," published in 1888, we look in
vain for any article relating directly to the etiology of
the prevalence of disease among women. Indirectly,
several of the authors speak of the causes of certain con-
ditions, but only in brief. Dr. George T. Harrison, in
writing upon uterine displacements, in the second vol-
ume, makes the pertinent statement : " Prophylaxis is
usually left out of the question by systematic writers."
In the " Cyclopaedia of Gynecology," brought out by
William Wood & Co., in 1887, chiefly the work of Ger-
man writers, the eight volumes contain no reference to
prophylaxis, and only very casual reference is made to
etiology.
Pozzi deals only with pathological details and treat-
ment.
Garrigues, in a work of 660 pages, devotes less than six
to the discussion of " Etiology in General " Prophy-
laxis is spoken of here and there, but at no great length.
Thomas, fifteen years ago, and the recent Thomas and
Mund6, devote one chapter to the etiology of uterine
disease, and throughout these books, especially the later
work, appear constant hints as to the prevention of cer-
tain conditions. Tait has no chapter on etiology, but be
never fails to make his opinions upon the causes of spe-
cific conditions clear.
There is little difference of expression in these scant
comments upon etiology. Briefly, the causes of these so
common pathological conditions in women are of two
varieties :
1. Etiological factors for which the woman is chiefly
1 Read before the Eastern Kansas Medical Society, at Kansas City,
Kan., October ot 1894.
December 29, 1894]
MEDICAL RECORD.
805
responsible. 2. Etiological factors for which someone
else is chiefly responsible.
Under the first head belongs the list which Thomas
gives: "Neglect of outdoor exercise; excessive develop-
ment of the nervous system; improprieties of dress;
imprudence during menstruation ; imprudence after par-
turition; prevention of conception and induction of
abortion ; marriage with existing uterine disease ; " and
I add from Garrigues, *' over- education, particularly in
music." These the woman might prevent.
Under the second head : Child-bearing and its conse-
quences, many evil results of which the doctor might
prevent ; and infection by the gonococcus, which in or-
dinary cases the husband might prevent.
Here are eighty-five per cent, of the diseases of women.
To the remaining fifteen per cent, belong the neo-
plasms and malformations, which we shall turn over to
the surgeon without protest or comment.
Concerning the last-mentioned etiological factor, the
gonococcus : If the infection of the utero-tubal tract by
the germs of gonorrhoea meant inevitable, sudden death to
the woman thus infected, some means would be found
potent enough to reduce such fatalities to the minimum.
But since it means only a life of such misery that death is
a longed-for release, wives and mothers continue to be ex-
posed to that infection ; and too often, alas ! the protec-
tion of the physician is given the offender rather than
the innocent offended. And the modern gynecologist,
secure in his new found ability to diagnose pus tubes,
views with complacency the seed- sowing that is every-
where before his eyes, and smiles a little as he contem-
plates the harvest of long rows of ticketed jars.
Concerning child-bearing as a cause of uterine disease,
too much has been written to warrant even a passing re-
mark from me. Yet something must be radically wrong
somewhere, that so many neglected cases of lacerated
cervix and perineum, with the accompanying subin voluted
uteri and long train of nervous symptoms, com* into the
specialist's hands.
It is with the first variety of etiological factors, how-
ever, that this paper has principally to deal. There
seems to be a tendency in all these works to accept the
present condition of woman as an inevitable one, even im-
plying that they prefer to be ill, and choose a life of per-
nicious dressing and reckless imprudence, especially to
exaggerate nervous phenomena and induce uterine affec-
tions. What wonder that the art of extirpation has sup-
planted the science of prevention in . treating such
irrational beings, and that the very latest and most
approved method of dealing with diseased pelvic organs
is to preserve them entire in alcohol, as being too com-
plicated a mechanism for the ordinary woman to be en-
trusted with !
It is far from my purpose to decry the results of surgi-
cal gynecology. No one realizes more keenly than I
the utter futility of " treating " a tube distended with
pus, and that we need no further demonstration of the
fact that most pathological processes of long standing in
the pelvis are only aggravated by much of the so-called
conservative treatment.
But to return to the list of the causes of disease above
quoted as being those for which woman herself is largely
responsible. One of them is hardly worth a discussion.
Woman's dress bears the brunt of masculine denuncia-
tion whenever her ill health is mentioned ; yet I venture
to assert, as a matter I have been at no small pains to in-
vestigate, that nine tenths of the women in the ordinary
walks of life dress comfortably, and of the women who
have learned to think for themselves, the other tenth is
busy inventing some advanced and enlightened costume.
For all the rest of the imprudence, carelessness, and
the like in that list enumerated, there is but one excuse,
which is no more an excuse in dealing with physiological
law than in the violation of the voice of civil authority,
but which is too often pleaded as an excuse in both cases ;
that is ignorance, and an ignorance which is density it-
self.
Two great necessities, contingent upon mere physical
existence, confront every woman ; by conformity to their
laws she must lose or win, live or die. Nature insists
upon self-preservation and preservation of the species.
Moreover, she scorns to perpetuate a deteriorating type.
How little the ordinary wife and mother, even in these
boasted fin de-siecle days, knows of the real significance
of life, or those mighty forces that know no deviation ;
and how little she is prepared for the part she must needs
play, whether she will or no, in this fierce struggle for
mere survival. If it takes three years of constant study
and clinical observation to fit a man to wait upon a woman
in confinement, and to faithfully discharge the few small
duties nature has left undone at that time, how much
longer ought it to take to fit that woman for her part in
the preceding nine months, and for the responsibility
which becomes hers at that time?
Tait alone, of the authors whom I have mentioned,
speaks of the ignorance of women in regard to the vital
processes of their nature, as largely responsible for the prev-
alence of uterine disease. He condemns such ignorance
as unnecessary and inexcusable, and suggests that it may
be removed by the study of the analogous sciences ; that
the laws of reproduction are the same wherever manifested ;
and to the observer of plant life who has witnessed the
development and understands the structural significance
of anther, oviduct, and ovary, the ordinary processes of
sexual life present no mysterious difficulty of compre-
hension. I may be pardoned for differing with % o great
an authority, but in my school-days, when fitting for col-
lege, with a head full of Latin, Greek, and pure mathe-
matics, a very nice little work, written upon the analo-
gous botany idea, was put into my hands as a safe and
proper thing for me to read. I don't think it did me
any harm, but it left a very confused idea of the semi-
physiological, semi-sentimental aspect of the subject so
distasteful that I never cared to investigate the subject
further.
What all women need as a preparation for their highest
function in life, is a thorough training in anatomy and
physiology. That train ing should begin at an early age in
preparation for the advent of menstruation, the physio-
logical import of which process should be made as clear
as our best authorities can make it. From fourteen to
eighteen or twenty, the aim of the young woman's train-
ing and education, in school and out, should be toward
physical perfection. Systematic exercise in the gymnasium
and out of doors should be a daily certainty, and the full
process of gestation and parturition, with the develop-
ment of the embryo, and the growth and needs of the in-
fant, should be unfolded in continuous instruction.
Any interference in the natural order of development
in the young girl should be taken in its very incipiency.
Interference in nutrition, which is often succeeded by
pathological conditions only amenable to the surgeon's
knife, may be easily handled in their early stages. When
women turn their attention to acquiring physical fitness
for motherhood, there will be less demand for the pro-
fessional laparotomists.
In all seriousness, this is no Arcadian dream. There
is not a mother alive but would spare her daughter the
suffering she has undergone in acquiring the " Wisdom
of Experience." The difficulty is, she does not know
how, but she does feel her ignorance. Over and over
again they say to me, " If I had only known."
More than that, there is a growing dissatisfaction with
the results of our present system of higher education for
woman. The women who go out from our colleges to
fulfil the law of their destiny by becoming the mothers of
families, feel that some very essential subjects are left out
of our college curricula, and they would be glad enough
to exchange a few books of Homer, or even the enjoyment
of Dante. in the original, for some sound facts about life
and health.
Garrigue says that our girls are over educated, and es-
pecially in music. Not over- educated, but educated in
books too soon. Physical education must come first, and
8o6
MEDICAL RECORD.
[December 29, 1894
there will be plenty of time afterward for culture and
art.
It doubtless has occurred to some of you that this paper
would better have been read before some enthusiastic
bydy of organized women, who might forthwith form
themselves into a club for the collection of bones and the
exchanging of specimens.
Not at all. Clubs are well enough in their place, but
this is a question involving the great modern principle of
prophylaxis in medicine.
If the diseases of women are many of them preventable,
then should the medical profession have a care that they
are prevented. If women are reasonable beings — and who
would deny that they are — then they can be taught, and
it is the medical profession who must decide what they
are to be taught.
Dr. Holmes has given a priceless example to the pro-
fejsion of America, and he lived to see the second and
third generations rise up and call him blessed. No greater
tribute can be paid his life and works than by the per-
petuation of the spirit in which his work was done, the
enthusiasm for the science of prophylaxis wherever dis-
ease is found.
EMERGENCY CASES OF SKIN DISEASES.
By FRED. J. LEVISEUR, M.D.,
DERMATOLOGIST TO BAMDAIX'S ISLAND HOSPITALS.
When the surgeon is called in cases of emergency, he
certainly will be pleased to find a wound already cleanly
covered with a temporary dressing, or a fractured limb
in an improvised splint. Wrong or delayed action in
these cases is frequently followed by very serious conse-
quences. The first help in some skin diseases is not of
such great importance, it is true, but it is a fact that mis-
takes are made continually which it takes a good deal of
time or trouble to correct afterward. In his paper, read
at Rome, and entitled "Non Nocere,M l Dr. A. Jacobi
has collected a treasure of advices and warnings. It is
to be regretted that time and space limited his remarks
to certain affections occurring in infancy. Harm is done
quite frequently in the treatment of skin diseases, and es-
pecially in emergency cases, 1 e.y cases in which the pres-
ence of alarming symptoms or the apprehension of the
development of such, prompts the patient to seek imme-
diate medical help.
Make a Correct Diagnosis .—A correct diagnosis form-
ing the basis for our therapeutical action is essential in
the first place. Acute eczema, for instance, is sometimes
mistaken for erysipelas, even by the better-versed physi-
cian. I am referring to that special form of eczema
which makes its appearance in the face near the ears,
nose, or eyes, and consists of a patch with round, dis-
tinct border line. Its color is brownish red. Its sur-
face is covered entirely or in part by a thin layer of
brown crust. In the very beginning close inspection
will reveal the presence of millet-sized vesicles. In the
majority of cases, however/ the appearance will already .
have been changed by the application of some irritating
lotion or salve, applied under the impression that the af-
fection is erysipelas. The itching is now aggravated un-
til it becomes almost unbearable. The patient's general
condition suffers considerably from sleepless nights or
from the weakening effects of morphine or chloral ; and
if— as happens not infrequently — the patient becomes
somewhat feverish, the phantom of erysipelas is complete.
One should carefully bear in mind the characteristic symp-
toms of erysipelas. Typical cases begin with a chill and
vomiting, followed, after twelve to twenty- four hours, by
an eruption, which at first consists of a spot of about the
size of a silver dollar, irregular in outline and painful on
pressure. Its border is somewhat raised, and it pro-
gresses rapidly, not unlike a miniature wave. At a later
stage the entire face may become swollen, the eyes
closed, the ears thickened, and possibly the affected
* Mbdical Record, May 19, 1894.
area studded here and there with' bullae or crusts. The
fever is usually high, and the patient makes at once
the impression of being seriously sick. To return to
eczema, there is generally a history of nasal catarrh, a
chronic affection of the middle ear, or a conjunctivitis.
We are justified, I believe, in assuming that the patho-
logical cause of this particular form of eczema is a micro-
organism, not yet known, but differing essentially from
Fehleisen's coccus of erysipelas and Rosenbach's of ery-
sipeloid. E. Fridenberg l and a few others before him
report that they have observed this eczema to occur after
the instillation of mydriatics. I have no objection to the
name dermatitis periocularis medicamentosa, but I be-
lieve it better not to call it pseudo erysipelas. Elliot %
defines erysipeloid as an inflammation of the skin which
develops in a wound as the result of its infection with
certain special micro-organisms found in dead or de-
composed animal matter. It manifests itself primarily
in the form of a sharply defined, slightly elevated, dark,
violaceous, almost livid red zone, which appears around
the point at which the infection has taken place. The
area of redness extends peripherally, and at the same
time involution and fading of the portion first attacked
takes place. During the entire course of the process
itching and burning exist, being oftentimes exceedingly
annoying. There is no desquamation or scaling of the
epidermis at any stage, and no systemic disturbance.
Again, erysipeloid should not be confounded with
pseudo- erysipelas. This latter affection is usually ush-
ered in — according to Kaposi 8 — by a chill and fever, and
consists of a tense, painful swelling, of vivid red color.
It is found, as a rule, to affect the extremities. After
two or three days the tissues break down and suppu-
ration sets in, often followed by an enormous destruction
of the subcutaneous tissue, fasciae, muscles, bones, and
joints.
The eruptions caused by the internal use of drugs often
simulate other diseases. Caspary4 remarks correctly,
that the physician who is called upon to treat an acute
eruption, the diagnosis of which is not beyond doubt,
should think of the possibility of having to deal with a
drug eruption, and try to find out by inquiring of the
patient or those around him. Morrow9 says that the
scarlatiniform rash of belladonna, quinine, chloral, mor-
phia, etc., may be distinguished from scarlatina by its
sudden onset, without prodromic symptoms, and the ab-
sence of fever and high temperature. The rubeolaform
eruption of antipyrine, copaiba, etc., maybe differen-
tiated from measles by the same negative evidence. The
pustular eruption of bromine and iodine may closely
simulate small pox. There are some popular patent
medicines in the market which contain some iodine and
are liable to produce lesions, the umbilicated character
of which may suggest small pox.
The difficulty to discriminate between varicella, vari-
oloid, and variola,6 is a subject which has been discussed
so often that I hardly need enlarge upon it. Varicella,
as is well known, is a disease occurring mostly in chil-
dren from six months to ten years old. It has very slight
prodromic symptoms, and consists of the appearance of
successive separate crops of superficially seated vesicles.
Severe constitutional symptoms are absent.
The hemorrhagic affections of the skin may furnish
emergency cases which are difficult of diagnosis. Purpura
hemorrhagica may be confused with scurvy, or the
hemorrhages of haemophilia, leucocythaemia, and perni-
cious anaemia. Fortunately, the treatment of these
hemorrhagic affections is so similar that, by mistaking
one for the other at first, no serious consequences will
follow.
If I were not prevented by the limitation of space from
1 N. Y. Medicin. Monatsschrift, November. T804.
* G. T. Elliot, in Morrow's System of Genito-urinary Diseases, etc.,
p. 130.
8 Patholgie 11. Therapie der Hautkrankheiten, 1893.
4 Archiv f. Derm, u Syph. , I. , 1804.
* System of Genito-urinary Diseases, etc., p. 353.
* Variola and Vaccinia. Published by the New England Vaccine
Company.
December 29, 1894]
MEDICAL RECORD.
807
going into details, I could extend the list of possible mis-
takes much further by mentioning rarer cases; for in-
stance, erythema scarlatiniforme,1 precocious malignant
syphilis, pemphigus vulgaris and foiiaceus, dermatitis
exfoliativa neonatorum, pityriasis rubra, scleroderma, etc.
It may suffice to quote in this connection Dr. H. R. Crock-
er's advice, which is, to make the diagnosis in a given case
by settling the following questions in the order named :
" How long has the patient had the disease ? What was
its cause ? What symptoms, especially as regards itching,
fever, etc., attend or preceded the eruption ? What is its
cause?"
Ohmann Dumesnil2 says that diagnostic skill of the
highest character will frequently prove of little or no
avail in cases of eruptions due to the artifices of malinger-
ers. The ingenuity and tact of the physician are called
into requisition, and it is more the motive of the patient
than the actual condition which will lead to any suspi-
cion.
Look Out for Possible Complications. — It is not
sufficient to merely make a correct diagnosis, but it.
is also necessary to be on the lookout for complica-
tions. The case of a patient in one of the city hos-
pitals is still fresh in the minds of many. A man who
suffered from alcoholism and at the same time had a
tuberculo pustular syphilide, contracted small- pox. The
symptoms of the latter disease were so much obscured
by the other two affections that the failure to make a cor-
rect diagnosis was perfectly pardonable. The patient
died, and the true nature of the disease which caused his
death was revealed upon the dissecting table.
The following complication came under my personal
observation : M. H , a boy, nine months old, had an
infantile eczema on both cheeks for which the family phy-
sician prescribed tinctura rusci to be painted on the affected
parts every day. At first there was some improvement,
but suddenly a very acute pustular dermatitis spread over
the face. On opening the lids of the left eye, which was
closed by considerable swelling, I found a small pustule
in the centre of the cornea. Dr. Gruening, who was
consulted at once, predicted (and such was the result),
that a central opacity of the cornea causing strabismus
would remain.
I also had occasion to observe a peculiar complication
in a severe attack of urticaria :
O. S , a boy nine years of age, who was subject to
outbreaks of urticaria after eating fish, one evening, at a
children's party, partook of the forbidden food and im-
mediately developed alarming symptoms. He was taken
home almost unconscious, unable to breathe, his lips and
tongue were bluish red and swollen, and the body covered
with large wheals. I was informed that he was suffering
at the time from adenoid vegetations in the vault of the
pharynx, for which he was under treatment. Six years
later, after taking a teaspoonful of white vaseline, which
was recommended to him as an effective laxative, by a
friend, he had again an attack of urticaria with ex-
tremely severe dyspnoea, etc. Examination showed that
the adenoid vegetations had returned in spite of repeated
operations which had been performed in the meantime.
The treatment in both attacks consisted of putting* the
patient into a bath tub and sponging him with cold water
until breathing was somewhat easier. On account of the
pharyngeal swelling it was not deemed safe to give him
an emetic, and a tablespoonful of castor oil was admin-
istered.
Dr. Mendel has reported a case which in some respects
closely resembles the above. An exanthema caused by
copaiva was complicated by the presence of adenoid vege-
tations. There was a great deal of swelling, pain in the
pharynx, and severe dyspnoea.8
Be Careful in the XTse of Antipruritic Remedies. —
It is a fact well known but deserving to be emphasized
1 C. W. Allen : Concerning some Unusual Eruptions, Mbdical
Rbcord, August. 1893.
* Some Points in the Diagnosis of Diseases of the Skin, Cincinnati
Medical News, i., 1891.
* Bulletin Medical, 24, 1894.
again, that our best antipruritic remedies, tar and its
chief derivative, carbolic acid, do more harm than good
in cases of general pruritus. They may afford some tem-
porary relief, but the skin is liable to get irritated, fu-
runculi may form everywhere, and the patient is apt to fall
from the Scylla of itching into the Charybdis of general
dermatitis or furunculosis. Besides, a peculiar intoler-
ance of the integument against all local treatment is fre-
quently established. If a new attack occurs it may be so
severe as to drive the patient almost crazy and to the
verge of committing suicide. In such cases a hypodermic
injection of morphine, chloral internally, or even chloro-
form anaesthesia, must be resorted to. A cold douche or
bath containing sulphur, carbonate of soda, alum, or
sublimate may be given a trial. There is no doubt that
mental depression is one of the most important factors in
the etiology of this distressing affection. The physician
called in such an emergency case should therefore carry
out his treatment with energy and tact.
The old error of treating the most prominent symp-
toms instead of the disease is frequently committed in pre-
scribing antipruritic remedies for acute general eczema,
drug eruptions, or similar acute inflammatory conditions
of the skin. The following case may serve as an illustra-
tion of the truth of this statement :
Mrs. A. P , forty six years of age, had had for
years a slight chronic eczema on the fingers of both
hands. During a sickness of a member of her family she
happened to come in frequent contact with preparations
of carbolic acid, and thus developed an acute eczema on
the hands, forearms, and face. In order to relieve the in-
tense itching, her family physician gave her a wash con-
taining some carbolic acid. Soon after the first applica-
tion a most acute eczema spread over the entire body, and
when I was called to see the patient, I found her in a
deplorable condition. She had to be swathed in band-
ages saturated with zinc-calamine solution for several
hours, after which her body was covered with Lassar's
paste spread on strips of linen. Wherever possible these
strips were bound down with bandages. This treatment
not only relieved her itching but was also the first step
to a final cure.
The Use of Antiseptic Remedies. — Antisepsis in the
treatment of skin diseases differs in a great many re-
spects from surgical antisepsis. A healing by first in-
tention, of most lesions, is not to be expected ; certainly
not if the corium has been destroyed ; but even if it is
only impaired, denuded of the epidermis, or if bulls
have been formed, the process of reparation can solely
be accomplished by catarrhal (epithelial) suppuration, the
product of which is the " dry scab n under which heal-
ing takes place easily and undisturbed. This is nature's
own antiseptic routine, which we should try to imitate
as far as possible by using remedies which, although
inert as it were, are capable of absorbing moisture and
forming a coating that furnishes protection against ail
and against infection from the outside. In this sense
these remedies are better antiseptics than those which
have earned their reputation in the realm of surgery as
being destroyers or antagonists of microorganisms.
In emergency cases of dermatitis ambustionis of the
second degree, *.*., burns and scalds, the old-fashioned
carron oil or corn starch, with the addition of boric acid,
oxide of zinc, salicylic acid, bismuth, dermatol, etc., is
far more effective and reliable than iodoform. Or, if
lotions or the continuous bath are used, solutions of boric
acid or liquor aluminii acetici (ten per cent.) are prefer-
able to solutions of carbolic acid, sublimate, etc. In
herpes zoster simple cornstarch, dusted on freely and
bound down carefully by the aid of a thick layer of ab-
sorbent cotton, is by far the best treatment. In two
cases of this disease I have seen the lesions break down
and an extensive dermatitis develop under a dressing of
iodoform gauze. In a case of intertrigo between the
legs of a female infant, a dressing with carbolic acid gave
rise to deep ulceration. In short, it has been my expe-
rience in such emergency cases that I was more often
8o8
MEDICAL RECORD.
[December 29. 1894
concerned in the removal of antiseptics previously ap-
plied and their bad effects, than in advising their use.
I present this epitome in the hope of creating an in-
creased interest in this class of cases of skin diseases
which are apt to confront the practitioner at any mo-
ment and should not find him unprepared, but able to
meet all requirements.
41 Hofjmah Arms," 640 Madisoh Avknuv.
THE CARD INDEX OR CARD CATALOGUE AS
ADAPTED TO HISTORY-TAKING IN PRIVATE
PRACTICE.
By ROBERT L. DICKINSON, M.D.,
LECTURER ON OBSTETRICS, AND ASSISTANT OBSTETRICIAN. LONG ISLAND COL-
LEGE HOSPITAL ; OBSTETRICIAN TO KINGS COUNTY HOSPITAL.
Synopsis. — This method of keeping records consists in
using one or more cards (measuring about 6 x 6}
inches) for each case, the cards being ranged under an
alphabet index and stacked on edge in a drawer or box,
and folded down the middle for carrying in the pocket.
Such a system (the card size being immaterial) is the
only portable, elastic, simple, orderly and self indexing
way of keeping records and is as readily used at the bed-
side or operating table as in the office.
Disadvantages of Books.— Books are inelastic. If
the case runs to the foot of one page, where shall it be
continued ? One can rarely guess at the space required
in beginning a history. The next page is occupied ; one
must skip to the first blank page, or borrow part of a
page near by, with the result that a long record will be
in scraps through one or more case-books and scattered
so that the parts of the history cannot be assembled. A
separate index, in a separate book, is required after a
while, in order to avoid searching the index of each book.
Books are not portable. Notes taken at the house or
hospital must be copied or pasted in. Books grow worn
and shabby from much handling, if large, and if thin
many are required. After all the other cases are closed
up, one may have still to use an old book for a single
case. He cannot keep its history with his recent cases.
Disadvantages of Sheets. — Sheets of stiff paper may be
kept in alphabetical order in a letter file or binder, but
they inevitably become frowsy at the corners, they do
not stack on edge, they are not readily run through the
fingers like the leaves of a book when a bunch of them
under a certain letter is picked up, as cards are, and they
are generally too large for carrying in the pocket. The
method is only suited to hospital conditions. Dr. Rich-
mond Lennox and I have used both sheets and cards
and find we save much time and discomfort with the
cards.
Advantages of Cards.— Portability.— For office use
cards will be found to be handier than a book, and the
specialist, above all men, will find them convenient. For
bedside notes this is the only handy method. For im-
mediate record of consultation work and for operative
1
Smith, Mrs. John. 3a. Father tuberc. Pneumon. 6 years ago. Slender, overworking, worrier. Headaches every 2-3 dys ; good
eyes ; goDd dig., but costive. Piles, rarely bleeding ; chest, right ; clothes tight ; corset springs 3 inches ; urine: 60 oz , 1023 ; no alb.
or casts.
G. Mar. 6 yrs ; 2 children ; oldest, 4 ; ygst, 1 ; o Misc.
labors severe, forceps. Puerperiums fever.
Menses^ formerly not painful, irregular.
Now pain, none slight, Severe cramps front R. L. iliac reg.
Backache, before, .during, after, b.twecn, constant.
In bed 1% dys. Much dragging.
Flow free, scanty. Clots, membrane.
Irregular every 20-30 days, weeks, lasting 6 dys. Last men.
7je-
Vag. discharge constant^ prof use^ slight mucus, puruly foul.
Urination frequent, not painful. Dyschezia^ dyspar.
Walking, working, not painful. Dates trouble from last
labor.
Retroversion.
Subinvolution.
Induration right brd.
Ext. hetmorrhoids.
Uterus mobile.
Ovaries moderately
placed, not tender.
Kg-
dis-
Partial reposition ich. tamp, iac to cervix. Basham's mixture ; cascara ; loose clothing ; sea-bathing. 23 Je, same. 29 Je, backache
and leuc , less do. 5 July, s. r., Smith pessary. 10, easier period ; impr. position ; 3 Aloin Strych., bellad. 20, hard r. pess.; much
better ; 7% cavity, and so forth.
Fig. i. — Card for taking case histories,
notes, are also shown.
Actual size. The rubber stamp that is ust J to print part of the history, if desired, and the stamp of aa outline ferjgrapbic
December 29, 1894]
MEDICAL RECORD.
809
and obstetric cases, it is exactly adapted, while for medi-
co-legal cases notes made on the spot are the only ones
the medical man may consult in the witness chair. In
reporting a single case or a group of cases at a society
meeting, or in getting together case histories in writing
a paper, the cards required are picked out and sorted as
desired. One carries in the pocket the cards of patients
ill at home, selecting those needed as one leaves the
office, and dropping the convalescents.
Elasticity. — Whether there be twenty cases, or two
thousand or twenty thousand, the whole history of each
patient is assembled and whatever the number of histories
they are always in order, yet there is always room for
more.
Self-indexing. — The cards are ranged under an alpha-
bet printed on buff bristol cards (guides) that stand
taller than the history cards. This index can be in
twenty-six letters or carried to two, three, or four letters,
as in the Burr index, i.e., Bradley might come under B
in the simple way, Br for the two-letter method, Bra for
the three-letter index. Beyond two thousand, however,
Fig. 3.— Clip to hold cards
over
or wallet of average size, with one fold. This fold must
be upright, so that cards will stack and turn easily when
replaced in the drawer. Paper stock cuts
economically to this size. The material
is the thinnest that will stand on edge
without sagging. The ruling is a standard
adopted by librarians as suiting the aver-
age handwriting ; and all these things, and
other important details, are based
on the long study and elaborate
experience of the Library Bureau,
makers of standard supplies for our
great Libraries. Satisfaction will
be wanting from the hands of an or-
dinary printer ; a perfect edge, ab-
solute exactness of size, and an even
distance of ruled top-line from the
top, so that the names appear in
exactly the same spot, are all essen- S^S^TSrta:
tial tO Speed and COmfort in running the rear before and after fast-
a bunch of cards. The Li- S^hi uppeTco^er. mS"
brary Bureau (of 146 Frank- dieton paper fastener.
lin 'Street, Boston, and Stewart Building, Broad-
way, New York) do very handsome and satisfac-
tory work at reasonable rates.
The proportions and details of this arrangement
have been the outcome of much study, and all the
fittings are kept in stock. Variations in size of
card will cost more in money and delay, but varia
tions in details, such as a printed form, any ruling
or none, or any kind of card as to thickness, color,
or variety of tints of edge for different kinds of
cases, are easily adapted. For some specialists, as
ophthalmologists, whose notes are brief and who
write small, the standard postal size, nearly 3x5
inches, works very well and is much cheaper Ope
who writes large may desire a wider ruling than
three sixteenths of an inch, but it is to be clearly
understood that my plan will not suit men who
take copious notes in a large handwriting.
Practically it is found that two-hundred to three
hundred cards make a working list for a busy man.
The consultation cases, and the patients gone or
moved away, can go under a separate alphabet in
the back of the drawer when the lists grow bulky.
Fig. a.-Box to hold the cards, where a drawer is not available. The ru«rd rod here Another alphabet may SCTVt tO index diseases, Or
shown at the bottom of the box is used in library work to prevent removal of the cards, but . * .£ t» «~ u* u •
is unnecessary in private practice. One of the blocks that slant the cards at the proper angle interesting Cases, OT tlie SUDjeCtS OU WtUCn One IS
is seen, with the hole- **••• -*—■«•«■ »»»- ~~»~i» «f *i— . — .- ui — i. * is...... :» r 1 r . ._•..«..« « .«
cards.
les that steady the catch of the rear block to adjust it for any number of gathering data, but at first all Cards may Stand
under the single alphabet, if desired.
In libraries the cards are made fast in place by a guard-
rod running through a hole in the bottom of each card.
A turn of the drawer knob unlocks the rod, and as it is
slipped out the card is freed. This can be applied to
our cards, but it is unnecessary.
The full outfit consists of,
we use the " directory " method by entering every
twenty-fifth name on a guide, as I have done in the identi-
ncation-and-rating-card- index to the thousands of men
examined for the civil service commission. Practically,
however, after a while we keep a small working list under
an alphabet in the front of the drawer, and under a
separate alphabet behind stand the histories which we
are not liable to need again.
Details. — The cards I am using are 6 x 6| inches,
thin, blue-ruled, with red line for headline, standing on
edge in a drawer where I look down on them at my side.
When Mrs. Bradley arrives I pick up the bunch of B's
and run them through as quickly as one does the index
of a book. For long cases cards can be fastened together
very solidly and conveniently by a Middleton Clip at
the upper right-hand corner. It is small and thin and
does not have to be punched through the paper.
Sketches or loose notes are readily pasted on the cards
or can be kept in envelopes of the exact size of the cards
provided for this purpose, at a small additional cost.
Instead of a drawer — and in any deep drawer a partition
can be fastened — a box with lid and lock can be had, but
a drawer is most convenient.
For the beginner it is especially important to start with
a system that cannot be outgrown, that is elastic, and
that will train him to orderly methods.
Reasons for this Size, Ruling, Grade of Paper, etc. —
The card is the largest that will go into the pocket-book
1,000 cards, weight No. 7506, ruled with double red line at
top, 29 blue lines -ft inch apart, not punched, costing. $4.00
1 alphabet index (A-Z guides) buff bristol board, costing. . . .95
2 blocks, the rear sliding in slot with catch, so as to set the
case for any number of cards, in a drawer 6i by 14$
inches, or longer, oak, mahogany or walnut, with han-
dle and label holder 4.50
Or box, oak, mahogany or walnut, with lock 3.50
The whole outfit costing, with box 8.00
with drawer 9.00
One may start with fewer cards, but it is best to get two
A-Z indexes. The Middleton paper fasteners can be
ordered also, or procured at a stationer's. In ordering,
specify carefully : Box with or without lock ; or drawer ;
kind of wood desired; two blocks, one with catch;
label-holder; number of cards, ruled or plain, un-
punched ; and number of alphabet guides.
Note. — I have found that this method is in use in the
Johns Hopkins Dispensary, but many details have been
bettered in these plans, as experience shows. Many
business houses employ the large cards extensively.
14s Clinton Sntarr, Bbooklyn, N. Y.
8io
MEDICAL RECORD.
[December 29, 1894
PUERPERAL FEVER.1
BY THERESA BANNAN, M.D.,
SYRACUSE, N. Y.
Puerperal fever is defined as a septicaemia developed
from the absorption of foul material through wounds
due to parturition* the most common source of such
material being the uncleanliness of the attendants.
Hence in these days of asepsis and antisepsis the physi-
cian who reports a case oi puerperal fever almost chal-
lenges the charge of gross negligence.
It will be unnecessary for me to touch on the litera-
ture of this subject, since it is the foundation of modern
obstetrics. In a city the size of this, where there is
no large maternity hospital, the infectious character of
lying-in fever is rarely brought to the notice of the pro-
fession. The following cases occurred in the Maternity
Department of one of our hospitals, being the first cases
of the kind in the history of the institution.
An outline of the care given during the puerperium
will not be out of place. The patient is prepared for
labor by a bath, a bichloride vaginal douche, and an
enema. Care is taken that the bladder is emptied. A
short night-dress is supplemented by a folded sheet tied
around the hips. Cotton stockings reaching half-way
up the thigh complete the toilet Everything about the
patient and her bed is clean. The nurses wear their
regular uniform, and the physician is dressed in a cotton
gown. The diagnosis of the presentation is first at-
tempted by external palpation, the internal examination
being made when labor is undoubtedly present. The
hands are prepared for this examination by being thor-
oughly scrubbed with soap and water — and then bathed in
a 1 to 3,000 bichloride solution. The examining finger
is protected from any contact until it enters the vagina.
Unnecessary examinations are avoided, although the peri-
neum is generally stretched to diminish the chances of
laceration. As soon as the head has cleared the vulva
one hand grasps the fundus of the uterus while the other
assists the delivery of the body. The placenta is ex-
pressed within five or ten minutes, ergot given in routine,
and a vaginal douche. A sterilized pad and abdominal
binder are applied, and the woman is removed to the
ward. Vaginal douches are given twice a day for one
week, not because it is considered necessary, but because
it seems best in a hospital. Such is the routine of the
Maternity Department, and such was the care of the two
following cases :
Case I. — L. E , aged eighteen, unmarried, pri-
mipara, had been in the hospital two or three months.
She had always been in good health and continued so
during pregnancy. Urine normal. Labor began about
midnight of July 9, 1894, and she was delivered about
7 a.m. Vertex presentation, first position. Perineum
was stretched, and laceration of first degree occurred and
was not repaired. Placenta and membranes expelled en-
tire. Everything normal until the morning of the second
day, when, at 7.30 a.m., the temperature was found 100.80
F. Four hours later the patient had a severe chill, accom-
panied by pains in the abdomen, and a temperature of
103. 20 F.; pulse, 100; respiration, 30. Ergot was given,
and two drachms of sulphate of magnesium and quinine,
grains two, £*.</., was begun. Free perspiration followed
the chill and the bowels moved freely, but at 10 p.m.
temperature had reached 104. 8° F. ; pulse, 147; respi-
ration, 56. Phenacetine, five grains, and another dose
of salts were given, hoping to produce a fall of tempera-
ture by natural channels of radiation. But the next
morning, at 7.30, temperature was 104.40 F. ; pulse,
1 20 ; respiration, 40. At 10 a.m. the uterus was irrigated
with sterilized water. This was done not because it was
indicated, the lochia being normal, the uterus hard and
not sensitive, but because I wished to protect myself
from censure, knowing well that the majority of physi-
cians would condemn such an omission. No shreds or
clots were washed out, and no odor was perceptible in
1 Read before the Syracuse Academy of Medicine, October 23, 1894.
the return flow. The double tube was used. Two hours
after irrigation the patient had a severe chill, and the
temperature went up to 105° F. Once again the uterus
was irrigated, this time with the single glass tube and a
1 to 8,000 bichloride solution. Nothing was washed oat
except a little fresh blood produced by the tube. Com-
pletely satisfied that if the source of infection was within
the uterus, irrigation was not the indicated treatment,
no other irrigation was made. The abdominal uneasi-
ness disappeared, however, after the second irrigation,
whether because of it or of the antipyrine, five grains,
which was given twice, while the two grains of quinine
were increased to five. Salines were also continued.
About this time the search for the focus of infection
disclosed three abrasions on the inner sides of the labia
minora. These were covered with a grayish exudate,
forming the so-called diphtheritic patches. Vaginal
douches of bichloride were ordered three times a day, and
the parts to be separated by iodoform gauze. Under
the two doses of antipyrine the temperature fell to
1 00. 6° F. ; pulse, 70, and remained so duriog the night.
To make an impression on the fever calomel and bi-
carbonate of soda, ten grains each, with fifteen grains of
quinine, were administered at one dose, but three hoars
later, 11.30 a. m , she had another severe chill and tem-
perature, 102.40 F.; pulse, 90. This being the third chill,
and occurring at the same time each day, a malarial
element seemed, in the absence of other factors, to be a
cause of the high temperature. Quinine was given in
large doses until cinchonism was produced. There was
no splenic tenderness nor mammary disturbance. Feel-
ing that the lacerated perineum might have some causal
influence, although it had not been covered with the
grayish patch, it was now, on the fifth day, gently scraped
and repaired. Peroxide of hydrogen was now applied
to the gray patches every three hours, and was continued
until they disappeared. At 9 p.m. the temperature
reached the highest point of the day, 1030 F. Daring
the night it remained at 1020 F., and at noon of the fol-
lowing day, when a chill was expected, there was only a
sensation of chilliness with temperature 101.40 F. This
seemed favorable; but three hours later the thermometer
recorded 1040 F. Antipyrine was employed to reduce
the temperature, and small doses of calomel and the
salines were given to keep the bowels loose.
Next day at 9 a m. temperature was 100.40 F., and at
noon 1050 F.; pulse, 100, without a chill. In spite of
antipyrine it continued 1040 F.; pulse, no, all the after-
noon until 9 p.m. Quinine in full doses and phenacetine
were used, but temperature was 103° F. all night, and
during the following morning continued to rise. With a
feeling akin to desperation all medication was ordered
stopped except salol and phenacetine, two and one-half
grains each, which were given every two hours, alternating
with phenacetine, five grains. Regular diet was given
instead of liquid. Such a step was decided upon be-
cause of the inefficiency of the treatment, which, whether
local or systemic, appeared to produce no effect on the
course of the disease. Moreover, the patient was very
comfortable, even during the highest fever. Only dar-
ing the chill did she complain of discomfort, and so in-
credible did the presence of so much fever seem that she
was watched while the temperature was being taken to
exclude trickery.
Under the salol and phenacetine, begun on the eighth
day after labor, temperature continued to fell until it
was 990 F., and remained down for one day. On the
next day, the tenth, at 9 a.m., temperature was 1030 F.;
pulse, 98, and at noon 103.40 F.; pulse, 116. Fowler's
solution was now begun, for its tonic and antimalarial
effect, quinine having been abandoned. The tempera-
ture remained at 102. 40 F. all the afternoon, and in spite
of the antipyretics, reached 1030 F. in the early morning.
It varied from 1010 to 1020 F. for the next two days and
the antipyretics were stopped. Without again reaching
ioo° F. it returned to normal, and the patient went on to
recovery, much the worse physically for her experience.
December 29, 1894]
MEDICAL RECORD.
811
Five days after the delivery of Case L, another woman
was delivered in the same room, under identical condi-
tions, and placed in the same ward with her. Though
her labor had been long and tedious, necessitating man-
ual dilatation of the os and constant attention to free the
anterior lip from the occiput, she passed a perfectly nor-
mal puerperium.
Case II. — A. H. , forty years of age, primipara,
unmarried, was delivered under the same conditions as
Case I. on August 30, 1894. She had slight pains all
day, and at 7 p. m. they became vigorous, and she was
delivered about 11 30 p.m., being a short labor for one
of her age. Everything was normal until the head
cleared the vulva, when the cord was found so tightly
around the neck that the least traction imperilled its
continuity. The head had become so elongated from
pressure that the cord could not be slipped over it, so
was tied and cut and the child extracted. There was no
laceration of the perineum.
Next day the temperature was 99-4° F.; but thirty six
hours after delivery reached 102.8 F., rising to 103.20
F. in the evening. At 3 p.m. of the following day tem-
perature was 104. 6° F.; pulse, 120. Ten grains of qui-
nine and salines were given, and the next morning tern,
perature was 101.40 F., and in the afternoon 103. 20 F.
The following day, the fifth day after delivery, tempera-
ture was 103. 6° in morning, and 105. 20 F., with pulse
1 28, in the afternoon. During this day the abdomen had
become very much distended with gas in the intestines.
Pressure discovered not the least pain in any part, and
except for the difficulty of respiration, due to the dis-
tention, the patient felt very comfortable. In the even-
ing Dr. Allen saw the case with me, and discovered a
slight bogginess in the left broad ligament. Diphtheritic
patches were sought, but not found until the following
morning.
The treatment decided upon was to give an intra-ute-
rine douche and note the effect, and to support the pa-
tient's strength by strychnia, whiskey, and peptonized
food. The lochial discharge was normal. Next morn-
ing a uterine irrigation of 1 to 3,000 bichloride was
made, which washed out two or three small inoffensive
clots. The abdominal distention had, in the meantime,
increased and was treated by turpentine enemata and
stupes, and also by turpentine per mouth. The rectal
tube was inserted also, and the tincture of nux vomica
substituted for strychnia, nevertheless the temperature
remained stationary at 104. 20 F.; pulse, 120; respira-
tion, 28 to 44. On the following day improvement by
the lessened distention was noted ; the pulse did not rise
above 120, but the temperature was 103. 40 F. in the
morning, 104.80 in the evening. The diphtheritic
patches had been treated as in Case I., but nothing seemed
to control the fever, and as the temperature was 1040 F.
the following morning, the phenacetine and salol were
given twice and temperature fell to 1010, ascending to
103.6° F. at 9 p.m. One ounce of sulphate of magnesium
was then given, smaller doses having little effect. The
temperature remained at 104 40 F. all the following morn-
ing, yielding somewhat to the antipyretics in the after-
noon. The salts having little effect one ounce of castor-
oil was given, and the salol and phenacetine administered
every two hours. Still the temperature fluctuated be-
tween 1030 to 104.80 F., with pulse 120. The oil was
repeated, and next morning, the eleventh after delivery,
temperature 99-2° F. at 9 a.m. and 104. 20 F. at noon.
This was the last rise, and patient went on to recovery.
At the first rise of temperature the patient had been
removed to the medical ward.
The Maternity Ward was thoroughly fumigated and the
labor- room furniture washed with bichloride. Within a
week two women were confined, one of whom entered
in labor. She developed two diphtheritic patches, but
had not the slightest disturbance of temperature or pulse.
The only change in care was the omission of douches
after labor.
The above cases are similar in having, as far as could
be discovered, the same cause — diphtheric patches on the
abrasions due to parturition. The fever was unusually
high in both cases, while the discomfort produced was
slight. They differ in that one case severe chills oc-
curred, while the pulse rarely corresponded with the tem-
perature ; in the other case great abdominal distention
and much cardiac disturbance were present. Both women
had emotional paroxysms, which, no doubt, somewhat
disturbed the nervous poise. The treatment, though far
from satisfactory, was in accordance with my best judg-
ment. To repeatedly irrigate the parturient canal when
not clearly indicated seemed meddlesome. Antipyretics
were not used early lest they should obscure the condi-
tion without affecting the cause. When all other treat-
ment failed to reduce the temperature, and the evils of
its constant elevation were feared, antipyretics then used
confessed failure along more scientific lines of treatment.
The preservative power of Mother Nature was not for-
gotten. Both patients received excellent care, day acd
night, from the nurses in charge, and, whatever the
cause of their illness, it would seem far removed from
neglect.
503 Wairen Street.
CASES OF MONSTROSITIES, WITH SPECIAL
REFERENCE TO THE THEORY OF MATER-
NAL IMPRESSIONS.1
By JOHN H. BARRY, M.S., M.D.,
LONG ISLAND CITV, N. V.
Medical genius and scientific investigation have done
much to make the physician of to-day feel envious of the
proud advantage he holds over the minds of long ago.
But the self same scepticism, the same disinclination
to attempt a translation of the wonderful and the mon-
strous, actuates us as actuated our forefathers, and we
pause spell- bound at the diverse manifestations of the
workings of an Infinite Being, just as they acknowledged
their inability to cope with the miraculous and myste-
rious.
Thus it is that the etiology of monstrosities is as vague
as ever, and medical pride bows in abject submission
when confronted with the task of averting the misfor-
tune, or even comforting the pangs of sorrow and dis-
tress incident upon a monstrous conception. It is with
no likelihood, then, of diverting from the well-beaten
path, but rather to furnish my quota of evidence, that
the record of the appended cases has been undertaken
for your interest and possible instruction.
Case I. Anencephalus. — Mrs. A , twenty- four
years of age, primipara, was delivered on October 18,
1893, °f 3Ln anencephalic infant, presumably full teim,
and bearing the following gross characteristics: No
frontal bone developed above supra orbital ridges, latter
marking summit of skull ; collapsed membraneous cov-
ering over? frontal area of calvaria; three segments of
dense tissue, resembling placental tissue, arising from a
common stem in the region of foramen magnum, each
segment being about the size of an almond. Bulging
eyes, frog- faced countenance; ovoid contour to chest
and trunk plainly observable while babe lies prone. Six
fingers on either hand ; six toes on either foot. Ten-
dency to apposition of plantar surfaces of feet when
brought in contiguity. Spinal column intact ; no spina
bifida : notable tumefaction of abdomen. Lived about
three minutes. No autopsy allowed.
Case II. Hernia Cerebri {Occipital Meningocele ;
Breech Presentation). — On August 29, 1894, same
mother as in Case I., delivered spontaneously what was
presumably an eight months' -foetus, bearing the follow-
ing characteristics : Frontal bone present ; marked cleft
antero-posteriorly extending from nasal process of frontal
bone to anterior fontanelle. Superior angles of either
half of frontal bone marked by delayed osseous develop-
ment, the same condition obtaining in anterior and
1 Read before Queens County Medical Society, October 30, 1894.
8l2
MEDICAL RECORD.
[December 29. 1894
posterior superior angles of parietals and anterior supe-
rior angles of occipital bone, so that each semilunar
segment going to form anterior and posterior fontanelles
contrived to form unduly large ones, into which the tip
of finger could be readily inserted. Skull development,
notwithstanding, more perfect than in Case I. Coun-
tenance nearer normal, more or less ovoid contour to
chest and trunk. Spinal column seemingly intact;
marked luxation of hip-joint in flexed position ; double
genu recurvatum ; plantar surfaces of feet clearly apposed
(talipes varus) ; six toes on either foot ; six fingers on
left hand ; five on right hand. A hernia the size of a
goose egg, and analogous in its nature to the sense of
feeling imparted by squeezing a loop of intestine, was
situated over region of foramen magnum. A smaller
hernia, the size of a hen's egg, situated over region of
upper cervical vertebrae. On attempting reduction of
larger hernia, smaller one enlarged, and vice versa.
There was also to be found a circular cleft of hard pal-
ate, about midway between alveolar process of superior
maxilla, and vault of pharynx, of about the calibre of a
thermometer case. Marked abdominal tumefaction.
In left hypochondriac region could be felt large, irreg-
ular, resisting tumor, possibly a misplaced viscus. Lived
about fifteen minutes. No autopsy allowed, but photo-
graphs obtained.
Case III. Birth-mark on Neck. — Mrs. C , aged
twenty-nine, primipara, about seven months pregnant ;
consulted me on April 24, 1894, for diffuse cervical
phlegmon, at that time unilateral. Palliative measures
were resorted to in the hope of checking suppuration,
but to no purpose. With considerable diffidence regard-
ing patient's delicate condition, chloroform was admin-
istered on April 26 th, and an incision made in right cer-
vical region, but without reaching pus of any account.
Wound was packed with iodoform gauze, and immediate
effect of operation was to diminish tension and swelling
of tumor. On morning of April 28th, tension and swell-
ing were much exaggerated over original condition, and
diffuse, deep seated adenitis of left side of neck was
clearly observable. Symptoms of septicaemia appeared
and rapidly progressed ; foetal heart-sound was looked
for with negative result. Radical operation was sug-
gested and refused, and a grave prognosis given. On
morning of April 29th labor pains came on, and the
patient was delivered, within a few hours, of a premature
foetus, presumably dead about forty- eight hours, with a
denuded, swollen, circular area about one and one half
inch in diameter in left cervical region and correspond-
ing to the site of the mother's latter formed phlegmon.
Patient went on with a temperature of 1050 F., and
pulse of 160, and died at xo p.m. of same day.
Case IV. Supernumerary Digit. — Mrs. B , forty-
two years of age, multipara, was delivered on October 4,
1894 of a female child, with last phalanx of a little finger
hanging by a slender thread from middle of fifth finger
of left hand. Specimen snipped off and here presented.
No history of maternal impressions could be elicited.
In reviewing the literature of the subject of maternal
impressions, we find recorded, in turn, all phases of mon-
strosities, some of which will bear recital in an abbre-
viated form :
x. Anencephalus attributed to maternal impressions :
Mother saw while pregnant the body of a man, the top
of whose head had been cut off in a railway accident
{University Medical Journal, Philadelphia).
2. E. Giraud, in the International Journal of Surgery ,
New York, reports a case of anencephalus which lived
twelve days, moaning constantly.
3. Same author, and Armstrong, in London Lancet ',
report cases of anencephalus with spina bifida (latter's
case, whole length of spinal column), in which mothers
were scared by just such sights while two months pregnant.
4. E. T. Shelley, in New York Medical Journal, re-
ports anencephalus, born at seven months. Brain was
represented by dark mass on child's neck and back ;
spinal canal open for some distance down back.
5. In Annual of Universal Medical Sciences, 1894, is
reported a case of occipital meningocele which lived sev-
eral days without cerebral symptoms.
6. Venables (Halifax) delivered female foetus, well
developed except head. Face depressed, ears not fully
developed ; calvaria entirely absent ; skin covered red-
dish, pulpy mass, having slight resemblance to brain.
Frontal bone rudimentary.
7. Clarke {British Meaical Journal) also showed
monster of this kind, with double genu recurvatum,
talipes, and proptosis of one eye.
8. M. M. Brown {Medical World, Philadelphia) re-
ports complete spina bifida; absence of occipital, pari-
etal, and frontal bones.
9. J. B. Elkins (Massachusetts Medical Journal, Bos-
ton) reports case of diaphragmatic hernia; lived one
hour. At autopsy, coils of intestine in left pleural
cavity, as were also spleen, pancreas, stomach, and entire
intestinal tract, with the exception of a small loop of
duodenum, ascending colon, and rectum. Left lung
collapsed ; liver had fallen downward and occupied nearly
whole of abdominal cavity.
10. Joseph Collins, in Medical Record, reports a
case of complete transposition of viscera in a foetus, and
the same is reported of a girl fourteen years of age.
11. Croon, in Edinburgh Medical Journal, reports a
case of blind intestine ; no viscera ; abdomen filled with
loose, fibrous tissue.
12. Theresa Bannon in Medical Record, June 23,
1 894, reports a case of anencephalus in which spinal cord
and nerves as far as eighth dorsal were exposed, all bone
development having been arrested in posterior spinal
arches ; all joints rigid ; defective muscular development
at umbilicus two inches in diameter.
13. Any number of cases are reported of polydac-
tylism and syndactylism.
I shall endeavor to treat of the several aspects sug-
gested by these cases ; of their etiology, in the abstract ;
of interesting points of diagnosis, with especial refer-
ence to Case I.; of their bearing, pro and con, upon the
theory of maternal impressions; of observations regard-
ing said theory ; and lastly, as to the duty of the phy-
sician toward impressionable, nervous, pregnant women.
And first as to etiology. Psychic impressions, anxiety,
grief, fear, have long been looked upon as the sheet-
anchor in our translation of the cause of monstrosities.
Further, we know that any cause tending to produce
separation of the fecundated ovum from uterine mucous
membrane, e.g., endometritis, attempts at abortion, etc.,
to be operative in producing monstrosities. Syphilis is
set down as a cause, and hydramnios as, at least, a frequent
concomitant. Regarding etiology in the abstract, we
learn that even before the ovum reaches the uterus the
mucous membrane becomes thickened and vascular, so
that its opposing surfaces entirely fill the uterine cavity.
Those changes differ in degree, but not in kind, to
those taking place at each menstrual epoch. As a result,
a distinct membrane is formed which affords the ovum a
safe anchorage and protection until its connections with
the uterus are more fully developed. Is it not possible
that in such cases as result in monstrosities this change
in the mucous membrane is not perfected, and, as a re-
sult, we' have a barren soil for the development of the
ovum ? Or again, the decidua serotina, that part of the
decidua vera on which the ovum rests, and which, nor-
mally, is characterized by its extreme vascularity and
serves the purpose of supplying nutriment to the foetus
may be imperfectly developed, and, as a result, an im-
perfect or anomalous foetus developed? The fact that
psychic impressions are more operative in the first three
months of pregnancy, during which time adhesion of
decidua vera and refiexa has not taken place, would
seem to be corroborative of this view. The division of
blastodermic membrane into epiblast and hypoblast, and,
later, into mesoblast, being imperfect or irregular from
any cause, may operate to the end of an imperfectly de-
veloped foetus, as we learn that these layers have each its
December 29, 1894]
MEDICAL RECORD.
813
special province in the formation of the foetus. The epi-
blastic membrane! going to form just those parts of the
foetus which are more frequently undeveloped in mon-
strosities must, as a matter of course, be most frequently
impaired.
As to the cases in point : Mrs. A , mentioned in
Cases I. and II. had distinct predilection for lower animal
tastes. She was much devoted during her first pregnancy
to the care of a dog and a pet rabbit, the latter of which
was to be frequently seen nestled in her lap or poised on
her shoulders. Her friends repeatedly discouraged these
attentions on her part, but to no purpose. Regarding
her second pregnancy, she studiously eschewed these at*
tentions, and her statement warrants the belief that if
impressions were potent, or operative to the end of a mon-
strous conception, they could only be found in the fact
that she was constantly upbraided with her misfortune,
and most agreeably informed that she could beget noth-
ing better than a dog.
With regard to Case III. I can only say that patient
had considerable misgivings regarding what effect any
operation might have upon her as yet unborn child, and
that, sick as she was, she apprehended disfigurement of
her baby, and inquired immediately upon its birth as to
whether it bore any birth marks.
Regarding Case IV., as already stated, no history of
maternal impressions could be elicited, save the far-
fetched one of an injury to the ankle of one of her other
children early in her last pregnancy, about which she
was considerably exercised.
Case I. proved a very interesting one in the matter of
diagnosis. Upon examination the presenting part, on
the one hand, lacked the symmetry and density of the
normal globular head; on the other hand, manifested
many points of difference from a presenting breech.
The jut of tissue arising from the region of the foramen
magnum, and referred to in the history of the case, was
a very confusing feature. It felt not unlike a prolapsed
cord, and feeling more satisfied, at best, that it was a
head rather than a breech, and being able to trace and
feel its insertion, the thought occurred whether, though
never having heard or read of it, a funis could arise from
any other situation than that of the umbilicus. The ap-
plication of the forceps lent only some vague informa-
tion, for while their easy and perfect fitting made it
more certain that a head was engaging, the supposed pro-
lapsed cord, with its point of insertion, came better into
the range of the examining finger, and was more confus-
ing and embarrassing than ever. Finally, in despair, I
acknowledged my inability to diagnose the condition, and
declared to the attendants that the case must be a freak,
which in truth, and I take no credit for saying it, proved
to be a most admirable diagnosis.
Case II. was immediately diagnosed upon the begin-
ning of labor as a breech presentation. It was born
spontaneously and unexpectedly after but a few pains.
When born, this foetus appeared to have considerably
more vitality than one reported as Case I.
As to the theory of maternal impressions, there seems to
be a general opinion among writers on the subject that a
psychic impression is more apt to produce an effect, if of
considerable duration ; that feelings of anxiety, grief, and
fear stand in closer etiological relation to the impression
theory than those of joy and delight ; that impressions
occurring during early pregnancy are more potent in re-
spect to defects of development, while impressions oc-
curring late in pregnancy are more apt to be attended
by scars or marks upon the foetus. Further, the fact of
a mother anticipating a defective child, and the state-
ment on the part of a mother made prior to birth of a
child, respecting reasons why she might expect a de-
formed or monstrous foetus are each given its respective
weight in arguments pro and con upon the plausibility
of the maternal-impression theory.
In a table of ninety most remarkable cases, published by
Professor W. C. Dabney, of Virginia, in Keating's " En-
cyclopaedia of Diseases of Children," it is observable
that a very large majority of casfsare referred to the
early period of pregnancy.
Regarding cases in aforesaid table which can be
deemed in any way correlated to those mentioned in this
paper, we find that Case IX. is that of a mother fright-
ened by a rabbit— child born with hare- lip ; two subse-
quent children normal.
Case LXXXV., mother frightened by a pet squirrel
attempting to bite her. Child born with compact mass
of hair extending from eyebrows over head and back,
and closely resembling a squirrel. Also two well de-
veloped incisor teeth. Case XC, wherein child was
born dead, with large, fresh-looking blebs correspond-
ing in site to extensive burns mother had received
thirty six hours prior to birth of child, shows consider-
able parallelism to Case III. of this paper, both as re-
gards necessary brevity of impression and the fact of
scar or mark rather than defect of development.
Regarding Anticipation on the part of Mother. — In
Cases L, II., and IV. mothers did not expect defect.
In Case III. mother did apprehend birth mark.
Regarding Duration of Impression. — In Cases I. and
II. probably long. In Case III. not longer than
seventy-two hours.
Regarding Circular Cleft of Palate.— Embryologists
say that superior maxillary processes of first branchial
arches come together during the first eight or ten weeks
of foetal life, and at the ninth week, or soon afterward,
the hard palate is closed, and on it rests the septum of
the nose. So that if Case II. is to be explained on the
theory of maternal impressions, such impression must
have taken possession of patient early in pregnancy in
order to account for circular cleft of palate.
Dr. W. T. Taylor, of Philadelphia, has reported the
case of a lady who gave birth to five children in succes-
sion, each of whom had cleft palate. In the first in-
stance defect was attributed to maternal impression.
And as defect was slighter in each successive child, it is
supposed impression was gradually effaced. And right
here is a point regarding Cases I. and II. Case II. being
doubtless nearer normal than Case I., can we find the
reason for it in the fact of a less intense causative prin-
ciple in the latter pregnancy, of a less impressionable
nervous organization on the part of the patient ?
The theory of maternal impressions, from the litera-
ture of the subject, may be summarized or epitomized,
without any claim to original observation, as follows :
Maternal Impressions. — A. (i) Are responsible for
foetal defects, or (2) are not responsible. B. (1) If re-
sponsible, then it must # be shown that impression was
made at a period of pregnancy, antedating developmental
period of deformed part. (2) If not responsible, then all
deformities are due to errors of development. C. Judg-
ment dictates latter premise untenable, as many marks
doubtless occurred late in pregnancy, when development
was practically complete. D. Long impressions more
apt to influence foetus. Short impressions less apt to
influence foetus.
Foetal Defects. — A. Mental: Due to emotional dis-
turbances; as to how caused, we know absolutely noth-
ing. As to frequency, only six out of four hundred and
forty- three cases made out in a certain statistics. B.
Bodily: Vascular, supposedly most frequent, doubtless
very frequent, but often overlooked.
In conclusion, what can be the practical import of
these, or any other observations uponnhe subject at issue ?
It seems to be the concensus of opinion that one can-
not go far wrong by assuming it to be his duty to dis-
courage morbid reflection, worriment, or apprehension
ot defective progeny in the minds of nervous, impres-
sionable, pregnant women. If the minds of our preg-
nant patients are schooled in the aversion of voluntary,
catastrophal sightseeing, are taught that it is rather the
prolonged impression that is more operative for harm, it
is just possible that monstrous conceptions might be a
less frequent misfortune.
126 Ninth Stkbbt, Long Island City.
814
MEDICAL RECORD.
[December 29. 1894
Medical Record:
A Weekly Journal of Medicine and Surgery.
GEORGE F. SHRADY, A.M., M.D., Editor.
Publishers
WM. WOOD & CO., 43, 45, &. 47 East Tenth Street.
New York, December 29, 1894.
AN ATTACK ON THE DIPHTHERIA ANTI-
TOXIN*.
A paper of the greatest interest and importance was read
at a recent meeting of the Berlin Medical Society, by
Dr. Hansemann. The paper carries especial weight be-
cause the author is announced as an assistant of Professor
Virchow's, and his work and conclusions are presumably
endorsed by the dean of modern pathology.
Dr. Hansemann comes out in flat contradiction of the
alleged properties and powers of the Bearing immunizing
serum. He asserts that in Bretonneau's diphtheria the
Loeffler bacillus is not always present, and is not its sole
cause. This view will appeal to some clinicians and
bacteriologists at least, for it is admitted that the Loeffler
bacillus is present in some very mild cases of diphtheria
as well as in apparently healthy throats, while', on the
other hand, it is also known that a streptococcus diph-
theria (or sore throat) is sometimes extremely severe and
dangerous.
Dr. Hansemann asserts that Loeffler's bacillus is found
constantly in rhinitis fibrosa, without producing diph-
theria, and that these alleged pathogenic microbes may
multiply in the throat without modifying the course of
the diphtheria. All this, we believe, will have to be ad-
mitted by pathologists who have without bias studied the
disease. Dr. Hansemann asserted further that in the
case of animals an injection of a Loeffler bacillus culture
caused not diphtheria, but a disease sui generis, the
Loeffler bacillus disease; that epidemic diphtheria had
never been observed in animals; that guinea-pigs, in
contact with diphtheria patients, had never taken diph-
theria ; but that a case is known where a cat, with which
a child suffering from diphtheria had played, had de-
veloped all diphtheria symptoms, without, however, any
Loeffler bacilli being discoverable.
He then proceeded to describe the three qualities
claimed for the antitoxin — namely, its therapeutic action,
its harmlessness, and its immunizing power. He said
that the present statistics give an erroneous impression
(as already shown by Gottstein in his recently published
pamphlet), as many children suffering from lighter forms
of throat complaints are now sent to the hospitals to
be treated with serum, thus swelling the proportion of
cured cases, which would, he said, otherwise not be
higher than the usual average. He said that the serum
injections could by no means be considered harmless, as
affections of the kidneys had frequently followed — in
one case more severe in type than had ever yet been
observed after diphtheria. He said that it was clear,
from Behring's new directions to increase the immuniz-
ing dose from sixty to one hundred and fifty unities,
that no results have yet been achieved as far as immu-
nizing goes.
The final criterium of the efficacy of the antitoxin
treatment is clinical experience. Even if Hansemann's
pathology is correct, therefore, it will make no differ-
ence provided the diphtheria patients get well
The difficulties in estimating exactly the value of a
new therapeutic procedure which comes loudly heralded
and solidly endorsed are very great. Unusual attention
is paid to every patient, greater watchfulness, more
thorough supervision, and earlier diagnosis and treatment
are always found. These factors must all be considered
in estimating the results of the serum treatment.
It would be not only a disappointment to all well-
wishers of humanity, but would be a serious blow to the
rising prestige of medical science, if, after all, the serum
treatment should fall short of its high expectations.
EVERY MAN HIS OWN EDITOR.
It is a well-known fact that many large business firms
publish a special journal to advertise their particular line
of industry. These journals are all printed by the same
house and contain the same articles, but differ in the
title page, being in one city Brown <5r* Co's Monthly* in
another Smith 6r Co.'s Magazine, etc.
According to the Medical News, an attempt to foist
this ingenious product of modern journalism upon the
medical profession is being made. A circular contain-
ing the propositions made gives these interesting de-
tails:
" First, we will get out a journal in every way as good
as the one you have in hand each month, in size, quality,
etc. We will allow you one page to be filled with your
own items of interest relating to your own doings, those
of your patients, friends, and institution, or whatever
you may choose. We will carefully eliminate the word
from the journal. Instead of it being called
the Medical Journal, as now, you may give it any
name you choose, as the Grand View Sanitarian, or The
Lewiston Medical Reporter, or whatever seems appro-
priate to you for your location and institution. In the
space now used for our motto, ' A magazine for the doc-
tor and his family,' we will print your name as local
editor, publisher, or whatever you wish.
" We shall be glad to have at any time short articles of
practical value and general interest from yourself or col-
leagues for publication in the body of the journal, which
we will insert as we find opportunity.
" In return it is hoped you will take at least one hun-
dred copies of the journal each month at $6 a hundred,
additional copies to be furnished you at the rate of 5
cents each. In no case can less than 100 copies be
sent. The pay in each instance must accompany the
order, and also copy for your local news page, and be
received at the home office by the 15th of each month.
The price we have made you is cost. (No publishing
house in the country could get you up exclusively 100
such journals as ours for less than $225.) We are able
to make this price to you only on account of the great
December 29, 1894]
MEDICAL RECORD.
815
number we issue. Our pay comes through our adver-
tising columns, which are valuable and appreciated.
" The gain to be derived by you taking hold of this
enterprise is great, we believe, beyond all proportion of
the cost. In the first place, it binds you to nothing.
You are at liberty to stop whenever you choose. You
may secure subscribers to your journal in your own
town and county. It will be worth more than the reg-
ular price and make it pay for itself in dollars and
cents. You can send other copies to desirable parties
with your compliments and attention, which will win
and hold their regard. Other copies left with your
druggist for judicious distribution will be like bread cast
upon the waters. But undoubtedly the greatest benefit
of all will be the prestige that your connection with such
a journal will give you and your institution wherever it
goes.
" In short, there is no end to the usefulness to which
doctors may and do put their journals. Please give this
matter the careful attention its importance merits.
"Very truly yours,
" The Medical Journal Co.,
" , Manager \
" P. S. — In case you do not care to furnish copy for
local page at any time, a notice with cut of your institu-
tion can occupy the space very effectively."
This plan, as will be seen, enables every doctor to have
his own journal if he wishes.
We do not think, however, that it will succeed, and
hence spare our readers any elaborate comments. The
trouble will lie in the fact that all medical journals ap-
peal to the same class of readers, and the appearance of
syndicate journals will soon be detected and exposed.
MOUTH HYGIENE.
The care of the patient's teeth is a matter too often
neglected by the medical adviser, principally, no doubt,
because of the important position the dentist now occu-
pies in relation to every well-to-do family. The vast
majority, however, of those seeking medical advice never
go near a dentist unless for the purpose of having a root
extracted. School children, the inmates of homes, asy-
lums, prisons, and even hospitals are shamefully neglected
in this particular. In most public institutions not only
is the tooth-brush unknown, but it is almost an impossi-
bility to secure proper cleansing of the teeth even in
those taking mercury, for instance, where the danger of
salivation is much increased by this neglect. Many in-
stitutions have gentlemen of the dental profession con-
nected with their boards, but the teeth are much more
apt to be overlooked than any other portion of the econ-
omy, and their every-day toilet slighted. It is, indeed,
not an uncommon experience to find those who in health
never omit the morning brush, go for days and weeks
together without proper mouth-cleansing when they are
sick— the time above all others when the brush is most
required. Of course, if the patient is too ill an antiseptic
mouth-wash may replace it in a measure. A little vol-
ume of popular essays on the care of the teeth and mouth
has just been published by Victor C. Bell, A.B., D.D.S.,
and we mention it here, not because of any new ideas or
theories it embodies, nor because of its literary merit or
beauty of illustration, for many things are more attractive
than casts of irregular teeth and pictures of false sets.
Such information as it contains, however, is most im-
portant for all to know, and if the advice given were fol-
lowed many a pain would be spared and many a tooth
saved.
The proper care of the teeth of school- children is re-
ceiving more attention in England than it formerly did,
and no little credit is due to Dr. Cunningham, of Cam-
bridge University, for his efforts in behalf of school chil-
dren's teeth and his contributions on this subject to the
Seventh International Congress of Hygiene and Demog-
raphy, and his essay on oral hygiene, for which he was
awarded the gold medal prize at the International Den-
tal Congress held in Chicago during the World's Fair.
This gentleman says that parents and schoolmasters pay
so much more attention to the quality of the child's food
than they do to an efficient dental mechanism for its
mastication, because of their ignorance of its importance
and of the advantages, both economic and educational,
to be derived from adequate attention to the teeth.
In speaking of tooth powders he says, " The principal
action should be mechanical rather than medicinal.
The powder should be very finely grained and should
contain no cuttle- fish powder, no powdered oyster- shells,
no pumice powder. It should consist of alkaline sub-
stances and contain no acid ingredients, nor such as are
capable of changing to acid in the mouth. All ferment-
able substances such as carbo hydrates are contra* indi-
cated." He agrees with Miller, that precipitated chalk
should form the basis of a powder, and also recommends
a dash of neutral or slightly alkaline soap. He also con-
siders a tooth-soap preferable to tooth-powder.
The physician needs not to be told how great is the
necessity to the economy of sound teeth, nor need we
enumerate the pathological conditions traceable to their
decay ; but all must admit and regret the shocking lack
of general information upon this important subject, and
the need for instruction, especially in the schools. We
commend therefore the diffusion of knowledge concern-
ing teeth, and if the woodcuts of artificial upper dentures,
interdental splints, cleft palates, obturators, and drills
contained in Dr. Bell's book will have the effect of fright-
ening people into an early visit to a dentist, and if in-
fants will gaze upon irregular dentition as depicted upon
page 61, and never after suck their thumbs, much will
have been gained for the cause of mouth beauty as well
as mouth purity.
HOSPITAL STAFFS AND MANAGING BOARDS.
The recurrent irritation between medical boards of hos-
pitals and the trustees shows, if nothing else, that there
is something wrong in the system as it usually exists. We
do not say that medical boards are always right and lay
trustees always wrong, but we do assert that a method of
management that provokes constant quarrelling and out-
breaks of ill-feeling is seriously at fault.
In our opinion the fault lies chiefly in the fact that the
medical staffs are not allowed sufficient share in the man-
agement. In some hospitals their advice is asked only
as a matter of form, and the rules absolutely forbid any
physician being a member of the managing board. The
capacity of physicians to manage their executive and or-
8i6
MEDICAL RECORD.
[December 29, 1894
ganizing skill, have been, we are sure, much underrated.
Few men who attain that large success which gives to
them hospital positions, do not possess considerable busi-
ness capacity. When this is combined with technical
knowledge, it makes the physician a person whose coun-
sel is eminently valuable in directing the management
of a great hospital.
If this fact were better known and more wisely appre-
ciated, we should not have a hospital scandal every year,
to fret the soul and disturb the serenity of academic dis-
cussions.
We refer to this now because Philadelphia has just been
much disturbed by hospital controversies. The Medical
News of December 8th describes a " flagrant instance
of the outrageous impertinence of laymen, in their office
of hospital trustees, in disposing of the services of physi-
cians in a dictatorial and unjust manner."
The protest of the News had little effect, for in its
issue of December 2 2d it says: "We little expected
that a more striking illustration of the same spirit would
so soon be shown, as happened the next week in Phila-
delphia. A member of the visiting staff of a great hos-
pital was displaced ignominiously and without warning,
without an official charge being made against him, or
an official opportunity being offered him for replying to
possible charges. Not even an official notice was sent
him of his summary dismissal. From newspaper reports
one learns that the reasons for this remarkable proceed*
ing were that the physician thus contemptuously treated,
in order that he might obtain blood from the patient's
finger for purposes of diagnosis and investigation, had
not given quinine to a patient so soon as he might have
done."
ONLY IMPORTED ANTITOXIN EFFECTIVE.
By resolution of the New York City Board of Health,
Drs. T. Mitchell Prudden, and Herman M. Biggs, were
requested to " prepare and submit some plan for the de-
termination of the strength and purity of the various
preparations of antitoxin which are now, or may be here-
after, offered for sale in the city of New York, so that the
public may have some guarantee that only genuine
preparations of antitoxin of proper strength are furnished
for sale."
In response to this request a report was made to the
Board of Health, in which it was stated essentially that
no trustworthy antitoxin is as yet manufactured in this
country.
They assert that it is of the utmost importance to those
who use this remedy that there should be some reliable
guarantee, for every preparation placed upon the market,
that it has been prepared by competent persons, and that
in every case it possesses the requisite purity and power.
The preparations now occasionally furnished in this coun-
try, in small quantity, by the German pharmaceutical
houses, Schering and the Farbwerke (Hochst-am-Main).
have specific guarantees as to strength and purity by bac-
teriologists of universally recognized skill and experience.
Unless some such security is afforded, it would be quite
easy for unscrupulous persons willing to commit such a
crime, to place on the market small bottles of yellowish
fluid labelled "antitoxin," containing an inefficient
amount of the healing agent, or even none at all, and
for a time at least profit by the extraordinary demand
for it, perhaps at the cost of life and at the risk of dis-
crediting a most potent and beneficent remedy.
That this is not a merely fancied and only possible
menace to the welfare of those stricken with this dreaded
disease, and so often the wards of the Department of
Health, is shown by the fact that already in the city of
New York several different preparations of alleged diph-
theria antitoxin, said to have been prepared in this
country, and wholly, so far as we can learn, without
proper guarantee of efficiency, have been furnished and
used for the treatment of diphtheria. One of these
preparations has been already subjected to the necessary
crucial tests by the Department, and found wholly inef-
ficient and inert.
It is not stated whether tests were made of the im-
ported articles.
DR. CONAN DOYLE IN CHICAGO.
No visitor to this country has received warmer hospitality
or treatment more fully commensurate with his reputa-
tion than Dr. Conan Doyle. We trust that he is not
responsible therefore for circulating stories reflecting on
the intelligence and even vanity of his hosts. The Brit-
ish Medical Journal publishes the following somewhat
weird tales of the doctor's Chicago experiences :
" He was," says the Journal, " introduced to the lead-
ing literary club of Pigstickopolis as ' Canon ' Doyle.
This led to his being mistaken for an ecclesiastical dig-
nitary, and at a breakfast given in his honor the creator
of ' Sherlock Holmes ' was considerably taken aback
by being invited tr 'ask a blessing/ He is also said
to have been overwhelmed with requests to preach in half
the churches of Chicago. He was deluged with letters
addressed to the 'Rev. Dr. Doyle/ 'Rev. Canon
Doyle/ 'Very Rev. Canon Doyle/ and, finally, by
swift promotion, 'Right Rev. Dr. Doyle.' To add to
the tribulations of the distinguished writer whom we are
still proud to claim as a professional brother, though he
has definitively exchanged the lancet for the pen, he has
been mistaken for the creature of his own imagination,
and it is said was actually invited by the Mayor of Chi-
cago to enter the service of the municipality as Chief of
the Detective Police. Such are some of the penalties of
fame."
The Philadelphia Board of Charities and Correction
has appointed Dr. Hobart A. Hare a member of the
staff of physicians at the Philadelphia Hospital, in place
of Dr. Judson Daland, who has been dropped. The
reason given for this action on the part of the board is,
that Dr. Daland is alleged to have allowed certain pa-
tients suffering from malaria to go untreated for a cer-
tain length of time in order that he might study the de-
velopment of the peculiar organism which produces
malaria. To a board capable of such action for such
reasons it probably makes very little difference what crit-
icisms may be made upon its action, but we think it
likely that the medical profession and the medical press
will not rest content without knowing more and saying
something about such a policy. — Boston Medical and
Surgical Journal.
December 29, 1894]
MEDICAL RECORD.
817
Hears of rtte $KiteetL
The Death of Dr. George A. Peters.— The following
resolutions were passed December 7, 1894, by the Medi-
cal Board of St. Luke's Hospital. " After many years of
faithful and distinguished service as Attending and Con-
sulting Surgeon of St. Luke's Hospital, the career of our
honored colleague, Dr. George A. Peters, has come to
its inevitable close. His career has been more intimate-
ly, and for a longer period, identified with the history of
this hospital than that of any surgeon ever connected
with its staff. Dr. Peters was appointed an attending
surgeon on the organization of the first medical staff of
the hospital in March, 1859. He retired from active
service in December, 1863. lie was consulting surgeon
until January, 1872, when he was reappointed on the at-
tending staff and again retired from it in December, 1887.
From that time until his death he was consulting sur-
geon, and President of this Board. During the entire
period of the existence of this Hospital, therefore, Dr.
Peters gave to it his best energies and his loyal service.
For twenty years he performed active service in the
wards, and for fifteen years he gave to his colleagues the
benefit of the ripe judgment which was the fruit of his
large experience. In his personal and professional relap
tions to his associates and subordinates, Dr. Peters al-
ways commanded confidence and respect. Toward his
patients his conduct was marked by a cheerful and sym-
pathetic spirit, and by a quaint and characteristic humor
which often dispelled gloom and inspired courage. His
work as a physician and surgeon, both in public and
private practice, was distinguished by a singularly keen
perception and alert intelligence, by remarkable readi-
ness in resources, by practical common sense, and above
all, by an earnest purpose, at any sacrifice of time and
strength, to help those who sought his skill and counsel.
The long and intimate association of Dr. Peters with the
administration of St Luke's Hospital will endear his
memory to the managers, and to his colleagues of the
Medical Board. In the history of this institution, no
one has earned more truly the commendation and the
reward promised to ' the good and faithful servant.'
" Signed, W. H. Draper, M.D.,
"Robert Weir, M.D.,
" Committee:'
Dr. Thomas B. If orris died suddenly on Friday, De-
cember 2 1 st, at his home, 106 Pennsylvania Avenue,
Brooklyn, in his sixty- third year. He came to this coun-
try from Ireland when he was a boy. He became prom-
inent in the Democratic organization in Brooklyn, and
served as Coroner, Commissioner of Charities, and Super-
intendent of the Poor.
An Outbreak of Eabies. — Sixteen persons were bitten
by a mad dog in Salem, N. J. , recently. Six of them have
been put under treatment at the New York Pasteur Insti-
tute. Of ten bitten persons three were found to be unin-
jured owing to the protection afforded by clothing.
Bacteria in Railway Cars.— Investigation of the at-
mosphere of English railway coaches shows that there
are sixteen thousand microbes to the cubic inch in the
first class, thirty-four thousand in the second class, and
seventy -eight thousand in the third-class compartments.
There is a suspicion that the railroad managers have
prompted these statistics in order to check the waning
popularity of the expensive classes.
Physicians Strike. — The physicians of the city of
Newburgh, forty in number, and of the town of Corn-
wail, recently met and passed resolutions which they pre-
sented to the Orange County Board of Supervisors, in
session at Goshen, in which they demand that the scale of
prices fixed by the Board for attendance of physicians at
coroners' inquests be increased from $$ to $ 10 for post mor-
tems and for autopsies from $15 to $30. Drs. Wooley and
Jova, a committee representing the physicians, appeared
before the Board of Supervisors yesterday and stated that
under no circumstances would the physicians act unless
the prices demanded be paid. The Board refused to
raise the rates, claiming that the price established is good
pay, and that it would be unfair to the physicians of oth-
er parts of the county to pay more to those from New-
burgh and Cornwall. The Newburgh Coroner will be
compelled to employ a doctor from one of the county
towns not in the combine at future inquests. An effort
was made to get all the physicians in the county to or-
ganize in the strike, but it did not succeed. Coroners'
inquests are very expensive in Orange County, and cost
the tax-payers from £5,000 to £7,000 a year, while the
State of Massachusetts, under a different system, is taxed
but little over three times as much per year for inquests
as this county. Yesterday the Supervisors passed a reso-
lution requesting Senator Lexow and the two Orange
County Assemblymen to advocate the abolition of the
office of Coroner by the Legislature, as provided by the
amended Constitution, and to adopt a more modern and
economical system.
Antitoxin Legislation in France. — The Paris corre-
spondent of the Medical Press writes (November 28th),
that, in view of the danger to the public likely to arise
from the uncontrolled manufacture and sale of curative
serums and antitoxin, the French Government is invited
to incorporate in the bill Regulating the Practice of
Pharmacy, a section specially dealing with this class of
remedies. In order to ensure that the horses employed
in the preparation of serum are perfectly healthy, and
generally to provide for the requisite skill and care being
brought to bear, the following clauses are proposed:
That attenuated virus/therapeutical serum, modified tox-
ines, and similar products intended to be used in the
prophylaxis or treatment of contagious diseases, can
neither be sold nor distributed gratuitously without a
personal permit to be accorded by the Government on
the advice of the Council of Public Health and the
Academy of Medicine, such permit to be temporary, and
its maintenance to be subject to the result of periodical
inspections by a special commission. The products in
question are to be sold exclusively by duly qualified
pharmacists, and each phial is to bear the source and
date of the preparation. Provided always (as the
lawyers say) that these regulations will not be held to
apply to Jennerian vaccine, whether human or animal.
The Value of Pancreas Extract in Diabetes. — Dr.
P. Watson Williams, of Bristol, England, reports three
cases of diabetes treated with extract of pancreas, and he
thinks that practically nothing can be accomplished by
this mode of treatment as at present employed.
INDEX.
Abbott, A. C, notice of book by, 788.
Abbott, George E., a snare wire receiver,
35°-
Abdomen, penetrating wound of the, 319.
Abdominal surgery, erysipelas as a compli-
cation of, 151 ; some unusual cases of,
516 ; the incision in, 440.
Abernethian Society, centennial celebration
of the, 573.
Abortion, criminal, 9 ; management of, 428 ;
medico-legal aspect of, 151; treatment
of, 353.
Abrahams, R., apex catarrh or tuberculosis,
603, 659 ; lead-poisoning and the mor-
phine habit, 599; pilocarpine in the
treatment of urticaria, 342.
Abrams, Albert, physiological pulmonary
atelectasis, 268.
Abscess, boiling treatment of, 704 ; sub-dia-
phragmatic, communicating with the
pleura, 665 ; sub-phrenic, 154.
Absinthe, the consumption of, 16.
Academy of Medicine, American, 336 ; of
New York, see New York Academy of
Medicine; of Paris, library of the, 439.
Acanthosis nigricans, 125.
Acetanilid in medicine and surgery, 153.
Acromegaly and gigantism, 640.
Adams, Robert S., Klebs- Loeffler bacillus
in healthy throats and in measles throats,
402.
Adamson, Dr. W. R., death of, 49.
Adeno-carcinoma of the skin starting in the
sweat-glands, 86.
Adrenals, tuberculosis of the, without bronz-
ing, 552.
Advertise, a new way to, 531.
Aiken, Hugh K., epilepsy at times a blad-
der reflex, 556.
Aiken, William F., an improved phoroscope,
Six. t
Albuminuria in foot-ball players, 769 ; meth-
od of testing for, 414.
Alcohol and sunstroke, 39.
Alexander, Dr. Reid, death of, 660.
Alexander's operation, ten years' experience
with, 33.
Alger, Ellice M., two common forms of
alopecia and their treatment, 536.
Alopecia, two common forms of, and their
treatment, 536.
Amaurosis, quinine, 219.
Amblyopia, toxic, 45.
Ambrose, Daniel R. , a rare case of sclero-
corneal stab, 360.
Ambulance, a private, 405 ; an electric, 337.
Ameer of Afghanistan, physician to the
household of the, 128.
Amenorrhea after oophorectomy, 94.
American Academy of Medicine, 336.
American Association of Genito-urinary Sur-
geons, 116.
American Association of Obstetricians and
Gynecologists, 440.
American Climatological Association, 120,
181.
American Dermatological Association, 86.
American Electro therapeutic Association,
469.
American Gynecological Society, 79.
American Laryngological Association, 21, 58.
American Medical Association, section on
obstetrics and diseases of women, 147 ;
section on practice of medicine, 310 ;
section on surgery, 152.
American Neurological Association, 88, 179.
American Orthopedic Association, 143.
American Pediatric Society, 84.
American Physiological Society, 53.
American Public Health Association, 472.
American Surgical Association, 82.
Amputation, modern, contribution to the
study of, 546; near the ankle, 27.
Amyl, valerianate of, 623.
Anaemia, pernicious, new cure for, 531.
Anaesthesia, by cerebral pressure, 57; by
ethyl bromide and chloroform, 560;
new agents to produce, 1 1 1 ; posture in
accidents during, 539; the German
commission of, 50; to celebrate the
discovery of, 378 ; use of ethyl bromide
for, in France, 128.
Anaesthetic, origin of the term, 736, 799*
Anaesthetizers, a plea for public, 239.
Anastomosis, intestinal, with Murphy's but-
ton, 763.
Anatomical material, collection and preser-
vation of, 543* 639.
Anatomy, plea for the better teaching of, 153.
Andrews, Dr. Judson B., death of, 177.
Aneurism, intracranial, 782; of the basilar
artery, 573 ; of the aorta, latent, a dis-
tinguishing sign of, 123.
Animal extracts, therapeutic value of, 431.
Angina pectoris, 151.
Angioma serpiginosum, 87.
Announcements, medical, in the press, 627.
Anophthalmia defectus oculorum, 565.
Anthrax in London, 241.
Anti-diphtherin of Klebs, 192.
Anti-opiate Society, 438.
Anti-phthisin of Klebs, 783.
Ant is, a group of, 416.
Antiseptic surgery, points to be remembered
in the practice of, 333.
Antitoxin, diphtheria, an attack on the, 814 ;
only imported effective, 816; legislation
in France, 817.
Anti- vaccinationists, dangerous, 351.
Anti-vivisection absurdities, 64, 209, 627.
Antrum of Highmore, early operation in
diseases of the, 59 ; follicular odontoma
* invading the, 59 ; sarcoma of the, 312.
Anus, fistula and fissure of the, 153.
Aorta, a distinguishing sign of latent aneu-
rism of the, 123 ; atheroma of the, 664.
Apex catarrh of the lungs, 369, 509, 602,
659.
Aphasia, syphilitic, 623.
Apium graveolus, therapeutic employment
of, 75-
Apoplexy, infantile, and infantile paralysis,
146.
Apothecaries, female, 800; prescribing by,
764.
Appendicitis, 308 ; an unusual case of perfor-
ating, 463 ; cases of, 441 ; acute, med-
ical aspect of four recent cases of, 421 ;
acute, surgical aspect of four recent
cases of, 424 ; notes on, 689 ; prema-
ture delivery of a dead child induced
by, 678 ; treatment of, 301 ; tubercu-
lous, 462.
Appendix, palpation of the, 635.
Armatage, George, notice of book by, 597.
Army, annual report of the Surgeon- General
of the, 695 ; reduction in the medical
service of the, 241, 784.
Arteries, ligation of, 793.
u As others see us," 335, 415.
Ascites, echinococcus cyst simulating, 107.
Ashmead, Albert S., beriberi on the bark
Robert S. Patterson at Perth Amboy,
N. J., 652 ; cause of beriberi, 768 ; in-
troduction of leprosy into Japan, 255 ;
the immune serum of the goat, 702 ; two
more cases of preventive inoculation of
immunized scarlet -fever blood serum,
351.
Asphyxia, tractions on the tongue for, 141,
454.
Ass, the serum of the, in tuberculosis, 466.
Association of American medical colleges,
318.
Association of American Physicians, 23, 91.
Asthenopia, muscular, treatment of, 26.
Asthmas, reflex, 202.
Ataxia, 251.
Atelectasis, physiological pulmonary, 268.
Atheroma of the aorta, 664.
Athletics, college, 528.
Atkinson, William, notice of book by, 500.
Aulde, John, a modern idea in scientific med-
icine, 165.
Autopsy, a bureau of, 534.
Axilla, lead-pencil in the, mistaken for fract-
ured clavicle, 763.
B
Babes, Victor, notice of book edited by, 307.
Babies, summer comfort for, 42.
Bacteria, effect of various metals on the
growth of, 23 ; in the eye, 754; in rail-
way cars, 817; in the water of Lake
Ontario, 472 ;. modifications of, in mixed
cultures, 23.
Bacterial growth and formation, 313.
Bacteriology, dangers of practical, 560 ; of
hospital bed-cards, 639.
Baginsky, Adolf, treatment of diphtheria,
with special reference to the efficacy of
antitoxin, 417, 727.
Balfour, George William, notice of book by,
59*.
Balfour, Mr. Arthur, on science, 189.
Bancroft, Dr. Joseph, death of, 275.
Bannan, Theresa, puerperal fever, 810.
Barry, John H. , cases of monstrosities, with
special reference to the theory of ma.
ternal impressions, 811.
Bartley, E. H., notice of book by, 503.
Baruch, Simon, the rationale of hydrothera-
Basedow's disease. See Exophthalmic goitre.
Bashore, Harvey, bathers' cramp, 285.
Basilar artery, aneurism of the, 573.
Bathers' cramp, 285, 478.
Baths in inflammatory affections in children,
284.
Beard, George M., notice of book by, 758.
Beck, Carl, statistical facts and inaccuracy,
94-
Beebe, Alfred L., diphtheria and pseudo-
diphtheria, 385,
Beer in lunatic asylums, 381 ; praise of,
592 ; the consumption of, 332, 635.
Bellamy, Russell, a typhoid fever bed-bath ap-
paratus, 253.
Benedict, A. L., the resorcin test for free
hydrochloric acid, 638.
Beriberi, 182; and beans, 734, 768; cause
of, 768 ; in a Dublin asylum, 541, 572,
720 ; in New Jersey, 626, 652.
Bernard, Claude, a statue to, 336, 658.
Bicycle, medical views concerning the use of
the, 159, 188, 496, 5281 543» 5*3, 67i-
Biggs, Hermann ML, report to the New
York City Health Department on the
use of bacteriological examinations for
the diagnosis of diphtheria, 321.
December 29, 1894]
INDEX.
819
Bile, digestive action of, 18.
Billings, John S., report of vital statistics by,
277.
Bissell, Mary T., notice of book by, 504.
Bistoury, an aseptible, 670.
Blackwell, Elizabeth, notice of book by, 211.
Bladder, brain centres of the, 55 ; choice of
operation for stone in the, 1 16 ; excision
of, for epithelioma, 162 ; exfoliation of
mucous and submucous coats of, preceded
by renal and vesical calculus, 117 ; lac-
eration of the, complicating fracture of
the pelvis, 72 ; papilloma of the, 164 ;
relation of residual urine to irritation of
the, 762 ; removal of stone in the, 83 ;
rupture of the, 347, 765 ; tuberculosis of
the, lactate of cocaine in, 224 ; tumors
of the, 153. See also Cystitis.
Blair, Louis E., some further observations
on reflex asthma, 202.
Bleyer, Jf. Mount, the phonograph, its
physics, physiology, and clinical import,
261.
Blindness, prevention of, 150.
Blood corpuscle, red, amoeboid movements
°ff 173 ; red, caryocinetic changes in,
494; nucleus of the red, 669; third,
value of, in tuberculosis, 41.
Bloomingdale Asylum, house-warming of the,
498.
Blumenthal, Oliver A. , Politzer's opinion on
medical education in America, 191.
Boas, I. , notice of book by, 503.
Bogle, J. C, Must the parson pay ? 3a
Bones, mineral matter in, 480.
Book Notices :
Abdominal Surgery, Text-book of, by
Skene Keith, 501.
Alkohol als Genuss-und Arzneimittel, von
A. Jaquet, 504.
American Gynecological Society, Trans-
actions of the, 503.
Anatomie und Physiologie, Jahresbericht
iiber die Fortschritte der, 276.
Anatomy and Physiology, Text-book of,
for Nurses, by D. C. Kimber, 597.
Anatomy, Essentials of, by C. B. Nan-
crede, 211.
Anatomy, Manual of Practical, by D. J.
Cunningham, 277.
Appendicitis, a Treatise on, by G. R.
Fowler, 503.
Aseptic Surgical Technique, by H. Robb,
501.
Association of American Physicians,
Transactions of the, 504.
Bacteriology, Directions ior Laboratory
Work in, by F. S. Novy, 597.
Bacteriology, Principles of, by A. C. Ab-
bott, 788.
Basedow, la Maladie de, by F. Chamber-
lain, 212.
Bee- hive Repertory, by Stacy Jones, 211.
Bellevue Hospital Alumni Association,
constitution of the, 502.
Biography of American Physicians and
Surgeons, edited by R. French
Stone, 276.
Boston Society of Natural History, Me-
moirs of, 502.
Braithwaite's Retrospect, 277.
Bucharest, Annales de PInstitut de Patho-
logic et de Bacttriologie,' edited by
Victor Babes, 307.
Census Report, Vital Statistics of New
York and Brooklyn, by J. S. Bill-
ings, 277.
Chemistry, Text-book of Medical and
Pharmaceutical, by E. H. Bartley,
SOS-
Children, Care and Feeding of, by L. E.
Holt, 500.
Children, Text-book of the Diseases of,
edited by L. Starr, 276.
Clinical Medicine, by J. S. Bury, 596.
Clinique Th6rapeutique, Precis de, par
A. F. Plicque, 502.
Dermatologische Zeitschrift, edited by O.
Lassar, 276.
Dermatology, Practical Lectures in, by
C. W. Cutler, 212.
Dictionary of Medicine and Allied Sci-
ences, by A. Duane, $96.
Book Notices :
Dictionary of Medicine and Allied Sci-
ences, by G. M. Gould, 503.
Electrolyse linlaire, traitement des
Retr^ciseraents par, by J. A. Fort,
• 212.
Embryology, a Bibliography of Vertebrate,
by C. S. Minot, 502.
Embryology, Human, Syllabus of Lect-
ures on, by W. P. Man ton, 758.
Genito-urinary Diseases, Syphilology, and
Dermatology, System of, edited by P.
A. Morrow, 597.
German, Practical System of Studying,
by Albert Pick, 211, 758.
Gonorrheischc, wann Dtirfer, Heirathen,
von E. Saalfeld, 504.
Gynakologische Anatomie, von C. H.
Stratz, 502.
Gynecology, a Text-book of, by J. C.
Wood, 211.
Heart, Congenital Affections of the, by
George Carpenter, 212.
Homoeopathy, American Institute of, 502.
Homoeopathy, Sharp's Tracts on, 503.
Homoeopathy, the Truth about, by W.
H. Holcombe, 307.
Horse, the, by George Armatage, 597.
Hospital and Charities Annual, by H. C.
Burdett, 307.
Hospitals, Establishment and Mainten-
ance of Small, by A. Worcester and
William Atkinson, '500.
Hydatid Disease, by J. D. Thomas, 277.
Hygiene, Manual of, by Mary T. Bissell,
5°4.
Index Catalogue of the Library of the
Surgeon - General's Office, United
States Army, 307.
Inebriety or Narcomania, by Norman
Kerr, 501.
Injured, Prompt Aid to the, by Alva H.
Doty, 276.
Insanity, Outlines of, by Francis Walms-
ley, 212.
Jewish Method of Slaughter, by J. A.
Dembo, 500.
Laryngological Association, Transactions
of the, 277.
Lepre, by Jules Goldschmidt, 596.
Leuksemie, die Behandlung der, by H.
Vehsemeyer, 212.
Lunacy, Fifth Annual Report of the New
York State Commission in, 788.
Lungentuberculose, Behandlung mittels
Koch'scher Inject ionen, by E. Thor-
ner, 277.
Macrobiotic, by J. Hensel, 502.
Magenkrankheiten, Diagnostik und The-
rapie der, von I. Boas, 503.
Materia Medica, Pharmacy, Pharmacol-
ogy, and Therapeutics, by W. Hale
White, 758.
Medical Record Visiting List, 758.
Medical Society of the State of New York,
Transactions of, 597.
Medicine, Flint's Treatise on the Prin-
ciples and Practice of, revised by F.
P. Henny, joi.
Medicine, Practice of, by E. M. Hale,
307.
Microscopy, Handbook of Medical, by J.
E. Reeves, 502.
Nervenkrankheiten, Lehrbuch der, by H.
Oppenheim, 277.
Nervous Diseases and Insanity, Essentials
of, by J. C. Shaw, an.
Neurasthenia, Practical Treatise on, by
Beard and Rockwell, 758.
New York State Medical Association,
Transactions of the, 307.
Nose and Throat, Diseases of the, by F.
DeH. Hall, 596.
Nursing, Handbook of Obstetric, by Haul-
tain and Ferguson, 500.
Ohio State Medical Society, transactions
of the, 788.
Ontario, Annual Report of the Provincial
Board of Health of, 788.
Orthopedic Surgery, Practical Treatise on,
by J. K. Young, 596.
Osseous Deformities of the Head, Face,
Jaws, and Teeth, by E. S. Talbot,
276.
: du Canada,
Book Notices :
Pachyderma Laryngis, by W. Sturmann,
211.
Pain in itsNeuro-pathoIogical Diagnostic,
Medico- legal, and Neuro- therapeu-
tic Relations, by J. L. Corning, 500.
Pelvic Surgery, Manual of Nursing in, by
L. S. McMurtry, 211.
Pharmacy, Essentials of, by L E. Sayre,
212.
Physiology, Essentials of Chemical, by W.
D. Halliburton, 212.
Physiology, Human, by J. Thornton, 502.
Physiology, Human, a Manual of, by J.
H. Raymond, 788.
Physiology, Laboratory Manual of, and
Urine Analysis, by J. H. Long, 597.
Praticien, Vade. Mecum du, par F.
Roux, 503.
Sanitary Reports, Weekly Abstract of,
vol. viii., 307.
Senile Heart, by G. W. Balfour, 596.
Sex, Human Element in, by Elizabeth
Black well, 211.
Skin, Diseases of the, by Malcolm Morris,
joo.
South Carolina Medical Association,
Transactions of the, 502.
Surgery, a Retrospect of, by F. J. Shep-
herd, 277.
Systeme nerveux, Nouvelles Ide'es sur la
Structure du, by S. K. Cajal, 277.
Tabes Dorsalis, Untersuchungen iiber, by
E. Leyden, 277.
Therapeutics, Principles and Practice of,
by H. C Wood, 758.
Therapeutics, Text-book of Practical, by
H. A. Hare, 504.
Throat, Clinical Manual for Diseases of
the, by T. W. Downie, 212.
University des Etats Unis et du
by O. Laurent, an.
When all the Woods are Green, by S.
Weir Mitchell, 758.
Wizard, a Modern, by R. Ottolengui, 212.
Women, Text-book on the Diseases of, by
H. J. Garrigues, 211.
Books as carriers of infections, 320.
Boracic acid, 306.
Bosworth, F. H., ethmoidal disease, 457.
Bottome, Frank A., car sanitation, 638;
etiology and prophylaxis of tuberculo-
sis, 721.
Bradshaw lecture, the annual, 701.
Brain, abscess of the, 220 ; action of chloro-
form on the, 791 ; acute softening of the,
101 ; concussion of, 152 ; ingravescent
hemorrhage in the, treated by ligature
of the common carotid artery, 1 80 ; loca-
tion and physiology of the visual cere-
bral centre, 679, 800; operations upon
the, 309 ; surgery of the, notes on, 43 ;
traumatic lesions of the, 760 ; trephining
for traumatic clot, 344 ; tumors of the,
non-operative treatment of, 90.
Brandenburg, F. D., the successful treat-
ment for the restoration of the injured
female pelvic floor, 488.
Bread and butter, dangers of, 626.
Bread, sterilization of, 416.
Breast, cure of cancer of, by radical opera-
tion, 225 ; improved method of radical
operation for cancer of, 746, 764 ; sim-
ultaneous appearance of cancer in the
uterus and the, 793 ; tumors of the, 246,
380.
Brewster, J. D., the recent typhoid epidemic
at Windsor, Vt., 647.
Briggs, M. D., an unusual accident to the
respiratory tract, 173.
Bright's disease, insanities of, 437.
British army, venereal disease in the, 142.
British Institute of Preventive Medicine, 189.
British Medical Association, 213, 222, 243,
278.
British Scientific Congress at Oxford, 286.
Brockway, Dr. William Gay, death of, 728.
Browne, Dr. John Mills, obituary of, 757.
Brown, Sanger, provisional treatment of in-
sanity, 299.
Brown-Sequard, last illness of, 32.
Brush, Dr. George R., death of, 728.
Bryant, Mr. Thomas, Hunterian lecture by,
666.
820
INDEX.
[December 29, 1894
Bull, William T., cure of carcinoma of the
breast by radical operation, 225.
Bullets, explosive power of modern, 41a
Bullitt, James B., a case of face presentation
with rotation into the sacral cavity, 136.
Billow, Hans von, brain of, 648.
Bunch, Mr. F. V., death of, 572.
Burdett, Henry C, notice of book by, 307.
Burial, premature, false report of, 382.
Burns from water-bags, 497.
Bury, Judson S., notice of book by, 596.
Butter and bread, dangers of, 626.
Butter, tuberculosis in, 437.
Cadwallader, Rawlins, malaria and drinking-
water, 767.
Caecum, opening the, in cases of rectal can-
cer, 765.
Cajal, S. R., notice of book by, 277.
Calculi, biliary, resume* of the subject of, 729,
749; vesical, choice of operation for,
116; vesical, removal of, 83.
Canada, influence of the climate of, on
health, 475.
Canadian Medical Association, 308.
Cancer, cause of, 96, 647 ; cinnamon in the
treatment of, 407, 636 ; discussion on,
1 52 ; galvanism in, 470 ; houses infected
by, 192; inoculability of, 724; of the
bladder, excision for, 162 ; of the breast
and uterus, simultaneous appearance of,
793 ; °f tne breast, cure of, by radical
operation, 225 ; of the breast, improved
method of radical operation for, 746,
764 ; of the colon, excision of the, 763 ;
of the gall-bladder, relation of cholelithi-
asis to, 781 ; of the liver, stomach, and
lungs, 184; of the oesophagus, 185; of
the rectum, resection for, 763; of the
stomach, 154, 186 ; of the stomach, chlo-
rate of sodium in, 207 ; popular belief in
the use of clover for, 376 ; relief of the
pain of, 511; supposed germ of, 142 ;
treatment of, with toxines of erysipelas,
82, 310; various specimens of, 709.
Cancer-cells, examination for, in living tis-
sue, 351.
Carbolic acid, poisoning by, 22a
Carbuncle, treatment of, 731.
Card index as adapted to history-taking in
private practice, 808
Cardiac pleurogram, 56.
Carlton, Th. B., leprosy in India, 479.
Carpenter, George, notice of book by, 212.
Carriage for medical men, 440.
Carroll, C. H. , Must the parson pay ? 477.
Cartwright, Silas S., the treatment of
quinsy, ill.
Castration for hypertrophied prostate, 760 ;
for masturbation, 534; for tuberculosis,
163 ; implantation of an artificial testis
after, 164.
Cataract, lid elevator in operations for, 287 ;
traumatic treatment of, 761.
Catarrh, aural and laryngeal, intra-nasal
growths as factors in, 204.
Catgut, sterilization of, by heat, 318.
Catharsis by means of hypodermic injections
impossible, 542.
Cattle quarantine station, 306.
Caverly, C. S., history of an epidemic of
acute nervous disease of unusual type,
673-
Celery, therapeutic use of, 75.
Cells, staining of living, 371.
Cellular therapy, 165.
Cellulitis, orbital, abortion of a case of, 564.
Cemeteries, gold mines in, 314.
Census of London, 315.
Centenarian, death of a, 159.
Cerebrospinal fluid, lumbar puncture for re-
moval of, 90.
Cerebrospinal meningitis, 157.
Chamberlain, Frederick, notice of book by,
212.
Chapin, Henry Dwight, a plan of infantile
measurements, 649.
Chapman, W. Louis, Is bathers' cramp a
popular fallacy ? 478.
Charcot, Professor J. M., proposed mon-
ument to, 562.
Charcot's disease, resection of the knee for,
538.
Chase, Dr. Charles T., death of, 728.
Chelsea Hospital for Women, trouble in the,
190, 222, 316, 541, 572, 665, 701.
Chicago, healthfulness of, 639 ; hospitals in,
43»-
Children, baths in inflammatory affections
in, 284 ; insurance of, a protest against,
142 ; treatment of typhoid fever in, 435 ;
tuberculosis in, 374 ; typhoid fever in, 1.
China, medical education in, 140, 638.
Chloral, poisoning by, 666.
Chloroform, action of, on the brain and
spinal cord, 791 ; death from, in Mel-
bourne, 142 ; points in the administra-
tion of, no; the Hyderabad commis-
sion on, 158, 189.
Chlorosis, tissue metabolism in, 46.
Chlorotic girls, breakfast for, 542.
Cholecystenterostomy with Murphy's but-
ton, 283, 339.
Cholecystotomy, an ideal, 763; and chole-
cystectomy for stone impacted in the
cystic duct, 554.
Cholelithiasis, 708 ; relation of, to primary
carcinoma of the gall-bladder, 781.
Cholera,' cause of, 446 • insolated cultures
of. 515; preventive inoculations against,
78, 210, 337 ; the epidemic of, 114, 142,
177. 190, 209, 242, 275, 282, 286, 306,
3i6, 337, 38f. 477, S05, 533. S61, 608,
672 ; transmission of the spirillum of,
by the house-fly, 38 ; value of quaran-
tine against, 704; the comma bacillus
in, 621.
Chorea, quinine in the treatment of, 760.
Christian science, 25, 175, 736.
Church Sanitary Association, 672.
Circulation time in organs, 55.
Circumcision, dangers of unclean surgery in,
6i9» 702 J results from, 173, 342, 593,
761.
Clark, L. Pierce, tabes dorsalis in a woman
twenty-three years old, 379,
Clavicle, fracture of, lead pencil in the axilla
mistaken for, 763.
Clay, Professor John, death of, 125.
Cleanliness, inculcation of, in schools, 582.
Cleaves, Margaret A., a new electrode for
hydro-electric applications of the con-
stant current, 252; electric light as a
diagnostic and therapeutic agent, 7 16.
Clergymen, payment for medical attendance
fy> 30. 477, 668.
Climate in therapeutics, 317, 505.
Clinic, a model surgical, 608.
Clover, popular belief in, as a remedy for
cancer, 376.
Club-foot, an astragalus removed from, 156 ;
anatomy of, 193; cure of, in adults,
145 ; elastic traction in the treatment
of, 145.
Coal-tar, medicaments derived from, 351.
Cocaine, a new method of local anaesthesia
by, 174.
Cold, therapeutics of, 755.
Coleman, Warren, tuberculosis of the ad-
renal bodies unaccompanied by bronz-
>g, 552.
Colic, pancreatic, 623.
Colleges, mushroom, 466.
Collins, Joseph, some recent measures in the
treatment of epilepsy, with special ref-
erence to the use of opium, 355.
Collyer, Herman L., a pocket pelvimeter,
287.
Colorado, meteorological data of, 181.
Comegys, C. G. , baths in inflammatory affec-
tions in children, 284.
Commissions given and received by doctors,
593-
Communion cups, individual, 272, 736.
Commutator, a short-circuiting, 57.
Congress of American Physicians and Sur-
geons, 21, S3, 70, 116, 143, 179.
Conjunctivitis, diphtheritic, 783.
Conklin, W. J., splenectomy, with report
of a successful case, 103.
Conn, H. W., the "oyster epidemic" of
typhoid fever at Wesleyan University,
743.
Constipation, mechanical treatment of, 591 ;
treatment of habitual, 697.
Constitutional Convention, report of the
committee of the New York Academy
of Medicine appointed to confer with
the, 606.
Contagious diseases in tenements, placarding,
576 ; weekly statement, 30, 65, 94, 128,
159, 191, 224, 256, 288, 318, 351, 383,
416, 448, 479, 511, S42, 606, 638, 670,
703, 736.
Contract medical practice, 192.
Convulsions, high temperature during, 495.
Cooke, Professor Josiah Parsons, death of,
?o6-
Cordier, A. H. , surgical problems in intra-
pelvic and abdominal diseases, 419.
Corion, cystic degeneration of the, 730.
Cornea, ulcer of, treatment by general prac-
titioner, 28.
Corning, J. Leonard, notice of book by, 500,
Coroner system and the State constitution,
114.
Corset, opposition to the, 466, 704.
Cough, simple remedy for, 382.
Counter-prescribing by druggists, proposal
to legalize, 64.
Craig colony for epileptics, 407, 630.
Craig, Thomas C, transmission of the chol-
era spirillum by the intestinal dejecta
of the house-fly, 38.
Cranio- tabes, 312.
Crary, George W., thyroid treatment of
psoriasis, 427.
Cremation, advantages of, 446 ; in England,
651.
Creosote in phthisis, 121.
Cretinism, sporadic, 570.
Cretins, skulls of, 63.
Crime, defective vision in relation to, 569 ;
relation of education to, 639.
Criminal psychology, 296.
Cross, W. A., a case of lymphadenoma
(Hodgkin's disease) accompanied by
features characteristic of myxcedema and
others suggestive of acromegaly, 269.
Crossfield, Fred. S., tuberculosis of the
larynx and pharynx, 411.
Croup and diphtheria, 26.
Cunnane, W. B., a case of fracture of the
pelvis, fracture of the femur, and lacer-
ation of the bladder — recovery, 72.
Cunningham, D. J., notice of book by, 277.
Current, constant, physics and current dis-
tribution of, 469.
Cushing, Clinton, some unusual cases of ab-
dominal surgery, 516.
Cutler, Condict W., notice of book by,
212.
Cyanide of potassium, a large dose of, 29 ;
nitrate of cobalt as an antidote to, 512.
Cyanodide or ferrocyanide of potassium,
256.
Cyanosis, a case of, 85.
Cystitis and pyelonephritis due to the colon
bacillus, 119; causation of, 238. See
also Bladder.
Czar, illness and death of the, 439, 531, 727,
736.
Dabney, Dr. William C, death of, 337.
Dalrymple, F. W., is malaria a water-borne
disease ? 604.
Daly, W. H., some practical observations on
so-called malaria being a water-borne
disease, 327, 702.
Dana, Charles L. , on the new use of some
older sciences, 737.
Danielssen, Dr. Daniel Cornelius, death of,
274.
Dare, Dr. Charles H., death of, 408.
Davis, Dr. George W., death of, 407.
Davy-Faraday research laboratory, 189.
Dawbarn, Robert H. M., an aseptic and
really surgical pocket-case, 735.
Dead, innocuous transportation of the, 473.
Deaf, oral education of the, 725.
Deafness, otic gymnastics as a cure for, 128;
relief of, by freezing the anchylosed os-
sicles, 384 ; removal of the ossicles for
the relief of, 761.
Death by electricity, 471 ; preventable,
566; signs of, 159.
December 29, 1894]
INDEX.
821
Death-rate, decreasing, in New York, 498 ;
and race, 542.
Degeneration and genius, 131, 242; and its
stigmata, 737.
Delirium tremens, traumatic, 246.
Delivery, version three weeks before, 733.
Dembo, J. A., notice of book by, 500.
Dentistry, instruction in, in France, 192.
Dermatitis, epidemic, 301 ; exfoliative, 540.
Dermographism, 301.
Diabstes, a family history of, 173 ; condi-
tion of the heart in, and its relation to
diabetic comi, 123; cramps in the legs
in, 416 ; the value of pancreas extract
in, 817.
Diagnosis, the face in, 511.
Diaphragm, abscess beneath the, communi-
cating with the pleura, 665 ; hernia of
the, 790.
Diarrhoea, treatment of, 440.
Dickinson, George S., a comparative study
between the results obtained by exami-
nation of the stomach contents by means
of a stomach tube and Einhorn's stom-
ach-bucket, 331.
Dickinson, Robt-rt L, the card index as
adapted to history taking in private
practice, 808.
Dickson. Dr. Walter, death of, 766.
Diet, effect of the mother's, upon the nurs-
ling, 300.
Digestion, part of the bile and Briinerian
glands in, 18.
Diphtheria, an historical case of, 672 ; and
croup, 26 ; and pseudo-diphtheria, 220,
385; antitoxin treatment of, 241,275,
288, 305, 375, 377, 417, 4i8, 439. 53;,
540, 562, S9«, 595, 59^,609, 613, 628,
629, 631, 696, 727, 741, 786 ; bacterio-
logical examination in the diagnosis of,
321 ; bacillus of, in healthy throats
and measles throats, 402 ; difficulties of
health officers in dealing with suspected
cases of, 473 ; disease of the heart in,
384; germs in cheese, 178; manage-
ment of epidemics of, in the country,
473; pastilles as a substitute for gar-
gling in the prevention of, 655 ; syringe
for cleansing the nasal cavities in, 633 ;
treatment of, 545, 570, 6S2.
Diphtheria antitoxin, an attack on the, 814.
Diploe, venous tumors of the, 83.
Dipsomaniac, power of a, 49.
Diseases, nomenclature of, 476.
Dislocation of the hip, congenital, Hoffa's
operation for, 143
Dispensary question in Cleveland, 669.
Divorce, syphilis as a ground for, 32.
Dixon- Jones, Mary A., criminal abortion, 9.
** Doc," the Nemesis of, 113.
Doctors, definitions of, 140.
Doctor** wife, some experiences of the, 336,
414.
D'Oench, F. £., an unusual case of toxic
amblyopia, 45.
Dogs. Is salmon poisonous to ? 637 ; tumors
from, 664.
Donner, Dr. Henry Hoffmann, death of,
512.
Dosimetric medication, 256.
Doty, Alva H., notice of book by, 276.
Douglas, Dr. Stuart, death of, 49S, 755.
Dowd, Charles N., some considerations on
different types of exudative inflamma-
tion, 289.
Downie, James Walker, notice of book by,
212.
Doyle, Dr. Conan, in Chicago, 816.
Drains, catgut, 636.
Drug*, new. and new names of, 68; syn-
thetic, from coal-tar, 351 ; where they
come from, 271.
Drunkenness in St. Petersburg, measures to
suppress, 672.
Duane, Alexander, notice of dictionary by,
596.
Dulles, Charles W., hydrophobia statistics
desired, 382.
Dunlap, Dr. Alexander, Dr. Reeve's me-
moir on, 208.
Dust diseases and their prevention, 47.
Dwarf, death of a, 800.
Dwight, Thomas, methods of estimating the
height from parts of the skeleton, 293.
Dyspepsia, nervous, 460, 506 ; some minor
measures in the diagnosis and treatment
of, 656.
Dystocia, induced labor in the absence of,
278.
Eastman, Joseph, the author's method of
supra-pubic hysterectomy, 284.
Echinococcus cyst simulating ascites, 107.
Eczema, hints on the treatment of, 779 ; par-
asitic theory of, 671.
Edes, Robert T. , palatable and digestible
milk, 224.
Editor, every man his own, 814.
Education, a factor in the prophylaxis of dis-
eases of women, 804 ; and crime, 639.
Electric light as a diagnostic and therapeutic
agent, 716.
Electricity, action of, on the sympathetic
nervous system, 469. 523 ; apparent
death by, 176; value of, in the diag-
nosis and prognosis of affections of the
peripheral nerves, 199.
Electrode, a new, for hydro-electric applica-
tions of the constant current, 252.
Electrolysis, metallic, 47a
Element, a new, 316.
Elmira Reformatory, investigation of the,
18, 756.
Ely, John Slade, on the relations of pathol-
ogy and practical medicine as bearing
upon the pathological departments of
our hospitals, 229.
Embden, Oscar, dangers of glycerine in-
jections into the uterus for the purpose
of inducing premature labor, 105.
Empyema, treatment of, 703.
End, is it the beginning of the ? 801.
English as a universal language, 338.
Engman, Martin F., hints on the treatment
of eczema, 779.
Enteric fever, see Typhoid fever.
Enteritis, membranous, 219, 346; mucous,
cures of, 240.
Enterolith, a case of, 341.
Enuresis, nocturnal, treatment of, 440.
Epididymis, syphilis of the, 75.
Epididymitis, tubercular, castration for, 35.
Epilepsy, 308 ; at times a bladder reflex,
556; some recent measures in the treat-
ment of, 355 ; the eye and surgical treat-
ment of, 176; traumatic, trephining
for, 765.
Epileptics, care of, in Minnesota, 628 ;
Craig colony for, 407, 630.
Epithelioma, giant-cells in. 538.
Equivalence, law of, in medical science, 310.
Erysipelas, a new treatment for, 566 ; and
tuberculosis, antagonism of, 308 ; as a
complication of abdominal surgery, 151 ;
toxin, sarcoma of the palate treated by,
616, 633.
Esquimaux, the teeth of, 509.
Estes, W. L., a contribution to the study of
modern amputation, 546.
Ether as an intoxicant, 629.
Ethics, code of, in New Jersey, 151.
Ethmoid bone, disease of the, 457.
Ethyl bromide and chloroform, anaesthesia
by, 560 ; use of, as an anaesthetic in
France, 128.
Etiquette, medical, among the ancients, 544.
Ewing, A. C, a few aphorisms relating to
obstetrics 69.
Exophthalmic goitre, 184 ; nature of, 125 ;
thyroid feeding in, 640, 671.
Explosive compounds, 160.
Eye, a source of infection in corneal abscess,
463 ; an improved cilia forceps, 350 ;
earning value of, mathematically ap-
praised, 178 ; foreign body in the, for
six years, 380 ; glasses vs. muscle-cut-
ting, 447 ; microbes of the, 754 ; rare
case of sclero-corneal stab, 360.
Eyesight, periodical testing of, in schools, 51.
Eye-strain headaches, 309.
Face, plastic operation on the, 340 ; sar-
coma of the, 156 ; the, in diagnosis, 511.
Face presentation with rotation into the
sacral cavity, 136.
Faith-cure in New Jersey, 497.
Fallopian tubes, treatment of distention of,
without laparotomy, 442.
Fast, a forty-five day, 466.
Fatigue, relation of tobacco to, 480.
Fecundity, instances of, 224, 305, 413 ; re-
wards for, 14a
Feek, Robert G., remarkable use of bicar-
bonate of sodium, 380.
Fees for medical services, 666 ; of doctors,
lawyers on the, 139.
Femur, bending the neck of the, 537.
Ferguson, J. H., notice of book by, 500.
Fever, 250 ; the man who fed, 718.
Fibula, fracture of the head of the, by mus-
cular action, 340.
Fiction, the doctor in, 704.
Fingers, losers of, 383.
Fischer, Louis, diphtheria antitoxin or
healing serum in the treatment of diph-
theria, 418, 613.
Flagg, Robert N., a painless labor, 346.
Flat-foot, 143, 247.
Flies, transmission of pathogenic bacteria
by, 38.
Flint, Austin, notice of book by, 501.
Foetus, abnormality of a, 600.
Foot, osteosis of the skin of the, 187.
Football, a game of, 728 ; albumin and casts
in the urine of players of, 769 ; as a
means of physical development, 465 ;
attractions of, for intellectual men, 499 ;
casualties and fatalities from, 853 ; perils
of, 490 ; the brutality of, 695.
Forceps, obstetrical, 149, 797.
Foreign body in the ej e for six vears, 380 ;
in the oesophagus, 731 ; in the respira-
tory tract, 173.
Formalin and bacterial growth, 313.
Fort, J. A., notice of book by, 212.
Fortunes left by doctors, 764.
Foster, Burnside, the marriage of syphilitics,
448.
Fowler, George R., notice of book by, 503.
Fracture of the head of the fibula by mus-
cular action, 340; of the lower end of
the humerus, treatment of, 152 ; of the
skull, depressed, trephining for, 345 ; of
the ulna and radius, 537 ; and sprains
of the ankle, massage in, 371 ; into
joints, fixation in the treatment of, 146.
France, measures to increase the birth-rate
in, 288; medical legislative section in,
78; new medical law in, 160; the late
President of, and his surgeons, 191.
Francis, Richard P., a case of pneumonia in
an infant five months old, treated with
inhalations of oxygen, 109.
Frank, J , tuberculosis of the frontal sinus,
553-
Fraser, Dr. John, death of, 765.
Freckles, treatment of, 305.
Freeman, Leonard, secondary suture of the
sciatic nerve, 409.
Freeman, Rowland Godfrey, Pasteurized milk
as suppUed to the poor of New York,
x33-
Friedenwald, Julius, resorcin test for the
detection and quantitative estimation of
free hydrochloric acid in the gastric
juice, 430.
Friedreich's disease, non hereditary, 171.
Frigo-therapeutics, 755.
Frost-burns, 639.
Fruit-eating, a new fad, 232.
G
Gage, Dr. C P., death of, 788.
Gage, W. V., a new treatment for erysipelas,
566.
Gall-bladder, acute biliary distention of the,
485 ; relation of cholelithiasis to pri-
mary carcinoma of the, 781 ; surgery of
the, 246, 723.
Gall-stones, resume of the subjeot of, 729,.
749-
822
INDEX.
[December 29, 1894
Gangrene, traumatic, 248.
Garbage, disposal of, 207, 475, 726.
Gardner, H. D., immediate repair of a lac-
erated cervix, 78.
Garrigues, Henry J. , notice of book by, 21 1 ;
on symphyseotomy, 577, 602.
Gas habit, 376.
Gasserian ganglion, excision of the, 703.
Gxstropexy, 692.
Generative organs, female, abnormal condi-
tions of, associated with melancholia or
mania, 135.
Genius and degeneration, 131, 242.
Germ theory, a belated assault on the, 786.
German medicine, modern trend of, 726.
German Temperance Society, 728.
Gerster, Dr. Arpad G., honors to, 594.
Gestation, ectopic, 282.
Getz, Charles, the cause of stricture in the
male urethra, 583.
Gibson, C. L., castration for primary tuber-
cular epididymitis in a patient eighty-
one years old, 35.
Gifford, H., the shady side of the surgical
treatment of trachoma, 231.
Goat, serum of, in tuberculosis, 637, 702.
Godfrey, Guy C. M., a case of orbital cel-
lulitis aborted, 564 ; the Indian woman
in labor, 69a
Gone, J. Riddle, vaginal hysterectomy by
enucleation without ligature or clamp,
691.
Goldschmidt, Jules, notice of book by, 596.
Goldstein, Samuel, a new nasal forceps, 575 ;
a new uvulatome, 314.
Goitre, electrical treatment of, 470; ex-
ophthalmic, see Exophthalmic goitre.
Gonorrhoea, fin-de-sidcle treatment of, 563 ;
in women, 789; treatment of, at the
Necker Hospital, 319.
Goodeli, Dr. William, obituary of, 595.
Gorton, Eliot, a case of insanity due to the
menstrual function — oophorectomy — re-
covery, 235.
Gould, George M., notice of dictionary by,
5<>3-
Gout, and rheumatUm, affinity of, 401 ; in-
testinal, 46.
Grandin, Egbert H., notes on appendicitis,
689.
Granular kidney, anxiety as a cause of, 658.
Graves's disease, see Exophthalmic goitre.
Greenhill, Dr., death of, 307.
Grief, emotion, and infection, 406.
Grisstm, J. D. , pseudo-rabies complicated by
delirium tremens, 341.
Groom, W. S., a large dose of morphine,
340-
Gross, M., the secretion of hydrochloric acid
by the stomach in health and disease,
490.
Grosse Isle quarantine station, 183.
Grflnhut, Dr. Bernhard, death of, 275.
Guaiacol in phthisis, 121.
Gunshot wound of the abdomen, 792 ; of the
lungs and heart, 204 ; of the spleen and
kidney, 790.
Guthrie, W. E., excision of head and four
inches of shaft of humerus, 333.
Gynecology, electricity in, 469; studies in,
26.
H
Hematocrit, an improved, 57.
Hsematometra, 282.
Hagedorn needle, a holder for the, 116.
Hairs, ingrowing, 174.
Hale, Edwin M., notice of book by, 307.
Hall, F. DeHaviland, notice of book by,
Halliburton, W. D., notice of book by, 212.
Hance, Irwin H. , use of crude tuberculin in
cows, 74.
Hand, epithelioma of the, 313.
Hare, Hobart A. , notice of book by, 504.
Harlequin foetus, 86.
Hartley, Frank, anatomy of club-foot, 193.
Hart wig, Marcell, an echinococcus cyst sim-
ulating ascites, 107.
Hat-pin, swallowing and extraction of a, 380.
Haultain, F. W. N., notice of book by, 500.
Hawkes. J. Marshall, trephining the frontal
bone for chronic headache, 237.
Hay fever, hygienic treatment vs. " ear-
rubbing" for, 284.
Head, surgical treatment of injuries of the,
760.
Headache from eye-strain, 309; trephining
for, 237.
Healey, Joseph S., some practical observa-
tions on malaria not due to drinking
well- or surface water, 477.
Health authorities, a conflict between state
and national, 275.
Health Bureau, National, 20, 27, 77, 725,
727.
Health Congress in London, 222.
Health Department of New York, new quar-
ters for the, 468.
Health officers, tribulations of, 571.
Hearing, application of the graphic method
to, 510 ; see also Deafness.
Heart, abnormalities of the, 311; action of
calcium on the, 54 ; and lungs, gunshot
wound of, 206 ; apocynum cannabinum
in disease of the, 654 ; condition of, in
diabetes, and its relation to diabetic
coma, 123 ; disease, baths and massage
in, 376 ; diseases of, in infectious fevers,
384 ; dosimetric granule tonic for the,
7 j ; enlargement of, without valvular
disease, 759 ; functional diseases of the,
24.8; idiopathic hypertrophy of the, and
degeneration of the heart muscle, 46 ;
lipomatosis of the, 796 ; pain in the re-
gion of the, after influenza, 124 ; pri-
mary tumor of the wall of the, 185 ;
Schott treatment of disease of the, 123 ;
signs of failure of the, in fevers, 653 ;
stenosis of the tricuspid orifice, 796 ;
syphilis of the, and angina'pectoris, 623 ;
the use of sedatives in disease of the,
539 ; thrombosis of the auricle of the,
796 ; valvular disease of, strychnine in,
557 ; varix of the right auricle ending in
rupture, 5 ; wild cherry as a tonic for
the, 2a
Heart-tonics, value of combining, 147.
Hedges, B. Van D., the rational treatment
of diphtheria, 682.
Heffron, John L., * study of the medical
aspect of four recent cases of acute ap-
pendicitis, 421.
Height, estimating the, from different parts
. of the skeleton, 293.
Helmholtz, Professor II . L. F.f obituary
notice of, 338.
Hemicrania, ophthalmic, 273.
Hemiplegia, infantile, craniotomy for, 180.
Hemorrhage, accidental, 280; cerebral, 90;
control of, in amputation of the arm,
703.
Hemorrhoids. 153.
Henry, Frederick C, notice of book by,
501.
Hensel, Julius, notice of book by, 502.
Hernia, discussion on, 153 ; in the aged,
246 ; radical treatment of, 442 ; treated
by the wire-mattress method, 537.
Herpes zoster, protozoa-like bodies of, 87.
Herrick, Henry J., a case of transposition
of the viscera, 10*.
Herrick, J. F., right-handedness, 495.
Heterophonia, treatment of, 26.
Hiccough, fatal, of unknown origin, 700.
Hickey, Dr. Amanda Sand ford, obituary of,
630.
Higgins, F~ W., a large dose of cyanide of
potassium, 29.
Highmore, antrum of, see Antrum.
Hill, J. SutclifTe, large dose of sulphonal for
a child, 337.
Hill, W. J., premature labor before the
sixth month — survival of the child for
one week, 344.
Himalayas, climate of the, 96.
Hinde, Alfred, a contribution to the study
of the location and physiology of the
visual cerebral centre, 679.
Hindu medicine, a revival of, 288.
Hip, Hoffa's operation for congenital dislo-
cation of the, 143 ; disease of the, acetab-
ular form of, 157 ; disease of the, in the
aged, 246.
Hochlemer, R., circumcision, Do we need
legislation for it ? 702.
Hodgkin's disease, a case of, 269.
Hoelscher, Dr. J. H., cholelithiasis, 708.
Hog cholera in Kansas, 337.
Holcombe, W. H., notice of book by, 307.
Holland, the universities of, 346.
Holmes, Dr. Oliver Wendell, death of, 465 ;
reminiscences of, 533, 590, 659, 736,
799 ; sonnet by, 628 ; the eighty-fifth
birth-day of, 275.
Holt, L. Emmett, notice of book by, 500.
Hopkins, George C, two cases of tre-
phining of the skull, 344.
Horton, D. B. , fracture of the head of the
fibula by muscular action, 340.
Horton, Thomas, an account of the late
epidemic of typhoid fever in Montclair,
N. J., 651.
Hospital, a long service as surgeon to a,
615; poisoning of the inmates of a, 552 ;
the Chambers Street, 49; stalls and
managing boards, 815.
Hospital Sunday collection in London, 19a
Hospitals, free treatment of pay patients in,
637; managing boards of, and travel-
ling healers, 113; naval, 240; New
York State, doctors wanted in the, 468 ;
pathological department of, 229.
Howell, J. Morton, treatment of carbuncle,
731-
Hubbard, Dr. Samuel T., in mcmoriam of,
159-
Humerus, excision of head and four inches
of the shaft of, 333.
Hunt, Dr. Ezra M., death of, 20.
Hunterian lecture, the annual, 666.
Hupp, John C, anomalous foetal nutrition
in twin gestation, 74, 141.
Hutchinson, Proctor S., death of, 126.
Hutton, T. J., treatment of cerebrospinal
meningitis, 341.
Hydramnion with atresia am in the child,
565.
Hydrocele, 761.
Hydrochloric acid in the gastric juice, re-
sorcin test for, 430, 638 ; secretion of,
in health and disease, 490.
Hydro-electric therapeutics, 470.
Hydronephrosis, etiology and treatment of,
138.
Hydrophobia, death from, 50 ; Pasteur on,
52; pseudo-, complicated by delirium
tremens, 341 ; statistics on, desired,
382.
Hydrosalpinx, 443.
Hydrotherapy, the rationale of, 519.
Hygiene, address on, 27 ; and demography,
International Congress of, 446 ; awards
at the International Exposition of, 52 ;
in schools, 475 ; lectures on, to legisla-
tors, 64 ; mouth, 815 ; report of the com-
mittee on, of the Medical Society of the
County of New York, 601.
Hyperpyrexia, 160.
Hypochondriasis, 486.
Hyrtl, Professor Joseph, characteristics of
the late, 141; death of, 114; reminis-
cence of the late. 355.
Hysterectomy for uretero-uterine fistula,
671; supra-pubic, 147, 284; vaginal,
by enucleation without ligature or damp,
691 ; vaginal, for cancer of the uterus,
281.
Hysteria, apomorphine in, 542 ; tongue trac-
tion in, 378.
Ichthyol, antiseptic power of, 138; efficacy
of, on inflamed tissues, 539.
Ichthyosis congenital, 86.
Idaho, State medical law in, 5C2.
Ilium, sarcoma of the, treated by erysipelas
virus, 538.
Ill, Edward J., management of abortion,
428.
Immigration, a year's, 728.
Immunity, 446.
Impetigo herpetiformis and pemphigus vege-
tans, relation of, 88.
Income-tax and professional workers, 115-
December 29, 1894]
INDEX.
823
Incorporated Medical Practitioners* Asso-
ciation of Great Britain, 63.
Incurables, opening of a new hospital for,
756.
Indian Medical Congress, 115.
Indians, labor among, 484, 690.
Indigestion, intestinal, 759.
Inebriety, influence of, on public health, 474 ;
strophantus for, 320.
Infancy, migraine in, 383.
Infant life, international congress for the
protection of, 1 14.
Infantile measurements, a plan of, 649.
Infants, infection by the bacillus pyocyaneus
as a cause of mortality in, 476.
Infection, books as carriers of, 32a
Infectious diseases, coexistence of, 238.
Inflammation, exudative, different types of,
289.
Influenza, 216; pathogenesis and treatment
°f» 7<>3 5 tachycardia and cardiac pain
after, 124 ; use of quinine in, 64a
Ingersoll, Dr. Horace, death of, 377.
In graham, Dr. Timothy M., death of, 657.
Insane, care of the, in Minnesota, 628 ; con-
ference of hospitals for the, in New
York, 532; transportation of the, to
hospitals, 76, 158,254.
Insane asylum management, Dr. Weir
Mitchell on, 48.
Insanity and crime, 177 ; from tea-drinking,
160 ; in Great Britain, 315 ; increase
of, in Great Britain, 254 ; inheritance
of, 209 ; menstrual, 235 ; physiological
epochs predisposing to, 506, 529 ; pro-
visional treatment of, 299 ; treatment of
convalescence of, 179; with Bright's
disease, 437.
Insomnia, the golf cure for, 534.
International Medical Congress, awards at
the, 210.
Intestinal indigestion, 759.
Intestines, acute obstruction of the, 790;
end to end anastomosis of, with Mur-
phy's button, 326; gout of the, 46;
laparotomy for perforating ulcer of the,
637 j micro-organisms in the, after in-
gestion of milk, 653 ; new method for
treating diseases of the. 96; occlusion
of the ileo-csecal valve by a plug of mu-
cus, 188; operative treatment of per-
forating ulcer of the, 244 ; restoration
of the continuity of the, with mechani-
cal devices, 445 ; toxins in the, 384.
Intussusception in the infant surgical treat-
ment of, 442.
Iodism, prevention of, 32.
Iron, absorption of, 461.
Italy, hygienic notes on, 472 ; university re-
forms in, 275.
j
Jacket, paper, its history and applications,
218.
Jacobi, A., an explanation and a correction,"
224.
Jacobson, Nathan, four recent cases of acut o
appendicitis considered from their sur-
gical aspect, 424.
Jaisohn, Philip, method of testing for albu-
minuria, 414.
Japan, introduction of leprosy into, 255 ;
the French language in, 96.
Japanese army surgeons, status and pay of,
533-
Jaquet, A., notice of book by, 504.
Jaundice, intra lobular occlusion, 661 ; treat-
ment of obstructive, 724.
Jeffery, Aaron, some minor points to be ob-
served in administering chloroform, 1 10.
Jejunostomy, 782.
Jennings, Charles G. R., a case of loose
cartilage in the knee-joint, 137.
Jerusalem, water-supply of, 672.
Johns Hopkins University, female education
at the, 468.
Johnson, Walter B., a case of sarcoma of
the palate successfully treated with the
toxins of erysipelas, 616, 633.
Joints, fixation in the treatment of fractures
into, 146.
Jones, Isaac I., is malaria a water-borne
disease? 701.
{ones, Stacy, notice of book by, 211.
ournals, medical, in the United States, 438.
Jurisprudence, medical, a new departure in,
625.
Kammerer, Fred., osteoplastic resection of
the sacrum, 97.
Keen, W. W., oophorectomy vs. oophorec-
tomy, 64.
Keith, Skene, notice of book by, 501.
Keloid, skin-grafting for, 174.
Kennedy, A. D., transportation of insane to
hospitals, 158.
Kerr, Norman, notice of book by, 501.
Kidney, congenital absence of one, 349 ; gun-
shot wound of the, 790; movable, 151,
792 ; relation of insufficiency of, to sur-
gical operations, 444 ; removal of a fortv-
pound tumor of the, 792; stone in
the, nephrectomy for, 732 ; surgical,
treatment of, 82, 325 ; tubercular, sur-
gical interference in, 118; uric acid
infarcts of the, 312.
Kimber, Diana Clifford, notice of book by,
597.
King, Herbert M., etiology of tuberculosis,
644.
Kissing, the curse of, 693;
Klebs, Edwin, the present status of the spe-
cific treatment of diphtheria, 741.
Knee, resection of, for separation of the
lower epiphysis of the femur, 761 ;
spring-, 237.
Knee-jerk, crossed, 88.
Knee-joint, 'etiology of deformities of the,
129, 143; loose cartilage in the, 137;
tumor albus of the, 761.
Knowles, Francis £., symptoms of poison-
ing from a probable overdose of phen-
acetin, 564.
Krieger, G. £., recent investigations of the
therapeutic value of organic fluids, espe-
cially spermine, 431.
Kumyss, poisoning by, 141.
Kunz, S., tuberculosis of the frontal sinus,
553.
Labor, a painless, 346; Indian women in,
484, 690 ; premature, before the sixth
month, 344; separation of the after-
coming head, 282; sloughing of the
cervix after, 138.
Lamkin, J. S , the relationship between
bovine and human tuberculosis, 412.
Lamphear, Annette £., cyst of pharyngeal
tonsil, 137.
Lanphear, Emory, a new aseptic trephine,
3*3-
Landes. Leonard, a case of anophthalmia
delectus oculorum, 565.
Lane, Dr. L C, gift of, to Cooper Medi-
cal College, 318.
Laparotomy, extra-median incision in, 302 ;
for pelvic disease not necessary, 762.
Laryngectomy, new method of, 60.
Larynx, carbolic acid in cysts of the, 62 ;
cockle burr in the, 60 ; extirpation of
the, 84 ; neoplasms of the, 60.
Lassar, O., notice of journal edited by, 277.
Laurent, O., notice of book by, 211.
Lead-poisoning and the morphine habit, 599.
Leeches, extract of, in the prevention of
thrombosis, 137.
Leipsic, students in, 178.
Legacy, a doctor's, 93.
Legislation of interest to physicians, 30; an-
titoxin, in France, 817.
Legislators, lectures on hygiene to, 64.
Lendon, Alfred Austin, notice of book edi-
ted by, 277.
Lepers, a missionary to, in trouble, 448 ; a
Russian colony for, 140.
Leprosy in Iceland, 672 ; in India, 479 ; in-
troduction of, into Japan, 255.
Leszynsky, William H., the value of electric-
ity in the diagnosis and prognosis of
affections of the peripheral nerves, 199.
Letters from London, 63, 93, 124, 158, 189,
222, 286, 315, 381, 477, 507, 540, 572,
636, 665, 701, 764, 799 ; from Vienna,
Leucocythaemia, new cure for, 531 ; splenic,
796.
Levien, Henry, circumcision, 619.
Leviseur, Fred. J., emergency cases of skin
diseases, 806.
Lewis, J. C. , an unusual case of perforating
appendicitis, 463.
Leyden, E , notice of book by, 277.
Liell, Edward Nicholas, nephritis of preg-
nancy and its sequelae, 368.
Life, value of, in cases of accident, 13a
Life insurance, some curious details of, 416 ;
companies, chart illustrating mortality
tables used by, 540.
Ligaments, broad, ligature and division of
the, 94.
'Lightning-stroke, 51.
Lister, Sir Joseph, award of the Albert med-
al to, 78.
Little, Dr. William J., death of, 177.
Liver, abscess of the, 156; abscess of, mis-
taken for empyema, 184 ', functional dis-
orders of the, 309 ; glycogenic function
of the, 785 ; miliary tuberculosis of the,
797; movable, 133; rupture of the,
154.
Liverpool, causes of the high death-rate of,
338-
Locomotor ataxia, 251 ; in a woman twenty-
three years old, 379.
London, letters from, 63, 93, 124, 158, 189,
222, 286, 315, 381, 477, 5<>7» 540, 572,
636, 665, 701, 764, 799 ; medical schools,
opening of the, 507 ; mortality-rate of,
125.
Long, John H., notice of book by, 597.
Longevity, 660; among physicians, 695, 733 ;
effect of alcohol upon, 563 ; in Russia,
448.
Lonsdale, Dr. Philip, death of, 274.
Loveland, Bradford C, water in diet and
therapeutics, 33a
Lucky numbers and lucky medical students,
192.
Lungs, a new disease of the, 336 ; and heart,
gunshot wound of, 206 ; apex catarrh,
509, 602, 659 ; apex catarrh of, disease
of the ear and upper air- passages in,
369 ; extreme interstitial emphysema of
the, 188 ; physical signs of oedema of
the, 182 ; surgery of the, 635 ; throm-
bosis and infarction of the, 1 55.
Lymphadenoma, with features suggestive of
myxcedema and of acromegaly, 269.
Lymphangitis, tuberculous, of the arm, 573.
M
McBrayer, L. B., pilocarpine in urticaria,
564.
McCartie, D. B., a case of fatal hiccough
of unknown origin, 700 ; hypochondri-
asis, 486.
McChesney, Willard, extra-uterine preg-
nancy, 598.
McCourt, P. J., non-operative treatment of
uterine diseases, 589.
McCullough, John W. S., results from cir-
cumcision, 342.
McFarlane, Andrew, post-graduate medical
study abroad, 232.
McGee, W. C, medical colleges and the
medical profession, 316.
McGuire, C. Monroe, unsuccessful employ-
ment of potassium permanganate m
morphine poisoning, 343, 734.
McMurtry, Lewis C, notice of book by,
211.
Macalester, R. K., the nervous symptoms of
patients suffering from chronic urethritis,
684.
Mac Armey, W. N., danger from indiscrim-
inate mtra-uterine irrigations, 541 ; is
pleurisy rheumatic ? 366.
Macfarlane, Andrew, albumin and casts in the
urine of football players, 769.
MacPhatter, Neil, a case of Porro's opera-
tion, 567.
824
INDEX.
[December 29, 1894
Magill, William S., medical opportunities of
Paris, 126.
Maillot, Dr. Francis Clement, death of,
142.
Maine, Frank £., the marriage of syphilitics,
605, 767.
Maisch, Charles 0. , the infectivity of phthisis
pulmonalis, 464.
Malaria and enteric fever, mixed infection
of, 23; infection of, 567; organism of,
in the blood plaque, 408 ; our present
knowledge of the cure of, by means of
quinine, 526; water-borne theory of,
182, 327, 447, 477, 604, 701, 759, 767.
Maloney, F. W., permanganate of potassium
as an antidote to rattlesnake venom,
567.
Malony, J. A., the physics of the phono-
graph, 382.
Mann, Edward C, a new cardiac tonic
dosimetric granule, 73.
Manton, Walter Porter, notice of book by,
758. .
Marcy, William H., skin grafting, 206.
Marriage in England, 471 ; of syphilitics,
448, 635, 668, 767; the decline of,
383-
Marsh, James P., gunshot wound of lungs
and heart, with survival of patient for
fifteen hours, 206.
Martin, Robert W. , an improved conical
rectum speculum, 350.
Martin, William A., a new snare, 510.
Massachusetts State Board of Registration,
50.
Massage, establishment for, and prostitution,
222, 659, 766; in gynecology, 149;
notes on pelvic and general, 45.
Masturbation, castration for, 534.
Maternal impressions, 811.
Mauthner, Dr. Ludwig, death of, 595.
May, Charles H., an improved cilia forceps,
3SO.
Mayo, W. J., surgery of the stomach, 580.
Measles in Samoa, 72.
Meckel's diverticulum, strangulation of, 83.
Medical colleges, and the medical profession,
316; is there a need for more ? 1 1 2 ; new,
659 ; to limit the number of, 381.
Medical education, in America, Politzer's
opinion on, 191 ; some questions of,
666.
Medical legislators in France, 439.
Medical Library Association at Grand Rap*
ids, 660.
Medical men as companions, 499.
Medical practice, act concerning, in Great
Britain, 215 ; contract, 192.
Medical schools, cramming in, 25.
Medical societies, the uses of, 759.
Medical Society of New Jersey, 1 50.
Medical Society of the County of New York,
506, 601.
Medical Society of the Missouri Valley,
373.
Medical Society of the State of Pennsylva-
nia, 24.
Medical staff of the Army and Navy, ex-
amination for, 755.
Medical stulents, religious care of, 630.
Medical University Extension, 530.
Medical warehouse, co-operative, 628.
Medication, a plea for rational, 587.
Medicine as a profession, 509 ; pleasure of,
572.
Melanosis, artificial, 24.
Meniere's disease, 42.
Meningitis, cerebrospinal, 76, 157, 341 ;
tubercular, 27.
Menstrual insanity, a case of, 235.
Menstruation, 282 ; during pregnancy, 731.
Mental training, importance of, in medical
study, 508.
Merit, the recognition of, 530.
Merycism, 181.
Metabolism in chlorosis, 46.
Metric system in Great Britain, 210.
Mettler, L. Harrison, management of val-
vular heart disease, with particular ref-
erence to the use of strychnine, 557.
Mexico, second medical congress of, 627.
Meyer, Willy, an improved method of the
radical operation for carcinoma of the
breast, 746, 764.
Michels, John, nucleus of red blood corpus-
cle of mammals, 669.
Michigan, "jag cure act * in, 319.
Micro-organisms, action of sunlight on,
607.
Mid wives' registration question in England,
9?. 215, 316.
Migraine in infancy, 383.
Military service, the place of physical train-
ing in the, 455.
Milk, bacteria in the intestines after the in-
gestion of, 653 ; chemical and bacterio-
logical characters of, 24; from tuber-
culous cows, 336 ; human, bacteria in,
174; palatable and digestible, 224;
Pasteurized, as supplied to the poor of
New York, 133 ; the digestion of, 113 ;
value of boiled, as an article of diet,
436
Milk-supply, examination of, for tuberculo-
sis, 474.
Milk teeth, treatment of the, 480.
Mind, address on diseases of the, 26 ; influ-
ence of, upon the body, 309 ; sedatives
to the, 407.
Mind-curers, Professor James1 splea for the, 77.
Mineral waters, rules for bottling, in France,
274.
Miners, life-saving appliance for, 242.
Minot, C. S., notice of bibliography by, 502.
Mississippi Valley Medical Association, 759.
Mistakes, value of, 256.
Mitchell, Dr. Howard F., death of, 210.
Mitchell, S. Weir, notice of book by, 758.
Moffat, Henry, cholecystenterostomy with
Murphy's button, 339.
Molluscum contagiosum, contagiousness of,
86.
Monks, medical, 178, 497.
Monster, an ectromelic, 571.
Monstrosities, with special reference to ma-
ternal impressions, 811.
Montgomery, Charles J., history and treat-
ment of a case of traumatic tetanus and
sequela, 44.
Montreal, advances of public health in, 475.
Moody, Dr. George W., death of, 562.
Moor, William, permanganate of potassium
in opium poisoning, 478
Moore, II. B., apex catarrh or tuberculosis?
509.
Morphine, large dose of, 340, 564, 565;
potassium permanganate in poisoning
by. 343» 478. 5*9-
Morphinomania in the medical profession,
383. 542.
Morris, Malcolm, notice of book by, 500.
Morrow, Prince A., notice of book edited
by, 597.
Mortality rates m town and country, 243.
Morton, William J. , origin of the term an-
aesthetic, 799.
Moser, William, a few words in reference to
living cells versus staining, 371 ; caryo-
kinetic changes in the red blood corpus-
cles, 494 ; have the red blood corpuscles
amoeboid movements? 173.
Mosher, Dr. Francis G., death of, 438.
Mosquitoes as carriers of yellow fever, 670.
Mountain sickness, experimental determina-
tion of the cause of, 374.
Mouth, care of the, in sick persons, 334 ;
hygiene, 815.
Mullen, J- J , a successful plastic operation
the "
Marion Sims, the
y, 514; pre-
bild indi
on the face, 340
Munde\ Paul F., Dr.
father of modern
mature delivery of a dead child induced
by acute appendicitis, with remarks on
appendicitis in women, 678 ; ten years'
experience with Alexander's operation
for shortening the round ligaments of
the uterus, 33.
Muscle, chemistry of, 54 ; volume changes
in, during activity and rest, 56.
Mushroom poisoning, sulphate of atropine as
an antidote to, 532.
Mynter, Herman, nephrectomy on account
of nephrolithiasis and pyonephrosis, 732.
Myopia in relation to school hygiene, 475.
Myxcedema, 448; infantile, 85, 1 184; thy-
roid feeding in, 192, 724.,
i
N
Naevus, 790.
Nammack. Charles E., a case of non-heredi-
tary Friedreich's disease, 171 ; a plea
for immediate cceliotomy in ruptured
tubal pregnancy. 622 ; psoriasis treated
by thyroid extract with negative result,
343-
Nancrede, Charles B., notice of book by,
211.
Napper, Mr. Albert, death of, 765.
Nasal forceps, a new, 575.
National guard, medical department of the,
219.
Naval hospitals, 240
Navy, report of the surgeon-general of the,
754 ; statistics in the medical department
of the, 727.
Negro, the, as a hospital interne, 115.
Nephrectomy, 444 ; for nephrolithiasis and
pyonephrosis, 732.
Nephritis, acute, hereditary syphilis associ-
ated with, 671 ; chronic, lactose in, 151:
granular, anxiety as a cause of, 658 ; of
pregnancy and its sequelae, 368 ; of ty-
phoid fever, 493 ; retinitis from, 494.
Nerves, peripheral, electricity in the diagno-
sis and prognosis of diseases of the, 199.
Nervous disease of an unusual type, history
of an epidemic of, 673.
Nervous force, effect of fatigue on the rate
of transmission of, 53.
Neuritis, multiple, from excessive consump-
tion of tea, 1 10 ; treatment of, by elec-
tricity, 471 ; treatment of peripheral,
526.
Neuro fibromata, multiple, 538.
Neuroglia stain, a new, 88.
Neuromata, multiple, 88.
Neuroses, nutritional element in the causa-
tion of, 84.
New Jersey, health of, 150.
New York Academy of Medicine, 504, 569,
661 ; anniversary discourse, 737 ; report
of committee appointed to confer with
the constitutional convention, 606 ; Sec-
tion on General Medicine, 570, 729;
Section on Obstetrics and Gynecology,
600, 797 ; Section on Pediatrics, 631 ;
Section on Surgery, 537.
New York County Medical Association, 218,
539. 697.
New York Pathological Society, 91, 154,
183, 220, 311, 347. 538* 633, 794.
New York Pharmaceutical Club, 66a
Newkirk, Dr. Jacob, death of, 408.
Newton, Richard C, may the shock of a
railroad accident ever be beneficial to
the recipient? 719.
Night calls, the dangers of, 574.
Norbury, Frank, is malaria a water-borne
disease? 447.
Normandy cattle, immunity of, from tuber-
culosis, 16.
Norris, Dr. Thomas R., death of, 817.
Nose, cauterization of the, 310; cutting
operations on the septum, 58 ; growths
in the, as factors in aural and laryngeal
catarrh, 204 ; metallic electrodes in dis-
ease of the, 23; papillary hypertrophy
of the mucous membrane, 22 ; perfor-
ations of the septum, 771 ; polypus
of the, 21 ; red, electrical treatment for,
306; serrated scissors for removing
hypertrophies of, 638.
Novy, Frederick S., notice of book by, 597.
Noyes, William B , an easy method of bath-
ing in typhoid fever, 43 ; enteric fever
in infancy, 1.
Nuclein, physiological and therapeutic value
off S3-
Nursling, effect of the mother's diet upon the,
300.
Nymphfebulation, 79S.
Obesity, thyroid extract in, 178.
Obstetrics, aphorisms relating to, 69 ; studies
in, 26.
Oculo-motor paralysis, recurrent, 89.
December 29, 1894]
INDEX.
825
Odontoma, follicular, invading the antrum,
59-
CEdema, acute supia glottic, 108 ; angio-
neurotic, 42, 634.
CEsophagus, cancer of the, 185 ; foreign body
in the, 731 ; perforation of, by a sword
swallower, 220 ; stricture of the, 248.
Old age, and the death rate, 319; hernia in,
246 ; hip- disease in, 246 ; operations in,
35-
Oldest man in the world, 176.
Omphalo-enteric duct, persistent, 631.
Oophorectomy, pronunciation of the word,
64. See Ovariotomy.
Ophthalmia neonatorum, treatment of, 692.
Ophthalmic hemicrania, 273.
Ophthalmologics! Congress, eight interna-
tional, 306, 316.
Opium, the Indian commission to study, 381 ;
potassium permanganate as an antidote
to. 343, 345. 448, 478. 569. 734-
Oppenheim, H., notice of book by, 277.
Oppenheimer, JL. S., doses of morphine
habitues, 564.
Optician, the refracting, 657.
Orbital cellulitis, abortion of a case of, 564.
Osteomalacia, 91.
Osteomyelitis, acute vertebral, 16.
Osteosis of the skin of the foot, 186.
Otis, W. K., the marriage of syphilitics, 668.
Ottolengui, Rodrigues, notice of book by,
212.
Outerbtidge, Paul, report of complicated
cases involving uterus, tubes, and ovaries,
tieated successfully, 166.
Ovarian disease, pseudo-, 282.
Ovariotomist, an early, 208.
Ovariotomy, 248, 443 ; amenorrhea after,
94-
Ovaritis, 46.
Ovary, abscess of the, 572; and fallopian
tubes, diseases of the, 309 ; cauteriza-
tion o£ instead of removal, 319, 639 ;
papilloma and papillomatous cysts of the,
183 ; point of origin of a tumor of the,
600; sarcoma of the, 311 ; tumor of the,
664.
Overholser, W. P., a plea for more rational
medication, 587.
Overton, Dr. William P., death of, 762.
Oxytocic, sugar as an, 439.
Oysters, typhoid fever carried by, 656, 657,
743- t . .
Ozone in phthisis, 124. •
Pagani, Dr. Joseph, death of, 77.
Page, Charles £., consumption : roughing it
vs. the coddling treatment, 481 ; hy-
gienic treatment vs. '* ear -rubbing" for
" hay- fever," 284 ; summer comfort for
babies, 42.
Pain, pleasure, and aesthetics, 304.
Palate, perforation of the, in scarlet fever,
701 ; sarcoma of, treated by erysipelas
toxins, 616, 633.
Pancreas, carcinoma of the head of the, 91.
Pancreatic and hepatic tissue, chemical prod-
ucts of the anaerobic putrefaction of, 91.
Pancreatic colic, 623.
Pancreatitis, acute, 573, 692.
Paralysis, in a telephone employee, 147 ; in
children, an epidemic of, 475 ; infantile,
and infantile apoplexy, 146; infantile,
excision of the knee for crippling after,
145 ; recurrent oculo-motor, 89.
Paris, medical opportunities of, 126 ; med-
ical students in, 20.
Park, William Hallock, diphtheria and
pseudo-diphtheria, 385.
Parotid gland, rare tumor of the, 654.
Parotiditis, chronic double, 283.
Patent medicines, and Texas doctors, 19 ;
restriction of the sale of, 320 ; scourge
of, 190.
Paternal impressions, 303.
Pathology and practical medicine, new re-
lations of, as bearing upon the path-
ological department in hospitals, 229.
Patients, scarcity of, 562.
Patterson, Dr. Theophilus, death of, 377.
Peat fibre for surgical dressings, 636.
Pelvic abscess, diagnosis and treatment of,
442 ; treatment of, 435.
Pelvic diseases, laparotomy not necessary
for, 762 ; surgical problems in, 419.
Pelvimeter, a new, 600 ; a pocket, 287.
Pelvis, fracture of, with laceration of the
bladder, 72 ; treatment of inflammatory
troubles of the, 443.
Pendleton, Edward, points to be remem-
bered in the practice of antiseptic sur-
gery, 333.
Penis, epithelioma of »he, 117.
Pennsylvania State Board of Medical Ex-
aminers, 543.
Perineum, influence of laceration of, on the
uterus, 80 ; operations for complete
lacerations of the, 791 ; restoration of
the, 488.
Peritonitis, acute, 792 ; chronic, with intes-
tinal and abdominal fistula?, 168 ; diffuse
septic, surgical treatment of, 636 ; tub-
ercular, recovery from, after operation,
445-
Permanganate of potassium, as an antidote
to rattlesnake venom, 567 ; in opium
poisoning, 343, 345, 448, 478, 569, 734.
Pertussis, 26 ; cold baths in, 64 ; treatment
of, 440.
Pessary, the decline of the, 640.
Peters, Dr. George A., obituary of, 788;
resolutions on death of, 817.
Pettenkofer, Professor Max, resignation of,
140.
Pexinogen, 54.
Pharmacy, laws relating to the practice of,
427.
Pharyngeal tonsil, cyst of the, 137.
Pharyngitis, exudative, 60.
Pharynx, mycosis of the, 62.
Phelps, A. M., etiology of deformities oc-
curring in the knee-joint, 129 ; the dan-
gers of night calls, 574.
Phelps, W. C, a case of enterolith, 341.
Phenacetin, poisoning from an overdose of,
564.
Philadelphia as a medical centre, 499.
Philadelphia Hospital, high-handed action
of the commissions concerning a physi-
cian to the, 785.
Phillimore, R. H., the patent medicine
scourge, 190
Phillips, George A. , a family history of dia-
betes, 173.
Phonograph, physics of, 382 ; physics, phy-
siology, and clinical import of, 261.
Phoroscope, an improved, 511.
Phosphorus butter. 160.
Phthisis. See Tuberculosis.
Physic, the sunny side of, 657.
Physical culture in unhealthy schools, 499.
Physician, confidential relations of the, 272,
416 ; the composite, 437.
Physicians strike, 817.
Pick, Albert, notice of book by, 211, 758.
Pilcher, James E., the place of physical
training in the military service, 455.
Pinney, Dr. Charles H., death of, 498.
Pirogoffs operation, modifications of, 24.
Placenta previa, 148.
Plague, the, 20, 49, 114, 141, 177, 209, 241,
286, 288, 337, 544.
Pleurisy, Is it. rheumatism ? 366.
Pleurogram, the cardiac, 56.
Plicque, A. F , notice of book by, 502.
Plumbing, sanitary, 474.
Plummer, Frederic H., a case of hydramnion,
with atresia ani in the child, 565.
Pneumatic cabinet, 377.
Pneumonia, chloride of calcium in the treat-
ment of, 693 ; in an infant tieated with
inhalations of oxygen, 109 ; sewer-gas a
cause of, 537 ; strychnine in the treat-
ment of, 754.
Pocket-case, an aseptic and really surgical,
735-
Poisons, 760.
Polypus, nasal, 21.
Pons, internal capsule, caudatum and lentic-
ula, circumscribed softening of the, 89.
Porro's operation, 567.
Portland, hospitals in, 318.
Post-graduate medical study abroad, 222.
Post, Sarah E., notes on pelvic and general
massage, 45.
Pott's disease, early diagnosis of, 85 ; rubber
heels for patients with, 145.
Practitioner, an excited, 467 ; genera], song
of the, 657, 672 ; the country, and post-
graduate study, 378.
Practitioners' Association of Great Britain,
*3-
Practitioners, irregular, in the United States,
46;.
Practitioners* Society of New York, 283,
634.
Pregnancy at an advanced age, 178 ; effects
of quinine upon, 301 ; extra-uterine,
282, 598, 600 ; extra-uterine, cceliotomy
in, when the foetus is living and viable,
641 ; extra-uterine, immediate cceliot-
omy in ruptured, 622 ; hemorrhage in
late, 280;! menbtiuation during, 731;
nephritis of, and its sequelae, 368.
Pregnant women, the care of, 441.
Prescriptions, 760.
Preston, George J., the malarial organism
in the blood plaque, 408.
Preventive medicine, future of, 244.
Prize, Alvarenza, 595 ; for an essay on tuber-
culosis, 78, 305, 318; of the Accademia
dei Lincei, 274 ; Orloff-Davidoff, 64 ;
the Samuel D. Gross, 696.
Prostate, abscess of the, 347 ; castration for
hypertrophy of the, 635, 760; hyper-
trophy of the, 184.
Prostitution and massage establishments,
659 ; in Berlin, 384.
Prtmus virginiana as a heart tonic, 20.
Pruritus, menthol in, 476 ; treatment of, 47.
Pryor, John H., a case of acute supra-
glottic oedema without apparent cause,
108.
Psoriasis, 24; thyroid treatment of, 343,
427.
Psorothermosis, 87.
Psychology, criminal, 296.
Ptyalinogen, 54.
Puerperal fever, 810.
Puke, venous, significance of the, 404.
Pulmonea, 336.
Pupils, unequal dilatation of the, in tubercu-
losis, 320.
Purgatives, inefficiency of, when injected
hypodermically, 542 ; time of action of,
287.
Putnam, W. E., notes on brain surgery, 43.
Pyelitis, acute, in infants, 85.
Pylorectomy with gastro-duoden ostomy pos-
terior, 591.
Pyonephrosis, nephrectomy for, 732.
Pyothorax, resection in, 29, 94, 158.
Pyrexia, 250.
Pyuria, 93.
Quack, ingenious plea for a, 471.
Quack, nurses, 305.
Quackery in Paris, 318 ; in Russia, 192 ; the
spirit of, in the pale of the profession,
479-
Quacks, collective investigation of, 115.
'• Quilling " as an oxytocic, 703.
Quinine, acquired idiosyncrasy for, showing
peculiar cutaneous manifestations, 87 ;
amaurosis from, 219.
Quinsy, see Tonsillitis,
R
Rabies, see Hydrophobia.
Race and death-rates, 542.
Rachitis, 143.
Railway accidents in the United States, 408;
car sanitation, 475, 574, 638; injuries,
bone and joint tuberculosis excited by,
759 5 physical strain involved in high
speed on, 736; surgeon, development
of the, 208 ; surgeons, National Asso-
ciation of, 728, 786 ; Southwestern As-
sociation of, 787.
Rake, Dr. Beaven Neave, obituary of, 379.
Rankin, D. N. , new serrated scissors for re-
moving hypertrophies and turbinated
tissues, 638.
826
INDEX.
[December 29, 1894
Ranney, Dr. Martin L., death of, 786.
Ravoth, Dr. Fr., some surgical observations
of, 3Si
Raymond, Joseph H., notice of book by,
788.
Raynaud's disease, 42.
Reading notices in medical journals, 625.
Rectal tube, dangers of the long, 238.
Rectum, conical speculum for the, 350;
diseases of the, 160 ; new method of re-
section of the, 724; resection of, for
cancer, 763.
Reeves, James £., notice of book by, 502.
Reflex irritation as a cause of disease, 760 ;
nasal, 256.
Remittent (non-malarial) fever, 40.
Reprint, abuse of the, 408.
Resorcin test for free hydrochloric acid in
the stomach, 430, 638.
Respiration, types and methods of, 67.
Respiratory paths in the cord, 57.
Respiratory tract, peas in the, 173.
Restiform body, removal of the, 648.
Retinitis from chronic diffuse nephritis,
494.
Reynolds, Dr. Dudley Sharpe, Jr., death
. of'595* • ,
Rheumatism, acute articular, as a germ dis-
ease, 20, 693; and gout, affinity of,
401 ; due to tonsillar diseases, 63 ; gas-
troenteric, 91 ; is pleurisy a form of,
366.
Richardson, Maurice H., cholecystotomy
and cholecystectomy for stone impacted
in the cystic duct, 554.
Richmond, Nelson, Is there a northern re-
mittent (non malarial) fever ? 40.
Rickets, infantile scurvy in relation to, 701.
Right-handedness, 495.
Robb, Hunter, notice of book by, 501.
Robinson, Beverley, acute biliary distention
of the gall-bladder, 485 ; sewer-gas as a
cause of throat disease ; or the effect of
bad drainage on the throat, 257.
Robinson, Byron, landmarks of visceral
disease, 714 ; the cervical ganglion of
the uterus, 403.
Rockwell, A. D , action of electricity on the
sympathetic nervous system, 469, 523 ;
notice of book edited by, 758.
Rose, A., " As others see us," 415 ; pastilles
as a substitute for gargling to prevent
diphtheritic infection, 655.
Rosenberry, H. L., incontinence . of urine
and faeces cured by circumcision, 173.
Rossbach, Dr. M. , death of, 734.
Roux, Fernand, notice of book by, 503.
Roy, Philip S , temperature of two children
during spasms, 495; three cases of
nervous diseases, 42.
Royal College of Surgeons, politics in the,
158, 665.
Runge, Edward C, a case of tetanus neona-
torum, 698.
Rupp, Adolph, perforations of the nasal
septum, 771 ; who is to blame? 381.
Russian Physicians, the Society of, 285.
Saalfeld, Dr. E., notice of book by, 504.
Sabathu Leper Asylum, 177.
Sacrum, osteoplastic resection of the, 97.
Safranin reaction in sputum, 302.
St. Louis as a medical centre, 561.
Salicyd- chloroform, 50.
Salmon, Is it poisonous to dogs ? 637.
Sanborn, Dr. Noah, death of, 337.
Sanitary congress in Liverpool, 507.
Sanitary regulations, necessity of interna-
tional, governing the migration of large
bodies of people, 449.
Sanitary Sunday, 192.
Sarcoma treated by erysipelas toxins, 538,
616, 633.
Satterlee, Richard H., Is it time to call a
halt ? 447.
Sayre, Lucius E., notice of book by, 212.
Scalded tissues, toxicity of, 492.
Scalp, cylindroma of the, 184.
Scapula, excision of the, 765.
Scarlet fever, disease of the heart in, 384 ;
perforation of the palate in, 701 ; pre-
ventive inoculation against, 351.
Schools, hygiene in, 474, 475 ; periodical
testing of eyesight in, 51 ; physical cult-
ure in unhealthy, 499.
Schirman, A., malarial infection, 567.
Scbumpert, T. E., internal urethrotomy for
stricture, 170.
Sciatic nerve, secondary suture of the, 409.
Sclerosis, infantile amyotrophic lateral, 180.
Scoliosis, an improved machine for treating,
145.
Scorbutus, infantile, 146; infantile, in its
relation to rickets, 701.
Sculpture, medical, 542.
Seitz, Albert, examination for cancer-cells
in living tissue, 351.
Seminal vesicles, extirpation of, for tuber-
culosis, 163; inflammation of the, 118.
Semmelweiss, monument to, 416, 446.
Seoul, Woman's Hospital in, 242.
Septicaemia, medical, m children, 86; spon-
taneous, in the rabbit, 794.
Sero- therapy, progress of, 756.
Sewage, electrical treatment of, 94.
Sewer-gas a cause of pneumonia, 537 ; ef-
fects of, 243, 257.
Shaw, John C, notice of book by, 211.
Shepherd, Francis J., notice of book by,
«77.
Sherman, W. H., the relationship between
bovine and human tuberculosis, 412.
Shock of a railway accident, may it ever be
beneficial? 719.
Shorthand in medicine, 114, 224.
Shoulder-joint, amputation at the, 309 ; dis-
ease of the, 146.
Shrady, George F., Dr. J. Marion Sims, sur-
geon and philanthropist, 513.
Siegfried, C. A., beriberi and beans, 734.
Sigmoid flexure, diverticula of the, 220;
volvulus of the, 763.
Sim, Dr. Frank L., obituary of, 788.
Sims, Dr. J. Marion, reminiscences of, in
Paris, 705; statue to, 513, 514, 528,
535 ; surgeon and philanthropist, 513 ;
the father of modern gynecology, 514.
Singer1 s nodes, 61.
Sinusoidal current, 471.
Skeleton, estimating the height from differ-
ent parts of the, 293.
Skin, symmetrical atrophy of the, 87.
Skin-disease, an epidemic, 301 ; and visceral
affections, 692 ; emergency cases of,
806 ; thyroid treatment of, 427 ; treat-
ment of the more ordinary, 309.
Skin-grafting, 206 ; for keloid, 174.
Skull, bullet wound of the, 766 ; measure-
ments of the infantile, 649 ; trephining
for depressed fracture of the, 345 ; two
cases of fracture of the, 43.
Small-pox, former ravages of, 52 ; in Eng-
land» 15?, 316 ; in Leicester and the
anti- vaccinationists, 125; Lady Mary
Montagu on inoculation of, 319 ; safe-
guards against, 659.
Smell, the sense of, 771.
Smith, Carl B., hydronaphthol in pulmo-
nary phthisis, 72.
Smith, Dr. S. Hanbury, death of, 378.
Smith, E. A. , climate as affecting the princi-
ples of applied therapeutics, 317.
Smith, J. Gardner, types and methods of
respiration, 67.
Smith, Stephen, the necessity of interna-
tional sanitary regulations governing the
migration of large bodies of people in
the prevention of the spread of contagi-
ous and epidemic diseases. 449.
Smith, William G., varix of the right auri-
cle ending in rupture, 5.
Smith, W. Harvey, application of the graph-
ic method to hearing, 51a
Snake-bites, protection against, 594.
Snake-poison a toxic proteid, 406 ; antidote
to, 567, 608.
Snare, a new, 51a
Snare wire receiver, 350.
Snow, Sargent F. , intra nasal growths as
factors in aural and laryngeal catarrh,
204.
Sodium bicarbonate, large consumption of,
380.
Sorrow, the hygiene of, 406.
Souchon, Edmond, reminiscences of Dr. J.
Marion Sims in Paris, 705.
Soul, a location for the, 271.
South Carolina State Examining Board,
660.
Southern Surgical and Gynecological Associ
ation, 789.
Southworth, Thomas S., a resume' of the
subject of biliary calculi, 749.
Specialism and medical practice in Texas,
694.
Speed, high physical strain involved in, 736.
Spence, Arnot, a question of fact and accu-
racy in statistics, 29 ; the reliability of
statistics, 158.
Sperk, Dr. Edward, death of, 237.
Spermine, therapeutic value of, 431.
Spinal cord, action of chloroform on the,
791 ; action of strychnine on the, 58 ;
respiratory paths in the, 57.
Spine, acute osteomyelitis of the, 16; sur
gery of the, 246 ; the typhoid, 109, 479.
Spleen, a lacerated, 312 ; gunshot wound of
the, 790.
Splenectomy, 103.
Sprains of the ankle, massage in, 371.
Spratling, William Philip, the excessive con-
sumption of tea as a cause of multiple
neuritis, no.
Sputum, safranin reaction in, 302.
Staphylococci, renewed virulence of, after
long period of latency, 374.
Starke, G., version three weeks before de
livery, 733.
Starr, Louis, notice of book edited by, 276.
Starr, M. Allen, location of the visual cere
bral centre, 800.
Stebbins, Roswell O., the Esquimaux and
their teeth, 509.
Steele, Thomas B., the swallowing of a hat-
pin, and its subsequent extraction, 38a
Stephenson, F. B.t some surgical observa-
tions of Dr. Fr. Ravoth, 351 ; the So-
ciety of Russian physicians, 285.
Sterilization of doctors, 178.
Stewart, Thomas M., foreign body in the eye
for six years, 380.
Stewart, William W., end-to-end intestinal
anastomosis by the use of Murphy's
button, with report of case, 326.
Stomach, cancer of the, 154, 186 ; cancer of,
chlorate of sodium in, 207; diagnosis
and treatment of diseases of the, 310 ;
dilatation of, associated with tetany, 573 ;
education of the, 634 ; examination of
the contents of, by the stomach-tube and
Einhorn's stomach-bucket, 331 ; new
methods for treating diseases of the, 06;
operative treatment of perforating ulcer
of, 244, 302 ; resorcin test for free hydro-
chloric acid in the, 430, 638 ; surgery of
the, 580.
Stomach reefing, 724.
Stone, Dr. Warren, memorial address on,
789.
Stone in the bladder, treatment of; 635.
Stone, R. French, notice of book edited by,
276.
Storrs, Frances, education a factor in the
prophylaxis of diseases of women, 804.
Stowell, Wm. L., feeding after weaning, 65.
Strabismus, failure in the surgical treatment
of internal, 28.
Straight, Howard S., apex catarrh or tuber-
culosis, 602 ; notes on disease of the ear
and upper air-passages in apex catarrh,
369.
Stratz, C. H., notice of book by, 502.
Stricture, formation of, and urine leakage,
116; oesophageal, 248; urethral, 24;
urethral, cause of, 583 ; urethral, electro-
lysis in, 470 ; urethial, internal urethrot-
omy for, 170 ; urethral, relief of deep,
without external urethrotomy, 117 ; ure-
thral, treatment of, 153.
Strophantus, Jo.
Strychnine, action of, on the spinal cord, 58.
Study, Joseph N., the typhoid spine, 109.
Sturges, Dr. Octavius, death of, 696, 701.
Sturmann, W., notice of book by, 211.
Suicide, 543; exhibition of the brain of a,
179.
Sulphonal, large dose of, for a child, 339.
Summers, J. Will, varicose ulcers treated by
a new and painless method, 655.
December 29, 1894]
INDEX.
827
Sunlight, action of, on micro organisms. 607.
Sunstroke, 305; and alcohol, 39; deaths
from, 142.
Supra-renal tumor, 404.
Surgeon, the art of the, 216.
Surgery, pleasures of, 572.
Surgical technique, modem, 762.
Swasey, Edward, a lid elevator for cataract
operations, 287.
Sweeney, M. J., sixty grains of morphine at
a dose, 565.
Sydenham, Thomas, a statue to, 316, 480.
Sympathetic, action of electricity on the,
469, 5*3- . , .
Symphyseotomy, 577, 602 ; vs. induction of
premature Labor, 81.
Syndicate, a medical, 283.
Syphilis, aphasia from, 623 ; as a ground
for divorce, 32; contagious period of,
154; excision of the initial lesion of,
117; extra-genital, 210; hereditary,
associated with acute nephritis, 671 ; in-
fluence of early treatment in the late
manifestations of, 759 ; late hereditary,
765 ; mental symptoms of cerebral, 760 ;
of the epididymis, 75 ; period of com-
municability of, 120.
Syphilitica, the marriage of, 448, 605, 668,
767.
Tabes dorsalis, 251.
Tablet triturates, 479.
Tachycardia after influenza, 124.
TafeC L. H., notice of book translated by,
502.
Talbot, Eugene S., notice of book by, 276.
Tannigen, a new intestinal astringent, 671.
Tariff, lowered duties on drugs under the
new, 209.
Tarsoclasis, 145.
Taylor, Dr. David, death of, 125.
Tea, multiple neuritis from the excessive
consumption of, 1 10.
Tea-drinking, insanity from, 160.
Teeth, mineral matter in, 480; treatment of
the milk, 480.
Telephone, paralysis in a, employee, 147 ;
taking the, to bed, 383.
Temperance Reform League of Massachu-
setts and the Keeley cure, 628 ; break-
last of the, 315.
Temperance reform, physicians as pioneers
Temperatures, sensible, 181.
Tenement-houses, placarding contagious dis-
eases in, 576 ; report of the commis-
sion on, 764.
Terry, Dr. M. C, the new Surgeon-General
of the N. Y. S. N. G., 728.
Testelin, a monument to, 377.
Testimonials to medical men, 765.
Testis, implantation of an artificial, after
castration, 164 ; tumor of the, 119.
Tetanus, anti toxin o£ 416, 787 ; neonato-
rum, 698 ; puerperium, 149 ; traumatic,
report of a case of, 44.
Tetany associated with dilatation of the
stomach, 573.
Texas, specialism and medical practice in,
694.
Thalamus, lesion of the, 89.
Therapeutics at the International Medical
Congress, 48.
Therapy, cellular, 165.
Thermogen, the, 242.
Thermogenesis, cutaneous application of cer-
tain alkaloids as regulators of, 113.
Theses, some ancient medical, in Paris, 192.
Thioform, 462.
Thirst following abdominal section, cause of,
Thomas, John Davies, notice of book by,
277.
Thompson, J. H., a source of infection in
corneal abscess, 463.
Thome, Dr. Thorne, public health services
of, 477-
Thorner, E , notice of book by, 276.
Thornton, James B., congenital deformity,
346.
Thornton, John, notice of book by, 502.
Throat, malignant tumors of the, importance
of early diagnosis of, 62 ; neurasthenic,
62 ; sewer gas as a cause of disease of
the, 257.
Thrombosis, extract of leeches in the preven-
tion of, 137 ; primary, of the pulmo-
nary artery, 311.
Thyroid extract, dangers of, 306; new
method of giving, 439.
Thyroid feeding, for Basedow's disease, 640,
671 ; in myxoedema, 724 ; in psoriasis
and other skin diseases, 427 ; toxic ef-
fects of, 692.
Thyroidism, relation of, to exophthalmic
goitre and hysteria, 704.
Tobacco and fatigue, 480.
Todd, Dr. John M., death of, 210.
Toe-nail, ingrowing, 635.
Tolstoi on vaccination, 736.
Tongue, extirpation of the, for cancer, 634 ;
sarcoma of the, 154; tractions on the,
for asphyxia, 141, 454 ; traction on the,
in hysteria, 378.
Tonsil, concretions in the, sore throat due
to, 761 ; mycosis of the, 62 ; pharyn-
geal, cyst of the, 137 ; rheumatic affec-
tions due to disease of the, 63 ; sarcoma
of the, 6 1.
Tonsillitis, treatment of, 111, 242.
Tooth, fight for a, 800.
Toxins, antidiphtheritic, see Diphtheria ; in-
testinal, 384.
Trachoma, shady side of surgical treatment
of, 231.
Transfusion, claim for damages by one giv-
ing blood for, 95
Trent, J. H. , cyanide or ferrocyanide of po-
tassium, 256.
Trephine, a new aseptic, 313.
Trephining for traumatic clot, 344.
Trichinosis, 542.
Trismus neonatorum, 313.
Tri - State Medical Society, Jacksonville,'
meeting of the, 617.
Trusses, glycerin pads for, 736.
Tuberculin, diagnostic use of, in cows, 74.
Tuberculosis, and erysipelas, antagonism of,
308 ; articular, 152 ; asses1 serum for,
466; bovine, 150, 186 • bovine, diag-
nostic use of tuberculin in, 74 ; conta-
giousness of, 310; channels of infection
in, 624 ; Colorado as a climate for suf-
ferers from, 27 ; creasote, guaiacol, and
benzoyl of guaiacol in, 121 ; etiology of,
644, 721 ; general, 93, 663 ; goat serum
in, 637 ; hydronaphthol in, 72 : immune
serum of the goat in, 702 ; in butter,
437 ; in children, 374 ; in domestic pets,
124, 559 ; infection of, in a laboratory,
658 ; of the adrenals without bronzing,
552; of the bladder and kidneys, 186;
of the bladder, lactate of cocaine in,
224; of the frontal sinus, 5^3; of the
larynx and pharynx, 411; of the semi-
nal vesicles, extirpation for, 163 ; ozone
in, 124; osseous, excited by railway in-
juries, 759 ; perineal, injections of glyc-
erin and sulphur for, 765 ; peritoneal,
recovery from, after operation, 445 ;
prophylaxis of, 27, 309, 721 ; pulmo-
nary, climatic segregation of persons af-
fected with, 474 ; climatic treatment of,
120; pulmonary, contagiousness of,
464, 736 ; pulmonary, marriage of per-
sons affected with, 474; pulmonary,
roughing it vs. coddling, 481 ; pulmo-
nary, treatment of, 654; pulmonary,
treatment of the fever of, 591 ; rarity of,
in the highlands of Pennsylvania and
New York, 181 ; relationship between
bovine and human, 412 ; renal, surgical
interference in, 1 18 ; restriction and pre-
vention of, 473; sanitarium treatment
of, 120; social causes of. 405 ; State
prevention of, 122 ; strychnine in, 27 ;
the serum treatment, 496 ; unequal dila-
tation of the pupils in, 320 ; value of
third blood-corpuscle in, 41.
Tuberculous lymphangitis of the arm, 573.
Tumors, malignant, toxines of erysipelas in,
82.
Turpin, Dr. Virginius A., death of, 534.
Twin gestation, anomalous foetal nutrition in,
74. Hi.
Twins, double pay for, 286.
Typhoid fever, 310; a bed-bath apparatus
for use in, 253 ; abortion of, 760 ; and
malaria, mixed infection of, 23 ; com-
bined carbolic acid and chloroform in,
512 ; diseases of the heart in, 384 ; easy
method of bathing in, 43 ; in children,
treatment of, 435 ; in infancy, 1 ; in
Montclair, N. J., 651: in the Dis-
trict of Columbia, 785 ; lactophenin in,
302 ; nature and prevention of, 507 ;
nephritis of, 493 ; no class distinction in,
755 ; or typhus fever, a doubtful case,
155 ; origin of, 274 ; recent epidemic of,
at Windsor, Vt., 647 ; relation of the
bacillus coli communis to, 527 ; relation
of, to drinking-water, 447 ; susceptibility
to vaccination after, 310; the oyster as
a carrier of, 656, 657, 743 ; treatment
of, 782 ; treatment of, twenty-five years
ago, 51 ; with an unusual history, 663;
with extensive ulcerations, 155.
Typhoid infection, putrefactive gases as pre-
disposing agents in, 492.
Typhoid spine, the, 109, 479.
Typhus fever, in Paris, 405; or typhoid
fever, a doubtful case, 155.
Tyrrell, R. Shawe, the affinity of gout and
rheumatism, 401.
U
Ulcers, varicose, treated by a painless meth-
od, 655.
Ulna and radius, fracture of the, 537.
Umbilical cord, compression of, during for-
ceps delivery, 174; entanglements and
shortening of the, 798; spontaneous
rupture of the, 798.
UnderhiU, Mr. W. L., death of, 125.
United States, observations on medicine in
the, 335.
Universities, Professor Jebb on the, 315.
Ureter, impacted stone in the, 703.
Uretero-ute ine fistula, hysterectomy for,
671.
Ureters, inflammation of the, 81.
Urethra, electrolysis in stricture of the, 470 ;
relief of deep stricture of, without ex-
ternal urethrotomy, 117; stricture of
the, 24; stricture of, cause of, 583;
treatment of stricture of the, 153.
Urethritis, nervous symptoms of patients
with chronic, 684.
Urethrotomy, internal, for stricture, 170.
Urinalysis, importance of, in diagnosis, 760.
Urine, ammoniacal, a new salt in, 479; cor-
rection of the odor of, 563; inconti-
nence of, cured by circumcision, 173 ;
leakage and stricture formation, 1 16.
Urticaria, pilocarpine in, 342, 564.
Uterus, adenoma of the cervix, 94 ; Alex-
ander's operation for shortening the
round ligaments, 32 ; cancer of the grav-
id, 793 ; cervical ganglia of the, 403 ;
danger from indiscriminate irrigations of
the, 541 ; dangers of glycerine injections
in the, for the purpose of inducing prema-
ture labor, 105 ; extirpation of, for my-
omata, 279 ; extirpation of, in pelvic sup-
puration, 600 ; fibroid of the, discharged
per rectum, 794; fibroid of the, removed
by morcellement without hemorrhage,
794 ; fibroids of the, 279 ; immediate
repair of a lacerated cervix, 78 ; inflam-
matory disease of the, 443 ; injections
into the cavity of, in antiquity, 382 ; li-
gation of the arteries of the, for the cure
of fibroid tumors and the checking of
hemorrhage, 441 ; ligation of the circular
artery of the, 219 ; non-operative treat-
ment of disease of the, 589; operative
treatment of fibroids of the, 147 ; resec-
tion of the, 279 ; rupture of the, 79, 80 ;
sarcomatous degeneration of fibroids of
the, 600; simultaneous appearance of
cancer of the breast and of the, 793 ;
sloughing of the cervix after labor, 38 ;
surgical treatment of anteflexion of the
828
INDEX.
[December 29, 1894
798 ; total extirpation of, in disease of
the adnexa, 175 ; treatment of corporeal
endometritis, 762; treatment of fibroids
of the, 79; treatment of retro-displace-
ments of the, 80; tubes and ovaries,
complicated cases involving, 166; vag-
inal hysterectomy for cancer of the, 281 ;
vaginal hysterectomy, history of, 793.
Uvulatome, a new, 314.
Vacation, advantages of, 438.
Vaccination, a plea for, 476 ; illustration of
the value of, 764 ; susceptibility to,
after typhoid fever, 310.
Vaccine and vaccination, 474.
Vagina, congenital annular stenosis of the,
617.
Vaginismus, treatment of, 436.
Valentine, Ferd. C, the doctor's wife, 414.
Van Dyke, F. W., is salmon poisonous to
dogs ? 637.
Van Etten, Dr. Solomon, death of, 49.
Van Winkle, Dr. Edward Henry, death of,
756.
Varicocele, 793 ; plastic operation for, 153 ;
treatment of, by means of a truss, 351.
Varicose ulcers treated by a painless method,
Vasoconstriction and vaso -dilatation, reflex,
55-
Vehsemeyer, H., notice of book by, 212.
Vena cava superior, obliteration of the,
404.
Version three weeks before delivery, 733.
Vienna, letter from, 446.
Villemin, a monument to, 532.
Vineberg, Hiram N., congenital annular
stenosis of the vagina — an improved
method of operating, 617.
Viscera, a case of transposition of, 108.
Visceral disease, landmarks of, 714.
Vision, defective, in relation to crime, 569.
Volkmann, the late Professor, a monument
to, 178, 377.
Volvulus of the sigmoid flexure, 763.
Vomer, exostosis and enchondroma of the,
Vulva, progressive cutaneous atrophy of the,
445-
W
Wagner, Charles W., transfer of the insane
to hospitals, 254.
Wainwright, Dr. William A. M., obituary
of, 468.
Walmsley. Francis, notice of book by, 212.
Ward, J. M., membranous enteritis, 346.
Warfield, Clarence, the antidotal action of
potassium permanganate in opium poi-
■ soning, 448.
Washburn, W., car sanitation, 574.
Wasse, G. M., dosimetric medication, 256.
Water in diet and therapeutics, 330 ; purifi-
cation of, 128; sand- filtration of, 472 ;
sedimentation in, 472.
Water-sampling apparatus, 312.
Water-supply, danger of abundant, without
sewerage, 472 ; of farms, 472 ; of Jerusa-
lem, 672 ; pollution of, 472.
Watkins, Robert L., value of third blood-
corpuscle in tuberculosis, 41.
Weaning, feeding after, 65.
WeBer, Leonard, dyspepsia neivosa and gas-
trointestinal neurasthenia, 460.
W«bster, David, retinitis from chronic dif-
fuse nephritis, 494.
Weir, Jas., Jr., criminal psychology, 296;
genius and degeneration, 131, 242 ; is it
the beginning of the end? 801.
Weir, Robert F., cases in genito urinary
su'gery, 161; surgical treatment of sur-
gical kidney, 325.
Wells, Brooks II., treatment of abortion,
353-
Wells, Dr. Horace, celebration of the dis-
covery of anaesthesia by, 627 ; erection
of a tablet to the memory of, 7(6.
Werdrr, X. O., coeliotomy in ectopic gesta-
tion where the foetus is living and viable,
641.
White, A. Campbell, treatment of diph-
theria, 545, 609, 631.
White, W. Hale, notice of book by, 758.
Whooping cough. See Pertussis.
Wiener, Alexander C, treatment of fracture
and sprains of the ankle by massage,
371.
Wife, the doctor's, 336, 414.
Wiggin, Frederick Holme, a case of chronic
peritonitis, with intestinal and abdomi-
nal fistula — enterorrhaphy — recovery,
168.
Wilcox, Re>nold W., notice of book edited
by, 758.
Williamson, Dr. Charles H., death of, 338.
Windows, porous glass for, 720.
Winking, reflex time of, 57.
Wirt, William E., the dispensary question
in Cleveland, 669.
Witnesses, medical, rights and duties of, 759.
Wood, H. C, notice of book by, 758.
Wood, James C, notice of book by, 211.
Worcester, A , notice of book by, 500.
Woman' s hospital, a new, 728.
Women, causes of diseases peculiar to, 17 ;
education a factor in the prophylaxis of
diseases of; 804 ; gonorrhoea in, 789 ; in
medicine, 438 ; medical students in Glas-
gow, 209 ; physicians in America, 240 ;
practice of medicine by, in 1572, 562.
Wright, Dr. C. R. Alder, death of, 315.
Wry-neck, operation for, 146.
Wylie, W. Gill, some abnormal conditions
of the generative organs associated with
melancholia or mania, 135.
Yellow fever, in quarantine, 337 ; mosquitoes
as carriers of, 670 ; prevention of trie
spread of, 475.
Young, James K. , notice of book by, 596.
Zakharin, Professor, the Czar's physician,
543, 56l.
Zangger, Theodore, sewer-gas a cause of
pneumonia, 537.
Zenner, Philip, acute softening of the brain,
101.
Zwisohn, L. W., cystic degeneration of the
colon, 730.
\SSVSNTY-TWO PAGES IN THIS NUMBER.]
7
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- ORIGINAL ARTICLB8.
Th« Presenoeof Albumin and OmU
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Br Andrew Maofarlana, A.B.,
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Ferforationii of the Nasal Septum ;
Btiology, OUnloal Bignifloanoe,
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Hints on the Treatment of ■osema.
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New York 7TO
PROORB88 OP MBDICAL
8CIBNCB.
The Relation of OholoUthlaala to
Primary Oarolnoma of the Gall-
781
Intracranial Ansttrism— The Treat-
ment of Typhoid Fever— Jejonoe-
tomy 78S
Diphtheritio OonjunctiTitia 7B8
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ark, N. J.— Death of Dr. Martin
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from Portrait Exhibition — The
Antitoxin Treatment of Tetanus
—A Gold Oup for Discovering a
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787
OBITUARY.
George A. Peters, M.D., New York 788
Frank L. Sim, M.D„ Memphis,
Term 788
0. P. Gats, M.D., Oonoord, N. H. . 788
RBVIBWS AND NOTICES.
Transactions of the Forty-ninth
eOhlof
Annual Meeting of the 01
Medical Society too
A Manual of Hunan Physiology.
Prepared with Special Reference
to Btndents of Medicine. By Jo-
seph H. Raymond, A.M., M.D.. 788
Fifth Annual Report of the New
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September 80, 1893 788
Twelfth Annual Report of the Pro-
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tario, Being for the Year 1898.. 788
The Principles of Bacteriology: A
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BOCIBTY RBPORT8.
BOUTHB&lf SUBGIOAL AHD am-
oologioal Association :
Seventh Annual Meeting, held in
Charleston, 8. 0., November
18, 14, and 16, 1894. First
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Dr. Warren Stone- Gonorrhoea
in Women 789
Some Oases of Acute Intestinal
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Second Day, Wednesday, Novem-
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Third Day, Thursday, November
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Paris — Cancer of the Gravid
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Cancer in Breast and Uterus —
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r:
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Chloroform Bottle- Nymphfebn-
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flexion of the Uterus 796
CORRB8PONDBNCB. ,
Our London Letter. Medioo-Chirur-
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Pathological Society- Malignant
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"Origin of the Term Anesthetic."
By William J. Morton, New York 799
Localization of Visual Cerebral \
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A Fight for a Tooth — A Thirty-
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JUST PUBLISHED.
A CLINICAL MANUAL
OP
DISEASES OF THE EYE,
Including a Sketch of its Anatomy.
By D. B. ST. JOHN ROOSA, M.D., LL.D.,
Professor of Diseases of the Eye and Ear in the New York Post-Graduate Medical School and Hospital ; Surgeon to the Manhattan Eye and Ear Hospital ;
formerly Professor of Diseases of the Eye in the University of the City of New York, and in the University of Vermont ; Consulting Surgeon to the
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Society of Edinburgh ; Honorary Fellow of the Academy of Medicine of Havana, Cuba, etc., etc.
This work presents, in a convenient and eminently practical form, the results of the author's long and
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Part I. contains a "Sketch of the Anatomy and Physiology of the Various Parts of the Eye and its
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Part III. treats of " Diseases of the Eyelids, the Lachrymal Apparatus, the Conjunctiva, Eyeball, and Orbit,"
Part IV. discusses "Conditions of the Eye Requiring the Use of Glasses — Errors of Refraction and
Accommodation — Strabismus — Affections of the Ocular Muscles."
This work consists of one volume of 650 pages octavo, uniform with the Treatise on the Diseases of the Eart
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TOTTSSA.INTS
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This justly popular preparation is a pure product, made in vacuo, according to approved methods
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PYROPHOSPHATE OF IRON. For Ansmla and Chlorosis. Each table-
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IRON AND PEPSINS. Each tablespoonfnl contains thbxb grains each of
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IRON AND QUINIA. For Strengthening the System. Each, tablespoonfnl
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THIRD EDITION.
PRACTICAL HUMAN ANATOMY.
By FANEUIL D. WEISSE, M.D.,
Professor of Practical and Surgical Anatomy in the Medical Department of the University of the Oiqr of New York ;
Professor of Regional Anatomy in the New York College of Dentistry, etc, etc.
A Working Guide for Students of Human Anatomy and a Retrospect for Prac-
titioners of Medicine and Surgery.
PRESS NOTICES.
•The
The plates are decidedly clear, and neither too diagrammatic as m
Ehgnah works, nor too highly nnislied, as to some IVenoh produetfoiis.w
"An structures receive lair, systematic treatment, and the author
wisely avoids departing from the paths of what neurologists term 'coarse'
4 As a work of reference for any anatomist, surgeon, or physician it
rves to be placed in every library attached to medical or biological lnstl-
■Oidsh Mescal Journal,
" The book In lte entirety surpasses to point of practical utility anything
ever offered the profession."
- " me dissections of the female perineum alone are worth to a surgeon
Ike price of the book."
" As a book of reference a practitioner can use It to advantage without
sauoh study or search.0
"In our Judgment this work is a desideratum to the surgeon's library
long needed."— Daniel's Texas Medical Journal.
Br. Welsse, taking up Gray's plan, to a certain extent, and improving
wjxm It, has succeeded in giving na a work of far more practical utility than
anything of the kind that we have ever seen."
•• Medical students will never regret taking our advice in obi
in preference to any other anatomy extant/'— The Texas Courier*,
Of Medicine.
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physlolan can afford to be without this work. If we were able to have but
one anatomy in our library, this would be the one we would choose."
^Buffalo Meaical ana Svrgical Journal.
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shelves of every live practitioner of surgery and medicine."
" The plates elucidate every part so well that they appear to speak to us.*
" The explanations of the illustrations are brief but to the point, and each
sentence expresses no more or less than knowledge of the partjuatlflee."
—me Southern Practitioner.
"Taken as a whole, this book is one which reflects high credit upon
American medicine."— PhUaaelpMa MeaUsal Times.
** The plates are almost an drawn from nature, and deserve great praise."
"We congratulate Br. Welsse on the sucoess of his work, which wt
believe wfl] be a favorite with students.1*
—Boston Meatoal ana Surgical Journal.
"We Should expect it to become the favorite ds- Atlantic dissector's
manual."- American Journal of the MeOioal Sciences.
In one Svo volume, with two hundred and twenty-two full-page plates, exquisitely executed. Price, 4m
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MEDICAL RECORD.
TREATMENT OF nTTESTDTAL ATPEOTI05S
AID HEDE08EB OF THE EE8PIEAT0EY OSQAHS.
We are too liable to regard any affection of the lanes,
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Influenza, bronchitis^ pleurisy, and many cases of pneumonia
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three principle symptoms. To control any one of these three
is many times sufficient to cause the others to disappear, so
closely are they related to one another.
, In a "Note on Codeine," in the London Lancet, Dr. James
Braithwaite, of Leeds, says : "Codeine seems to have a special
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THE LANCET.
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NATIONAL AND STATE
MEDICAL SOCIETIES OF AMERICA.
NATIONAL.
AMERICAN ASSOCIATION OF GENITOURINARY
SURGEONS.
Annual Meeting at Niagara Palls, last week in May, 1890.
Wm. K. Ona, MD., Bee, L. Bolton Bangs, M.D., Prest,
6 West 60th St., New York City. 31 East 44th St , New York City.
AMERICAN ASSOCIATION OP OBSTETRICIANS AND
GYNECOLOGISTS.
Annual Meeting at
William Warbsn Potter, M.D., Sec, J. Henry Carstenb, M.D., Preat.,
284 Franklin St., Buffalo, N. Y. Detroit. Mich.
AMERICAN ACADEMY OF MEDICINE.
Annual Meetlug at Baltimore, May 4 and 6, 1895.
Charles MoIntibs, M.D., Sec, J. McFaddkn Gaston, M.D., Preat.,
JBaston, Pa. Atlanta, Ga.
ASSOCIATION OF AMERICAN PHYSICIANS.
Annual Meeting at Washington, D. C. May 88, 89 and 30, 1805.
Henry Hun, M.D., See. William Osleb, M.D., Preet.,
149 Washington Aye., Albany, N. Y. l W. Franklin St., Baltimore, Md.
ASSOCIATION OF ACTING ASSISTANT SURGEONS OF
THE U. S. ARMY.
Annual Meeting appointed by the President.
W. Thornton Parker, M.D.. Recorder, Daniel Smith Lamb, M.D., Prest,
Grooveland. Mass. Washington, D. C.
AMERICAN DERMATOLOGICAL ASSOCIATION.
Annual Meeting at Montreal, Can., about Sept. 16, 1895.
Charles W. Allen, M.D., Sec., Samuel Sherwell. M.D., Preet.,
640 Madison Aye., N. Y. City. 83 Schermerhorn St., Brooklyn, N. Y.
AMERICAN GYNECOLOGICAL SOCIETY.
Annual Meeting at Washington, D. C, May 88, 1896.
Henrt C. Cob, M.D., Sec., Matthew D. Mann, M.D., Prest,
ST E. 54th St., New York City. Buffalo, N. Y.
AMERICAN MEDICAL ASSOCIATION.
Annual Meeting at Baltimore, May 7, 1896.
W. B. Atkinson, M.D., 8ec., Donald Maclean, M.D., Preat.,
1400 Pine St., Philadelphia, Pa. Detroit, Mich.
AMERICAN NEUROLOGICAL ASSOCIATION.
Annual Meeting at Boston.
Graeme M. Hammond, M.D., Sec , Philip Ooombb Knapp, M.D., Prest.,
58 W. 46th St., New York City. Boston, Mass.
AMERICAN LARYNGOLOGICAL ASSOCIATION.
Annual Meeting at Rochester, N. Y., May, 1895.
Chas. H. Knight. M.D., Sec, John O. Rob, M.D., Prest,
147 West 57th St., New York City. Rochester, N. Y.
AMERICAN OPHTHALMOLOGICAL SOCIETY.
Annual Meeting at New London, Conn., July 84, 1895.
& B. St. John, M.D., Sec., Geo. C. Harlan, M.D., Prest.,
84 Pratt St., Hartford, Conn. Philadelphia, Pa.
THE AMERICAN ORTHOPEDIC ASSOCIATION.
Annual Meeting at Chicago, September 19, 80 and 91, 1896.
Rotal Whitman, M.D., Sec., John Ridlon, M.D., Prest,
186 West 59th St., New York City. log state St. , Chicago, 111.
AMERICAN ELECTRO THERAPEUTIC ASSOCIATION.
Annual Meeting at Toronto, Can., first week of September, 1896.
Emil Heuel, M.D., Sec,, A. L. Smith, M.D., Prest,
369 Willis Ave., New York City. Montreal, Can.
CANADIAN MEDICAL ASSOCIATION.
Annual Meeting at Kingston, Ont, August 88, 89 and 80, 1695.
F. N. G. Starr, M.D., Sec., William Bayard, M.D., Prest.,
894 Markham St, Toronto, Ont St John, N. B.
THE MEDICO-LEGAL SOCIETY.
Annual Meeting at New York, Dec. 18. 1894.
Meets second Wednesday each month (except July and August) at Academy
of Medicine.
Clark Bell. Bsq., Sec, H. W. Mitchell, M.D., Prest..
New York, N. Y. New York, N. Y.
THE ASSOCIATION OF MILITARY SURGEONS
OF THE UNITED STATES.
Annual Meeting at Buffalo, May 31, 88 and 83, 1896.
Bustathiub Chancellor, M.D., Sec., 8urg.Gen Geo. M. Sternberg, Prest,
515 Olive St, St Louis. Mo. Washington, D. C
NATIONAL ASSOCIATION OF RAILWAY SURGEONS.
Annual Meeting at Chicago.
Jab. M. Dinnen, M.D., Sec., S. 3. Thorn, M.D , Prest,
Fort Wayne, In<L Toledo. Ohio.
AMERICAN PEDIATRIC SOCIETY.
Annual Meeting at Hot Springs, Va., last week in May, 1896.
Samuel 8. Adams, M.D., Sec., F. Fobcbheimrr, M.D., Prest.,
1639 K St., N. W. Washington, D. C. Cincinnati, Ohio.
ARMY AND NATY MEDICAL ASSOCIATION.
Annual Meeting at Decatur, 111., May. 1896.
Edward P. Bartlett. M.D., Sec., E. P. Cook, M.D., Prest,
Springfield. 111. Mendota, IB.
TRI-STATE MEDICAL SOCIETY.
Annual Meeting at St. Louis, Mo., April 8, 8 and 4, 1896.
Frank P. Norbubt, M.D., Sec., Jambs Mooreb Ball, M.D., Prest,
Hoffman Fld'g, Jacksonville, HI. 810 Olive St., St Louis, Mo.
MISSISSIPPI VALLEY MEDICAL ASSOCIATION.
Annual Meeting at Hot Springs, Ark., Not. 80, 81, 89 and 88, 1894.
F. C. Woodburn, M.D., Sec, X. C. Soott, M.D., Prest..
Indianapolis, Ind. Cleveland, Ohio.
MEDICAL SOCIETY OF THE MISSOURI VALLEY.
Annual Meeting at Council Bluffs, la., September 19, 1895.
Spring Meeting— Migratory- 3d Thursday in March.
F. S. Thomas, M.D., Sea, A. F. Jonas, M.D., Prest.,
Council Bluffs, la. Omaha, Neb.
STATE.
MEDICAL ASSOCIATION OF THE STATE OF ALABAMA.
Annual Meeting at Mobile, April 16 to 19, 1895.
Jambs Reid Jordan, M.D. , Sec., Richard Matthew Fletcher, M.D., Prest.,
Montgomery, Ala. Madison, Ala.
THE ARKANSAS MEDICAL SOCIETY.
Annual Meeting at Little Rock, May 1, 1895.
L. P. Gibson, M.D.. Sec, A. C. Jordan, M.D., Prest,
Little Rock, Ark. Pine Bluff, Ark.
CONNECTICUT MEDICAL SOCIETY.
Annual Meeting at New Haven, May 1, 1895.
N. R. WORDIN, M.D., Sec., Francis N. Braman, M.D., Prest,
174 Fairfield Ave. , Bridgeport Conn. New London, Conn.
THE MEDICAL SOCIETY OF THE STATE OF CALIFORNIA.
Annual Meeting at San Francisco, April 16, 1895.
Wm. Watt Kerr, M.D., Sec, G. L. Simmons, M.D., Prest.,
688 Sutter St., San Francisco, Cat Sacramento, Cal.
COLORADO STATE MEDICAL SOCIETY.
Annual Meeting at Denver, June 18, 19 and 80, 1896.
Caret Kennedy Fleming. M.D., Sec, Hubert Work, M.D., Prest.,
Denver, CoL Pueblo, Col.
MEDICAL ASSOCIATION, DISTRICT OF COLUMBIA.
8eml-Annual Meeting at Washington, April 8, 1896.
James D. Morgan, M.D., Sec, George B. Harrison, M.D., Prest,
919 15th St, N. W., Washington, D.C. 60S 14th St., N. W., Washington, D.C.
MEDICAL SOCIETY OF DELAWARE.
Annual Meeting at Wilmington, June 11, 1896.
Wm. C. Pierce, MD., Sec, Frank Bbllyillb, M.D., Prest,
887 Washington St, Wilmington, DeL Delaware City, Del.
FLORIDA STATE MEDICAL SOCIETY.
Annual Meeting at Gainesville, April 16, 1895.
J. D. Fbrnandiz, M.D., Sec, J. D. Rush, M.D., Prest,
Jacksonville, Fla. Apalachicola, Fla.
THE MEDICAL ASSOCIATION OF GEORGIA.
Annual Meeting at Savannah, April 18, 19 and 80, 1895.
Dan. H. Howell, M.D., Sec, Willis F. Westmoreland, M.D., Prest,
Atlanta, Ga. Atlanta, Ga.
ILLINOIS STATE MEDICAL SOCIETY.
Annual Meeting at Springfield, 111., May 14, 15 and 16, 1S96.
John B. Hamilton, M.D., Sec, Daniel R. Browbr, M.D., Prest,
Room 80 p. O. Building, Chicago, III. Chicago, R].
12
MEDICAL RECORD.
NATIONAL AND STATE
MEDICAL SOCIETIES OF AMERICA.
STATE— CONTINUED.
INDIANA STATE MEDICAL SOCIETY.
IOWA STATE MEDICAL SOCIETY.
Annual Meeting at Creston, April IT, 1896.
J. W. Coksnowkr, M.D., Sec., A. L. W bight, M.D., Prest.,
Dee Moines, la. Carroll, la.
INDIAN TERRITORY MEDICAL ASSOCIATION.
Semi-annual Meeting at Wagoner, December 18, 18M.
Q. R. Ruoker, M.D., Sec, Mklvin C. Masks, M.D., Prest.,
Olaremore, Ind. Ter. Claremore. Ind. Ter.
IDAHO STATE MEDICAL SOCIETY.
Annual Meeting at Boise City, Sept. 9, 10 and 11, 1896.
C. L. Sweet, M.D., Sea and Treas., I. H. Moors, M.D., Prest.,
Boise, Idaho. Pooatello, Idaho.
KANSAS MEDICAL SOCIETY.
Annual Meeting at Topeka, May, 1896.
Q. A. Wall, M.D., Sec., H. & Priest, M.D., Prest.,
Topeka, Kan. Concordia, Kan.
KENTUCKY STATE MEDICAL SOCIETY.
Annual Meeting at Harrodsburgh. June 6, 1896.
Steele Bailey, M.D., Sec., J. B. Martin, M.D., Prest,
Stanford, Ky. Louisville. Ky.
THE LOUISIANA STATE MEDICAL SOCIETY.
Annual Meeting at New Orleans, May T, 1896.
P. B. MoCutohon, M D., Sec., R. Matas, M.D., Prest.,
669 Prytanla St., New Orleans, La. TB South Ramport St., New Orleans, La.
MAINE MEDICAL ASSOCIATION
Annual Meeting at Portland, June 6, 1896.
Chas. D. Smith, M.D., Sec., W. P. Giddings, M.D., Prest..
1S6 Free St., Portland, Me. Gardiner, Me.
MEDICAL AND CHIRURGIOAL FACULTY OF MARYLAND.
Annual Meeting at Baltimore, April 98, 1896.
Jas. M. Craighill, M.D., See, Robert W. Johnson, M.D., Prest,
1780 N. Charles St, Baltimore, Md. 101 W. Franklin St. Baltimore, Md.
MASSACHUSETTS MEDICAL SOCIETY.
Annual Meeting at Boston, June 11 and 19, 1896.
F. W. Goes, M.D., Sec., F. K. Paddock, M.D., Prest.,
Roxbury, Mass. Pittafleld, Mass.
MICHIGAN STATE MEDICAL SOCIETY.
Annual Meeting at Bay City, first week In June, 1896.
Chas. W. Hitchcock, M.D., Sec., Henry O. Walker, M.D., Preit,
99 Henry St., Detroit, Mich. Detroit Mich.
MINNESOTA STATE MEDICAL SOCIETY.
Annual Meeting at St Paul, June 90, 91 and 99, 1894.
Chas. B. Witherle, M.D., Sec., W. J. Mayo, M.D., Prest,
Bndicott Arcade Bldg., St Paul, Minn. Rochester, Minn.
MISSISSIPPI STATE MEDICAL ASSOCIATION.
Annual Meeting at Jackson, ApxU 10, 1896.
H. H. Haralson, M.D., Sea, P. W. Rowland, M.D.. Prest.,
Forest Miss. Coffeevllle. Miss.
MISSOUBI STATE MEDICAL ASSOCIATION.
Annual Meeting at Hannibal, May 91, 1896.
Frank R. Fry, M.D., Sea, J. M. Richmond, M.D., Prest,
8188 Pine St., St. Louis, Mo. St Joseph. Mo.
MEDICAL ASSOCIATION OF MONTANA.
Annual Meeting at Anaconda, April, 1896.
W. M. Bullard, M.D., Sea. Geo. W. Kino, M.D., Prest.,
Helena, Mont. Marysville, Mont.
NEW HAMPSHIRE MEDICAL SOCIETY.
Annual Meeting at Concord, May 80 and 81, 1895.
G. P. Conn, M.D., Sec , David P. Goodhue, M.D., Prest.,
Concord, N. H. Springfield, N. H.
NEW YORK STATE MEDICAL ASSOCIATION.
Annual Meeting at New York, October 16, 16 and IT, 1896.
R. D. Ferguson, MD, Sec., Thomas D. Strong, M.D., Prest,
Troy, N. T. Westfleld, Chautauqua Co., N. Y.
THE MEDICAL SOCIETY OF THE STATE OF NEW YORK.
Annual Meeting at Albany, Feb. 6, 1895.
F. C. Curtis, M.D., Sec. George H. Fox, M.D., Prest.,
17 Washington Aye., Albany, N. Y. 18 R. 81st St, New York City.
MEDICAL SOCIETY OP NEW JERSEY.
Annual Meeting at Cape May, June 95 and 96, 1896.
William Pierson, M D., Sec, O. H. Sproul, M.D., Prest.,
Orange, N. J. Flemlngton, N. J.
NEBRASKA STATE MEDICAL SOCIETY.
Annual Meeting at Grand Island. May, 1895.
Geo. Wilkinson, M.D., Sec, Hamilton B. Lowry, M.D., Prest,
Omaha, Neb. Lincoln. Neb.
MEDICAL SOCIETY OP THE STATE OP NORTH CAROLINA.
Annual Meeting at Goldsboro, May 14, 16 and 16, 1896.
Robert D. Jbwett, M.D., Sec, John H. Tucker, M.D., Prest.,
Wilmington, N. C. Henderson, N. a
NEW MEXICO MEDICAL SOCIETY.
Annual Meeting at Las Vegas. July 10. 1896.
Francis H. Atkins, M.D.. Sec, G. W. Harrison, M.D., Prest.,
East Las Vegas, New Mez. Albuquerque, New Mez.
THE OHIO STATE MEDICAL SOCIETY.
Annual Meeting at Columbus, May 15, 16 and 17, 1895.
Thos. Hubbard, MD , Sec, D. N. Kinsman, M.D., Prest,
Toledo, Ohio. Columbus, Ohio.
OREGON STATE MEDICAL SOCIETY.
Annual Meeting at Portland, June, 1895.
F. Cauthorn, M. D., Sec, J. A. Fulton, M.D., Prest.,
Portland, Ore. Astoria, Ore.
ONTARIO MEDICAL ASSOCIATION.
Annual Meeting at Toronto, June 5 and 6, 1896.
J. N. R. Brown, M.D., Sec. R. W. Bruce Smith, M.D., Prest,
659 Church Street, Toronto, Canada. Seaforth, Ontario, Canada.
THE STATE MEDICAL SOCIETY OP PENNSYLVANIA.
Annual Meeting at Chambeniburg, May si, 1895.
Wm. B. Atkinson, M.D.. Sea, John B. Roberts, M.D., Prest,
1400 Pine St, Philadelphia, Pa. Philadelphia, Pa,
RHODE ISLAND MEDICAL SOCIETY.
Annual Meeting at Providence, June 6, 1896.
William R. White, M.D. , Sec. , Robert F. Notes, M.D., Prest,
Providence, R. L Providence, R. I.
SOUTH DAKOTA STATE MEDICAL SOCIETY.
Annual Meeting
W. J. Mattum. M.D., Sec. and Treas. R. T. DOTT, MD., Prest
Alexandria, 80. Dak. Alexandria, So. Dak.
SOUTH CAROLINA MEDICAL ASSOCIATION.
Annual Meeting at Columbia, April 94, 1896.
Thomas J. McKie, M.D., Sea, Edward F. Parker, M.D., Prest,
Woodlawn, 8. C. Charleston, S. a
TENNESSEE STATE MEDICAL SOCIETY.
Annual Meeting at Nashville, April 9, 1896.
S. 8. Crockett, M.D., Sec, F. L. Sim, M.D., Presto
Nashville, Tenn. Memphis, Tenn.
THE TEXAS STATE MEDICAL ASSOCIATION.
Annual Meeting at Dallas, April 94, 1895.
H. A. West, M.D., Sec, J. W. McLaughlin, M.D., Prest.
Galveston, Texas. Austin, Texas.
VERMONT STATE MEDICAL SOCIETY.
Annual Meeting at Burlington, October 10 and 11. 1896.
D. C. Hawlet, M.D., Sec, A. B. Bibber, M.D.. Prest,
Burlington, Vt Montpelier, Vt
MEDICAL SOCIETY OP VIRGINIA.
Annual Meeting at Wythevllle. Va., October, 1896.
J. F. Winn, M JD., Corresponding Sec, Robert J. Preston, M.D., Prest,
Richmond, Va. Marlon, Va.
THE WASHINGTON STATE MEDICAL SOCIETY.
Annual Meeting at Seattle, May, ISM.
R. L. Thomson, M.D., Sec, Darius Mason, M.D., Prest ,
Spokane, Wash. Spokane, Wash.
THE WISCONSIN STATE MEDICAL SOCIETY.
Annual Meeting at West Superior, June 5, 6 and 7, 1896.
Charles S. Sheldon, M.D., Sea, Almon R Clarke, M.D., Prest,
Madison. Wis. Sheboygan, Wte.
THE MEDICAL SOCIETY OF WEST VIRGINIA.
Annual Meeting at Rlklns, Jury, 1895.
G. A. Asohman, M.D., Sec, D. Mater, M.D., Prest.
Wheeling, W. Va. .Charleston, W. Va
Societies not found in this list have not responded to our request for information.
MEDICAL RECORD.
13
^
JMflM
COCA WINE.
A. New Liquid Preparation.
BACH FLUID OUNCE CONTAINS
ERYTHROXYLON COCA,
30 GRAINS.
<y
Please mention this Journal.
Owing to the great diastasic strength of Maltine, there will be found in a dose
of "Maltine with Coca Wine" (notwithstanding that it contains only 40% of Maltine),
diastase enough to convert more starch than can be converted by a dose of any unat-
tenuated extract of malt now made, whether dry or semi-liquid. It should be borne in mind
that the employment of wheat and oats, in addition to malted barley in its preparation, has
raised Maltine far above the level of a mere extract of malt, and has placed it, in the almost
unanimous estimation of the medical profession, in the front rank of food products as well
as digestive agents.
We will send to any physician, who will pay expressage, an eight-ounce bottle of
" Maltine with Coca Wine ' and an eight-ounce bottle of any other preparation selected from
our list.
THE MALTINE MANUFACTURING CO.,
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Hiek's Thermometer, Sterling Sliver Case and Chain 3.50
Hick's Thermometer, Lens Front, Certified 1.60
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Grave's Bivalve Speculum, Nickel-plated 1.10
Coin Silver Probes 85
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14 MEDICAL RECORD.
CALCULI DISSOLVED
By the Buffalo Lithia Water
MIAUII UCDQCDT PI AIDflDIIC of Petarrirawr, Va., ex-President end Honorary FeUow Media*
. junn ntnotni luuDunnt, 8o^iety of rirgMa> ^ a fetor> dated SepUmber 8j 189a^ to
Dr. E. 0. Laird, Besident Physician at the Buffalo Lithia Springs, Bay*: —
"I send by this mail a bos of Calculi, passed at various times within the
last year by Hon. T. J. Jarratt, our former Mayor, whilst drinking the
Buffalo Lithia Water. They give him but little pain now when passing. I
have never critically examined the broken Calculi passed in such quantities
from Mr. Jarratt' a bladder, but am under the impression that the most of
them are magnesian phosphates. There were specimens, however, which
presented the appearanoe of oxylates, and some, I remember, impressed me
specially as being uric acid. I do not pretend to account for the mode of
their solution by the Buffalo Lithia Water. There is nothing in its analysis
which would warrant such results ; but the results are there, and seeing is
believing. I can only suppose that in Nature's alembic there has been sosse
subtle solvent evolved, too subtle to be caught by our coarse re-agents,
which makes this wonderful disintegration. 'There are many things in
heaven and earth not dreamt of in our philosophy/ and his is a short creed
IUiistrmdoii of the Calculi referred to by Dr. Clal- , . „
borne. The engraving was made from a photograph who only believes what he can prove or explain."
and represent! the exact ahape of the Calculi ; thej
are four times Use of above.
URIC ACID DIATHESIS
Treatment with Buffalo Lithia Water
By eminent physicians as follows;
FIR HIINTFR MrPIIIRF **JB: "*n Urio Acid Gravel, and indeed in diseases generally dependent upon
UP. niin I tn mUUUint ^ Uric Ao£d pi^e^ Buffalo Lithia Water, Spring No. 2, is a remedy of
extraordinary potency. I have prescribed it in cases of Rheumatic Gout, which had resisted the ordinary remedier,
with wonderfully good results. I have used it also in my own case, being a great sufferer from this malady, and
have derived more benefit from it than from any other remedy."
Fir J T I PRI ANPHARn ProfeaBOr Montreal Clinic, SM., SN., Y.U. "I have used Buffalo Lithia
Ul. J. I . LCDLUnUnHnU, Water ^ the moBt obgtinmte ^^ of Chronic Inflammation of the Bladder,
in Stone of the Bladder, in Uric Acid Gravel, with the most efficacious results."
DR WM R TOWLFS ProfeMOr of Anatomy and Materia Medica in the Medioal Department of the UmV
Yirginia. " Buffalo lithia Water, Spring No. 2, has proved mr
efficacious in many diseased conditions than any of the simple Alkaline Waters. I feel no hesitancy whatever in saying
that in Gout, Rheumatio Gout, Rheumatism, Stone in the Bladder, and in all diseases of Uric Add Diathesis, I know
of no remedy at all comparable to it. Its effects are marked in causing a disappearance of Albumen from the Uiine."
DR HARVFY I RYRR of Baltimore> President and Professor of Obstetrics and Diseases of Women and
Un. nHniLI L. UinU, children ^ ^ Baltimore Medical College, formerly Professor of Practioal Medicine,
etc. " I have witnessed the best results from the action of the Buffalo Lithia Water, Spring No. 2, in Chronic Gout,
Rheumatic Gout, Rheumatism, Gravel and Stone in the Bladder, and I do not hesitate to express the opinion that in
all diseases depending upon or having their origin in Uric Acid Diathesis, it is unsurpassed, if indeed it is equaled, by
any water thus far known to the Profession."
Water in eases of one dozen half -gallon bottles, $5.00 f. o. ft. here.
Sold by all first-class Druggists
THOS. F. GOODS, Proprietor
Buffalo Lithia Springs, Va.
MEDICAL RECORD.
IN CHRONIC ARTICULAR RHEUMATISM,
in all diseases of mucous membranes, and pain in the par-
enchymatous organs* which were formerly called rheuma-
tism, and attributed to cold, or for which no other cause
has been found, are readily relieved by
HENRY'S TRI-IODIDES.
I ranORWI IT ANO NKQUOfTlV TMd IT MVMkT FOR •out. O. J. RADEMAKER, M. O., LOUISVILLE, KY.
OF nm ALKALOIDS tfr Mtfr* matfiMato of:
thjbtt OBADfs anew oolchioSE
TBHTTORAnra FKTTOLAOA DB0AXMU;
TiJ?II-a5AI,!L?OLA1^7,l ©UWJAMABA;
AUD TEN ORAXV8 BAU0TLAT1 SODA
RENZ A HENRY,
OHEMI8T8,
LOUI8VILLE.KY.
DOSE-Om <
Sows la wtftw, will r*
1Ut« tS« pals of ini,
•rat* or ehreato rfcrama.
Um lm atz boon.
PROPRIETORS
ELIXIR THREE CHLORIDES
Ideal Alterative-Teiiique.
15
U
MOFERRU
.BLOOD-IRON
Is Soluble, Non-Styptic,
Non-Irritating, and
Non-Constipating.
It Is Haemoglobin in its best form, viz.;
OXYH/EHOOLOBIN.
CLINICAL EXPERIMENTS HAVE PROVEN ITS ~ A M A C KA I A
GREAT VALUE IN THE TREATMENT OF fiWH r\ C IY| I f\ ,
CHLOROSIS, AND ALLIED DISORDERS.
For literature, samples, and farther particulars, address
FREDERICK STEARNS & CO., Detroit, Mich.
Third Edition. Revised and Enlarged.
DISEASES OF THE
CHEST, THROAT, AND NASAL CAVITIES,
INCLUDING
Physical Diagnosis and Diseases of the Lungs, Heart, and Aorta, Laryngology and Diseases of the
Pharynx, Larynx, Nose, Thyroid Gland, and Oesophagus.
By E. FLETCHER INCALS, A.M., M.D.
Professor ol Laryngology and Practice of Medicine. Rush Medldal College ; Profeaaor of Diaeasea of Throat and Cheat, Northwestern University Women*
Medical School ; Profeaaor of Laryngology and Bhlnology, Chloago Polyclinic, etc
EXTRACT PROM PREFACE.
I have not discussed questionable theories, and have not referred to methods of treatment which do not
dtronglycommend themselves to my judgment.
The favor with which the preceding edition of this work has been received leads me to believe that I
have succeeded in my efforts, not only to aid laryngologists in their daily work, but also to place these subjects
clearly before students, and a large class of general practitioners who of necessity must be prepared to meet
any emergency. .
PRESS NOTICES OF THE SECOND EDITION.
" We heartily recommend the book to thoae who desire to become thor-
oughly acquainted with the beat literature upon diseases affecting the re-
spiratory tract"— Therapeutic QaseUe.
" An excellent book of reference for the student to laryngology, or the
practicing physician, and is essential to the library of the laryngoToelat."
— Boston Medical and Surgical Journal.
" The appendix is rich in therapeutic formula)— valuable alike to the gen-
eral practitioner and specialist— so that thla Is the one book that both laryn-
gologists, etc, and general practitioners should have."
—Virginia Medical Monthly.
" It Is the work of a specialist along broad lines, and of one whose ipeds>
Ism is the concentration and essence of jears of general practice.
" The volume is one of value alike to the special and general worker, and
we congratulate Dr. Ingals upon the successful accomplishment of a con-
fessedly difficult work*- Medical Record.
"The physical signs of disease occupy the most prominent place and
there is no book In which they can be better studied, since their direct con-
nection In the text with the description of the other features of disease is
calculated to give the student a more complete picture than he would get
from a work on physical diagnosis alone"— Northwestern Lancet.
One volume octavo, of 718 pages, illustrated by 244 wood-engravings and a oolored plate. Muslin, $5.00.
WILLIAM WOOD & COMPANY, Publishers, New York.
16
MEDICAL RECORD.
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Fl«, t.
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This Cocoa Butter shell melts at the temperature of the body and liberates the Glycerine, allowing it to oome in
direct contact with the mucous membrane.
The Glyoerine, being a liquid, is free to distribute itself over the mucous membrane, stimulating the surfaces, and
soon producing an easy movement of the bowels.
The Cocoa Butter is softening and lubricating, and prevents the griping that sometimes follows the use of Glyoerine
In the rectum.
Two of our Suppositories, separated by a wafer, are packed in a glass vial — Fig. 3.
Six of these vials, twelve suppositories, are packed in a wooden box, secure against breakage or deterioration.
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Diseases of the Bladder
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Second Edition, Thoroughly Revised.
One Volume. Octavo, 38a Pages. MM.«. *-*-
Illustrated. Fine muslin binding. **"««. •»*••
WM. WOOD & CO., Publishers,
43 to 47 East toth Street, - New York.
A <TM&A/TIS» ON
BRIGHT'S DISEASE OF THE KIDNEYS.
ITS PATHOLOGY, DIAGNOSIS, AND TREATMENT,
With Chapters on the Anatomy of the Kidney, Albuminuria, end the Urinary 8ecretion.
By HBNRY B. MILLARD, M.A., M.D.9
Felew of the Academy of Medicine of New York and of the American Academy of Medicine ; Foreign Corresponding Member of the Academy of Medicine of Parishes*
Third Edition, revised and enlarged. Complete in one volume, octavo, of 311 pages, with numerous original Illustrations, Beautifully
printed on heavy paper and bound in imported cloth. Price, fa.00.
WILLIAM WOOD & COMPANY, Publishers. - - - 43- 45 & 47 East ioth Street, New Y«»k.
MEDICAL RECORD.
17
RICHARD KHY & CO..
17 Park Placet - Few York, HT. T.,
MANUFACTURERS AND DEALERS DS
Surgical Instruments/
ASEPTIC OPERATING
— AND —
Hospital Furniture.
Please inspect and compare before buying.
No. 16297 -HOSPITAL WARD 8TAND FOR
DRESSINGS.
Price Lists upon Application.
THE STANDARD HYPNOTIC,
Dose— One-half to one fid. drachm in water or syrup.
THE STANDARD ANODYNE,
Dose— One fid. drachm, represents # gr. morphia In anodyne
principle, minus its constipating effect.
THE STANDARD ALTERATIVE,
Dose— One or two fid. drachms as indicated.
Clinical reports from eminent physicians throughout the World
furnished on application.
CHEMISTS' CORPORATION,
ST. LOUIS, MO., U. S. A.
i8
MEDICAL RECORD.
FRELIGH'S TABLETS,
(Cough and Constituent,)
70S THE PREVENTION AND CUBE OF
PULMONARY PHTHISIS.
FORMUUE.
• * —
COUCH TABLETS,
EACH TABLET CONTACTS
Morph. Sulph. (fa gr.), Atropia Sulph. (yj^ gr.),
Oodeia (fa gr.), Antimony Tart, (fa gr.), Ipecac,
Aconite, Pulsatilla, Dulcamara, Causticum, Graphite,
Bhus-tox, and Laohesis, fractionally so arranged as to
accomplish every indication in any form of cough.
* *
CONSTITUENT TABLETS.
EACH TABLET OOVTAIHS
Arsenicum (J^gr.), Precipitate Oarb. of Iron, Phos.
lime, Oarb. lime, Silica, and the other ultimate
constituents, according to physiological chemistry
(normally), in the human organism, together with
Garaccaso, Cocoa, and Sugar.
PRICE, THREE DOLLAR8 PER DOUBLE BOX.
Containing sufficient Tablets of each kind to last from one to three months according to the condition of the pfitiimi*
While the above formula have been in use, in private practice, over 80 years, and we could give testimonial*
from well-known clergymen, lawyers, and business men, we prefer to leave them to the unbiased judgment of the
profession with the following offer : On receipt of 60 cents, and card, letter-head, bill-head, or other proof that the
applicant is a physician in active practice, we will send, delivered, charges prepaid, one of the regular (double) boxes
(retail price, Three Dollars), containing sufficient of each kind of Tablets to test them three months (in the majority of
oases), in some one case. Card, letter-head, or some proof that the applicant is a physician in active practice must
aooompany each application. Pamphlet, with full particulars, price-list, eta, on request.
As we furnish no samples through the trade, wholesale or retail, for samples, directions, price-lists, eta, address
106 A IOe FULTON «T.|
I. O. WOODRUFF A CO.,
Manufacturers of Physicians' Specialties,
NEW YORK OITY. '
JUST PUBLISHED.
OPERATIVE SURGERY.
By TH. KOCHER, M.D.,
PROFESSOR AT THE UNIVERSITY AND DIRECTORY OF THE SURGICAL CLINIC AT TBS BERNE UNIVERSITY.
8vo, 288 pages, 163 illustrations. Extra muslin, $3.00.
Dr. Kocher has endeavored to produce a work that shall materially assist in acquiring that mastery of
operative technique which is absolutely indispensable to the successful surgeon. The book is divided into
four parts.
Part I. is taken up with general observations, including remarks and directions regarding Anaesthesia,
the Treatment of Wounds, and the Selection of the Direction of the Incision, which last is always of pri-
mary importance.
Part II. treats of Special Operations upon the Skull, the Face, the Cervical Triangles, the Spinal Col-
umn, the Lumbar Region and the Abdomen, the Extremities, etc, etc.
Part III. treats of Excisions (Resections) of the Extremities.
Part IV. of Amputations and Exarticulations.
The general observations and introductions preceding these different portions are remarkably suggestive
and practical. The operations themselves are clearly and minutely described, and the illustrations add dis-
tinctness to the graphic descriptions. The Journal of the American Medical Association (Feb. 17th) says of
it : " The book is remarkable for its extreme simplicity of style, its entire freedom from superfluities of any
sort, and its directness. These are indeed always characteristics of a master, whether the topic be warp
religion, law, or medicine"
WILLIAM WOOD AND COMPANY,
NEW YORK.
MEDICAL RECORD. 19
PANOPEPTON
is the entire edible substance of
prime, lean beef and best wheat flour, thoroughly cooked,
properly digested, sterilised and concentrated in vacuo,
and preserved in a sound sherry.
Panopepton is the food par excellence for invalids;
in all acute diseases, fevers, etc.; in convalescence; for
the large class of persons who from feebleness or de-
ranged digestion, or antipathy to ordinary foods, require
a fluid, agreeable, and quickly assimilable food.
Panopepton proves an effective resource against sleep-
lessness when this is due to excessive fatigue, stress of
mental work or malnutrition.
Panopepton is at once a grateful stimulant and food.
Originated and manufactured by Fairchild Bros. &
Foster, New York City.
MEDICAL RECORD.
''THE great popularity of PA VARA PILLS has induced many druggists to substitute or
recommend other pills, of inferior quality and less price, in place of them. Physicians
can prevent such substitution by advising their patients not to accept PAVARA PILLS
from a druggist unless put up in the original
packages, with the outside wrapper unbroken.
j&.
teLrwwrma
■toUVER, SICK HEW*
LM
— 1 fXVARA
Pa vara Pillc p™^*
produce natural movements of the bowels, without to uyer sickhw^
pain, nausea, or any inconvenience.
These Pills have a world-wide reputation for being
Directions
the standard remedy for
Constipation.
11HPJ
5*3^ --*
For Constipation during Pregnancy these Pills
are a perfect remedy. Formula printed on the
Thousands of physicians now use and prescribe them,
^s&HpsS
IH outside label. Thousands of physicians now use and prescribe them. Trial samples
III will be mailed, free of charge, to any physician who is not familiar with their merits.
Ift Prepared by C, L. Toruvr. New YorfcWP. O, Box Ml,-. Depot : 119 Fnlton Street.
>^^^^^^^^^^^^^^^^^^^^^^^^^ ^
Mellirfs Food
FOR
INFA1VTS -AJNTD TTSTV A T..TDS,
RECEIVED AT THE
CALIFORNIA MIDWINTER EXPOSITION,
SAN FRANCISCO, 1894,
TWO GOLD MEDALS AND TWO
SPECIAL DIPLOMAS OF HONOR.
San Francisco, July 2nd, 1894.
TO THE DOLIBER-GOODALE CO., Boston, Mass.
Dear Sirs : — Mellin's Food was selected for use in the Emergency Hospital at the
California Midwinter Exposition on account of its well-known superior qualities as a food for
invalids and the delicately sick.
I am pleased to inform you that it has been in constant use during the entire time of
the Fair, and has always given such complete satisfaction that no other prepared food has
been needed in the Hospital.
Yours truly,
(Signed) Martin Regensburger, M.D., Medical Director in Chief.
A liberal sample bottle o* M ELLIN'S FOOD, tuffloient for
trial, will be tent free to any phytioian requesting it.
DOLIBER-GOODALE CO., 291 Atlantic Avenue, Boston, Mass.
MEDICAL RECORD.
21
PHYSICIANS PRESCRIBE
GRANULATED EFFERVESCENT
SAL APERIENT
A. & HI.
FOB
K. & M.
CONSTIPATION,
(PARTICULARLY USEFUL IN HEMORRHOIDS;)
'VETITB VJSCS1
SPECIFY "KEASBEY <fc MATTISON" WHEN PRESCRIBING
KEASBEY & MATTISON CO.,
HYDROZONE
IS THE STRONGEST ANTISEPTIC KNOWN.
One ounce of this new Remedy is, for its Bactericide Power, equivalent to
two ounces of Charles Marchand's Peroxide of Hydrogen (medicinal), which ob-
tained the Highest Award at the World's Fair of Chicago, 1893, for its Stability,
Strength, Purity and Excellency.
CURES DISEASES CAUSED BY GERMS:
DIPHTHERIA, SORE THROAT. CATARRH, HAY FEVER, LA GRIPPE,— OPEN SORES J ABSCESSES, CAR-
BUNCLES, ULCERS,— INFECTIOUS DISEASES OF THE GENITO-URINARY ORGANS,— INFLAMMATORY AND
CONTAGIOUS DISEASES OF THE ALIMENTARY TRACT: TYPHOID FEVER, TYPHUS, CHOLERA, YELLOW
FEVER,— WOMEN'S WEAKNESSES: WHITES, LEUCORRHCEA,— SKIN DISEASES i ECZEMA, ACNE, Etc.
SEND FOR FREE BOOK OF 158 PAGES GIVING FULL INFORMATION.
Physicians Rjuottwg Twenty-Five Gents Postal Oedee will Receive Fees Sample by Mail.
AVOID IMITATIONS.
HYDROZONE is put up only in small, medium and large size bottles, bearing a red label,
white letters, gold and blue border.
QLYCOZONB
CURBS
DI8BA8B8 of tb« STOMACH.
thfa publication.
LEADING DHU04IST*.
Prepared only by
ChnmUt and gradual tftJu "EccU Central* duArtstt Mamu/acturu <U Pari*- {Frm*a±
28 Prince St, New Tort
22
MEDICAL RECORD.
NERiZES.
Suppose we find the patient a little giddy upon rising in
the morning. This means that the nerves do not have perfect
control of the muscular system. As a test for this, direct the
patient to stand with his feet close together, shut his eyes, and
if the tendency is to reel it is another evidence of lowered nerve
tone. Or stand with the arms extended, shut the eyes, and then
try to bring the tips of his forefingers together in front of him.
If , they pass by or meet imperfectly, it shows the same thing.
Or, the person may not be able to think as quickly as he should.
To test this ask the patient three simple questions in rapid. suc-
cession, as, "Where were you just before you came into this
room?" "What were you doing?" "How long did you remain?"
The rapidity with which the answers are given indicate the rap-
idity of brain action. All these things show that it is of the
utmost importance that the nervous system should be kept in
tone. Otherwise, every part of the body languishes. This con-
dition indicates the use of CELERINA (Rio) in teaspoonful doses
four times a day, TO INCREASE THE NERVE CAPITAL OF
YOUR PATIENT.
RIO CHEMICAL CO., St. Louis, Mo.
A full otto botUo of CELERINA mill 6* oent FREE to any Pkyol- 1
ekm mho ml$h— to toot tt If ho mill pay tho express okargoo. »
THE DELANO OIL ATOMIZER, No. 548.
Hood In position.
Hood removed:.
1*4* Atomizer is designed for Atomising OU Vaseline* Fluid
Oosmolinef Alboline9 Benmoinol9 Glymol, etc., etc.
The treatment of inflammation of the nose end throat with Oil Vaseline or some of its
■eflfflnatkwia as given above ie ojiiversallv established, and is generally regarded as the
tat method of treating these oomplainta.
The Delano Atomiser is very simple in oonstrnotion, is not liable to get clogged np,
■ai produces a strong, heavy spray.
. The hood or oap that covers the spray tabes is removable, whioh gives free aoosss
te the tabes in osse they should get dogged ap, and the shape of the liquid or oil tube in
Me bottle allows the instrument to be used in a horisontal position. The metal parts are
■Jekeled, and the bulb fa fitted with metal valves.
This fa the best instrument at a moderate prioe that has been placed on the market,
sad the impressing demand for it oonvinoes us that it is giving satisfaction wherever it is
BIAlfUFACTURBD BY
Z. DELANO, Boston, Mass.
DAVIDSON RUBBER CO.,
/br tM United flW» BOSTON, MASS,
Elixir Six Iodides
This Elixir is prepared from the Chemically Pars
Salts. Results can be looked for from its ad-
ministration that could not possibly he
expected from the Commercial Salts.
FORMULA.— Sach fluid drachm contains i
let Iodldvm 1-116 grain, Ferrl Iodldom Mi grata,
Hydrargyrl Iodldnm 1-1*5 grain, Manganesll Iod*-
dum 1-10 grain, Potsssll Iodldom one grain, Bodfl
Iodldnm one grain, with Aromattca.
MEDICAL PROPERTIES -The greatest esta*
of thli oomoffiotton is it relieves those obsourv and
chronic obstruoUono to gland ocMon— the Kdney,
Ueer, pancreas, ss well as the lymphatic system,
which may exert so great sn tnfluenoe for evil on
the economy. It enjoys the confidence of the
Medical Profession, as its nee Is indicated m a
wide range of diseases, particularly so to serat-
•fotttanann(a,slta diseases, both scaly snd j
lor; has remarkable curative effects in ~
Steeaeee snd other manifestations of si
infection, chronic, uterine, and peivio dUeassa,
snd In oomplamu where an aUerattoe and umte Is
Indicated.
This combination proves that the untied action
o/ remedies Is often reqalslte when either, alone, to
Insufficient. Physicians, when presenting, will
please write :
~ BUxir 8iX IodiOSS-WAUDOrQKMJD^B-OmO
Bottle,
The druggist will please write directions on his
own label. ELIXIR SIX IODIDES to always sold
to eight os. oval bottles snd mbvbb in bulk.
Attention Is also called to oar Bllxlr Six Bra-
■alelee, Bllxlr Six Hyp*FfcesB>Mltee,
am* Bllxlr Six Aperients, which are
celled for clinical efficiency snd palatabUlty.
Samples of the four Elixirs wfll be sent to i
Physician by express, prepaid, on receipt off
Wholesale price per dosen : Iodides, $8.00 ; B
phosphites, $6.00 ; Bromides, Ss.00 ; Aperlens, |
8ead far Descriptive Clrealar.
These Elixirs are kept to stock by Wholesale
Druggists generally thronghont the Untied States.
THE WAUCR-BRCCW. PMABsUCOmCAL CL,
(mO9IF0S41ll>)
Head Office, 180 W. Regent St., Glasgow, Scotlaad
WBSTsUtN DBPOT. U. S. A.,
17 W. Fifth St., Kansas City, Ms.
9
MEDICAL RECORD.
23
|1
5 s*.!
vXCs
*3
D£SIR£E \Qrav'lt Vesical calculi; Completes
" ▼ ( of the Kidneys.
DDtriPfTCr J Diseases of the Lher; Diabetes mi
( Disorders of the stomach.
■■PEMTRIOE \The best natural Table water
( ever known.
DSFOT AT ALL MnfBBAL WATBB8 DbALBBS.
PAMPHLET in PARIS. 4, Rue de Greffalh*
SAINT-RAPHAEL
.Tonic, strengthening, digestive wine. Ordered fo*
mak and fatigued stomachs, in chlorosis, anomiap and t#
convalescent people. Unrivaled adjnvanl
in consumption. Excellent flavor.
Jktwr* of worihUa imitation*. Sea that yam
[I get m each bottle the Tr ade Mirk here oppoaHi
and the Warranty Stamp of the Manufao*
torero1 Union.
I. MIGXI, 2 W eat 13th Str**l. tioar Fifth Avftntto. NEWTOEK,
A, XIQUES, 67 * a9 Dsottur Str«*t. KCW ORLEANS.
Vattry MM li£lj, & CO., laio OhutAul St., PHILADELPHIA,
UlIT-tAPMAIt WIIE 8SWAIY. fxl jutot (Drtna, trance).
The "Master" Surgical Elastic Stockings.
FOB VABICOtB VBaHB, WBA1 AND SWOLLEN JOINTS, DROPSY OF TUB
LIMBS, SPRAINS, BtC
THE PATENT NON-ELASTIC STATS AND ADJUSTABLE LOOPS,
By the aid of which they can be drawn on easily, like pulling on a boot. They will last much longer than the old style.
as the stays prevent them from being torn apart tn drawing them on.
ALL KINDS AND SIZES IN THRRAJ) OB SILKKLAflUC. Made nnder B. Master's Patents, Not. », UtL
March 81 1888. Bend for descriptive circular and prtoe-hst to
POMEROY COMPANY,
Daniel Pombbot, Pres.
SPECIALTIES:!
785 Broadway, New York.
Ghabijb B. Dsah, flea
POMEROY'S FRAME TRUSS,
Dr MEICS CASE'S SPINAL APPARATUS,
THE " MASTER" PATENT ELASTIC STOCKING,
IN REFERENCE TO
A SULPHONIC SALT OF ALUMINUM
ALUMNOL
IT PRECIPITATES
THE NEW A8TRINGENT.
ALBUMEN WHICH RE DISSOLVES IN EXCESS
IT ACTS. THEREFORE
BOTH
SUPERFICIALLY
AS A8TRINCENT AMD ANTISEPTIC IN
RHINO-LARYNGOLOGY
GYNECOLOGY
OPHTHALMOLOGY
OTOLOGY
DERMATOLOGY
IT IS
SUPERFICIALLY
AND
DEEPLY
DEEPLY
AS RESOLVENT AND RE8QRBENT IN
CHRONIC SKIN AFFECTION8
INDOLENT CALLOUS ULCERS
PLASTIC EXUDATES
LYMPHADENITIS
EPIDIDYMITIS, ETC.
ODORLESS-INNOCUOUS-UN-IRRITATINC
EMPLOYED IN POWDER-SOLUTION-OINTMENT
FOR FURTHER INFORMATION SEE LITERATURE.
MANUFACTURED BY
PARBWERKE VORM MEISTER LUCIUS A BRUNINC,
HOECH8T O. MAIN (GERMANY).
SOLE LICENSEES FOR U.S.
SCHULZE-BERCE A KOECHL,
79 MURRAY 8T., N. Y.
24
MEDICAL RECORD.
DR. D^CLAT'S
ANTI-SEPTIC
PREPARATIONS.
From Mbdioal Rboobd, N. Y., May 8, 1890, p. 507.
Dr. Glenn has used Dr. DecJat's preparations of phenio acid,
both internally and externally, with gratifying results, for the
last ten yean. During this time he has employed phenio acid ai
his chief remedy in all oases of malarial, typhoid, and scarlet
I evers, diphtheria, erysipelas, blood-poisoning, as a local applica-
tion to all wounds, whether the result of accident or surgical
operation, and has found the result so satisfactory that there is
little left to be desired.
Since he has been following this plan of treatment, in typhoid
fever, for example, he has never had a diarrhoea occur in any of
his patients ; never a hemorrhage from the bowel ; never a serious
tympanites ; never a death. He believed that with these prepara-
tions of phenio acid, and antif ebrin as an aid, physicians possessed
the treatment, par 4ocdbru36% of all symotie diseases.
I will send on request of physicians mentioning MEDICAL
Rbcokd, an abstract of Medical Reports on the Uses of Deolat'a
Preparations in all Zymotic Diseases, Garbnnole, Tumors, Oanoer,
Tuberculosis, Diabetes, Rheumatism, Skin Diseases, eta
J. MILHAU'S SON,
DRUGGIST AND IMPORTER,
And General Agent for the Dtfclat Mfg. Co.,
Established ih 1818. 183 Broadway, If. Y.
Hamilton's System of
[Now Ready im 2 Vols.
LEGAL MEDICINE.
A COMPLETE WORK OP BEFEKEMGE FOR MEDICAL AID LEGAL FRACBBflMEBS.
By ALI^AH MoLAJTE HAMILTON, M.D.,
Coninltiiig Physician to the Insane Asylums of New York City.
AisUted by LAWBBNOE GODKDf, Esq., of the Hew York Bar, sad Others.
Its list of thirty contributors includes the Dames of the i
writers and authorities upon Medical Jurisprudence in America,
reference it will be found an invaluable help to medical men, and to those of
the legal profession who desire the aid of the most advanced and sound opin-
ions of practical students of forensic medicine. So much opprobrium has
been attached to the word " expert," that It has been the aim of the Editor and
his colleagues to give the work a decided judicial and impartial tone, so that
it may be consulted with confidence by all as an authority of the highest order.
Until recently the literature of Medical Jurisprudence in the United States
has been exceedingly meager and limited in scope and character. Foreign
books are inapplicable for want of conformity to the legal usages of this
country.
A marked feature of the work la the introduction of short articles upon
legal subjects by distinguished members of the American Bar. The cases cited
are recent, and ohiefly American, and up to date in theory and practice.
PARTIAL LIST OF (COLLABORATORS.
WALTER HAINES. A.M., M.D., Chicago.
V. C. VAUGHN, A.M., Ph.D.. M.D., Ann Arbor.
F. A. HARRIS, M.D., Boston.
LEWIS BALCH. Ph.D.. M.D., Albany.
CHARLES L. DANA, A.M., M.D., New York.
F. R. STURGI8, M.D., New York.
A T. BBJSTOWR. M.D., Brooklyn.
BRANDRBTH STMONDS, M.D., New York.
B. 8ACB8. A.M.. M.D , New York.
J. F. BABCOCK, M.D., Boston.
CHARLES JEWETT. M.D., Brooklyn.
CHARLES K. MILLS. A.M., M.D ^Philadelphia.
CHARLES Q. CBADDOCK, M.D., St. Louis.
G. E. PELLBW, Ph. D., New York.
P. COOMBS KNAPP. MJX, Boston.
GEO. RYEB80N FOWLER. M.D., Brooklyn.
Judos C. 8. PRATT, Brooklyn.
Judos SIMEON B. BALDWIN, Connecticut.
JOHN B. PARSONS, Esq.. New York Bar.
R. C. McMURTRIR. Esq.. Philadelphia Bar.
WM. B. HORNBLOWB& Esq.. New York Bar.
Il «, „
fully Illustrated. In mechanical
CONDITIONS.— The work is comprised in two large royal octavo
volumes of about seven hundred pases each, fully IDuaf ' *
execution, the best known to the six of book-making.
In cloth, per volume, $6.00 ; lull sheep, per volume, $6.60.
Sold by subscription. SdHcitoravxtnted. Descriptive circulars on application.
E. B. TREAT, Publisher, Ho. 6 Coopei Union, Hew York.
TREATISE ON GYNECOLOGY,
MEDICAL AND SURGICAL.
By S. POZZI, M.D.,
Vrofesseur Agrege' a la Faculte de Mrfdecine ; Chlrurgien de PHdpital Lourcine-Pascal, Paris ; Honorary Fellow of the American Gynaecological
Society.
Translated prom the French Edition under the supervision op, and with Additions by
BROOKS H. WELLS, M.D.,
Lecturer on Gynaecology at the New York Polyclinic ; Fellow of the New York Obstetrical Society, and the New York Academy of Medicine.
This work, the latest and most comprehensive, and by far the best which has appeared for many years on the subject
«f practical Gynaecology, is the result of the author's long practical experience of a hospital service at Lourcine, devoted
-especially to the diseases of women.
It is essentially practical in method, and treating the subject as it does both from the surgical and the medical stand-
point, is calculated to be of the utmost value to the general practitioner as well as to the specialist But few changes
have been made or thought necessary in translating Prof. Pozzi's work into English, the endeavor having been to follow the
original as closely as possible. A number of editorial notes, referring mainly to minor points, have been added. Many
•of the illustrations are original, having been drawn under the supervision of the author, and appear here for the first time.
Certain cuts of instruments and accessories have been omitted or replaced by those which American practice has found to
be better suited to our needs.
A voluminous and complete bibliography accompanies the work together with a complete index in each volume.
Pozzi's Gynaecology will consist of two royal octavo volumes of about 6oo pages each. Volume I. contains, in addition to
the very numerous wood-cuts, six plates in colors. Volume II. will contain nine colored plates.
As a specimen of book-making Pozzi's Gynaecology is very handsome, being beautifully printed on extra heavy paper and
bound in red English muslin, brown sheep, and dark green half-morocco, at $6.oo, $7.00, and $8.00 per vohime, respectively.
A complete descriptive circular will be mailed free upon application, to any address.
The work is sold by subscription only.
WILLIAM WOOD & COMPANY, Medical Publisher*, 43 to 47 East Tenth Street. New York
MEDICAL RECORD.
25
THSL
Animal Extracts
Prepared aocording to the formula of
DR. WIN. A. HAMMOND,
In his laboratory at Washington, D. C, and under his immediate supervision.
Dr G. L. Dana, Professor of Nervous Diseases in New York Poet-Graduate Medical School, writes
in the Sanitary Era for January, 1894 :
"ANIMAL EXTRACTS : I am so firm a believer in the rationality of this line of therapeutical investi-
gation that I am willing to brave some misunderstandings in connection with the use of such preparations.
There is no more reason to doubt that there should be therapeutical properties in extracts obtained from
animal organs than that there should be such from vegetable organs. We might just as reasonably expect
good therapeutical properties from the extract of a gland as from the extract of a root or a leaf or a bean.
The remarkable results obtained from the use of the thyroid gland in myxoedema is of itself abundant
justification of this position."
The Animal Extracts 0EREBR1NE, OARDINE, MEDDLUNE, OVARINE, MUSCULINE, THY-
RODENTS, and TESTINE are being used now with gratifying success by progressive physicians all over the
country. All existing literature on the subject will be muled and the Extracts forwarded on receipt of price,
$2.50 per bottle, by
COLUMBIA CHEMICAL COMPANY,
Wholesale Agent, J. MHHAF8 SOH, 183 Broadway, Hew York.
WASHINGTON, D. C
A COMPLETE DRY CELL GALVANIC BATTERY
and SWITCH -BOARD for Utilizing
the Incandescent Current, Combined.
The Tetter Complete Portable Dry Cell Galvanic
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made. The Controller and Mil-ammeter can be used
independent of the oells, in connection with the In-
candescent Current, where same is available.
Dry Cell Galvanic Batteries, from
SIO.00 up.
Table Bases, Wail Bases, Cabinets, ete.9 for
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Send fob Illustrated Catalogue.
By means of the Vetter Current Tap, Storage Batteries can be charged free of cost*
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Send for a
Catalogue-
OF
WM. WOOD & CO.'S
Publications;
An Index of the.
PRACTICE OF MEDICINE.
By W. M. CARPENTER, M.D.
i6mo, 304 pages, full leather with
tuck, price, $2.50.
WM. WOOD & CO., NEW YORK.
THE PRINCIPLES AND PRACTICE OF SURGERY
By PRANK HA3HN05 HAMILTON, A.M., M.D., LL.D.,
Late Pro/steer of the Practice of Surgery, with Operation*, and of Clinical Surgery, in Bellevue Hospital Medical College
Consulting Surgeon U
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MEDICAL RECORD. 27
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The American Journal of Obstetrics
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MEDICAL RECORD. 29
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A TEXT- BOOK ON DISEASES OF
THE EYE.
By HENRY D. NOYES, M.D.,
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£oyal octavo, 816 pages, richly illustrated with chromo-lithographic plates and engravings. Second
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MEDICAL RECORD.
3i
OFFICIAL ANNOUNCEMENTS
OF MEDICAL COLLEGES.
Long Island College Hospital
AND HOAQLAND LABORATORY,
BROOKLYN, NEW YOBK.
BJBSSIOW 1894-96.
The Regular Term vrtll commence September 2ft, 1994. am continue rtx monika.
The Beating an4 Recitation Term wtdc&mmen*™ MttrvA 28. 1S&4.
The So«p!t*r»iid EUiiiwiisary* iu which If.Ttf patient* were treated In tttt, art
In ta«Huna building with the Collet- and two or tone noun on dally devoted
to Clinical Tew bins and Physical Dia*fiioii«. Quizs«s are held by Iba Professors
ud their osiiiBLA.il ta Ibroutfiiout tbfl course, without coat* Students also rv.ttve
instructions at ihe E>-« and Eur HoSfitsJ (7.000 patients annually treated}, ami she
BrooklFn Hospital itt.OQuj, The resident Main of tliew>. snd of fit. Jo ha 'ft, St.
Man% fit, Catherine's, Methodist E[;it§cc|ul, and KJuit'M Count? @oHt-ltaL», also
the Burgeons of the City Ambulance Service, &re am minted in Dually, ami the
positions sr« open to tho graduate* of the Loop Island ColJtve HoppftaL
Special Instruction ifc given witiutut c&rt, in Ovuecolugy, Midlife ry, Inwaaea of
the Bye. Ear, Throat. Noae, Skin, and Nervoiit frvvtem. Practical Obstetrics, aif
taught by daily eierctaes on the Manikin, Including ail the operative procedural
forceps, version, etc, and by alteD dance on case* of kid ft Dement In the Wards of
the Maternity and Out-door Obstetric Service. In the Boaaland Laboratory,
instruction b jttvpii in Ba«terlofo|f¥h lucrosOOpg. and Pathology,
Pais.— MmtncuLation for the Collegiate year. 16 ; Lett urns and Clinics of Regu-
lar Turin, f 1Q0 ; Graduation, 125 ; Lectures and ClLnicu of Heading and BacitatlOB
Term. NO.
Good board can be bad in Brooklyn for IS a week.
For pari! Millars ai to lectures* clinics, and fee*, send for Annual Auuoun; «, L.-mt
to J. ft, IU\jhisi», M.D,, Secretary of faculty, Long Inland College Hospital,
Brooklyn, N. Y.
AL.KX. «T, O. *MNM, M.D., presidam of tfte Ooiiesje.
Bellevue Hospital Medical College,
CITY OF NEW YORK.
Sessions of 1895-96.
Tne Rsgulab Session begins on Monday, September 88, 1895, and con-
tinues for twenty-six weeks. During this session, in addition to the regular
didactic lectures, two or three hours are daily allotted to clinical instruc-
tion. Attendance upon three regular courses of lectures is required for
graduation. Tbe examinations of other accredited Medical Colleges in the
elementary branches are accepted by this College.
The Spring Session consists of daily recitations, clinical lectures and
exercises, and didactio lectures on special subjects. This session begins
March 28, 18M, and continues until the middle of June.
The Cabnegib Labobatobt is open during the collegiate year for lnstruo
tion in microscopical examinations of urine, practical demonstrations in
medical and surgical pathology, and lessons in normal histology and in path-
ology, including bacteriology.
For the annual Circular, giving requirements for graduation and other
information, address Prof. Austin Flint, Secretary, Bellevue Hospital Medi-
cal College, foot of Bast 88th Street, New York City.
New York Post-Graduate Medical School and Hospital.
THIRTEENTH YEAR. SESSIONS OF 1894-95.
The Autumn and Wintbb Sessions of ibis Institution will begin on September 17th. The hospital of the School contains 190
beds. The teachers of the Institution are also connected with the following named Hospitals and Dispensaries : St. Luke's, Bellevue,
the Presbyterian, Woman's, Charity, Mt. Sinai, German, Skin and Cancer, New York Cancer, St Mark's, Ruptured and Oiippled,
Manhattan Bye and Ear, New York Bye and Ear Infirmary, Maternity, Randall's Island, New York Dispensary, Out- Door Department
of New York and Bellevue Hospitals, Insane Pavilion of Bellevue Hospital, German Poliklinlk, German Dispensary, Monteflore Home, and
others. The Laboratory is well equipped for pathological, histological, and bacteriological investigations. The Babies' Wards contain
60 beds and give great facilities for the study of infantile disease. Instruction is given in surgical anatomy and operations on the
cadaver. The instruction is intended for general practitioners who wish to acquire a knowledge of all departments of medicine and
surgery, as well as for those who are practicing in any special department Every branch of medicine and surgery is taught by a
system of personal and private instruction ; no formal lectures are given.
For Catalogue and Schedule, address
CLARENCE C. RICE. M.D., Secretary,
Second Ave. and Twentieth 8t~> New York CUy.
D. B. ST. JOHN ROOSA, M.D., LL.D., President.
F. E. FARRELL. Superintendent.
SOCIETY OF THE LYING-IN HOSPITAL OF THE CITY OF NEW YORK.
XDWABD W. LAMBERT. M.D.,
WILLIAM M. POLE, M.D.
(Organised 1796.)
CONSULTING PHYSICIANS.
THOMAS M. MABKOE. M.D., WM. T. LUSK, M.D.,
ATTENDING PHYSICIANS.
J. W. MABKOE, M.Dm 8. W. LAMBEBT, M.D., J. CLIFTON EDGAR, M.D., H MoM. PAINTER, MJ>.. AUSTIN FLINT, Ja,, M.D.
The Midwifery Dispensary has been absorbed by this Institution. The number of deliveries during 18*1, 856; during 1898, 8,070. The 'i
ttve building is in the most densely populated tenement-house district in the city. There are accommodations for twenty students, the regular term of lnstras-
Uon being two weeks, with six to fifteen detlveites for each student. Instruction ts given during the entire year and is open to practitioners of nudlclne sai
' \ who have attended one course of medlcaJJecturea. Studenta are admitted in the order to which their applicattona are received, or they may be
'thetwi
en practicable. While waiting they can attend the various hospital clinics, dispensaries, eld, In the city. All d< liveries are
attended at their houses ss in private practice. Lodging, instruments, and medicines are furnished at the hospital during i
ites are issued to those who have performed the service satisfactorily. For further information, apply to
to special dates when
antsmptlc. and all oases are ati
weeks' service, and certificates
CHA8. FORD, Superintendent, 314 Broome Street, New York City.
■pedal tnstructlon upon the manikin given by the attending physicians. Senarate apartments for graduates-
HEW YORE POLYCLINIC AND HOSPITAL
A Clinical School for Graduates in Medicine. Lectures continuous throughout the year. Physicians may enter at any time. The
winter Session extends from September 25th to June 15th. The clinical material is unlimited, and practical instruction is given
in every department of medicine. The opportunities for seeing operations in every branch of surgery are unlimited. Practical
obstetrics, clinical mlorosoopy, and intubation are also taught in the sohooL For further information, address
I*. BMMBTT HOLT, MJX, Secretary,
214.218 Bast 34th Street New York,
A PRACTICAL TREATISE ON RENAL DISEASES
AND
URINARY ANALYSIS.
By WILLIAM HENRY PORTER, M.D.,
Professor of Clinical Medicine and Pathology in the New York Post-Graduate Medical School and Hospital ; Curator to the Presbyterian Hospital.
One octavo volume of three hundred and sixty pages, illustrated by one hundred fine wood-engravings. Bound in extra muslin, price, ?3#0O>
WILLIAM WOOD & COMPANY, Publishers, - 43, 45 and 47 East 10th Street, New York.
32
MEDICAL RECORD.
OFFICIAL ANNOUNCEMENTS
OF MEDICAL COLLEGES.
MEDICAL DEPARTMENT OF
Harvard University,
BOSTON. MASS.
One hundred and twelfth Annual Announcement
(1804-05).
Instruction It given hj Lectures, Beeltatlons,
Clinical Teaching end Practical Exercises through-
oat the Academic year. The year begtm September
8T, ISM, and ends the last Wednesday In Jane,
1806. Persons who hold no degree In Arts or
Science mast pass an examination for admission
to this School. The admission examination will be
held In June at Boston, Andover, Qulncy, Oroton,
Southboro, Worcester, Exeter, N. H., Concord, N.H.
New York, Albany, Buffalo, Rochester, N. Y..
Philadelphia, Washington, Chicago, Cle?eland,
Cincinnati, St. Louis, Minneapolis, Denver, San
Vrandsoo, Belmont, CaL, Portland, Ore., and
Bonn, Germany ; in September at Boston only.
Examlnatlo 1 for advanced standing Sept. 84, ISM.
A catalogue containing detailed information and
of examination papers, will be sent on
DR. WM. L. RICHARDSON,
Dean, Harvard Medical Sohool. Boston,
University of Colorado
MSDIGAL DBTAKMEMT.
Three years' graded coarse. Instruction daring
the first year Is given in Boulder, and daring the
second and third years In Denver, owing to the
superior clinical advantages of the latter dry. The
District Court has recently decided that the Uni-
versity of Colorado has a right to teach medicine
wherever the beat clinical advantages are obtain-
able. Practical laboratory work In Chemistry,
Histology, and Pathology. The next session com-
mences the first week In September. 1884.
Tuition Is free to residents of Colorado. Non-
residents pay a nominal fee of twenty dollars.
H. W. MoLautblix. M.D, Secretary. a
Berth Block, Denver, CoL
Woman's Medical College
OF THB NEW YORK INFIRMARY,
991 Mast 16th Street, MMW YOBK.
Session of 18*4-95 opens October 1, 1884.
Four years* graded course. Instruction by Leo-
tores, Clinics, Recitations, and practical work, un-
der supervision la Laboratories and Dispensary of
College, and in New York Infirmary, operations
and CUnlos inmost of the City Hospitals and Dto-
pensarles open to women students. For Catalogues,
ate., address EMILY BLACEWBLL, M.D.. Dean,
sal Bast isth Street.
FOB
BOTE
COLLEGE
Physicians and Surgeons,
•OSTON, MAMT
connected.
Equal prlvUtgea for both asses.
Hol Edward Amy, PraUai S3 statist
New illustrated catalogue free.
Mil Mm lira] ScM
BOSTON, MASS.
For men and women. Will oom-
menoe its next oourae of lectures on
Weoneeday, October 3, 1894.
For particulars, address
Prof. Charles P. Thayer, M.D., Sec-
retary, 74 Boylston Street, Boston.
DARTMOUTH MEDICAL COLLEGE,
HANOVBB, JT. W.
SUMMER AND FALL SESSION.
Lectures begin July IS. 1895, and continue
twenty weeks. Healthful climate and excel-
lent corps of teachers. Mary Hitchcock Hos-
pital completed For circular, address
C. P. FROST, M.D..
Hanover, N. H.
Northwestern University
MEDICAL 8CHOOL.
(Chicago Medical College,)
The regular oourae includes four yean of
eight months each. The laboratory equip-
ment is complete. The clinical faolitiea
are exceptionally fine. For circulars of de-
tailed information, address the Secretary.
Dr. FRANK BILLINGS,
235 State Stf Chicago, I1L
■EDI00-0HIRUR8I0AL 00LLE8E
OF PHILADELPHIA.
Winter Session will begin October td and con-
tinue until May* Prellnunarj Session begins Sep-
tember 4th.
The Curriculum Is graded ; a preliminary
inatlftn and three Annual Winter Sessloi
required. Laboratory Instruction In Chemistry,
Histology, Pathology, Hygiene, and Physiology,
with Bedside Instruction In Medicine, surgery,
and Gynecology Is a part of the regular course.
All the specialties are folly and practically
taught. Fourth Year, free to those In attend-
ance three sessions, to all others, $100.
For announcement or Information, apply to
ERNEST LAPLACE, OLD.. Dean,
IBM 8. Rlitenhousc Square, Philadelphia* Fa,
UNIVERSITY OF MICHIGAN.
DEPARTMENT OF MEDICINE AND SUBGEBT.
ftrtv-nftaTey, otnassetag Eaaisy, Oot i, MM.
The Coarse of instruction oomprlses/oir eoUeglsts
rears of mas months each. Examination for admls*
Fasa:— For the first year— Besidents of Michigan,
fSS.OO : non-residents. 800.00. For each subaeaueni
wJSSi. Graduation ftetarall alike,' 01040*
°*^ASre^
tlE JEFFERSON MEDICAL 00LLE8E
OF PHILADELPHIA.
tsa tttk aaaaal Santa of tat JsSmmb Esttool OoUtgt
•egiai OoMoet lit sad wsnsuti 7 aostat.
Each student is Immediately and personally
taught m Obstetrics and Uynooology, Physical
Diagnosis, Laryngology, Ophthalmology, Medical
Chemistry, Pharmacy, Materia Medica, and Ex
rlmental Therapeutics, Anatomy, Histology. and
pertmental Physiology, Minor Surgery, Ban
Operations on the Cadaver, Pathology,
~~ > Tberapeutlos, Dermatology,
, and Genlto-urlnary Diseases.
partmental Therapeutics, Anatomy, Histology, and
Experimental Physic'
Operations
rj, Eleotro
die Surgery,
Three annual regular sessions are required.
daglng. Opi
Neurology. Bteotro Tberai
Orthopaedic Si
Bedside instruction fa Medicine, Oynascotooy.
Surgery, and Obstetrics is a part o/ the third year
saw as. No extra fee.
The Annual Announcement will be sent
an appnoatioo to
J. W. HOLLAND, M.D.V Dean.
Albany Medical College.
MEDICAL DBPABTKBUT, UHIOH CNIVIRBITT.
180448.
ALBANY, N. T.
Begolar Term begins September 85, 1804 and
closes April 16, 1895.
Instruction by Lectures, Beeltatlons, Cantos,
Laboratory Work, and Practical Operations. Three
year strictly graded course. Hospital advantages
excellent.
FBES-Matriculatlon, IB: Lectures, $100 (Per-
petual Ticket, t*o0) ; Dissection, $10 (material free);
Laboratory Courses In Chemistry, Histology, and
Pathological Anatomy, each, 810.00 ; Graduation
Fee, fas.
Catalogues and Circulars containing foil Infor-
mation, sent on application to ,
WILLIS O. TUCKER, M.D.. BMSTBAn,
Albany Medical Collect, Albany, N. T.
SEND FOR A CATALOGUE
— Of —
H. WOOD I CO/8 PUBLIC1TI0R
BOWDOIN COLLEGE.
MEDICAL DEPARTMENT.
The T5th Annual Coarse of Lectures at the Medi-
cal School of Maine win begin January 10, 1896,
and continue twtnty-four (04) week*.
FACULTY,— Ibbail T. Daka, MJ>., Pathology
and Practice ; ALrun Mitchell. M.D., Obstetrics
and Diseases of Children ; Frbobsice H. Qamnnm,
M.D., Anatomy ; Hon. Luctltob A. Bhbet, A.M.,
Medical Jurisprudence ; Stepheh H. Wkees, M D.,
Surgery and Clinical Surgery ; Chakles O. Hmr.
M.D., Materia Medica and Therapeutics ; Fuahk-
um C. ROBiraoM, A.M., Chemistry ; Chakles D.
Smith, M.D.. Physiology and Public Health ; Job*
P. Thomtsoh, M.D., Diseases of Women; Alios*
R. Moultom, M.D., Mental Diseases ; Willis B.
Moultok, M.D., CUnlcal Instructor in Diseases of
Eye and Bar ; Admbox I. Thatkb, M.D., Demon-
strator of Anatomy; William L. Daka, M.D.,
Demonstrator of Histology.
Circulars, containing lull Information, may be
obtained upon application to the Secretary.
ALFBBD MITCHELL. sLD., Secretory.
BBUMBWIOX, MB.. August 8, 1804.
wcsTam ramsYLVMM moicm. csuek
medical DBPAmrnxirr op tub
wistoh raivusiTT or pbevotltaeia.
Regular Session begins 0d Tursday in Sept.. 180s
-lasts six months. Spring Session begins Id Tues-
day in April. 1806 -lasts ten weeks. Three years'
graded course. Poor years required after April,
1806. Unequaled Hospital and Dispensary advan-
tages. Thoroughly equipped Laboratories. Cttnt-
cai Instruction regularly, and opportunities unsur-
passed. For particular*, see announcement—
enures* Prof. T. M. T. MCKENNAN, Sec Faculty,
810 Penn Avenue, Pittsburgh.
correspondence should be addressed to
Prof. W. J. A8DALB, Sec Board of Trustees,
nor Penn Ave., Pittsburgh, Fa.
THE BALTIM0IE MEDICAL C0LLE0L
Puldoiiabt Fall Counts begins September
1st i Regular Wnrni Cocas* begins October 1st
Excellent Teaching Facilities; Magnificent
New College Building; Superb Lecture Halls; large
and completely equipped Laboratories; capacious
Hospital and Dispensary ; Lyln*4n-Department for
teacnlng Clinical Obstetrics; TLarge CUnlca. Bead
tor Catalogue, and address
DAVID 8TREs7IT, M.D., Dean,
St^ Balttmote, MOL
Yale University,
DEPARTMENT OF MEDICINE,
Tue currleulum Is graded to extend U
three years, and consists chiefly of personal
mrueuon in Class-rooms, Laboratories, and catmosg
Udaotic lectures are retained to certatabnneaea,
The eoilege year contains thirty four weeka, sua
oeglos on the first Thursday in October.
FEES.— Matriculation, $0.00; Tuition, nrat and
second year, each $140; third year, $80^0, Grad-
uation, 800.00.
For announcements, giving particulars of fee
course and requirements for admission and grad-
uation, send to Da. HERBERT E. SMITH, DUAn,
Hew Haven, Conn.
NIAGARA UHTERSITY.
Medical Department, BuJBhlo, X . Y.
/The next regular course of lectures win begin
September 86. 1804, and clou May 10, 1800. Goad
laboratory and hospital advantages. Obstetric
opportunities unexcelled. For announcement* etc.
Address ALVIN A. HUBBELL, M.D..
810 Franklin St.. Buffalo, N. T.
A MANUAL OF OBSTETRICS,
By E. L. PARTRIDGE, M.D.
(Wood's Pocket Manuals.)
3*mo, jos pages, profusely illustrated with min-
iature engravings. Muslin, $i.oo.
WM. WOOD * CO., NEW YORK.
MEDICAL RECORD.
33
OFFICIAL ANNOUNCEMENTS
OF MEDICAL COLLEGES.
Chicago Polyclinic and Hospital.
A clinical school for Praotltlonars of Medtctne.
The Institution la thoroughly equipped for Post-
graduate Instruction in all branches of Kedldne
and Surgery ; nneqoaled Hoipltal Facilities, abun-
dance of clinical material. Bxcellent advantages
for Laboratory work, practical Anatomy and
Operative Surgery. For Information or the
announcement, apply to the Corresponding Sec-
retary, Br. M orean R. Brown, 1T4 to 176 Chicago
Avenue.
KEOKUK MEDICAL COLLEGE.
The regular Fall and Winter Session opens
September 4, 1894. and will continue six months.
The faculty la composed of experienced medical
teachers. Clinics regularly at St. Joseph's BoapltaL
A ten weeks' reading and recitation course fol
towing the regular Winter Beaalon la provided.
Fees for the regular Session, Matriculation,
10.00; Lecture Fees, Including Hospital Ticket,
188.00; Graduation Fee, $80.00. Material at coat.
For circular or Information, address
J. A. 80ROGQ8, M D , Secretary, or
T. J. MAXWBTJU M.D.. Cor. Secretary, Keokuk, la.
QEOROETOWN UNIVERSITY.
MEDICAL DEPARTMENT.
Forty-alxth Session opens October 1, 1804, and
win continue seven months.
Instruction is given by lectures, recitations, cMni
eal teaching, and practical demonstrations. In the
subjects' of Anatomy, Chemistry, Physiology,
Hygiene, Histology, Pathology, and Bacteriology
al practical Instruction Is given in well
>ped laboratories.
" nt and ample clinical facilities are fur-
For annual announcement, address the
equipped laboratories,
2X4
xoeUent and ami
nmnyl. For *nnn*»
Dean. G L. MAQRUDKB, M.D.
81* Vermont Ave., Washington, D. a
of
He*lesd
WESTERN RESERVE UNIVERSITY,
GLKVZLAHD, o»,
Presents a three years'
ft term of eight months. Instruction by recti
lectures, cunios, qulsses, and practical '
course, each year
tatlons,
Ample laboratory, dispensary, and hospital
Mas and equipments are provided for an students.
Tickets, per year, $100.
Ticket for whole course, fsffO.
Special courses as desired, and advanced stu-
dents given standing according to assured aoqulre-
ssents. Tear begins the middle of September.
Omasum F. Thwhto, D D., President of University.
Baltimore University.
SCHOOL OF MEDICINE.
The Regular Course of Lectures in this Institu-
tion wUlbegln October 1st.
The teaching faculties are excellent. Large
Qmlea,etc.
For Catalogue and other information, address
B. W. KILAU, M.D., Dean.
1887 Madison Ave., Baltimore, Md.
Cutaneous riemoranda
By H. Q. Pifford, H.D.
( Wood's Pocket Manuals.)
32mo, 274 pages, muslin, $1.00.
WM. WOOD & CO.. NEW YORK.
University of California.
MEDICAL DEPARTMENT.
Sam FaAMcmoo, - California.
The Session of 18M wfll begin January 7th, and
oontfnue six months. Four courses of lectures
are required. The clinical facilities are unsur-
passed. Fees: Matriculation, $6.00. Lectures,
$100. Graduation, $25.00.
For annual announcement, address
B. A. MoLBAN, M DM Dean,
806 Kearny Street.
Woman's Medical College
of Pennsylvania.
Tne Forty-flfth Akhual Sbbsioh opens Sept.
as, 18M. A four years' graded course of Lectures,
Qnlsses, Laboratory, and Clinical Work offers
superior advantages to students, who are also ad-
mitted to the olmtos of the public Hospitals.
Address CLARA MARSHALL, M.D., DXAM,
181 8.18th 8L, Phila.
Essentials of Chemistry,
Inorganic and Organic, for the Use of
-'■ ' nts In JV7
Students I
Twelfth Edition.
By R. A. WITTHAUS, A.M., M.D.
One volume, 321m), 320 pages, muslin, price, $1.00.
WM. WOOD & CO., NEW YORK.
OT8o laborious a task as the compilation of this closely printed volume of nearly 900 pages has not been previously attempted by any bacteriologist. Da
the publishers, too, the highest praise is due lor the admirable series of illustrations with which the text Is supplied."— Edinburgh Medical Journal*
A MANUAL OF BACTERIOLOGY
By GEORGE M. STERNBERG, M.D.,
Surgbon-Genbral U. S. Army;
Director of the Hoagland Laboratory (Brooklyn, N. Y.) : Honorary Member of the Epidemiological Society of London ; of the Royal Academy of Medicine
of Rome; of the Academy of Medicine of Rio de Janeiro ; of the American Academy of Medicine, etc., etc.
Illustrated by four heliotype and four chromo- lithographic plates and 321 engravings. 8vo, 850 pages. Price, maroon
muslin, $8.00; leather, $9 00.
This work is divided, generally, into four sections. In the first the author deals with classification, morphology, and general bacterio-
logical technique. In the second he takes up the general biological characters of micro-organisms. In the third division the patho-
genic organisms are considered, and in the fourth the saprophytic forms. The more practically important parts of the work are printed
in large type, while matters of less importance appear in smaller type.
In the first section the descriptions of methods will be found unusually clear and terse and the illustrations admirably calculated to
elucidate the text
The third section is the most important of all, dealing, as it does, with micro-organisms in their relations to disease. The general
questions of their mode of action and their manner of introduction into the body, together with the susceptibility and immunity of animals,
is discussed, and the various organisms associated with specific morbid conditions are described in detail.
Part four is devoted to the consideration of saprophytic bacteria, and includes chapters on those found in air, water, soil, on the surface
of the body and exposed mucous membranes, in the stomach and intestines, etc., etc.
In all, Dr. Sternberg gives an account more or less full of four hundred and eighty-nine species.
The book concludes with a remarkably complete bibliography, including all important articles and works on the subject from the
earliest times. It contains two thousand five hundred and eighty-two references.
The work consists of a single royal octavo volume profusely and beautifully illustrated throughout the text by numerous carefully
prepared wood-engravings and "half-tone" process cuts, many of the latter being direct reproductions of photo-micrographs, and all
executed and printed in an exceptional manner. Also four full-page heliotype plates from photo-micrographs by the author of the
important pathogenic bacteria, and four full-page chromo-lithographic plates.
Price, delivered free at any address in the United States, muslin, $6.00 ; sheep, $9.00.
WWL WOOD & CO., Publishers, 43f 45 & 47 East Tenth Street, New York.
34
MEDICAL RECORD.
PRIVATE HOSPITALS,
SANITARIUMS AND RETREATS.
fiREERMONT- ON -THE -HUDSON
for Mental and Nervous Diseases.
Balnh Lyman Parsons, KJ>.,
Balph Wait Parsons, stj).,
Sing Slug, H.T.
Cnrr Office : u Bast 44th Street,
Mondays and Fridays from *M to 4.M PJL
LAKE VIEW.
A imall private home for care and treatment
of Nervous and Mild Mental Diseases.
Located at Burlington, Vt. Extensive view of
Lake Champlaln, Adirondack and Green Moun-
tains. High rooms— large sonny windows— steam
neat in every room -pleasant wafts and drives
Patients are members of toe Doctor's own flamllj
affording a comfortable borne while under oon-
stent medical treatment and the care of experi-
enced nurses.
Special rates for continued cases.
Address, for circular, terms, etc,
DB. J. M. CLAJtKB, Burlington, Vt,
BRUNSWICK HOME.
AMITYVILLE, LONQ ISLAND.
▲ private institution for the care and treatment
of epileptics, feeble-minded, and alcoholic habitues;
duly licensed by the State Commission In Lunacy;
one hour from New York and Brooklyn ; five min-
utes from railway station; pleasantly situated close
to Great South Bay ; beautiful drives and walks ;
home comforts and careful medical supervision
day and night; private attendant If required;
electric light, modern conveniences, and sanitary
Improvements. Stage meets trains.
For terms and information, address
J. T. W. BOWK, M.D, Physician in Charge.
(Late of New York City Asylums for the Insane.)
THE WILLARD NERVINE HOME.
For the treatment of Nervous Prostration and
other diseases of the Nervous System Also known
as "Use Nervine" and "The Best-Cure."
Under the supervision of Or A. J. Wlllard (Yale
'68), Burlington, Vermont. This Is an attractive
modern building, of the Queen Anne style of archi-
tecture, situated on tbe " College Hill," and com-
manding a one view of the Adlrondacks and Lake
Cbamplaln. It has every necessary appliance for
Its special purroee, sunshiny rooms with numer-
ous ore-places, a large solarium, convenient ve-
randas, and ample grounds. Dr. Wlllard's medical
system, based upon extended study and experience,
is largelya modification of the Mitchell Rest Treat-
ment. This Is simple and scientific and has thus
far yielded very satisfactory results, other meth-
ods, however, are used according to the indications
of the esse. Full Information and satisfactory
references furnished. Correspondence solicited.
DR. FLIPPIN'8
PRIVATE SANITARIUM,
For the cure and treatment of
Coatisiptioi aid all Cfemic Diseases.
For terms and references, address
Dr. J. MEIGS FLIPPIN,
Ihomasville, JT. C.
SPECIAL RATES TO
Private Hospitals, Sanitarium*,
And Retreats.
DARIEN HOME AMD SANITARIUM,
Darien (N. Y. N. H. <&H. R.B.), Conn.
A country
home for the
private care
and treat-
ment of Men-
tal and Nerv-
ons Diseases.
Alcoholic and
NarooticHab-
itues. Delight-
fully situated
near Roton
Point, on Long
Island Sound,
88 miles from Grand Central Depot, N Y. City.
Excellent buildings, healthful and beautiful sur-
roundings, pleasant walks and drives. Patients
met at Stamford, Conn. (50 minutes fiom Grand
Central Depot), when notified. Maw York City
offloa hours (at 615 Lexington Ave.), WP.i
Thursdays, and by appointment. For terms and
information, call at New York City office, ls-l P.M.
dally, or address J. JOS. KINDRED, A.D.*
Medical Superintendent, Darien, Conn,
Mate Hospital for Mental Diseases,
Brookline, near Boston, Massachusetts.
Established 18T9.
WALTER CHANNING, M.D., Superintendent.
Post-office Address,
Garner Boylston St, and Chestnut Hill Ave*,
BBOOKUNE, MASS.
DR. S. a. WEBBER,
Lately Superintendent of Adamaf
Nervine Asylum, will reoeiyf
patients with nervous diseases, not
insane, in his house,
116 Marlboro' Street, Boston, Mtm
The> Private Institution for
FEEBLE-MINDED YOUTH
At BARRE, MASS.,
EBTaBUSHKD JUHE, 1848,
aflers to parents and guardians superior facfh
lies for the education and Improvement of thlt
slass of persons, sod the comforts of an elegant
aountry home,
GEO. A. BROWN. M.D.
THE PINES,
AUBURN, NEW YORK.
A Physician's Home for thet Care and '
of Nervous and Mental Invalids.
Duly lloensed by the State. Number of i
limited to twelve. A special nurse for each paOsoL.
Oulalne excellent. Buildings substantially con-
structed and well furnished. Pleasant srounOs,
twenty acres In extent; elevated, secluded, sad
within a mile of railway stations and center of tat
city. Address all communications to
FREDERICK 8EPTON. M.D.,
Phystdan In Charge.
MENTONE, FRANCE.
Physicians contemplating sending patients to
the south of France for the coming autussn and
winter can procure the best of accommodation
with the most delightful sunoundings of tat
Riviera, at Mentone, between Marseilles and Genoa,
being the residence (Villa Laurent!. Bass Bay.
Mentone) of WILLIAM FRANCKEN. M.Dl. cf
the Amsterdam University and of the Parte Faculty.
In summer, Medical Director of the seaside resort
st Schevenlngen. Holland. Full particulars ob-
tained personally or by addressing Pro! A.
FRANCKEN, 14* Hooper St. Brooklyn, N. T^or
Colonel W. R. Hopkins, Stamford, Oonn.
WALNUT LODGE HOSPITAL,
HABSFOnn, Oohw .
Organised in 1880 for the special
• of ALCOHOL AND OPIUM INKRRIA1
Elegantly situated In the suburbs of the etty, win
every appointment and appliance for the — "
ment of this class of esses, lndudtns; Ti
Russian, Roman, Saline, end Medicated
This Institution Is founded on the weH-r
fact that Inebriety la a disease, and c
all these oases require rest, change of t
living. In the best surroundings, eta, etc.
Applications should be addressed
T. D. CROTHS28. MJX.
8up*t Walnut Lodge, Hartford, Cans.
WALDEMERE
oso---r:B:ai-flioxTzarx>v
SEaunsuronecst, If. T.
For the private care and treatment of Mental and
Nervous Diseases, Aloohotto and Narcotic Habft-
ues. Waldemere Is twenty miles from Grand
Central Station, New York Oty. Trains every
hour. Applications can be made at US n^w^m
Avenue, New York City. 9 to 11 A. M
Da. R. N. CARPENTER, Superintendent
CROMWELL HALL,
tar Mervous and Mental Dfasaana,
CROMWELL, CONNECTICUT.
Established 18TT.
W.^B. Hillock, M.D. F. K. wsmpwr
Monthly Office Hours in New York. 1 to 4 PJL
Tmlrd Thursday, at «T West 60th St.
First Tuesday, st 8» Madison An
l» S^JBsTX-F^JEULXTBC
For Mental and Nervous Diseases,
WOO&HA.TMX, X. J„ cm mile from Brooklyn. Telephene: 7-1, M«s* JToew Tar*.
NBwYoaKOvFiOE: Dr. F. A McGUIRE, I Brooklyn Office : Dr. R. a F. COMBES,
681 Lexington Ave., 8-10 A. M., 1-2 and 6-8 P. M. | 887 Greene Avenue. MlV^c-TP.I,
Saratoga Springs, N, Y.f-
Beoeivee persons reoommended to it by their home physicians for Treatment* Changs,
Best, or Recreation. Send for illustrated circular.
THB BAR AND ITS DISEASES,
BEING PRACTICAL CONTRIBUTIONS TO THE STUDY OF OTOLOGY.
By SAMUEL SEXTON, M.D.,
Autal Surgeon to the Now York Eye and Ear Infirmary ; Fellow of the American Otologics! Society : Fellow of the New York Academy of MHHnt ; asembsc af
fha M*Hm*a1 (Motv i\t tit* P/Mintv rtf N»«r Vftrlr inrl nf thm Prakrit «nn»*>a' &vi«>hr at Nnr VnrV
the Medical Society of the County of New York, and of the Practitioners' Society of New York.
Bdlted by CHRISTOPHER J. COLLES, M.D.
la this work the author has not attempted to present a treatise on the ear embracing the entire field of Otology ; but the particular subjects embraced by tbe
I to which he has directed more special attention, cannot fail to be of service to the General Practitioner, while not devoid of interest to the Otologist.
The work is illustrated with numerous original wood-eagravings ; contains 473 large octavo pages, and is furnished with, a complete index. Price*
£4.00.
WILLIAM
WOOD & COMPANY, Publishers,
43 to 47 East 10th Street, New York.
MEDICAL RECORD.
35
PRIVATE HOSPITALS,
SANITARIUMS AND RETREATS.
KOMWA.LK, CONNECTIGTTT.
For the care and treatment of Insanity and
Nervous Diteasos. Alcoholic and Narcotic
Habitoiee. Address EDWIN EVERETT
SMITH, M.D., Booth Wilton, Connecticut.
Wednesdays, 2.80 to 480 P.M.
18 Bast 47th Street, New York City.
Mental and toons Diseases of Women.
A separate department for this class re-
quiring pelvic operations or treatments has
been connected with Or. Via dt Warker's
Private SaaatariMB far Wwata, and under his
charge. For terms, address
Dr. ELY VAN DB WARKBE,
Syracuse, N. Y.
Miss ALSTON'S HOUSE,
106 East 88th Street, New York City.
Miss A L. Alston, for nearly elgbt years Super-
intendent of Mount Sinai Training School for
Norses, has opened a house for the reception of
private patients. All classes of patients will be
received (including maternity oases) except pa-
tients suffering from contagious diseases or in-
sanity. For farther particulars or for circulars,
send to above address.
Tlie Riolxard. Gundry Home,
CatonavtOe, Balto. Co., MO.,
Wot Mental and Nkryoub Dihbjses, Oram, and
Alcoholic Addiction. For circulars, rates, etc.
•ddress Da. B. F. GUNDBY, box 107.
BrnmoBi : Dr. Henry M. Hurd and Dr. Wm,
Jaler, Johns Hopkins Hospital. Baltimore, Md.i
Or. John Morris, Baltimore, Md.; Dr. H. A Tobey,
Foledo. O.; Frauds White, Esq., Baltimore, M<tj
3Umor Meredith, Esq., Baltimore, Md.
Dp. Gundry can be consulted at the Baltimore Of-
tee^l B. Centre St., Tuesdays, from 12 to 1, or by
appointment.
Broadview Sanitarium,
HOLYOKE, MA88.,
For the private care and treatment of Nerv-
ous and Mental Diseases, Alcoholic and
Narcotic Habitues.
For terms and information, address
L. 11 SELLING, M.D., Medical Supt.
THK HIGHLANDS.
A private hospital established in 1875 by Ira
BuaeelL M.D., for the treatment of mild nervous
and mental diseases, the opium and alcoholic
habits, and nervous debility. The principles of
home and family life, non restraint and open air
are carried to an extreme. The surroundings are
sxceptlonally pleasant
For circulars, terms, references from all parts of
Che United States, address the Superintendent.
Dr. FMPgMOT W. ~~" '
THE INEBRIATES' HOME, FORT HAMILTON, N. T.
INCORPORATED 1866-
A Hospital for the Treatment of ALCOHOLISM and the OPIUM HABIT.
President: Bon. F. 8. If ASSET. Consulting Physlolaai 1* D. MASOM, M.B.
Bfedloal Superintendent: JAMBS A. BLANOHABD, Bf.D. Assistant Physlolan: F. T-. DOUEARB, Bf.D.
flie building is situated in a park of twenty-six acres, overlooking and commanding line views of the Narrows, and the upper and lower
hay of New York Harbor.
Hie accommodations, table, attendance, and nursing are of the best character and suited to first-class patients.
For manner and terms of admission, apply to the Superintendent, at the Institution, Fort Hamilton, Brooklyn, ft T.
KIRKE'S HAND-BOOK OF PHYSIOLOGY. 13th Edition.
Hand-book of Physiology.
BY
W. MORRANT BAKER, F.R.C.S.,
Late Surgeon to and Lecturer on Physiology at St. Bartholomew's Hospital, etc.,
AND
VINCENT DORMER HARRIS, M.D., Lond., F.R.C.P.,
Examiner in Physiology at the Conjoint Board of the Royal College of Physicians and Surgeons, and in the University of Durham ; Demonstrator
of Physiology at St. Bartholomew's Hospital ; Physician to the Victoria Park Hospital for Diseases of the Chest.
THIRTEENTH REVISED EDITION.
Kirke's Physiology has long been the text-book in this branch of medical science, and the fact that so many
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PRESS NOTICES.
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— The North American Journal of Homoeopathy, Philadelphia.
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*■ Indeed, the order of subjects and arrangement .of matter
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is an additional recommendation of its value. The illustrations
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siology."— The American Practitioner, Louisville, Ky.
The thirteenth edition of Kirke is complete in one volume of 840 pages, profusely illustrated by over 500 engrav-
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TWO VOLUMES ARE NOW READY.
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40 MEDICAL RECORD.
The Thyroid Gland.
Whatever may be the truth as to the virtue of the so-called "animal extracts" there seems
to be no doubt as to the efficacy of the sheep's thyroid. It has been used chiefly in the
treatment of Goitre and Myxoedema by physicians on both sides of the Atlantic, with most
gratifying results; but, as these ailments are rare in the United States, the opportunities for
testing this treatment have been limited. Recently, however, some prominent skin specialists
have used Desiccated Thyroids with great benefit in skin diseases such as Lupus, Psoriasis,
Scleroderma, etc., and we have heard of successful experiments in the treatment of obesity
by the same means.
m We quote by permission from Dr. Solomon Solis- Cohen's lecture on the "Therapeutic Proper-
1
I
I
i
I
i
ties of Animal Extracts," (Philadelphia Polyclinic, Nov. 15, '93).
"The administration of the Sheep's Thyroid is based on the same principle as that upon
which we administer Pepsin or Pancreatin in digestive disorders."
We prepare desiccated Thyroid Glands in a concentrated form, six grains representing one
entire average gland of the sheep. The usual dose is from two to six grains three times a
day. We also prepare Thyroid Tablets (5 grs.), each tablet containing two grains desiccated
Thyroids. i
The price of our Desiccated Thyroids is $1.00 per oz., packed in ounce bottles; the B
Tablets, 50 c. per oz. in ounce bottles. To any member of the medical profession desir- P
ing to experiment, we shall be glad to send samples, free. B
Armour & Company, Chicago. |
False claims as to its containing 50 per cent. Norway oil.
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Chemical modification of the oil.
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Emulsion so efficient as ^^ M II I I J^\ ^N f
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A truly delicious beverage. Try it. The proof of the Cocoa is in
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The Chas. H. Phillips Chemical Co., 77 Pine St, Hew York
B.P.LBindeiye.
NOV 26 189 &